Female Urology Update Lynnetta Faith Payne, DO, FACOS Urological Surgeon

Objectives: -diagnosis -risk factors -treatment

 UTI Incontinence

64 year old woman presents with a 3 year history of recurrent urinary tract infections (UTIs) treated with multiple antibiotic courses by a walk-in clinic What are the clinical symptoms associated with UTI?

Irritative symptoms  Urgency  Frequency  Dysuria  Hematuria  Foul odor  Suprapubic pain

Upper tract infections (pyelonephritis)  fevers  rigors  flank pain  nausea and emesis Congested vasculatures and extensive lamina propria hemorrhage Can be accompanied by sloughing of surface urothelium, ulceration or cytologic atypia depending on the cause of hemorrhagic cystitis Patient reports presumed bladder infections which occur every month or two associated with dysuria, urgency, and frequency. No gross hematuria, flank pain, or fevers. What is the differential diagnosis?

 Many processes and conditions may mimic the symptoms of bacterial urinary tract infection, so it is critical to rule out other causes during the evaluation prior to initiating treatment.  Urologic neoplasm  Atrophic vaginitis  Overactive bladder  Trauma  Congenital abnormalities  Urethral diverticulum  Sexually transmitted diseases – Herpes, Chlamydia, Trichomonas, Gonorrhea  Urinary lithiasis  Interstitial cystitis/painful bladder syndrome  Sepsis from non-urologic source Interstitial cystitis Urethral diverticulum Renal atrophy Diagnosis of UTI

 Presentation of clinical symptoms  Physical exam for atrophic vaginitis, urethral diverticulum etc  Clean-catch midstream urine sample  Chemical dipstick urinalysis  Quantitative urine culture; In general > 100,000 colonies/ml diagnostic Dipstick urinalysis evaluation

 Leukocyte esterase 63-90% specific  Nitrite very specific for gram negative but only 50% sensitive

 **Bottom Line  Positive dipstick + symptoms: – consider treatment (and culture)  Negative dipstick + symptoms: – consider culture When do you need radiologic imagining or further evaluation for diagnosis of UTI?

 Generally, uncomplicated cystitis or pyelonephritis does not benefit from imaging  Consider CT, ultrasound, voiding cystourethrogram (VCUG) and cystoscopic or ureteroscopic evaluation for patients with  *known anatomic abnormality  *those who do not respond to treatment Pathogenesis of urinary tract infections

 Ascending infection from periurethral area critical  Hematogenous spread is uncommon

 Risk factors  Reduced urine flow  Obstruction, stricture, neurogenic bladder  Factors that promote colonization  Sexual activity, spermacide, estrogen depletion  Facilitation of ascent  Catheterization, incontinence, residual urine What bacteria are associated with urinary infections and what pathogenic factors from both bacteria and the host contribute to colonization? Uropathogens

 Escherichia coli (80% of outpatient UTIs)  Klebsiella  Enterobacter  Proteus  Pseudomonas  Staphylococcus saprophyticus (5-15%)  Enterococcus  Candida  Adenovirus

 Normal perineal flora: Lactobacillus, Corynebacteria, Staphylococcus, Streptococcus, anaerobes -The bladder mucosal surface has antibacterial properties that eliminate some organisms, presumably through mucus trapping and a polymorphonuclear leukocyte response.

-In addition, urine that has a low pH, high or very low osmolarity, high urea concentration, or high organic acid content inhibits bacterial growth

-Abnormal micturition, a significant residual urine volume, or both will promote true infection.

-There are also acquired and intrinsic host factors, as well as bacterial virulence factors, which increase the likelihood of development of UTI. What are some correctable Urologic abnormalities that may provoke bacterial persistence? Bacterial persistence

 Infected stones  Fistula disease (colovesical, vesicovaginal)  Unilateral infected atrophic kidneys  Ureteral duplication and ectopic ureters  Foreign bodies (such as retained ureteral stent)  Urethral diverticula  Unilateral medullary sponge kidneys  Infected ureteral stump after nephrectomy  Infected urachal or renal cyst  Papillary necrosis Medullary sponge kidneys Kidney stones Patient found on exam to have poor water intake, atrophic vaginitis, and urine dipstick consistent with acute bacterial infection.

What are the treatment options? Treatment

 Encourage hydration and behavioral measures to increase fluid intake  Treat atrophic vaginitis with topical transvaginal estrogen if appropriate  Determine if infection represents uncomplicated or complicated infection Uncomplicated UTI treatment

 3 day course of trimethoprim/sulfamethoxazole (TMP/SMX)  For local TMP/SMX resistance pattern > 20% , consider fluoroquinolones  Full 7 day course in patients with diabetes, long duration of symptoms, pregnancy, > 65 years old, past history of pyelonephritis Complicated UTI treatment

 Culture essential  Ampicillin + aminoglycoside  Amp/Vancomycin + aminoglycoside or 3rd generation cephalosporin  Adjust according to culture results  If good clinical response, switch to oral agents in 48 hours  Treat for 14 days Follow-up and general rules of thumb

