Urology for the Gynecologist

Educational Objectives

The goal of this program is to improve the diagnosis and management of urinary incontinence, hematuria, and urinary tract infections in women. After hearing and assimilating this program, the clinician will be better able to:

1.   Describe the association of urinary incontinence with the risk for falls and fractures in older women.

2.   Ask patients 3 key questions to help diagnose uncomplicated urinary incontinence.

3.   Educate women about available options for prevention and treatment of urinary incontinence.

4.    Distinguish between the causes of and diagnostic approaches for macroscopic hematuria vs microscopic hematuria.

5.   Recognize the risk factors for recurrent urinary tract infections and choose appropriate measures for treatment and prevention.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the plan­ning committee to disclose relevant financial relationships within the past 12 months that might create any personal con­flicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the following has been disclosed: Dr. Brown has received an investigator-initiated research grant from Pfizer, and Dr. Shaw has served on the Speakers’ Bureau for Merck. The planning committee reported nothing to disclose.

Acknowledgements

Dr. Brown was recorded at Controversies in Women’s Health, held December 3-4, 2009, in San Francisco, CA, and pre­sented by the Division of General Internal Medicine, Department of Medicine, University of California, San Francisco. Dr. Shaw spoke at 20th Annual conference on Focus on the Female Patient, held July 26-30, 2009, in Kiawah Island, SC, and presented by the Southern Medical Association. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.

Diagnosis and Treatment of Urinary Incontinence: Simple As 1-2-3

Jeanette S. Brown, MD, Professor of Obstetrics, Gynecology, and Reproductive Sciences, Epidemiology, and Urol­ogy; Director, University of California, San Francisco, Women’s Continence Center, and Co-Director, UCSF Women’s Health Clinical Research Center, San Francisco, CA

Background: 25% of women of reproductive age and 40% of postmenopausal women have urinary incontinence (UI); chronic; causes social isolation, increases falls and fractures, and increases admissions to nursing homes 3-fold; costs $26 billion/yr

Falls and fractures: 20% to 40% of older women who live in community fall; 90% of hip fractures occur with falls; study of association with urgency UI showed weekly urgency UI increased risk for falls by 26% and risk for frac­tures by 34%; risk for falls associated with frequency, urgency, and getting up at night; important to counsel pa­tients about preventive measures (eg, nightlight) for falls and fracture while treating UI

Diagnostic Aspects of Incontinence Study (DAISY): used 3 incontinence questions (3IQ) questionnaire to diagnose UI vs extended evaluation (extensive history, neurologic S2 through S4 examination, pelvic examination, postvoid resid­ual, cough stress test, dipstick urinalysis [UA], and 3-day diary); included women with incontinence appropriate for primary care (ie, community dwelling, ambulatory, with weekly UI bothersome enough to seek treatment); excluded women with complex UI (eg, failed surgery, failed treatment for UI, fistula, central nervous system etiology, multiple sclerosis, or spinal cord injury); 3IQ questionnaire had good sensitivity, specificity, positive predictive value, and like­lihood ratio for urge and stress UI

3IQ questions: 1) have you leaked urine during previous 3 mo (even small amount)? 2) if yes, is it stress (eg, physical activity, coughing, sneezing, lifting, or exercise, or urge incontinence (eg, feeling need to urinate, but unable to get to toilet fast enough)? which type occurs most often (stress, urge, mixed [ie, equal amounts of both], or other)?; results of evaluation  —simple, inexpensive, feasible, and reproducible; accuracy for determining type of UI acceptable for outpatient setting

Initial visit: use 3IQ and UA to diagnose; ask patient’s expectations; consider diary; educate and empower (patient educa­tion available on internet); consider bedside commode to prevent falls and fractures; study found biofeedback, verbal/vaginal instructions for pelvic floor muscle exercises, and self-help booklet equally effective in women with urge UI

Helpful recommendations: stress UI  —  timed voiding to prevent full bladder; consider pessary; surgery; urge UI  —urge suppression or distraction; quick pelvic contractions; consider medication; general tips  —  fluid management (drink for thirst); avoid caffeine; pelvic floor muscle exercises (squeeze as if holding back gas, hold for 2 sec, relax for 2 sec, and increase by 1 sec each day until 10 sec reached); bladder control (eg, freeze and squeeze before urge or stress); helpful websites include National Association for Continence (for men and women); diary  — available online; useful for planning therapy, fluid adjustment, timing and type of medication

