A PRIMARY CARE APPROACH TO COMMON UROLOGIC PROBLEMS: UTIS AND
INCONTINENCE
| URINARY TRACT INFECTIONS ----- Khalil Ghanem, MD, Assistant Professor, Department of Medicine, Division of
Infectious Diseases, the Johns Hopkins University School of Medicine, Baltimore, MD
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| Definition: presence of pathogenic organisms in urinary tract, accompanied by symptoms (required; otherwise, asymptomatic
bacteriuria); presence of ≥105 colony-forming units (CFU)/mL of single uropathogen diagnostic for urinary
tract infection (UTI), but misses many cases (100 CFU/mL more sensitive cutoff for symptomatic patients); UTIs
include urethritis, cystitis, pyelonephritis, and perinephric abscess
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| Clinical characterization: uncomplicated or complicated (important for determining duration and success of treatment);
factors associated with complicated UTI—fever \>38°C; symptoms persist \>7 days; abdominal pain, nausea,
and vomiting; gross hematuria in women \>50 yr of age (associated with abnormalities of genital tract); immunosuppression;
diabetes; kidney stones; recurrence within 2 wk of treatment; recent urologic procedure; indwelling catheter;
urologic abnormalities (eg, polycystic kidney disease, neurogenic bladder, renal insufficiency, problems secondary to
spinal cord injury)
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| Pathophysiology: typically, pathogens from rectal flora colonize periurethral or distal urethral sites; persistent colonization
more common in women with recurrent UTIs (compared to those with occasional UTIs); risk factors—sexual
intercourse (most important risk factor in young women); other important risk factors include use of spermicides and
history of UTI; less important risk factors include maternal history of UTIs and childhood onset; inconclusive whether
history of bacterial vaginosis (BV) increases risk; factors that do not increase risk—postcoital voiding; douching
(but may increase risk for BV); use of hot tubs; wiping patterns; pantyhose; body mass index (BMI)
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| Self-diagnosis: studies in college students found 80% to 95% of women with history of UTI (diagnosed by physician)
accurately diagnosed recurrent episodes; accuracy may be lower in other populations, but generally good
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| Diagnosis of uncomplicated UTI: rule out risk factors for complicated UTI; assess pretest probability for UTI; get
urine culture if pretest probability ≤20%; pretest probability—5% of young women have asymptomatic bacteriuria;
50% of women with 1 symptom (dysuria, frequency, or hematuria) have UTI (ie, high pretest probability; culture not
cost-effective); only 9% of women with 1 symptom plus vaginal discharge have UTI (ie, low pretest probability; requires
culture); ≈80% of women with all 3 symptoms or 1 symptom plus positive dipstick (either nitrite or leukocyte
esterase) have UTI; 23% of women with 1 symptom plus negative dipstick (both nitrite and leukocyte esterase) have
UTI (speaker recommends culture); findings on physical examination—only costovertebral angle tenderness increases
probability of UTI; vaginal symptoms—rule out sexually transmitted infections in sexually active women
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| Diagnosis of complicated UTI: get urine culture in patients with ≥1 symptom plus ≥1 risk factor for complicated
UTI; initiate appropriate treatment based on culture findings
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| “Sterile” pyuria: patient has symptoms, but urine culture negative; note—process unrefrigerated urine quickly;
false-negative and false-positive results occur when time between collection and processing exceeds 2 to 3 hr; differential
diagnosis—urethritis (eg, gonorrhea, chlamydia); tuberculosis of genitourinary tract (rare); BV or yeast infection
(contamination of sample with vaginal leukocytes); interstitial nephritis; kidney stones; tumor (rare)
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| Recurrent UTI: 27% of healthy college women have ≥1 recurrence of uncomplicated UTI within 6 mo; 10% to 15%
of women \>60 yr of age have frequent recurrent episodes (≥3 per year); reinfection—second infection by same or
different pathogen \>2 wk after appropriate treatment of UTI; relapse—recurrence of infection with same pathogen
<2 wk after treatment; but, many of these women actually have reinfection, not relapse; relapse certain only if
symptoms never improved or if interim culture documented persistent infection
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 | Risk factors: premenopausal women—sexual intercourse; use of diaphragm or spermicide; history of UTI at early
age; family history of UTI; recent use of antimicrobial drug; short anourethral distance; pregnancy; postmenopausal
women—hypoestrogenism (most important); functional abnormalities of bladder (eg, incontinence, cystocele,
large postvoid residual); premenopausal risk factors (eg, sexual intercourse); note—in postmenopausal
women, topical estrogens (but not oral estrogen replacement) found to reduce incidence of UTIs
