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Female Urology
I have been asked periodically by ladies if Urologists treat female patients. I answered them all with an emphatic "yes" and apologized that we, urologists, had not communicated to the general public our expertise in the field of female urology. One patient of mine stated that she felt a bit uneasy in the waiting area of our office because of the predominance of men, and was unsure if she was in the correct office. I assured her that indeed she was in the correct office and that other ladies would probably soon enter. I also informed her that females make up approximately 30% of our practice. As a tribute to our female patients, we dedicate this newsletter, entitled Female Urology.
The technical name for the field of Urology is Genitourinary (GU). The Urologist has traditionally provided health care for both the genital and urinary systems of males and the urinary system in females, with the Gynecologist caring for the genital system in females. Recently, the Urologist and Gynecologist have expanded their roles in the field of Urogynecology, which I shall expand upon later in this newsletter.
Women experience some of the same urologic diseases as do men, albeit with different incidence and prevalence; e.g., 1.) Cancers (adrenal, kidney, arterial, bladder, and urethral cancers), 2. Urinary Stones, 3. Urinary Infections, 4. Urinary Injuries, and 5. Voiding Dysfunction. However, with the exception of Voiding Dysfunction, the evaluation and management of the above diseases are similar for both men and women. Voiding Dysfunction and Urogynecology are major areas of Female Urology that we will focus on in this newsletter.
As a result of clinical and technological advances of the last 20 years, we are more knowledgeable and better equipped to diagnose and treat disorders of the lower urinary tract in females. This new subspecialty of female urology will continue to expand and reach new horizons in the 21st Century. A new area of research in female urology is sexual dysfunction.
Dr. Rufus Green is Board Certified by the American Board of Urology, Fellow of the American College of Surgeons, Member of the Clinical Teaching Staff @ the University of Texas Southwestern Medical School, Member of the American Urological Society, and former Urology Consultant to the USAF Surgeon General. Dr. Green is the Medical Director of the Urology Institute in Dallas, Texas. He is on the medical staffs of St. Paul Medical Center, Centennial Medical Center, Medical City Dallas Hospital, and both RHD and Trinity Medical Centers. In this issue Doctor Green answers some important questions about FEMALE UROLOGY.
Q: Are female urology problems different from men?
Dr. Green: Although females experience some of the same problems that men experience such as urinary tract infections, kidney stones, congenital urinary abnormalities, urologic malignancies, and primary kidney diseases, there are some urology problems unique to females due to the anatomic developmental differences between men and women.
Q: What are some common female urology problems?
Dr. Green: Some common female urology problems are as follows:
Q: How common are UTIs ?
Dr. Green: Urinary Tract Infections account for approximately 7 million visits to physicians' offices, and necessitate or complicate over 1 million hospital admissions in the United States annually. UTIs are more common in women than in men, except in the neonatal period.
Q: Why are women more prone to UTIs than men?
Dr. Green: Women are more prone to UTIs than men due to the close proximity of the urethra, vagina, and rectum. Surveys have shown that 1% of school girls age 5-14 years have bacteria in the urine. This figure increases to about 4% by young adulthood.
Q: How does bacteria get into the urinary tract?
Dr.Green: Most bacteria enter the urinary tract from the fecal reservoir, entering the urethra into the bladder. Bacteria can also enter through the blood where the kidney is occasionally secondarily infected with Staphylococcus or the fungus Candida. A less common source of bacteria is direct extension from adjacent organs via lymphatics, such as a severe bowel infection or retroperitoneal abscess.
Q: What are the most common bacteria found in UTIs?
Dr. Green: As mentioned previously, most UTIs are caused by facultative anaerobes from the bowel flora. Escherichia coli is the most common cause of UTIs, accounting for 85% of community-acquired and 50% of hospital-acquired infections. Other gram-negative Enterobacteriaceae, including Proteus and Klebsiella, and gram-positive Enterococcus faecalis and Staphylococcus saprophyticus, are responsibile for the remainder of most community-acquired infections. Nosocomial infections, or hospital-acquired UTIs, are frequently caused by Enterococcus faecalis as well as Klebsiella, Enterobacter, Citrobacter, Serratia, Pseudomonas aeruginosa, Providencia, and Staph epidermidis.
Q: Are bladder infections and UTIs the same?
