Urologic Disorders in Women

Educational Objectives

The goal of this program is to improve management of urologic disorders in women. After hearing and assimilating this program, the clinician will be better able to:

1. Perform a thorough evaluation of women who present with dysuria.

2. Select effective antibiotic therapy for urinary tract infections.

3. Recognize signs and symptoms of atrophic vaginitis and interstitial cystitis.

Summary

Urologic Disorders in Women

Ashley B. Bowen, MD, Assistant Professor, Department of Urology, University of Oklahoma College of Medicine, Oklahoma City

Dysuria: painful urination caused by inflammation; often accompanied by frequency, hematuria, and urgency; affects 3% of adults >40 yr of age

Differential diagnosis of dysuria: dysuria most commonly associated with urinary tract infections (UTIs), but also occurs with sexually transmitted infections (especially chlamydia, gonorrhea, trichomoniasis, bacterial vaginosis); consider vaginal candidiasis in patients recently treated with antibiotics; consider herpes simplex and human papillomavirus infection; noninfectious causes of dysuria include interstitial cystitis (IC; chronic bladder pain syndrome), bladder stones (rare), and urethral diverticulum (can be easily identified on physical examination); bladder cancer; hemorrhagic cystitis in patients who underwent radiation therapy or chemotherapy; overactive bladder; dysfunction of pelvic floor; endometriosis; atrophic vaginitis

Patient history: symptoms — frequency; urgency; fever; hematuria; pain (in, eg, flank or suprapubic region above bladder, or during intercourse); ask about personal or family history of kidney stones; smoking (consider bladder cancer); pain worsens when bladder full or improves when bladder empty (suggestive of IC); recent pelvic surgery

Physical examination: kidney — while patient supine, press posteriorly and anteriorly; distinguish musculoskeletal back pain (tenderness along paraspinus muscle) from kidney pain (occurs between paraspinus muscle and rib [perform imaging study]); pelvic floor muscles — palpate along lateral edge of vagina; tightness (“like banjo string”) and tenderness suggestive of pelvic floor dysfunction or spasm (can be improved with physical therapy; underdiagnosed and undertreated); bladder and urethra — palpate bladder and underside of urethra to check for tender areas and urethral diverticulum; cervix and vagina — palpate cervix to localize source of pain; in atrophic vaginitis, introitus smaller, white, appears drier, and more tender (treatment with vaginal estrogen improves redness, moisture, and tightness); urethral diverticulum closer to midline and middle of urethra, compared to Skene gland cyst (off midline toward meatus of urethra); treatment of lichen sclerosis same as that of atrophic vaginitis; urethral caruncle (thrombosed blood vessel at urethral meatus; easily treated with vaginal estrogen [larger ones may require surgery])

Testing: urinalysis (UA) — look for blood, leukocyte esterase, and nitrates; blood on dipstick falsely positive 10% to 15% of time (confirm with microscopy before diagnosing hematuria); cultures — obtain to diagnose recurrent UTI and to identify bacterial strains; prevent contamination of specimen by placing catheter and by storing specimen in refrigerator; imaging studies — not required for all patients with UTI; recommended for women with febrile UTIs, most men with UTI (to workup for kidney stones or poor emptying of bladder), patients with suspected obstruction, patients who underwent recent surgery, patients with persistent (5-6 days after therapy) pyelonephritis, very ill patients (due to, eg, septic shock or in intensive care unit), and patients with rapid recurrences of infection; when obstruction or anatomic problem suspected, computed tomography (CT) provides more detailed image than renal ultrasonography (misses ≈40% of kidney and ureteral stones); renal ultrasonography most reasonable for evaluating suspected anatomic problem in low-risk patients; magnetic resonance imaging of pelvis gold standard for diagnosis in patients with urethral diverticulum on physical examination; urine cytology — recommended for smokers with symptoms of UTI and negative culture; urodynamics — reserved for patients with complex issues not resolved with initial treatment (eg, incontinence, storage issues)

Therapy for uncomplicated UTI: healthy nonpregnant women — 3-day course of ciprofloxacin or trimethoprim-sulfamethoxazole (TMP-SMZ [eg, Bactrim, Cotrim, Septra]) or 7-day course of nitrofurantoin (Macrobid, Macrodantin) first-line options; consider 7-day course in patients with symptoms >7 days, recurrence of recent UTI, age >65 yr, diabetes, and in patients using diaphragm; pregnant women — amoxicillin; cephalexin (Keflex); nitrofurantoin

