This chapter deals primarily with APGO Educational Topic Areas:
TOPIC 36 SEXUALLY TRANSMITTED INFECTIONS AND URINARY TRACT INFECTIONS
TOPIC 37 PELVIC ORGAN PROLAPSE AND URINARY INCONTINENCE
Students should be able to distinguish normal and abnormal pelvic anatomy and support structures. They should understand the different types of urinary incontinence and prolapse and outline a basic approach to their initial evaluation and management. They should describe both medical and surgical options for treatment. Additionally, students should be able to outline evaluation and management of urinary tract infections.
Clinical Case
A 64-year-old multiparous woman presents with urinary incontinence. She describes loss of small amounts of urine when she coughs or lifts heavy objects. This started several months ago and has resulted in her having to wear a pad to avoid wetting her clothes. Her older sister said that she should have surgery to “pin up her bladder.” Physical examination is normal. During the office visit, there is no evidence of urine loss when she is asked to cough with her bladder full.
Pelvic support defects are conditions that reflect a loss of connective tissue support of the reproductive tract organs. They include loss of support of the uterus, paravaginal tissue, bladder wall, and urethra and urethrovesical angle as well as the distal rectum. Pelvic organ prolapse is a disorder in which organs have lost their support and descend through the urogenital hiatus. In order to identify patients who would benefit from treatment, the physician should be familiar with the types of pelvic support defects, the symptoms related to each, and the therapeutic options available.
PELVIC SUPPORT DEFECTS
Pelvic support defects are more common among women of advancing age, because tissues become less resilient, and accumulated stresses have an additive effect. Possible risk factors include genetic predisposition, parity (particularly vaginal birth), menopause, advancing age, prior pelvic surgery, connective tissue disorders, and factors associated with elevated intra-abdominal pressure (e.g., obesity and chronic constipation with excessive straining). Loss of pelvic support can have both medical and social implications that necessitate evaluation and intervention. Signs include cervical hypertrophy, excoriation, ulceration, and bleeding. Life-threatening symptoms, such as ureteral obstruction, systemic infection, incarceration, and evisceration, are uncommon. Most women with a pelvic support defect on physical examination are asymptomatic; physical findings do not correlate with specific pelvic symptoms.
Causes
The pelvic organs are supported by a complex interaction of muscles (levator muscles), fasciae (urogenital diaphragm and endopelvic fascia), and ligaments (uterosacral and cardinal ligaments). Each of these structures can lose its ability to provide support through birth trauma, chronic elevations of intra-abdominal pressure (e.g., in obesity, chronic cough, and repetitive heavy lifting), intrinsic weaknesses, or atrophic changes caused by aging or estrogen loss. Historically, pelvic support disorders were believed to result solely from attenuation or stretching of pelvic connective tissue. More recent findings demonstrate that breaks or tears of site-specific connective tissue result in identifiable anatomic defects in pelvic support.
Types
Loss of adequate support for the pelvic organs may be manifest by descent or prolapse of the uterus, urethra (urethral detachment, or urethrocele), bladder (cystocele), or rectum (rectocele). A true hernia at the top of the vagina allowing the small bowel to herniate through (enterocele) can also occur. These anatomic defects are illustrated in Figure 30.1.
A useful concept that can help in understanding these disorders is to visualize the anterior vaginal wall as a hammock. With good support, the hammock is pulled tight, allowing the bladder to rest on the hammock. When support is lost, the hammock sinks, as if someone were now sitting in the hammock. The bladder now forces the anterior vaginal wall down and out, creating an anterior wall defect, or cystocele. A similar force occurs in creating a rectocele, a posterior wall defect. The posterior vaginal wall loses the lateral support, and, thus, the pressure from the rectum forces the posterior vaginal wall in an upward direction. Loss of support for the uterus can lead to varying degrees of uterine prolapse. When the cervix descends beyond the vulva, it is termed procidentia. Loss of tissue support can also result in prolapse of the vaginal vault in patients who have had a hysterectomy. Although loss of support may affect any of the pelvic organs individually, multiple organ involvement is most common.