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| When to get urine cultures: before instituting long-term suppressive therapy (to ensure clearance of pathogen); when
infection recurs within 2 wk of treatment (to assess resistance); if breakthrough infection occurs during long-term
suppressive therapy (to assess resistance)
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| When to get urologic evaluation: in women with recurrent UTIs with no clear risk factors for recurrence
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| Asymptomatic bacteriuria: present in 5% of young women, up to 30% of older women, and 60% to 70% of patients
with spinal cord injuries requiring placement of Foley catheter; low pH of urine typically prevents bacteria
from causing active infection and inflammation; patients who require treatment—pregnant women; renal transplant
recipients; neonates; those scheduled to undergo invasive genitourinary procedure; patients who do not benefit
from treatment—diabetics; elderly patients; young women with normal genitourinary tracts; those with long-
term catheterization (treatment promotes resistance)
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| Special considerations: pregnant women—UTI most common complication of pregnancy (occurs in 1%-2% of pregnant
women); risk factors include older age, higher parity, history of UTIs, diabetes mellitus, and sickle-cell disease
or trait; pregnant women with risk factors should be screened and treated; diabetics—although these patients have
increased risk for atypical or resistant organisms and complications resulting from symptomatic UTIs, data show no
benefit for treating asymptomatic bacteriuria
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| Elderly patients: atypical presentation (eg, altered mental status) common; increased risk for drug interactions and
adverse effects (eg, fluoroquinolones may cause altered mental status); diagnosis—often difficult; positive culture
alone does not confirm diagnosis; pyuria not related to presence or absence of bacteriuria; asymptomatic patients do
not need urinalysis; urinalysis required in symptomatic patients; treatment considerations include agent and duration
of therapy
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| Pathogens: 80% of UTIs caused by Escherichia coli; patients with \>1 UTI caused by pathogen other than E coli may
have structural anomalies; other pathogens that may cause UTIs include Staphylococcus saprophyticus (second most
common), Proteus, Pseudomonas, Klebsiella, and Enterobacter; note—presence of S aureus in urine may indicate
hematogenous infection (eg, endocarditis); follow-up required
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| Antimicrobial resistance: ascertain rate of antimicrobial resistance within community (ie, not inpatients) before
treating empirically; avoid empiric treatment with agents associated with resistance rate ≥20%; risk factors associated
with resistance to trimethoprim–sulfamethoxazole (TMP–SMX, [eg, Bactrim])—diabetes; recent hospitalization;
recent use of antibiotic, especially TMP–SMX
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| Treatment: regimens—single dose less effective than 3- to 5-day regimens; 5-day course recommended for nitrofurantoin
(eg, Macrodantin) and β-lactams; 3-day course sufficient for fluoroquinolones, trimethoprim, and TMP–
SMX; note—trimethoprim alone good option for patients with sulfonamide allergies
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| Antimicrobial prophylaxis: first, modify exacerbating factors (eg, spermicide or diaphragm use); consider for
women with ≥2 UTIs in 6 mo or ≥3 UTIs in 12 mo; begin after acute infection completely cleared; approaches—
intermittent self-treatment (patient fills prescription when symptoms recur and contacts physician if symptoms persist
≥48 hr); postcoital (patient takes antimicrobial 2 hr before or after coitus); continuous; duration—discontinue and reassess
after 6 mo; if UTIs recur, continue for 2 yr (Macrodantin and Bactrim safe for up to 5 yr); agents—Bactrim
(half tablet daily; contains 80 mg trimethoprim), trimethoprim (100 mg daily), and nitrofurantoin (50 mg daily); available
agents have similar efficacies; speaker prefers Macrodantin (generally well tolerated); prevention—cranberry
juice has compounds that impair adherence of bacteria; patient must drink 200 mL/day or take capsules; moderate evidence
of benefit
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| Questions and answers: asymptomatic bacteriuria with antimicrobial resistance—treat only when necessary (eg,
pregnant women, recipients of renal transplants); unnecessary treatment increases resistance; culture shows antimicrobial
resistance, but patient responding—agents concentrated in kidneys (may exceed minimum inhibitory concentration);
no need to change agent in patients with uncomplicated UTIs, but consider switching agents in patients
with complicated UTIs; assessment of UTIs in men—check for urethritis; rule out gonorrhea and chlamydia; treat
first episode if no red flags; refer if patient has second episode