Recurrent UTI: repeat culture after antibiotic therapy to determine whether cleared infection returning or antibiotics failed to clear infection; if repeat culture negative 4 days after completion of antibiotics, then patient has bacterial persistence (caused by kidney stones and urinary stasis [perform imaging study and treat obstruction]); reinfection due to intercourse-related infection or atrophic vaginitis (treat with daily low-dose antibiotic prophylaxis for 6 mo); infections related to intercourse treated with single-agent prophylaxis after intercourse; refer patients with ≥2 symptomatic UTIs in 6 mo (or 3 symptomatic UTIs within 1 yr) to urologist to rule out anatomic or functional obstruction; vaginal estrogen effective adjunct for prevention; recurrent UTIs with Escherichia coli can benefit from cranberry juice (eg, 750 mL/day); short courses of bladder antiseptics (eg, methenamine and methenamine combinations [eg, Urogesic Blue]) shown to prevent recurrent UTIs; deconstipation and lactobacilli (oral tablet twice daily or vaginal suppository) helpful; not effective for prevention — vitamin C; oral estrogen; ignoring anatomic abnormalities; timed voiding; white cotton undergarments; avoiding hot tubs; wiping front to back

Treatment: daily low-dose antibiotic for 6 mo most effective; resistant UTI — patients insensitive to TMP-SMZ, ciprofloxacin, and nitrofurantoin; if patient not toxic, treat as outpatient for 7 to 10 days; if patient admitted with sepsis, treat with antibiotics for 14 to 21 days; fosfomycin (Monurol) can be used ≤3 times for complicated or multidrug-resistant UTIs; intramuscular gentamicin once daily can be used in patients who fail oral therapy; perform test of cure 7 days after completion of antibiotics; in development — vaginal suppository vaccines for E coli; new antibiotics; D-mannose

Atrophic vaginitis: genitourinary syndrome of menopause; lack of estrogen in vaginal epithelium; affects 45% to 63% of women; symptoms — vaginal dryness and dyspareunia most common; irritation and itching not as common; bleeding or spotting during intercourse; dysuria; worsened frequency and urgency, especially with atrophic vaginitis; treatment shown to reduce recurrent UTI in postmenopausal women; treatment — estrogen vaginal suppositories; vaginal ring with estrogen; over-the-counter (OTC) vaginal lubricants (eg, Astroglide [glycerin, propylene glycol, parabens]) dry out quickly; silicone-based lubricants (may stain bedding) and oil-based lubricants can be used as needed with intercourse; Replens [glycerin, mineral oil, and methylparaben]) lasts longer than K-Y Jelly (glycerin, hydroxyethyl cellulose, and methylparaben) and reduces symptoms; estradiol (eg, Vagifem, Estrasorb) suppositories placed in vagina daily for 1 to 2 wk, then 3 times per wk, then 2 times per week; conjugated estrogen ring placement for 1 wk; esterase and vaginal estrogen cream (eg, Estrace Vaginal Cream, Ogen Vaginal Cream, Premarin Vaginal Cream) can be used at higher or lower doses; important to use lowest effective dose; ospemifene (Osphena; newer oral selective estrogen modulator; carries potential risks associated with estrogens, but shown safe in women with breast cancer; no clinical data show increased recurrence of estrogen-sensitive cancer with use); laser therapy and vaginal rejuvenation increase angiogenesis of vaginal tissue and restore natural pH and thickness (approved by Food and Drug Administration [FDA]; data limited); testosterone with aromatase inhibitors shown effective (data limited); with vaginal estrogen in endometrium, no evidence of increased recurrence or increased susceptibility to cancer with treatment

Interstitial cystitis: unpleasant sensation perceived to be related to urinary bladder associated with lower urinary tract symptoms >6 wk with no other identifiable cause; true diagnosis of exclusion; consider in patients with chronic pelvic pain, worsening symptoms with full bladder, and urinary frequency; patient history — rule out extruded mesh or recurrent UTI in patients with history of pelvic surgery and UTI; other bladder disorders; location of pain (eg, front or side); pain related to bladder filling, or correlated with other events (eg, stress); autoimmune diseases; irritable bowel syndrome; fibromyalgia; chronic fatigue syndrome; physical examination — kyphosis; surgical incision; hernia; tender areas on hips; pain with movement of hips; perform pain mapping and vaginal palpation; UA and culture mandatory (evaluate for bladder cancer); treat UTI; check urine cytology in smokers with hematuria; cystoscopy not necessary for diagnosis