Evaluation
Patients with pelvic relaxation may have symptoms that include urinary or fecal loss or retention; vaginal pressure or heaviness; abdominal, low back, vaginal, or perineal pain or discomfort; a mass sensation; difficulty walking, lifting, or sitting; difficulty with sexual relations; and anxiety or fear related to the condition. A comprehensive physical examination includes the evaluation of specific anatomic sites with measurements that define the severity of prolapse. Landmarks evaluated include the urethra, vagina (including the anterior and posterior vaginal walls, paravaginal wall, and vaginal apex), perineum, and anal sphincter.
Pelvic Organ Prolapse Quantification
The POP-Q (Pelvic Organ Prolapse Quantification) examination is a classification of pelvic support that measures six specific points in the vagina relative to the hymen. The findings are used to define a stage of prolapse (Fig. 30.2):
• Stage 0: No prolapse. The cervix (or vaginal cuff, if the patient has had a hysterectomy) is at least as high as the vaginal length.
• Stage I: The leading part of the prolapse is more than 1 cm above the hymen.
• Stage II: The leading edge is less than or equal to 1 cm above or below the hymen.
• Stage III: The leading edge is more than 1 cm beyond the hymen, but less than or equal to the total vaginal length.
• Stage IV: Complete eversion.
Urinary Incontinence
A common complaint of patients with a cystocele or urethrocele is urinary incontinence. When the bladder loses its support, the mobility of the urethra increases as it pulls away from its attachment to the pubic symphysis. This is exacerbated when intra-abdominal pressure increases repetitively (e.g., when the patient performs the Valsalva maneuver, coughs, sneezes, or lifts heavy objects). Incontinence does not occur in all patients, and the degree of incontinence is often not commensurate with the degree of pelvic relaxation.
The presence of urethral hypermobility is sometimes assessed by the Q-tip test. With the patient in the lithotomy position, a cotton-tipped swab lubricated with lidocaine jelly is placed into the bladder and pulled back until resistance is met. Then the patient is asked to bear down. If there is urethral hypermobility, the end of the swab rotates upward, suggesting that the urethral–vesicular junction (UVJ) is being deflected downward by the intra-abdominal pressure. If the angle of the Q-tip rotation is greater than 30°, it is considered a positive test. The Q-tip test does not predict incontinence but provides more detail to the physical examination. It may also be used to predict the success of treatment options that work by stabilizing the urethra. Although widely used, it has limited value in predicting the presence of genuine stress incontinence and/or success of incontinence surgery. More reliable and clinically useful information is available with sophisticated urodynamic testing.
Of note, some patients with stage III or IV prolapse do not present with incontinence, because they have a kink (i.e., functional obstruction) in the outflow tract that can simulate continence. On occasion, such patients may develop hydronephrosis or hydroureter due to this obstruction. A renal ultrasound is helpful to evaluate this scenario.
History
Most pelvic relaxation disorders are the result of structural failure of the tissues involved, but other contributing factors should be considered in the complete care of the patient. Questions that should be asked include the following:
• Has there been a change in intra-abdominal pressure? If yes, what is the cause?
• Does the patient have a chronic cough or constipation that has precipitated her symptoms?
• Is a neurologic process (such as diabetic neuropathy) complicating the patient’s presenting complaint?
FIGURE 30.1. Pelvic support defects. (A) Cystocele (prolapse of bladder). (B) Rectocele (prolapse of rectum). (C) Uterine prolapse. (D) Uterine prolapse with enterocele (herniation of small bowel). (E)Combination of defects. (Used with permission from the American College of Obstetricians and Gynecologists.)
FIGURE 30.2. Pelvic relaxation classified by stage. (A) Stage 0 (no prolapse). (B) Stage I (leading edge of prolapse is more than 1 cm above the hymen). (C) Stage II (leading edge of prolapse is less than or equal to 1 cm below the hymen). (D) Stage III (leading edge of prolapse is more than 1 cm beyond hymen, but less than or equal to the total vaginal length). (E) Stage IV (complete eversion).