Dr. Green: No. Although it has become commonplace among some physicians to lump all UTIs together, a more specific classification is uncomplicated and complicated or lower tract vs upper tract (cystitis vs pyelonephritis). Cystitis is an uncomplicated UTI confined to the lower urinary tract (bladder and urethra), whereas a complicated UTI involves the upper tract (kidneys) commonly referred to as pyelonephritis. Pyelonephritis is more serious and usually involves fever and flank pain. Lower tract UTIs are characterized by irritative voiding symptoms such as frequency, burning on urination, urgency, and sensation of incomplete voiding. Complicated pyelonephritis can lead to bacteria in the blood stream with fever and vascular collapse (sepsis). If untreated, sepsis can lead to death.
Q: How do you diagnose UTIs?
Dr. Green: For patients with urinary symptoms the following should be done:
1. Microscopic urinalyses for bacteriuria, pyuria, and hematuria should be performed.
2. In addition, a urine culture should be done.
3. When localization is necessary, ureteral catherization allows separation between upper and lower tracts and also separation of infection between kidneys.
Q: Are radiologic studies necessary for UTIs?
Dr. Green: Radiology studies are unnecessary for evaluation of most patients with UTIs; however, in certain cases they may be useful to determine if further intervention is necessary and to find the cause of the complicated infection. Examples of such cases are: UTI associated with possible urinary traction obstruction; persistent UTI (pyelonephritis) unresponsive to medication after one week, patients with papillary necrosis, diabetes, on dialysis, T.B., proteus or fungal infection; or persistent-recurrent UTIs. Patients with persistent pyelonephritis often have perinephritic or renal abscesses.
Q: What are some of the useful radiology tests and how are they different?
Dr. Green: These tests are as follows:
1. The IVP (Excretory Urogram) has been a routine examination to evaluate patients with complicated infections but is not required in uncomplicated infections.
2. The renal ultrasound or sonogram is noninvasive, easy to perform, and offers no radiation or contrast risk to the patient. It is useful in eliminating the concern of hydronephrosis associated with urinary tract infection, pyelonephrosis, and perirenal abscesses.
3. The Computed Tomography (CT) offers the best anatomic detail, but its cost prevents it from being a screening procedure. It is more sensitive than the IVP ultrasound in the diagnosis of acute frcal bacterial nephritis and renal and perirenal abscesses.
4. Radionuclide Studies are helpful in cases in which an intra-abdominal abscess is suspected but localizing signs are absent, or in cases in which clinical suspicion of abscess remains high but ultrasound and CT studies are equivocal or negative.
Q: How do you treat UTIs?
Dr. Green: The mainstay of treatment is antibiotics. However, a source should be sought for recurrent, persistent, or complicated UTIs and corrected: e.g., obstruction from urinary stones, congenital urinary tract anomalies, indwelling catheters, diabetes, & spinal cord injury.
Q: What antibiotics and do you use and how long do you treat UTIs?
Dr. Green: The treatment is dictated by the category of infection. For uncomplicated lower tract infections such as cystitis, Trimethoprim-sulfamethoxazole and trimethoprim for three days is usually effective in young women. The fluoroquinolones are also highly effective but more expensive. Uncomplicated upper tract infections (pyelonephritis) usually respond to the above antibiotics and should be treated for at least 14 days. Complicated pyelonephritis should be treated for at least 21 days ,guided by urine & blood cultures.
Q: What are recurrent UTIs and why is it important to distinguish between recurrence and reinfections?
Dr. Green: Recurrent UTIs are usually new infections from bacteria outside the urinary tract (re-infection). Recurrent infections due to the re-emergence of bacteria from a site within the urinary tract (bacterial persistence) are uncommon. The distinction between re-infection and bacterial persistence is important in management because women with re-infection usually do not have an underlying alterable urologic abnormality and usually require long-term medical management. Conversely, patients with bacterial persistence can usually be cured of recurrent infections by identification and surgical removal or correction of the focus of infection.
Q: Does menopause cause increased UTIs?
Dr. Green: Post-menopausal women do have frequent re-infections usually due to increased residual urine after voiding, which is often associated with bladder and uterine prolapse. Also, the lack of estrogen causes changes in the vaginal microflora including a loss of lactobacilli and increased colonization by E.Coli. Estrogen replacement will frequently restore the normal vaginal environment and allow recolonization. Estrogen replacement in these cases has decreased the re-infection rate.
Q: My friend takes "preventive" antibiotics. Is that OK?
Dr. Green: Yes. Prophylactic therapy is effective in the management of women with recurrent urinary tract infections, with recurrences decreased by 95% when compared to controls. Prophylactic therapy requires only a small dose of antibiotics daily for 6 to 12 months.
Q: What is urinary incontinence?
Dr. Green: Urinary incontinence is defined as the uncontrollable loss of urine. It is the most common urologic disorder affecting both men and women in the United States. Women are affected more than men in a 3:1 ratio.