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| PRIMARY CARE APPROACH TO URINARY INCONTINENCE ----- Murray S. Feldstein, MD, Assistant Professor,
Department of Urology, Mayo Clinic School of Medicine, Scottsdale, AZ
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| Contributing factors: multifactorial etiologies; presence of multiple factors may push patient past threshold of tolerance
and lead to mixed patterns of incontinence; treating each contributing factor may reduce symptoms to acceptable
level; biologic problems may occur in central nervous system (CNS), peripheral nervous system, or end organs (detrusor
and sphincter); problems unrelated to integrity of urinary system may occur elsewhere and cause patient to leak
beyond threshold of concern
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| Neurologic incontinence: etiologies include stroke, Parkinson’s disease, multiple sclerosis, spinal cord injuries, and
neuropathies; assessment—consider neurologic disorders in differential diagnosis; ask about history of incontinence
in patients with known neurologic disorders
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| Detrusor-based incontinence: overactive bladder (OAB)—involuntary smooth muscle of detrusor defaults to urinate;
volitional control learned, but many factors may interfere; factors include age-related changes (men and women),
interruption of CNS inhibition, and bladder irritation (caused by, eg, infection, kidney stones, cancer, interstitial cystitis);
overflow incontinence—contractility of detrusor impaired; factors include aging, diabetes, medications, and obstructions
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| Sphincter-based incontinence: impaired anatomic support (eg, prolapse in women) or intrinsic sphincteric deficiency
(as may occur in older women and men who have undergone radical pelvic surgery) may impair function of
sphincter; compromised integrity allows small amount of urine to enter posterior urethra (eg, during Valsalva maneuver);
presence of urine may trigger reflex contraction of detrusor (ie, lead to stress incontinence or reflex overactivity)
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| Mixed incontinence: 30% to 40% of patients with incontinence have OAB plus stress incontinence, requiring combined
treatment modalities; patients with multiple complicating factors (eg, diabetes, Parkinson’s disease, prostatic
obstruction) may develop detrusor hyperactivity with impaired contractility (DHIC) and should be referred to urologist
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| Functional incontinence: patients with normally functioning urinary tract may have episodes of incontinence because
of impaired cognition, communication, or ambulation
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| Other medical causes of incontinence: infection; neoplasm; kidney stones; diabetes; poliomyelitis; inflammatory
disorders (eg, interstitial cystitis)
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| Evaluation: thorough history and physical examination critical; history—identification of provoking activities; precise
characterization of leakage (eg, onset, timing relative to activity, quantity); patient’s response; awareness of episode;
presence of pain; number of protective pads used daily; relevant medical history; physical examination—assess
mobility; assess severity (eg, “sniff test”); observe gait and facies (eg, evidence of Parkinson’s disease); palpate abdomen
for signs of masses or bladder distention; examine vaginal introitus and assess pelvic support; check rectal tone
(lax rectal sphincter may suggest lax urethral sphincter or detrusor); perform bulbocavernosus reflex; have patient perform
Valsalva maneuver (standing and supine); laboratory tests—urinalysis to identify infection or hematuria; other
tests may help diagnose or rule out contributory diseases; assessment of postvoid residual useful in patients with recurrent
infections or severe diabetes
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| Treatment: stepwise approach—correct reversible factors first; institute behavioral modification; initiate medical therapy
if needed; refer complicated patients (minority); reversible incontinence (DIAPPERS mnemonic)—delirium;
infection; atrophic vaginitis; pharmaceuticals; psychologic disorders; endocrine disorders; restricted mobility; stool
impaction; dietary modifications—limit fluid intake to ≤2000 mL/day (unless contraindicated); limit consumption of
substances that can irritate bladder (eg, alcohol, caffeine, carbonated beverages, citrus juices); avoid foods with high
water content at night; voiding diary—samples available on National Institutes of Health Web site; good educational
tool, helps identify contributing factors
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| Behavioral therapy: timed or prompted voiding; pelvic muscle exercises (Kegel exercises; practice decreases incontinence
by 1 episode per 24 hr; teach technique during pelvic or rectal examination); physical therapy (eg, biofeedback,
vaginal weights, electrical stimulation); smoking cessation (to reduce cough); weight loss (to decrease