These issues as well as others should be considered prior to the selection of a diagnostic or therapeutic plan.
Differential Diagnosis
The presumptive diagnosis of a pelvic support defect is based on the evaluation of the structural integrity of pelvic support by physical examination. Other considerations include urinary tract infection (UTI), which may cause urgency, and urethral diverticulum or Skene gland abscesses, both of which can mimic a cystourethrocele and, in the case of diverticula, may be a cause of incontinence. These conditions can be identified by the patient’s symptoms, careful “milking” of the urethra, or cystoscopy. It is occasionally difficult to differentiate between a high rectocele and an enterocele. This distinction may be facilitated through rectal examination or the identification of the small bowel in the hernia sac. It is common for the diagnosis of an enterocele to not be confirmed until surgical repair is being performed.
Treatment
Women with prolapse who are asymptomatic or mildly symptomatic can be observed at regular intervals, unless new, bothersome symptoms develop. The option of nonsurgical management should be discussed with all women with protic lapse. Nonsurgical alternatives include pessaries, pelvic floor exercises, and symptom-directed management. A variety of surgical procedures can also be considered.
Pessaries
Pessaries are removable devices made of rubber, plastic, or silicone. They can be utilized as first-line therapy for most cases of prolapse regardless of prolapse stage or site of predominant prolapse. Pessary devices are available in various shapes and sizes as shown in Figure 30.3 and can be categorized as supportive (e.g., ring, Smith, Hodge, or Gehrung) or space-occupying (e.g., donut, Gellhorn, or cube).
Surgery
Surgical treatments for prolapse when the uterus is present include hysterectomy and uterine suspension. If the uterus has been removed, procedures include sacral colpopexy (attachment of the vaginal cuff to the sacral promontory) and fixation of the cuff to the uterosacral or sacrospinous ligament. Colpocleisis (complete obliteration of the vaginal lumen) can be offered to women who are at high risk for complications with reconstructive procedures and who do not desire vaginal intercourse.
FIGURE 30.3. Examples of commonly used pessaries. (A) Ring pessary (for mild prolapse with mild cystocele). (B) Gellhorn pessary (for third-degree prolapse/procidentia). (C) Inflatoball (for mild cystocele/rectocele associated with procidentia/prolapse). (D) Cube pessary (for stress urinary incontinence, uterine prolapse, cystocele, and rectocele).
Many women with advanced prolapse, particularly prolapse involving the anterior vagina, will not have symptoms of urinary incontinence. Some of these women will become incontinent after prolapse surgery.
The potential risks and benefits of performing a prophylactic anti-incontinence procedure at the time of prolapse repair should be discussed with each surgical candidate.
URINARY INCONTINENCE
The prevalence of urinary incontinence appears to increase gradually during young adult life, has a broad peak around middle age, and then steadily increases in older adults. Urinary incontinence has been shown to affect women’s social, clinical, and psychological well-being. It is estimated that less than one half of all incontinent women seek medical care, even though the condition can often be treated.
Types
Several types of urinary incontinence have been identified, and a patient may have more than one type (Table 30.1).
Urge Incontinence (Detrusor Overactivity)
The normal voiding “reflex” is initiated when stretch receptors within the detrusor muscle, the layer of muscle that lines the interior bladder wall, send a signal to the brain. The brain then decides if it is socially acceptable to void. The detrusor muscle contracts, elevating the bladder pressure to exceed the urethral pressure. The external urethral sphincter, under voluntary control, relaxes, and voiding is completed.
Normally, the detrusor muscle allows the bladder to fill in a low-resistance setting. The volume increases within the bladder, but the pressure within the bladder remains low. Patients with an overactive detrusor muscle have uninhibited detrusor contractions. These contractions cause a rise in the bladder pressure that overrides the urethral pressure, and the patient will leak urine without evidence of increased intra-abdominal pressure. Idiopathic detrusor overactivity has no organic cause, but has a neurogenic component.