 Test for cure by repeat culture for pregnancy, pyelonephritis, and complicated or relapsing UTI  Consider single dose post-coital self-treatment in select cases  Do not treat asymptomatic bacteruria  Treatment often not indicated for patients on self catheterization protocols

Urinary Incontinence

 Bladder dysfunction  Urethral dysfunction Bladder dysfunction

 Urge incontinence  detrusor overactivity  detrusor overactivity of nonneurogenic origin  detrusor overactivity of neurogenic origin  poor compliance  Overflow incontinence

Urethral dysfunction

 Stress incontinence  anatomic ( due to mobility of the bladder neck)  Intrinsic sphincter deficiency (due to bladder neck dysfunction)

Transient Causes of Incontinence

Cause Comment Delirium Incontinence may be secondary to delirium and will often stop when acute delirium resolves.

Infection Symptomatic infection may increase urinary tract irritation and resulting incontinence

Atrophic vaginitis Vaginitis may result in the same symptoms of an infection.

Pharmacologic

Sedatives Alcohol and long-acting benzodiazepines may cause confusion and secondary incontinence.

Diuretics brisk diuresis may overwhelm the bladder's capacity and cause uninhibited detrusor contractions, resulting in urge incontinence.

Anticholinergics Many nonprescription and prescription medications have anticholinergic properties. Side effects of anticholinergics include urinary retention with associated frequency and overflow incontinence.

Alpha-adrenergics Tone in the bladder neck and proximal sphincter is increased by alpha adrenergic agonists and can manifest with urinary retention, particularly in men with prostatism.

Alpha-antagonists Tone in the smooth muscles of the bladder neck and proximal sphincter is decreased with alpha adrenergic antagonists. Women treated with these drugs for hypertension may develop or have an exacerbation of stress incontinence.

Psychological Depression may be occasionally associated with incontinence.

Excessive urine production Excessive intake, diabetes, hypercalcemia, congestive heart failure and peripheral edema can all lead to polyuria, which can exacerbate incontinence.

Restricted mobility Incontinence may be precipitated or aggravated if the patient is unable to toilet in a timely fashion.

Stool impaction Patients with impacted stool can have urge or overflow urinary incontinence and may also have concomitant fecal incontinence. Bladder dysfunction

 Storage  Emptying

 Urge incontinence occurs when the bladder pressure is sufficient to overcome the sphincter mechanism.  The sphincter is programmed to open during periods of elevated detrusor pressure and this occurs during normal voiding.  Elevation in detrusor pressure may occur from abnormal bladder contractions also known as detrusor overactivity. Elevation in pressures also occur in a poorly compliant bladder. Detrusor overactivity with UUI

 Idiopathic  Neurologic disease (detrusor overactivity of neurogenic origin)  Detrusor overactivity is exceedingly common in the elderly and may be associated with bladder outlet obstruction  Poor bladder compliance results from loss of the visicoelastic features of the bladder or because of a change in neural-regulatory activity  Patients with urgency incontinence may appreciate a sudden sensation to void which is difficult to defer. Urge incontinence

 The patient may not be aware of the sensation of needing to void until they are actually leaking.  The amount of leakage in patients with urgency incontinence is variable, depending on the patient's ability to suppress the contraction and the strength of their outlet.  Patients with urgency incontinence will often manifest frequency, nocturia, and occasionally nocturnal enuresis.  Overactive bladder has become the popularized term for describing patients with frequency and urgency with or without urgency incontinence.

Overflow incontinence

 Occurs at extreme bladder volumes or when the bladder volume reaches the limit of the urethral mechanism or the bladder's viscoelastic properties  The loss of urine is driven by an elevation in detrusor pressure which overcomes the outlet resistance  Overflow incontinence is seen with incomplete bladder emptying caused either by obstruction or poor bladder contractility  Obstruction is rare in women but can result from severe pelvic prolapse or following surgery for stress incontinence  Patients with overflow incontinence will complain of constant dribbling and often describe extreme frequency

Overflow incontinence continued

Cystocele

Urethral dysfunction

 Stress incontinence  anatomic ( due to mobility of the bladder neck)  Intrinsic sphincter deficiency (due to bladder neck dysfunction)

Stress incontinence

 Leakage of urine with any sudden increase in abdominal pressure  Incontinence associated with urethral hypermobility has been called anatomic incontinence, since the incontinence is due to malposition of the sphincter unit  Displacement of the proximal urethra below the level of the pelvic floor does not allow for the appropriate transmission of abdominal pressure that normally aids in closing the urethra.

 ISD (Intrinsic sphincter deficiency)  dysfunction of the proximal smooth muscle sphincter at the bladder neck and is often correlated with more severe stress incontinence.

