Female Urology

Urinary tract infections (UTIs)  

UTIs are very common in women and it is estimated that cystitis (bladder infection) will affect at least 30% of women at some time in their life. Untreated urine infections can cause septicaemia (bacteria into the blood), but most of the time they are localized to the bladder and result in irritating and bothersome urinary symptoms including

• passage of small and frequent amounts of urine
• pain on urination which can be severe “like passing razor blades”
• cloudy or smelly urine
• bladder pain
• feeling unwell  

Recurrent urinary tract infections

Investigations for recurrent urinary tract infections

Prevention of recurrent urinary tract infections

General measures that a woman can take to help reduce the development of urinary tract infections include:

• Wipe from front to back after bowel movements– this helps reduce pushing bowel bacteria towards the urethra and vagina
• Passing urine after intercourse- which helps flush out any of a woman’s own skin bacteria that may have been pushed into the urethra during intercourse
• Use of lubricant gel with intercourse if the vaginal area is dry
• Avoid the use of spermicidal creams and condoms containing spermicides as these can encourage the growth of bacteria that cause UTIs. Some studies have also shown a greater rate of UTI in women using diaphragms for contraception
• Avoid products that may irritate the urethra such as douches, feminine hygiene sprays and excessive washing with soaps. Recurrent UTIs are not related to hygiene, and in fact overwashing the vaginal area can make problems worse
•  Prevention of constipation which is a risk factor for urine infection
• Increased fluid intake at the time of a UTI can help flush out bacteria from the urinary tract    

Individualised treatment programmes can be tailored to help in early treatment and prevention of recurrent urinary tract infections once any significant abnormalities of the urinary tract have been excluded. A urologist may recommend different treatment regimes depending on the pattern of infections including:

“Self-start antibiotics”- starting antibiotics at home AFTER taking a urine specimen (MSU) to confirm infection.

Preventive antibiotics- a longer course of low dose antibiotics to help eradicate troublesome urinary tract bacteria which can help break the cycle of recurrent urinary tract infection.

“Post-coital antibiotics”- antibiotics which are used after intercourse in women for whom the trigger for infection is sexual intercourse.

Vaginal oestrogen – in the form of a cream or vaginal pessary (NOT the same as hormone replacement therapy) can help prevent recurrent infections in post-menopausal women where the vaginal tissues are dry and prone to colonization by urinary tract bacteria.    

Prolapse 

A prolapse occurs in a woman when one of the pelvic organs (ie the bladder, uterus, rectum or intestines) loses its supports and “falls” down into the vagina. A prolapse is a form of hernia into the vagina.

What can prolapse?

• The bladder sits in front of the vagina and a bladder prolapse into the vagina is called a “cystocele”.
• The rectum sits behind the vagina and rectal prolapse into the vagina is called a “rectocele”.
• The uterus sits at the top of the vagina and can prolapse resulting in uterine prolapse.
• After a hysterectomy (removal of the uterus), the intestines sitting on top of the vagina can prolapse into the vagina causing an “enterocele” or vaginal vault prolapse.  

Why does a prolapse develop?

Prolapse is due to a weakness in the usual supporting tissues and muscles of the pelvis. Factors that predispose to weakening of these tissues include:

• Pregnancy
• Childbirth with vaginal delivery
• Aging
• Conditions that cause increased pressure on the pelvic floor, e.g.
  • Chronic cough
  • Chronic constipation
  • Heavy lifting and straining
  • Obesity
• Abnormalities of the connective tissues  

What are the symptoms of prolapse?

Many women with less severe (low grade) prolapse have no symptoms and if this is the case, no further treatment is necessary. The less severe forms of prolapse may only be evident on a vaginal examination by a doctor and can occur without any symptoms. Women with more severe forms of prolapse may experience:

• a sensation of a vaginal lump which may be associated with a feeling of discomfort or pressure
• a visible lump protruding from the vagina, especially at the end of the day or with more strenuous activity
• if the prolapse is continually protruding from the vagina, vaginal discharge and bleeding can occur
• difficulties in passing urine with poor urine flow and a sensation of incomplete emptying of the bladder (in the case of a large cystocele)
• urinary incontinence
• difficulties in emptying the bowel (in the case of a large rectocele or enterocele)
• the need to press on the prolapse with a finger in the vagina to help the passage of urine or bowel actions
• problems with sexual intercourse

Does prolapse cause urinary incontinence?

• The underlying weakness of the pelvic floor muscles and tissues that causes prolapse also causes stress urinary incontinence (i.e. the loss of urine with activity, cough, straining), and hence the two conditions are often found together. In this situation surgical repair of the prolapse and surgery for the stress incontinence can be performed together.
• It may sound strange but more severe degrees of prolapse can actually hide problems with stress urinary incontinence. This is due to the fact that a large prolapse can kink the urethra (the tube which drains urine from the bladder) and hide the problem of urinary incontinence. When the prolapse is repaired (or pushed back into position with a pessary), urinary incontinence can sometimes be “unmasked”. It is important to look for this hidden form of urinary incontinence particularly with a larger prolapse as it helps determine if surgical treatment for incontinence will also be needed. A trial with a vaginal pessary for prolapse is another useful way of checking for hidden incontinence.  