A patient with detrusor overactivity presents with the feeling that she must run to the bathroom frequently and urgently. This may or may not be associated with nocturia. These symptoms may occur spontaneously, after bladder surgery to correct stress incontinence, or after extensive bladder dis-section during pelvic surgery.
Stress Urinary Incontinence
Normal physiology and anatomy allow for increased abdominal pressure to be transmitted along the entire urethra. In addition, the endopelvic fascia that extends beneath the urethra allows for the urethra to be compressed against the endopelvic fascia, thus maintaining a closed system and maintaining the bladder neck in a stable position. In patients with stress incontinence, increased intra-abdominal pressure is transmitted to the bladder, but not to the urethra (specifically, UVJ), due to loss of integrity of the endopelvic fascia. The bladder neck descends, the bladder pressure is elevated above the intra-urethral pressure, and urine is lost. Patients with stress incontinence present with loss of urine during activities that cause increased intra-abdominal pressure, such as coughing, laughing, or sneezing.
Mixed Incontinence
Some patients may have symptoms of both urge incontinence and stress incontinence. These patients present a significant diagnostic challenge and benefit from the use of appropriate evaluation. This clinical scenario may be treated as stress or as detrusor instability, although it is not clear which approach offers a better outcome.
Overflow Incontinence
In this form of incontinence, the bladder does not empty completely during voiding due to an inability of the detrusor muscle to contract. This may occur because of an obstruction of the urethra or a neurologic deficit that causes the patient to lose the ability to perceive the need to void. Urine leaks out of the bladder when the bladder pressure exceeds the urethral pressure. These patients experience continuous leakage of small amounts of urine.
Other Incontinence
In patients who have had a recent delivery, pelvic surgery, or radiation, involuntary leakage of fluid should suggest the possibility of fistulae between the vagina and the bladder (vesicovaginal), urethra (urethrovaginal), or ureter (ureterovaginal). A communication between the bladder and the uterus (vesicouterine) may also be found on rare occasions. A fistula may also occur between the rectum and vagina (rectovaginal fistula), resulting in the passage of flatus or feces from the vagina (Fig. 30.4).
Evaluation
The basic evaluation for urinary incontinence includes a history, physical examination, direct observation of urine loss, measurement of postvoid residual (PVR) volume urine culture, and urinalysis. The goal of initial testing is to rule out UTI, neuromuscular disorders, and pelvic support defects, all of which are associated with urinary incontinence. The patient should be asked about her fluid intake, the relationship between her symptoms and fluid intake and activity, and medications. A voiding diary may be helpful in this evaluation process.
Urodynamic Testing
Urodynamic testing may also be useful. These tests measure the pressure and volume of the bladder as it fills and the flow rate as it empties. In single-channel urodynamic testing, the patient voids and the volume is recorded. A urinary catheter is then placed, and the PVR urine is recorded. The bladder is filled in a retrograde fashion. The patient is asked to note the first sensation that her bladder is being filled. She then is asked to note when she has a desire to void and when she can no longer hold her urine. Normal values are 100 to 150 cc for first sensation, 250 cc for first desire to void, and 500 to 600 cc for maximum capacity. In multichannel urodynamic testing, a transducer is placed in the vagina or rectum to measure intra-abdominal pressure. A transducer is placed in the bladder, and electromyogram pads are placed along the perineum. This form of testing provides an assessment of the entire pelvic floor, and an uninhibited bladder contraction can be clearly documented.
FIGURE 30.4. Vesicovaginal fistula. (Used with permission from the American College of Obstetricians and Gynecologists.)
Cystourethroscopy
Cystourethroscopy, in which a slender, lighted scope is introduced into the bladder, is used to identify bladder lesions and foreign bodies, as well as urethral diverticula, fistulas, urethral strictures, and intrinsic sphincter deficiency. It is frequently used as part of the surgical procedures for incontinence.
Treatment
Often, treatments are more effective when used in combination.