Diagnosis

 History  onset, frequency, and severity of incontinence  pad usage  obstructive symptoms  previous treatments  comorbidities including diabetes, hypertension, and medications  Exam  pelvic organ prolapse  hypermobile urethra; what is the Q angle  urethral diverticulum  atrophic vaginitis  rectal sphincter tone  perineal sensation Diagnosis

 voiding diary

Mixed incontinence is very common, with at least 65% of patients with stress incontinence reporting associated urgency or urgency incontinence. Diagnosis

 Urinalysis and culture  hematuria, pyuria, glucosuria, or proteinuria  Post void residual  A normal PVR is less than 50 mL  A PVR in excess of 200 mL when associated with urinary symptoms should raise concern  A significant PVR may reflect either bladder outlet obstruction or poor bladder contractility  The only way to distinguish outlet obstruction from poor contractility is with functional urodynamic testing

Diagnosis

 Urodynamics  to accurately diagnose the etiology of patient's incontinence  examine bladder compliance, detrusor overactivity, urethral function, and to rule out obstruction as a cause of either overflow or urgency incontinence. Treatment

 Urge incontinence  Stress incontinence  Overflow incontinence Urge incontinence

 First line treatment will involve behavioral measures such as  timed voiding  modification of fluid intake  avoidance of bladder irritants  bladder retraining, where the patient attempts to consciously delay voiding and to increase the interval between voids Urge incontinence

 Medications  Anticholinergic-antimuscarinics  also used to decrease bladder pressure in patients with poor compliance  combined with clean intermittent catheterization in patients who have a significant PVR prior to treatment, or in patients who develop retention while on anticholinergics  Side effects: urinary retention, dry mouth, constipation, nausea, blurred vision, tachycardia, drowsiness and confusion  contraindicated in patients with narrow-angle glaucoma  caution should be employed utilizing anticholinergic medications in the elderly  Beta 3 adrenergic receptor agonists  promote detrusor relaxation during bladder filling and may reduce urgency incontinence without many of the adverse side effects of antimuscarinic agents

Urge incontinence

 Surgical intervention  Indicated when medications failed  Botox  Lasts average of 10 months  Sacral nerve stimulation Sacral nerve stimulation

-Urge incontinence refractory to medications -Urinary urgency and frequency refractory to medications -Idiopathic nonobstructive urinary retention -Fecal incontinence

Stress incontinence

 Pelvic floor exercises  Kegels  Weighted vaginal cones  Pessaries that support the bladder neck  Alpha agonists ; Sudafed  The bladder neck and proximal urethra have abundant alpha receptors. Activation of these receptors by alpha-agonists leads to an increase in smooth muscle tone

Stress incontinence

 Urethral bulking agents  Urethral sling

Sling

Studies have shown an 88 to 95 percent success rate in correcting urinary incontinence with the sling procedure. Overflow incontinence

 Overflow incontinence is treated by emptying the bladder  Poor detrusor contractility  CIC  Urinary diversion  Suprapubic cystotomy, Ileal conduit etc  If the cause of overflow is obstruction, then relieving the obstruction should lead to improved emptying  Cystocele repair or pessary  Urethrolysis

References

 Pontari, M. AUA Core Curriculum for Residents: “Urinary Tract Infections”  Shoskes, D. (2011): Urinary Tract Infections Retrieved From: The American Urological Association Educational Review Manual in Urology: 3rd Edition Chapter: 23 Page: 737-766  Smith's General Urology 16th edition 2004. Tanagho and McAninch, eds. Chapter 13. "Bacterial Infections of the Urinary Tract" Nguyen, Hiep. pp. 203 - 227.  Stamm, WE, Norrby, SR. Urinary Tract Infections: Disease Panorama and Challenges. J Infect Dis. 2001 Mar 1; 183 Suppl 1:S1-4.  Hooten, TM, Scholes, D, Hughes, JP, et al. A Prospective Study of Risk Factors for Symptomatic Urinary Tract Infection in Young Women. NEJM 1996; 335: 468-74  Nitti VW, Blaivas JG: Urinary incontinence: Epidemiology, pathophysiology, evaluation, and management overview, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds): CAMPBELL'S UROLOGY, ed 9. Philadelphia, WB Saunders Co, 2007, vol 3, chap 60, p 2046.  Burgio K. L et al. Behavioural vs drug treatment for urge urinary incontinence in older women. JAMA 280, 1995, 1998.  Dmchowski, Blaivas, Gormley et al. Female Stress Urinary Incontinence Clinical Guidelines Panel summary report on surgical management of female stress urinary incontinence. The American Urological Association. J Urol 2010.  Ward KL, Hilton P: A randomized trial of colpsuspension and tension-free vaginal tape (TVT) for primary genuine stress incontinence: 2 year follow-up. Int Urogynecol J Pelvic Floor Dysfunct 12 (supple 2): S7-8, 2001.  Gormley E.A. Urinary Incontinence. In Rakel, Robert E. (ed.) Conn's Current Therapy. W. B. Saunders Co, 2012.  Caruso L.B., Silliman R.A. Geriatric Medicine. In Fauci, et. Al (eds) Harrison's Principles of Internal Medicine, 17th Edition. 2008, pages 58-59.  Richter HE, Albo ME, Zyczynski HM, et al. Retropubic versus transobturator midurethral slings for stress incontinence. N Engl J Med 2010, 362: 2066-76.

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