Q: Are there different types of incontinence?
Dr. Green: Yes. Urinary incontinence can be divided into seven categories as follows:
Q: What are the causes and symptoms of the different types of incontinence?
Dr. Green: Patients with urge incontinence may wet themselves if they don't get to the bathroom immediately, get up frequently during the night to urinate, go to the bathroom every 1 ½ -2 hours, wet the bed at night, and feel they void out of proportion to what they consume. This is due to bladder overactivity, hyperreflexia, and instability. Stress incontinence is characterized by leak of urine with exertion such as coughing, sneezing, laughing, or physical activity. These patients usually leak upon getting out of bed in the morning or when they get up from a chair. This is usually due to urethral hypermobility, intrinsic sphincter deficiency, or stress hyperreflexia. Overflow incontinence is characterized by night time frequency, prolonged voiding, weak and dribbling stream, voiding in small amounts with a sensation of incomplete emptying, dribbling throughout the day, and feeling the urge to urinate but being unable to. This is usually due to bladder outlet obstruction secondary to urethral scarring, temporary swelling after childbirth, or pelvic surgery. This results in a full bladder with constant pressure on the bladder neck causing urinary leakage. Unaware incontinence occurs from bladder overactivity, sphincter abnormality, or extra-urethral incontinence, such as in ectopic ureter or urinary fistulae. Continuous leakage may be due to sphincter abnormality, abnormal bladder contractility, or extra-urethral incontinence, as mentioned above. Nocturnal enuresis is due to sphincter abnormality or bladder overactivity. Post-void dribble results in the collection of urine beyond the external sphincter from unknown reasons, urethral diverticulum, and vaginal pooling. Extra-urethral incontinence occurs when urine is expelled outside of the urethra such as occurs in vesicouretero, or urethro-vaginal fistula and ectopic ureter. The causes of these conditions are radiation, congenital, trauma, and post-surgical or obstetric injuries.
Q: What should I do if I experience some of the above symptoms and am incontinent of urine?
Dr. Green: Because urinary incontinence is often the source of great social embarrassment, it may be the sign of significant underlying pathology, and in most cases is successfully treatable. You should seek consultation with a urologist experienced in managing urinary incontinence as soon as practical.
Q: What's involved in the diagnostic evaluation of urinary incontinence?
Dr. Green: As with most medical problems, the evaluation begins with a good history and physical exam with special attention to the voiding history which may subsequently include creating a "voiding diary" and "pad test". Specific diagnostic tests may include the following:
- urine culture
- urine flow
- cystoscopy
- cystometrogram
- cystogram
- possible IVP
Q: How do you treat urinary incontinence?
Dr. Green: Treatment of urinary incontinence depends upon the type, cause, and severity of the problem. Most importantly, the treatment of incontinence should be predicated on a clear understanding of the underlying physiology and pathology. In some cases exercising the pelvic floor muscles (Kegels, biofeedback, or electrical stimulation) or periurethral injection of collagen may suffice in mild cases of stress incontinence. In some cases medications may be effective, e.g., estrogens may be effective when stress incontinence is due to hormonal imbalance. If urge incontinence also exists, combination therapy may be necessary. In severe cases associated with anatomical abnormalities such as intrinsic sphincter deficiency, large cystoceles, urethral diverticulum, vesico-vaginal fistulae or genital prolapse, surgery may be the best option. For the neurogenic bladder, clean, intermittent self-catherization is an option. Based on the results of your urologic evaluation, your Urologist will recommend the best management option for you. With today's advanced diagnostics and treatment options, the choice of doing nothing, wearing absorbent products, or stuffing one's undergarments with tissue/towels is usually a poor choice and unnecessary?Just say no to incontinence!
Q: Is it true that today's surgery for urinary incontinence is simpler than years ago and can be done as outpatient surgery with shorter recovery time and less loss of work/personal time off?
Dr. Green: Yes. With today's increased technology for diagnostics and understanding of the female anatomy and physiology and improved surgical skills, most surgery for urinary incontinence can be done through minimal (key hole) incisions, with the majority of the work done transvaginally in a day surgery environment. As would be expected with minimal incisions, the healing time is quicker and the return to normal activities is shortened.
Q: I have experienced chronic pelvic and bladder pain with irritative voiding symptoms for years, and was treated with multiple antibiotics and told that I have "bladder infections". My urine cultures are sterile and I have not shown any significant improvement. A friend suggested that I ask my doctor if I have interstitial cystitis (IC). Is this a possibility and what is IC?