pressure on bladder)
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| Medical therapy: antispasmodic agents (eg, tolterodine [Detrol], oxybutynin [Ditropan], trospium [Santura]) reduce
incontinence by 1 episode per 48 hr; good results in some patients; others discontinue medication due to adverse effects;
imipramine sometimes used for patients with mixed incontinence (but beware of drug interactions); complicated
patients (eg, those with DHIC) may need to perform intermittent self-catheterization in addition to medical
therapy; duloxetine (Cymbalta) used in Europe for stress incontinence; topical estrogen effective for patients with
atrophic urethritis or vaginitis (but oral estrogen plus progesterone may exacerbate stress incontinence)
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| Other interventions: identify barriers to communication and ambulation; recommend protective garments (if patient
not already using); recommend catheters (internal or external) for nonambulatory patients; urologic
interventions—Botulinum toxin type A (Botox) injections; sacral nerve stimulation; reconstructive procedures; relief
of obstruction; slings (for stress incontinence)
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| Question and answer: bulbocavernosus reflex—inform patient; insert finger in rectum; pinch clitoris, vulva, or
glans penis; assess contraction around finger (absence or clonus suggests problem in spinal segments S1 through S3)
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Suggested Reading
Aagaard EM et al: An interactive computer kiosk module for the treatment of recurrent uncomplicated cystitis in
women. J Gen Intern Med 21:1156, 2006; Avery KN et al: Questionnaires to assess urinary and anal incontinence:
review and recommendations. J Urol 177:39, 2007; Danforth KN et al: Physical activity and urinary incontinence
among healthy, older women. Obstet Gynecol 109:721, 2007; Gibbs CF et al: Office management of geriatric urinary
incontinence. Am J Med 120:211, 2007; Grover ML et al: Assessing adherence to evidence-based guidelines for the
diagnosis and management of uncomplicated urinary tract infection. Mayo Clin Proc 82:181, 2007; Huang AJ et al:
Urinary incontinence in older community-dwelling women: the role of cognitive and physical function decline. Obstet
Gynecol 109:909, 2007; Kim DK, Chancellor MB: Is estrogen for urinary incontinence good or bad? Rev Urol
8:91, 2006; Lopardo G et al: Uropathogen resistance: are laboratory-generated data reliable enough? J Chemother
19:33, 2007; Mazumdar K et al: Diclofenac in the management of E. coli urinary tract infections. In Vivo 20:613,
2006; Mazzei T et al: Pharmacokinetic and pharmacodynamic aspects of antimicrobial agents for the treatment of uncomplicated
urinary tract infections. Int J Antimicrob Agents 28(Suppl 1):S35, 2006; Morrisroe SN, Chancellor
MB: Botulinum toxin a in the treatment of neurogenic and idiopathic urinary incontinence. Rev Urol 9:44, 2007; Platt
FW, Keating KN: Differences in physician and patient perceptions of uncomplicated UTI symptom severity: understanding
the communication gap. Int J Clin Pract 61:303, 2007; Richtera HE et al: Non-surgical management of
stress urinary incontinence: ambulatory treatments for leakage associated with stress (ATLAS) trial. Clin Trials 4:92,
2007; Sussman DO et al: Onset of efficacy of tolterodine extended release in patients with overactive bladder. Curr
Med Res Opin 23:777, 2007.
Internet Resources
| Voiding diary available at http://kidney.niddk.nih.gov/kudiseases/pubs/pdf/diary.pdf
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Educational Objectives
| The goal of this program is to improve the treatment of common urologic problems. After hearing and assimilating
this program, the clinician will be better able to:
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| 1. Characterize urinary tract infections (UTIs) as complicated or uncomplicated.
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| 2. Distinguish between reinfection and relapse.
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| 3. Choose appropriate antimicrobial therapy for acute and recurrent UTIs.
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| 4. Educate patients about risk factors for UTIs.
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| 5. Identify factors contributing to urinary incontinence and design a plan for management.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty members 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 issue, the faculty reported nothing to disclose.
Acknowledgements
Dr. Ghanem was recorded in Baltimore, MD, at 2nd Annual Infectious Diseases Update for the Primary Care Practitioner
, presented by the Johns Hopkins School of Medicine and the Johns Hopkins Bayview Medical Center, and held
July 31 to August 1, 2006. Dr. Feldstein was recorded in Sedona, AZ, at 9th Annual Mayo Clinic Internal Medicine
Update, sponsored by the Mayo School of Continuing Medical Education and held October 5-8 and October 19-22,
2006. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of
this program.
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