Nonsurgical Treatment Options
Lifestyle interventions that may help modify incontinence include weight loss, caffeine reduction, fluid management, reduction of physical exertion (e.g., work and exercise), cessation of smoking, and relief of constipation. Pelvic muscle training (Kegel exercises) can be extremely effective in treating some forms of incontinence, especially stress incontinence. These exercises strengthen the pelvic floor and, thus, decrease the degree of urethral hypermobility. The patient is instructed to repeatedly tighten her pelvic floor muscles as though she were voluntarily stopping a urine stream. Biofeedback techniques and weighted vaginal cones are available to assist patients in learning the proper technique. When performed correctly, these exercises have success rates of about 85%. Success is defined as a decreased number of episodes of incontinence; however, once the patient stops the exercise regimen, incontinence typically recurs. Other treatments for stress incontinence include various pessaries and continence tampons that can be placed vaginally to aid in urethral compression.
Behavioral training is aimed at increasing the patient’s bladder control and capacity by gradually increasing the amount of time between voids. This type of training is most often used to treat urge incontinence but may also be successful in treating stress incontinence and mixed incontinence. It may be augmented by biofeedback.
A number of pharmacologic agents appear to be effective for treating frequency, urgency, and urge incontinence. The response to treatment is variable and unpredictable, with side effects occurring commonly. Generally, drugs improve symptoms of detrusor overactivity by inhibiting the contractile activity of the bladder. These agents can be broadly classified into anticholinergic agents, tricyclic antidepressants, musculotropic drugs, and a variety of other less commonly used drugs.
Surgical Treatment Options
Many surgical treatments have been developed for stress urinary incontinence, but only a few—retropubic colposuspension and sling procedures—continue to be recommended based on sound evidence (Fig. 30.5A, B). The aim of retropubic colposuspension is to suspend and stabilize the anterior vaginal wall and, thus, the bladder neck and proximal urethra in a retropubic position. This prevents their descent and allows for urethral compression against a stable suburethral layer. In the Burch procedure, which can be performed abdominally or laparoscopically, two or three nonabsorbable sutures are placed on each side of the midurethra and bladder neck. Another procedure, performed transvaginally, uses tension-free tape placed at the midurethra to elevate the urethra back into place. The success of tension-free vaginal tape has led to the introduction of other products with modified techniques of applying a midurethral sling (i.e., retropubic “top-down”) and transobturator approaches.
FIGURE 30.5. Surgical procedures for the treatment of incontinence. (A) Retropubic colposuspension. (B) Sling procedure. (C) Bulking agents. (Used with permission from the American College of Obstetricians and Gynecologists.)
In addition to retropubic colposuspensions and sling procedures, bulking agents, such as collagen, carbon-coated beads, and fat, can be used for the treatment of stress incontinence with intrinsic sphincter deficiency (see Fig. 30.5C). These materials are injected transurethrally or periurethrally around the bladder neck and proximal urethra, thereby providing a “washer” effect. These agents are usually used as second-line therapy in particular circumstances (e.g., after surgery has failed; when stress incontinence persists with a nonmobile bladder neck; or among older, debilitated women for whom any form of operative treatment may be hazardous).
Success rates vary depending on the skill of the surgeon and the technique used. Tension-free vaginal tape and the Burch retropubic colposuspension have success rates of 85% at 5 years. Because data beyond 5 years are limited, patients should be made aware that surgery is not necessarily a permanent solution. Evidence suggests that the cure rate of stress incontinence with Burch colposuspension may decrease over 10 to 12 years, reaching a plateau at 69%. Other suboptimal outcomes include partial continence only as well as urinary retention caused by overcorrection (making the sling too tight). Up to 10% of patients require at least one additional surgery to cure their stress incontinence.