Dr. Green: You may very well have IC. Your history, symptoms, and the findings of sterile urine are very suspect for Interstitial Cystitis/ Painful Bladder. IC is often misdiagnosed by physicians as recurrent UTIs, urethral syndrome, and urethral stenosis. The early phases of the disease may be known by many names, such as urethral syndrome, trigonitis, urgency-frequency syndrome, pseudomembranous trigonitis, or even bladder outlet obstruction.
Q: What are the signs and symptoms of interstitial Cystitis?
Dr. Green: The symptoms of IC can be summarized in one common complaint: the patient suffers from urinary urgency, frequency, and pain in the absence of any bacterial infection or other definable pathology. As the disease progresses, the appearance of pain is usually the major reason for most patients to seek medical care. Pain is the most disabling part of the syndrome and the most difficult for the urologist to treat.
Q: What is the cause of IC?
Dr. Green: The etiology of IC remains a subject of controversy. Its exact cause is unknown. However, multiple etiologies have been suggested, e.g., inflammatory, allergic, neurogenic, and epithelial dysfunction. The more popular theory concerning pathogenesis today is that of an `"epithelial leak". This theory suggests a loss/defect in the protective mucin layer of the bladder glycosaminoglycan (GAG) that allows the diffusion of potassium and small molecules across the membrane of the bladder into the muscular layer, which trigger mast cells to release histamines, serotonins, cytokines, chemotactic factor, and leukotrienes, inducing sensory nerves to depolarize, resulting in discomfort, urgency-frequency, and pain. It is important to emphasize that the potential for multiple etiologies of IC exists.
Q: What causes the pelvic pain?
Dr. Green: Due to the close juxtaposition of the bladder with the female pelvic organs (vagina, uterus, and gastrointestinal tract), inflammation of the bladder, vaginal area, or rectum is often associated with spasm of the pelvic floor muscles (pelvic floor dysfunction).
Q: What makes you suspect interstitial cystitis?
Dr. Green: Patients with signs and symptoms of:
- Urgency
- Frequency
- Negative urine culture
- Pain/discomfort
-Pelvic
-Bladder
-Perineal
-Dyspareunia
Suspect Interstitial Cystitis! The diagnosis of IC is more likely if symptoms have been present for at least 6 months. It is important to rule out bladder cancer, especially in high-risk patients (patients with exposure to certain industrial chemicals, cigarette smoking, age, and family history).
Q: How do you diagnose interstitial cystitis?
Dr. Green: General medical history, physical examination, urinalysis and culture, voiding history, urine cytology, urodynamics, and when indicated potassium sensitivity test, cystoscopy with hydrodistention. Interstitial cystitis is a chronic condition marked by periods of flares and remissions. Worsening of symptoms is frequently reported during stress, the perimenstrual phase, and sexual intercourse. These patients also become increasingly intolerant of acidic, alcoholic, or carbonated beverages and spicy foods.
Q: What are some other medical problems associated with IC?
Dr. Green: Concomitant gynecologic conditions include endometriosis, vulvodynia, ovarian cystic disease, and pelvic inflammatory disease. Patients may also be sensitive to food, chemicals, and environmental agents. Migraines are a common complaint, as are fibromyalgia, inflammatory bowel disease, and irritable bowel syndrome. IC patients also have a higher incidence of autoimmune diseases than the general population, including Sjogren's (dry eyes, dry mouth), systemic lupus erythematosus (SLE), Hashimoto's thyroiditis, and decreased lymphocyte counts.
Q: How do you treat interstitial cystitis?
Dr. Green: The treatment of interstitial cystitis can be divided into three arenas as follows:
1. Self-help
a) Dietary modification
b) Bladder retraining
c) Other
2. Pharmacologic
a) Intravesical
b) Oral
3. Surgical
a) Hydrodistention
b) Augmentation
c) Urinary diversion
Q: Would you expand on the management of interstitial cystitis?
Dr. Green: Yes. All patients with IC should be encouraged to begin a bladder retraining or holding protocol. Irrespective of successful therapy, the individual afflicted with the chronic form of the disorder will have a small-capacity bladder that is based on sensory urgency and frequent low-volume voiding. Patients should also keep track of what they eat in order to determine which kinds of food aggravate their condition, so they can modify their diet accordingly. In general, food with a high acid or potassium content, caffeine, and alcohol should be avoided. Other self-help programs include behavior modification, physical therapy, herbal therapy, biofeedback/electrical stimulation, and acupuncture. The majority of IC patients can be effectively treated with pharmacologic agents (oral and intravesical), self-help protocols, and complementary techniques such as acupuncture and massage.