Bringing simple urge incontinence diagnosis and treatment to providers (BRIDGES) study: under way with 636 women; to evaluate clinical usefulness and safety of 3IQ (ie, to determine whether serious conditions possibly missed or made worse); primary outcome  —  mean change from baseline in urge UI frequency (determined with 3-day diary)

Other diagnostic queries (3 Ps): ask about provocation (distinguishes between stress and urge UI), type of protection needed (pads or liners), and how problematic patient finds UI

Prevention and Treatment

Estrogen therapy: estrogen receptors present in urethra and bladder; 7 randomized controlled trials (RCTs) with »15,000 women showed therapy with conjugated equine estrogen plus progestin or estrogen alone increased risk for stress, urge, and mixed UI by 40% to 50% at 4 mo, and risk continued to increase for 4 yr

Weight reduction: in significantly overweight women, weight loss of >5% or 30 lb found to decrease frequency of UI by 50%; RCT found »50% decrease in UI with 5% to 8% weight loss in moderately overweight women; provides mo­tivation for weight loss

Medications for overactive bladder: side effects  —  dry mouth, constipation, drowsiness, blurred vision, and dizziness; contraindications  —  narrow angle glaucoma and severe hepatic or renal disease; drug choices  —  efficacy similar for  all; consider insurance reimbursement; oxybutynin (immediate release); extended release, patches, and gels available; adjunctive behavioral therapy improves results

When to refer to specialist: no definitive rule; generally, if UI does not improve after 3 to 6 mo (speaker may wait lon­ger), or if patient requests referral

Hematuria and Recurring Urinary Tract Infection

Howard A. Shaw, MD, Associate Professor of Obstetrics and Gynecology, University of Connecticut School of Medicine, and Chair and Director, Department of Obstetrics and Gynecology, St. Francis Hospital and Medical Center, Hartford, CT

Background: hematuria (HU) common in women; risk for malignancy increased in women >50 yr of age; urologic cause of HU often not identified; study of 1,900 patients referred to HU clinic found condition remained undiag­nosed in 61%; macroscopic HU involves grossly visible blood; microscopic HU detectable only on urine examina­tion

Diagnosis of macroscopic HU: color does not reflect quantity of blood (1 mL/L of blood causes recognizable color change); clots usually indicate source in lower tract (not renal); obtain urine culture; red-brown color in sediment af­ter centrifugation of urine indicates blood; heme-positive color in supernatant indicates hemoglobinuria or myoglo­binuria; in patients with underlying glomerular disease, usually caused by acute tubular necrosis (ATN) or IgA nephropathy in lupus

Diagnosis of microscopic HU: red blood cell (RBC) count  —  >2 RBCs per high-power field in centrifuged sediment consid­ered abnormal (gold standard;  no evidence to establish lower limit); >8,000 cells in centrifuged urine or >13,000 cells in uncentrifuged urine also considered abnormal; dipstick  —  can detect 1 to 2 RBCs per high-power field; false-positive re­sults more frequent, especially if pH of urine high, urine contaminated with solution from wipes, or patient has myoglo­binuria; always confirm dipstick with microscopic examination (false-negative results unusual)

Etiology: HU symptom of underlying disease; most common causes include inflammation, infection, or renal stones; re­nal or urinary tract malignancy more common among patients >50 yr of age or smokers; risk factors for significant disease  —  established by American Urological Association (AUA); age >40 yr; smoking; history of urinary tract in­fections (UTIs), analgesic abuse, irritative voiding symptoms, or pelvic irradiation; other etiologies  —  presence of pus or dysuria suggests UTI; postinfectious glomerular nephritis or IgA nephropathy possible after upper respiratory in­fection; history of renal disease and unilateral flank pain suggests ureteral obstruction or malignancy; recent vigorous exercise or trauma; bleeding disorders; cyclic HU may indicate endometriosis (menstrual blood contaminates urine); medications; travel