URINARY TRACT INFECTIONS
An estimated 11% of the U.S. women report at least one physician-diagnosed UTI per year, and the lifetime probability that a woman will have a UTI is 60%. Most UTIs in women ascend from bacterial contamination of the urethra. Except in immunosuppressed patients and those with tuberculosis, infections are rarely acquired by hematogenous or lymphatic spread. The relatively short female urethra, exposure of the meatus to vestibular and rectal pathogens, and sexual activity that may induce trauma or introduce other organisms, all increase the potential for infection (Box 30.1). Estrogen deficiency contributes to ascending contamination by causing a decrease in urethral resistance to infection. This increased susceptibility may explain the 20% prevalence of asymptomatic bacteriuria in women over age 65 years.
Of first infections, 90% are caused by Escherichia coli. The remaining 10% to 20% of UTIs are caused by other microorganisms, occasionally colonizing the vagina and periurethral area. Staphylococcus saprophyticus frequently causes lower UTIs. Proteus, Pseudomonas, Klebsiella , and Enterobacter species all have been isolated in women with cystitis or pyelonephritis. These bacteria are frequently associated with structural abnormalities of the urinary tract, indwelling catheters, and renal calculi. Enterococcus species have also been isolated in women with structural abnormalities. Gram-positive isolates, including group B streptococci, are increasingly isolated along with fungal infections in women with indwelling catheters.
BOX 30.1 Risk Factors for Urinary Tract Infection
Premenopausal Women
• History of urinary tract infection
• Frequent or recent sexual activity
• Diaphragm contraception use
• Use of spermicidal agents
• Increasing parity
• Diabetes mellitus
• Obesity
• Sickle cell trait
• Anatomic congenital abnormalities
• Urinary tract calculi
• Neurologic disorders or medical conditions requiring indwelling or repetitive bladder catheterization
Postmenopausal Women
• Vaginal atrophy
• Incomplete bladder emptying
• Poor perineal hygiene
• Rectocele, cystocele, urethrocele, or uterovaginal prolapse
• Lifetime history of urinary tract infection
• Type 1 diabetes mellitus
From the American College of Obstetricians and Gynecologists. Treatment of urinary tract infections in nonpregnant women. ACOG Practice Bulletin No. 91. Washington, DC: American College of Obstetricians and Gynecologists; 2008; 111(3):785–794.
Clinical History
Patients with lower UTIs typically present with symptoms of frequency, urgency, nocturia, and/or dysuria. The symptoms found vary somewhat with the site of the infection (i.e., symptoms of bladder or trigone irritation include urgency, frequency, and nocturia, whereas urethral irritation tends to lead to frequency and dysuria). Some patients may report suprapubic pain or discomfort of the urethra and bladder base. Fever is uncommon in women with uncomplicated lower UTI. Upper UTI, or acute pyelonephritis, frequently occurs with a combination of fever and chills, flank pain, and varying degrees of dysuria, urgency, and frequency ((Box 30.2).
BOX 30.2 Urinary Tract Infections: Key Definitions
• Asymptomatic bacteriuria: Considerable bacteriuria in a woman with no symptoms
• Cystitis: Infection that is limited to the lower urinary tract and occurs with symptoms of dysuria and frequent and urgent urination and, occasionally, suprapubic tenderness
• Acute pyelonephritis: Infection of the renal parenchyma and pelvicaliceal system accompanied by significant bacteriuria, usually occurring with fever and flank pain
• Relapse: Recurrent urinary tract infection (UTI) with the same organism after adequate therapy
• Reinfection: Recurrent UTI caused by bacteria previously isolated after treatment and a negative intervening urine culture result, or a recurrent UTI caused by a second isolate.
From the American College of Obstetricians and Gynecologists. Treatment of urinary tract infections in nonpregnant women. ACOG Practice Bulletin No. 91. Washington, DC: American College of Obstetricians and Gynecologists; 2008; 111(3):785–794.
Laboratory Evaluation
Evaluation of the patient suspected of having a UTI should start with a urinalysis. A standard urinalysis will detect pyuria, defined as 10 leukocytes per milliliter, but pyuria alone is not a reliable predictor of infection; however, pyuria and bacteriuria together on microscopic examination markedly increase the probability of UTI. Treatment of a symptomatic lower UTI with pyuria or bacteriuria does not require a urine culture. However, if clinical improvement does not occur within 48 hours or, in the case of recurrence, a urine culture is useful to help tailor treatment.