A variety of intravesical pharmacologic agents have been used for the treatment of IC. However, only DMSO is approved by the FDA for use in IC treatment. Some of the non-FDA approved agents are Chlorpactin, Silver nitrate, Hyaluronic acid (Cystistat), and Heparin.
Pentosan Polysulfate sodium (Elmiron) is the only oral agent approved by the FDA for the relief of bladder pain and discomfort associated with IC. It is analogous to the naturally occurring sulfonated glycosaminoglycans (GAGs) found on the surface of the bladder mucosa and is thought to control urothelial cell permeability, preventing irritating solutes in the urine from reaching the cells. Combination or multimodal approaches to therapy may be necessary. Antihistamines are useful in a subset of patients with a history of allergies or an increased mast cell count. Antidepressants may help patients sleep, in addition to managing possible underlying depression.
Hydrodistention, often performed during diagnostic cystoscopy, is effective in relieving symptoms in approximately 60% of patients, and remission may last for 4-12 months. Augmentation surgery is reserved for very severe, refractory patients. In augmentation cystoplasty, the bladder superior to the trigone is removed and replaced by a detubularized bowel segment. Supravesical urinary diversion with urostomy is a treatment of last resort for patients who failed other forms of therapy. Urinary diversion when done without cystectomy (bladder removal) is less successful than when done with bladder removal.
Q: How do you categorize the treatment of IC?
Dr. Green: IC treatment can be divided into 3 categories:
Destructive/regenerative, such as hydrodistention, DMSO, Silver Nitrate and Chlorpactin; Suppressive/Neurologic that use antidepressants, narcotics, antihistamines, and L-arginine; and Protective that use Pentosan polysulfate sodium (Elmiron), Heparin, or Hyaluronic acid ( Cystistat ).
Q: How long should patients take Elmiron before they can expect relief?
Dr. Green: Because IC has been affecting the patient's bladder for many years and such damage cannot be reversed overnight, Elmiron should be administered for 3-6 months before significant symptom relief occurs. In patients who responded to Elmiron, the improvement tended to continue over time and was sustained with continued treatment.
Dr. Q: Do you treat all patients with IC the same?
Green: No, instead I customize the treatment to the individual patient. The combination of diet modification, self-help techniques and Elmiron are my first line treatment for IC. In patients with a suspected allergic component, I add an antihistamine to the regimen. In patients with IC who may be suffering from depression and/insomnia, I add an antidepressant. In some patients where short-term pain relief may be desired, I perform hydrodistention with the instillation of an intravesical medication.
Current Trends
FYI?.Did You Know?
1. The vaginal ecosystem is a complex system of micro-organisms interacting with host factors and each other to create a normal "balanced state"; the pH is the most significant predictor of the vaginal ecosystem's status.
2. The most common cause of vaginitis symptoms is a non-specific vaginal infection referred to as bacterial vaginosis, generally thought to be a result of infection by Gardnerella, and usually responsive to Metronidazole, Ampicillin, or Clindamycin vaginal creme (can be used in pregnancy).
3. Trichomonal Vaginitis can be sexually transmitted and responds well to a 2gm single dose of Metronidazole. The sexual partner must also be treated.
4. Predisposing factors for Candida Vulvovaginitis are diabetes, recent antibiotic use, birth control pills, corticosteroids, debility, tight clothing, AIDS, obesity, pregnancy, immunosuppressants, and warm weather. Medical therapy consists of Imidazole topical agents, ketoconzole, or tioconazole intravaginally.
5. Human papilloma virus (HPV) infection is a sexually transmitted disease. A diagnosis can be psychologically harmful. Diagnosis requires a biopsy.
6. The incidence of non-obstetrical surgery during pregnancy is approximately 1:500 deliveries. Appendicitis is the most common cause in 1:4050 deliveries; cholecystitis 1:5000, and urinary stones 1:1500 deliveries.
7. Most urinary stones are diagnosed during the 2nd and 3rd trimesters. The initial management should be conservative, since 50-70% of stones will pass spontaneously. If conservative therapy fails, then cystoscopy with insertion of a ureteral stent should be done.
8. Trauma is the leading cause of maternal death during pregnancy. Blunt trauma is the most common trauma suffered during pregnancy.
9. Bladder injury occurs in 4-14% of women undergoing Cesarean section. Ureteral injuries occur during 1 in 1,000 deliveries.
10. Sexual dysfunction reportedly affects 10% of men and 30% of women, but because men need to achieve an erection to have sexual intercourse, their problem is perceived to be more serious. Because of the success of Sildenafil (Viagra) in men, researchers are now studying the effect in females and have been challenged to do so by women requesting Viagra.
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