Glomerular vs extraglomerular bleeding: patients with glomerular bleeding usually have RBC casts, increased pro­tein, and dysmorphic RBCs, but clotting not generally seen; causes include noninflammatory glomerulopathy or m-mediated injury (refer these patients)

Transient vs persistent HU: repeat UA after few days; transient microscopic HU occurs in £13% of women; can occur with UTI (with pyuria, bacteriuria, and dysuria); consider malignancy if persistent and patient >50 yr of age or smokes; study found 12% of patients with HU had bladder cancer and 0.7% had kidney or upper tract tumors (remain­der idiopathic); risk for malignancy 8.9% in women 50 to 59 yr of age with macroscopic HU and 1.9% with micro­scopic HU (increases to 21% in patients 60 to 69 yr of age)

Cytology: appropriate for patients with risk factors; sensitivity greatest for carcinoma of bladder (usually upper tract transitional cell carcinoma); rate of false-negative results »65%; perform cystoscopy if malignancy suspected or atyp­ical cells present

Imaging: expensive and has low diagnostic yield in younger patients; more important in patients with macroscopic or gross HU; no established guidelines for use; multidetector computed tomographic urography (CTU) primary method; intra­venous pyelography (IVP) has 40% to 65% rate of detection of neoplasms; ultrasonography has lower diagnostic yield, but appropriate in special populations (eg, pregnant women who may have stones); magnetic resonance urography less able to detect smaller lesions; retrograde pyelography less effective than multidetector CTU

Multidetector CTU: combines benefits of CT and IVP; provides good visualization of ureteral and pelvicalyceal sur­faces and entire urinary tract for detecting masses or calculi; initial imaging method of choice (in addition to cystos­copy) in patients at high risk with persistent HU; dose of radiation >2-fold higher than that with IVP; not recommended for patients <40 yr of age, pregnant women, or if contrast contraindicated

Cystoscopy: perform on all adult patients with unexplained persistent HU; possible to view entire bladder and biopsy tri­gone; may identify source of bleeding; allows view of urethra

Mild glomerulopathy or stone disease: most likely cause of HU if other causes ruled out, especially in young and mid­dle-aged patients; »50% of patients with idiopathic HU have glomerular disease

Follow-up: if CTU, cystoscopy, and cytology results negative, likelihood of malignancy low; recommend follow-up vis­its for older patients who may have detectable malignancy later; repeat cytology and UA recommended for patients with HU at high risk for malignancy at 6, 12, 24, and 36 mo; some clinicians also repeat cystoscopy and ultrasonogra­phy; follow patients at low risk with repeat UA and urine cytology (no guidelines for frequency of testing)

Screening: not recommended in asymptomatic patients because of low yield rate

Recurrent Urinary Tract Infections

Background: 27% to 40% of patients have recurrence of UTI (possibly higher in patients infected with Escherichia coli [most common uropathogen]); high morbidity and expense associated with recurrence, but no evidence that recurrence leads to other health problems; most recurrences due to reinfection; relapse requires longer therapy or surgery

Pathogenesis: similar to that of sporadic infection; rectal flora colonize periurethral area and urethra and ascend to blad­der; alteration of vaginal flora, eg, bacterial vaginosis (BV), can predispose women to colonization

Reinfection: defined as infection with different strain or organism or with same strain ³2 wk after completion of treat­ment; also UTI that occurs in patient who had sterile urine specimen after completion of antibiotics for previous infec­tion; most recurrences due to reinfection and occur £3 mo after first infection; study has shown E coli can cause recurrence 1 to 3 yr after first infection

Risk factors: biologic  —  greater propensity for adherence of coliforms to uroepithelial cells; genetic factors  —nonsecretion of ABH blood group antigens and interleukin-8 receptor (inflammatory cytokine that promotes migra­tion of neutrophils across epithelium); behavioral factors  —  frequency of sexual intercourse; use of diaphragm; his­tory of recurrent UTIs; recent use of antimicrobial spermicides; new sexual partner; other  —  first UTI at £15 yr of age; mother with history of UTIs; no association with  —  precoital and postcoital voiding patterns, frequency or de­lay of urination, wiping patterns, douching, hot tubs, pantyhose, or body mass index

Pelvic anatomy: study performed perineal and postvoid residual measurements in 213 women (100 with recurrent UTIs) and assessed urine voiding characteristics; women with UTIs had significantly shorter distance between ure­thra and anus; no differences found in other variables