A urine culture should be performed in all cases of upper UTIs, with the urine obtained as a “clean-catch midstream” sample. This involves cleansing the vulva and catching a portion of urine passed during the middle of uninterrupted voiding. Urine obtained from catheters or suprapubic aspiration may also be used.
“Dipstick” tests for infection based on the detection of leukocyte esterase are useful as screening tests; however, women with symptoms but negative test results should have a urine culture or urinalysis or both performed because false-negative results are common.
Cultures of urine samples that show colony counts of more than 100,000 for a single organism generally indicate infection. Colony counts as low as 10,000 for E. coli are associated with infection when symptoms are present. If a culture report indicates multiple organisms, contamination of the specimen should be suspected.
Treatment
Once infection is confirmed by urinalysis or culture, antibiotic therapy should be instituted.
Three days of therapy is comparable to longer durations of therapy, with eradication rates exceeding 90%. Recommended agents for 3-day therapy include trimethoprim–sulfamethoxazole, trimethoprim, ciprofloxacin, levofloxacin, and gatifloxacin.
In cases of acute pyelonephritis, treatment should be initiated immediately. The choice of drug should be based on the knowledge of resistance in the community. Once the urine and susceptibility culture results are available, therapy is altered as needed. Most women can be treated on an outpatient basis initially or given intravenous fluids and one parenteral dose of an antibiotic before being discharged and given a regimen of oral therapy. Patients who are severely ill, have complications, are unable to tolerate oral medications or fluids, or who the clinician suspects will be noncompliant with outpatient therapy should be hospitalized and should receive empiric broad-spectrum parenteral antibiotics.
Recurrence
Women with frequent recurrences of previously documented UTIs may be empirically treated without recurrent testing for pyuria. Management of recurrent UTIs should start with a search for known risk factors associated with recurrence. These include frequent intercourse, long-term spermicide use, diaphragm use, a new sexual partner, young age at first UTI, and a maternal history of UTI. Behavioral changes, such as using a different form of contraception instead of spermicide, should be advised. The first-line intervention for the prevention of the recurrence of cystitis is prophylactic or intermittent antimicrobial therapy. For women with frequent recurrences, continuous prophylaxis with once-daily treatment with nitrofurantoin, norfloxacin, ciprofloxacin, trimethoprim, trimethoprim–sulfamethoxazole, or another agent has been shown to decrease the risk of recurrence by 95%. Drinking cranberry juice has been shown to decrease symptomatic UTIs, but the length of therapy and the concentration required to prevent recurrence long term are not known.
Recurrence is common in postmenopausal women; the hypoestrogenic state with associated genitourinary atrophy likely contributes to the increased prevalence. Oral and vaginal exogenous estrogens have been studied with varying results.
Screening for and treatment of asymptomatic bacteriuria is not recommended in nonpregnant, premenopausal women. Specific groups for whom treatment of asymptomatic bacteriuria is recommended include all pregnant women, women undergoing a urologic procedure in which mucosal bleeding is anticipated, and women in whom catheter-acquired bacteriuria persists 48 hours after catheter removal. Treatment of asymptomatic bacteriuria in women with diabetes mellitus, older institutionalized patients, older patients living in a community setting, patients with spinal cord injuries, and patients with indwelling catheters is not recommended.
Clinical Follow-Up
This patient’s history is strongly suggestive of genuine stress incontinence, despite her not losing urine when coughing on the examination table. She is scheduled to undergo urodynamic testing, which can provide more sensitive evaluation of voiding function. The patient is shown to have a normal voiding pattern, but there is also evidence of genuine stress incontinence with no evidence of urge incontinence. She is instructed in performing Kegel exercises every day for 6 weeks. Upon return, her incontinence is significantly improved, and she no longer needs to wear a pad.
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