What can be done to prevent further prolapse?

The following measures are thought to help prevent worsening of prolapse and recurrence of prolapse after surgical treatment:

• Maintain a healthy weight
• Avoid heavy lifting and straining
• Have chronic cough and constipation investigated and treated
• Stop smoking
• Perform regular pelvic floor physiotherapy  

When is treatment needed for prolapse?

The two main reasons to have surgery for prolapse are:

• Bothersome symptoms – i.e. a woman will decide herself when the symptoms caused by the prolapse are bothersome enough to warrant treatment
• Complications related to the prolapse e.g. blockage of the flow of urine or rarely of the kidneys, incomplete emptying of the bladder. These complications are uncommon.

For the vast majority of women with prolapse, the decision to have treatment is elective, i.e. a woman decides if she needs treatment based on her symptoms.  

What treatments are available for prolapse?

• Not all women with prolapse require treatment and observation with ongoing review and performance of pelvic floor physiotherapy is all that may be required

  Non-surgical management of prolapse with a vaginal pessary. A pessary is a small plastic device inserted into the vagina to support the prolapsed tissue and return it to its correct position.
• Prolapse surgery. There are many different operations available for prolapsed which vary according to the type and severity of prolapse, whether the uterus is present, and both the woman’s and surgeon’s preference. Operations can be performed both through the vagina and through the abdomen. There is no one surgery that is effective in all women. It is important that the surgery is individualized to the woman.  

Which treatment is the right one?

The correct treatment for any individual can only be determined after thorough evaluation of the prolapse and consideration of multiple factors including prolapse severity, symptom severity, desire for further children or a woman’s preference in retaining the uterus, previous surgery performed for prolapse, and consideration of the potential risks and complications of any treatment. 

Painful Bladder Syndrome/Interstitial Cystitis

Painful bladder syndrome (PBS) is a long-term, painful condition of the bladder, the exact cause of which is unknown, although there are many theories. Interstitial cystitis (IC) is a subtype of painful bladder syndrome where specific inflammatory changes in the bladder are present at cystoscopy (a telescope examination of the bladder). The exact cause of this condition is unknown and its diagnosis is one of exclusion (i.e. other bladder conditions are excluded by further testing). 90% of affected people are women, most commonly in their 20’s to 40’s.  

What are the symptoms of IC/PBS?

The key symptoms of IC/ PBS are pain, frequency of urination and urgency (the urgent desire to pass urine). The pain or sensation of bladder discomfort/pressure in IC / PBS is felt classically as the bladder fills with urine and is usually relieved by urination. The sensation of bladder discomfort drives the need to urinate and results in frequency of urination, usually both day and night. Symptoms can begin gradually or suddenly and with no apparent reason. In mild forms of IC/ PBS or in the early stages of IC/ PBS, symptoms may occur as transient attacks known as “flares” which may be mistaken for urinary tract infections. It is therefore important to have a urine culture to help distinguish these symptoms from a bacterial urine infection.

How is IC/PBS diagnosed?

There is unfortunately no simple single test that diagnoses IC/ PBS.

IC/ PBS is essentially a diagnosis of exclusion –

the patient must have the characteristic features on history and examination of IC/ PBS

AND

other conditions that can be confused with IC/ PBS are ruled out e.g. overactive bladder, urinary tract infection, other bladder pathologies such as cancer and bladder stones, etc.  

Some of the tests that may be performed to rule out other bladder conditions include:

• Urine samples – to test for infection and abnormal cells in the urine
• Cystoscopy – or telescopic examination of the bladder lining to exclude other bladder pathologies is a standard investigation for IC / PBS
• Cystoscopy and bladder hydrodistension (performed under a general anaesthetic) – during which the bladder is stretched with sterile fluid using a telescope
• Urodynamic tests  

A patient may still have IC/ PBS even if all these tests are normal, if they exhibit all the symptoms of interstitial cystitis/ painful bladder syndrome.  

What are the treatment options for IC/ PBS?

There are many treatment options available for IC/ PBS. Unfortunately there is no cure for this condition and no single treatment that works for all patients. The choice of treatment will depend on the severity and type of the patient’s symptoms as well as patient and doctor preferences. Different treatment options are tried until good symptom relief is achieved. Often “multimodal treatment” is recommended for patients with IC / PBS which encompasses:

• Dietary changes
• Physical therapies including education in pelvic floor relaxation
• Cystoscopy and hydrodistension – This can be both diagnostic and therapeutic in IC/ PBS.
• Oral medications including Amitriptyline (Endep®) and Elmiron® (pentosan polysulfate or PPS), and others that can modulate pain.
• Bladder instillations – which involve the instillation of a chemical solution directly into the bladder using a catheter with medications such as DMSO (dimethyl sulfoxide)  or Chlorpactin®
• Many other treatment modalities have been tried, some of which are experimental, and some of which are only indicated in severe forms of the condition.

To discuss the management of Female Urology further, please call Australian Urology Associates on 8506 3600 to make an appointment with Dr Karen McKertich.