Treatment: stepwise and multimodal treatment; tier 1) behavior modification; dietary changes (eg, avoid spicy foods); OTC medications (eg, phenazopyridine [eg, Azo-Standard, Baridium, Phenazodine], calcium glycerophosphate [Prelief]); hot and cold packs between legs or over pelvic area; avoidance of sexual intercourse; deconstipation; tier 2) pelvic floor physical therapy helpful; however, Kegel exercises can worsen condition; trigger points can be massaged; 59% of patients improved with physical therapy vs 26% with back massage; physical therapist must have specialized training and desire to treat individuals with IC; urinary analgesics, methenamine, and nonsteroidal anti-inflammatory drugs; guidelines recommend narcotics (speaker recommends consulting pain medicine specialist); goal is for patient to resume normal activity; pentosan polysulfate sodium (PPS [Elmiron]) approved by FDA (start with 100 mg 3 times per day; nonserious adverse events [including hair loss] seen in 10%-20%); amitriptyline (Elavil) can be used; cimetidine (Tagamet) shown to improve patients; hydroxyzine (start with 10 mg and titrate up to 25 mg); tier 3) bladder instillations (with, eg, dimethyl sulfoxide, heparin, and/or lidocaine) for short-term benefit; hydrodistention — diagnostic and therapeutic; bladder inflated with saline to pressure of 80 cm of water for 10 min; relief can last 6 to 28 mo; no placebo-controlled trials, but 30% to 90% report improvement; efficacy improved by treatment of Hunner ulcers; tier 4) 200 units of botulinum toxin type A (Botox, Botox Cosmetic, Dysport) resulted in improvement, but also significantly higher risk for urinary retention and dysuria that required clean- intermittent or self-intermittent catheterization for 2 wk; hydrodistention and 100 units of botulinum toxin type A resulted in “middle of road” improvement but fewest adverse events; average time to retreatment 5.25 mo; InterStim therapy — bladder “pacemaker”; device approved by FDA for overactive bladder, urgency, frequency, and urge incontinence; used in patients with pelvic pain; outcomes best in IC patients who have predominant lower urinary tract component, with frequency and urgency more bothersome than pain; requires frequent reprogramming; expensive, but can be approved for insurance coverage; up to 28% of patients have device removed; tier 5) cyclosporine — shown in 1 randomized controlled trial to result in 75% improvement, compared to 19% in patients on PPS after 6 mo; associated with serious adverse events (eg, nephrotoxicity, immunosuppression, cutaneous lymphoplasia); 3 mg/kg divided in 2 doses (refer to IC specialist); tier 6) removal of bladder indicated but rarely performed; effective; 74% of patients pain free at 6 yr; many required secondary surgery due to pain; treatments to avoid — long-term antibiotics; intravesicle bacillus Calmette-Guerin therapy (no evidence of benefit; significantly harmful); high-pressure long-duration hydrodistention; long-term orthosteroids

Readings

Akiyama Y et al: Botulinum toxin type A injection for refractory interstitial cystitis: A randomized comparative study and predictors of treatment response. Int J Urol. 2015 Sep;22(9):835-41; Bremnor JD, Sadovsky R: Evaluation of dysuria in adults. Am Fam Physician. 2002 Apr 15;65(8):1589-96; Dieter AA et al: Oral antibiotics to prevent postoperative urinary tract infection: a randomized controlled trial. Obstet Gynecol. 2014 Jan;123(1):96-103; Eells SJ et al: Recurrent urinary tract infections among women: comparative effectiveness of 5 prevention and management strategies using a Markov chain Monte Carlo model. Clin Infect Dis. 2014 Jan;58(2):147-60; Flores-Carreras O et al: Interstitial cystitis/painful bladder syndrome: diagnostic evaluation and therapeutic response in a private urogynecology unit. Transl Androl Urol. 2015 Dec;4(6):620-3; Reimer A, Johnson L: Atrophic vaginitis: signs, symptoms, and better outcomes. Nurse Pract. 2011 Jan;36(1):22-8.

Disclosures

For this program, members of the faculty and planning committee reported nothing to disclose. In his lecture, Dr. Bowen presents information that is related to the off-label or investigational use of a therapy, product, or device.

Acknowledgements

Dr. Bowen was recorded in Midwest City, OK, at the 19th Annual Primary Care Update, presented May 3-7, 2016, by the University of Oklahoma College of Medicine in Oklahoma City. For more information about this sponsor, please visit https://ouhsc.cloud-cme.com. The Audio Digest Foundation thanks the speakers and the University of Oklahoma College of Medicine for their cooperation in the production of this program.

CME/CE INFO

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The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

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Lecture ID:

FP644402

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This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

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