Postmenopausal women: study of 149 postmenopausal women with recurrent UTIs and 53 without UTIs found high odds ratio in women with urinary incontinence, cystocele, or high postvoid residual urine

Prevention: counsel patients about risk associated with spermicides; no evidence supporting efficacy of postcoital void­ing or increasing fluid intake; cranberry juice inhibits adherence of uropathogens to uroepithelial cells and may help decrease risk for recurrence

Prophylaxis: consider treatment with antimicrobials for patients with ³2 symptomatic UTIs over 6 mo or 3 over 12 mo; options include continuous prophylaxis or postcoital prophylaxis; optimal choice depends on patient preference and frequency and pattern of recurrences; should have negative results from urine culture for 1 to 2 wk after previous UTI; continuous  —  first-line recommended agents (for treatment as well as prophylaxis) include trimethoprim/sulfamethox­azole, trimethoprim/ciprofloxacin, levofloxacin, norfloxacin, or nitrofurantoin; significantly decreases rate of recur­rence (by £95%) and recurrences per patient-year, with relative risk for recurrence 0.21; side effects include vaginal and oral candidiasis and gastrointestinal symptoms; 6 mo of nightly antibiotic treatment followed by observation rec­ommended, but most patients continue for >6 mo (even lifetime); postcoital  —  possibly more efficient and acceptable for patients who typically get UTIs after intercourse

Diagnostic procedures: CTU, cystoscopy, and excretory urography usually reveal few abnormalities in patients with re­current UTIs; further evaluation recommended if condition suggestive of structural abnormalities of genital tract or  presence of Proteus or continuous relapsing infections

Editor’s Note

Dr. Brown mentioned the following websites:

University of California, San Francisco, Women’s Continence Center http://coe.ucsf.edu/wcc/AboutBladderProbs_incont.html

National Association for Continence http://www.nafc.org/

Suggested Reading

Arruda RM et al: Comparison between oxybutynin, functional electrical stimulation and pelvic floor training for treatment of detru­sor overactivity in women: a review. Curr Opin Obstet Gynecol 21:412, 2009; Burgio KL et al: The effects of drugs and behavior therapy on urgency and voiding frequency. Int Urogynecol J Pelvic Floor Dysfunct Feb 10, 2010 [Epub ahead of print]; Caruso DJ: Medical management of stress urinary incontinence: is there a future? Curr Urol Rep 10:401, 2009; Cody JD et al: Oestrogen ther­apy for urinary incontinence in post-menopausal women. Cochrane Database Syst Rev Oct 7, 2009: CD001405; Coll-Planas L et al: Relationship of urinary incontinence and late-life disability: implications for clinical work and research in geriatrics. Z Gerontol Geri­atr 41:283, 2008; Daniel R et al: 10-Minute consultation: Female stress urinary incontinence. BMJ Feb 1, 2010 [Epub ahead of print]; Guay DR: Cranberry and urinary tract infections. Drugs 69:775, 2009; Malkell RM: The natural history of urinary tract in­fection in women. Med Hypotheses Jan 9, 2010 [Epub ahead of print]; O’Regan KN et al: The role of imaging in the investigation of painless hematuria in adults. Semin Ultrasound CT MR 30:258, 2009; Renganathan A et al: Female urinary incontinence – urody­namics: yes or no? J Obstet Gynaecol 29:473, 2009; Rogowski A et al: Reliability and clinical validity of a Polish version of the CONTILIFE: a quality of life questionnaire for urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct Feb 10, 2010 [Epub ahead of print]; Sandhu KS: Gross and microscopic hematuria: guidelines for obstetricians and gynecologists. Obstet Gynecol Surv 64:39, 2009; Sran MM: Prevalence of urinary incontinence in women with osteoporosis. J Obstet Gynaecol Can 31:434, 2009; Su­bak LL et al: Weight loss to treat urinary incontinence in overweight and obese women. N Engl J Med 29:360, 2009; Yang JM et al: Clinical and pathophysiological correlates of the symptom severity of stress urinary incontinence. Int Urogynecol J Pelvic Floor Dys­funct Feb 10, 2010 [Epub ahead of print].