Topics in Urology

From the 27th Annual Internal Medicine Update,sponsored by the University of Michigan Medical School

Educational Objectives

The goals of this program are to improve diagnosis and treatment of overactive bladder and to increase understanding of which patients with bacteriuria should be screened and treated. After hearing and assimilating this program, the cli­nician will be better able to:

1.   Use appropriate language to elicit information from patients about urinary problems.

2.   Identify techniques required to diagnose overactive bladder (OAB).

3.   Describe appropriate behavioral and medical treatments for OAB.

4.   Identify which patients should be screened and treated for bacteriuria.

5.   Describe the process for evaluating older adults for the presence of a urinary tract infection.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the plan­ning committee to disclose relevant financial relationships within the past 12 months that might create any personal con­flicts of interest. Any identified conflicts were resoled to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the faculty and the planning committee reported nothing to disclose. In his lecture, Dr. Roberts presents information that is related to the off-label or investigational use of a therapy, product, or device.

Acknowledgments

Drs. Roberts and Malani spoke at 27th Annual Internal Medicine Update, presented July 31 to August 2, 2009, at Mackinac Island, MI, by the University of Michigan Medical School. The Audio-Digest Foundation thanks the speakers and the Uni­versity of Michigan Medical School for their cooperation in the production of this program.

Successful Strategies to Support your Patients with Overactive Bladder

Richard Roberts, MD, JD, Professor of Family Medicine, University of Wisconsin School of Medicine and Pub­lic Health, Madison, WI

Overactive bladder (OAB): diagnosed and defined based on patient history and symptoms; urgency with or without urge incontinence, usually with frequency (³8 times/day; small urine volumes) and nocturia (>2 episodes/night)

Pathophysiology: efferent signals coming into bladder from brain and afferent signaling of bladder sensation to brain; neurogenic causes  —  age-related changes in nerve signals from bladder to spinal cord and brain; myogenic causes  —  increased irritability of bladder muscle; peripheral autonomy  —  bladder sensation more dramatic or ex­cessive as patient ages

Incontinence: any involuntary loss of urine; stress urinary incontinence (SUI)  —  involuntary leakage on effort or ex­ertion, or on sneezing or coughing; urge urinary incontinence (UUI)  —  involuntary leakage immediately preceded by urgency, also called “wet” OAB; mixed urinary incontinence (MUI)  —  combination of stress and urge inconti­nence

Terminology associated with OAB: increased daytime frequency  —  patient complains that he or she voids too often during day; urgency  —  sudden compelling desire to pass urine; warning time  —  time from first sensation of ur­gency to voiding (voluntary or involuntary)

Prevalence: OAB with UUI more common in women; OAB without UUI more common in men; 5% to 10% of pop­ulation £25 yr have OAB; with increasing age, »33% of men and women have symptoms

Evaluation: typically done by primary care physicians; Family Medicine Clinic Study  —  prevalence of incontinence increased with age in men and women; more common in premenopausal than in postmenopausal women; 2-fold in­crease in obese people; lower urinary tract symptoms (LUTS)  —  in men, may be due to benign prostatic hyperpla­sia (BPH) or increased muscle tone in prostate; £50% of men with LUTS have OAB rather than prostate-related condition

Impact: significant impact on quality of life (QOL); £10% of people with LUTS have clinically evident depression; 30% to 40% lose time from work; sleep disturbance; patients may  —  do “toilet mapping” ie, learn location of all toilets in area; change way of dressing, eg, avoid wearing white; refuse to leave their homes because of unpredict­able episodes; urge often more distressing than leakage

Barriers to treatment of OAB: patient  —  stigma; sense that nothing can be done; consider condition normal part of aging; fear symptoms result from serious disease; clinician  —often worried about embarrassing patient or time in­volved in dealing with problem; concerned that patient may not have motivation to make behavioral changes; un­derestimates impact on QOL; lacks time or tools needed for management

Risk factors: age; menopause; vaginal or rectal prolapse; pelvic surgery; pregnancy; vaginal delivery; prostate sur­gery; obstructive sleep apnea; high body mass index; continence problems during childhood

Presentation: women  —  better at devising adaptive behaviors to cope with condition; physician must differentiate OAB from interstitial cystitis, which results in frequent urination with pain; present to clinician when urinary in­continence begins to affect QOL; men  —  symptoms of increased frequency, nocturia, urgency, and incontinence; overlap with BPH and LUTS; overlap with bladder outlet obstruction when urethral stenosis results from prostate surgery; most likely to seek help when nocturia becomes excessive

Screening questions: physician can start conversation about urinary urgency and frequency with general question about “bladder behavior;” response to question will lead to additional questions about patient’s urinary habits; can follow with more complex screening tools

Medical Assessment

History and physical examination (women): focus history on areas relating to bladder function, eg, medications, obstetric history, surgical history; genitourinary examination looking for evidence of, eg, cystocele, atrophy; get sense of anal sphincter tone by asking patient to squeeze around finger; obtain dipstick urinalysis to look for uri­nary tract infection (UTI) and possible bladder cancer; determine whether condition present that may cause fluid overload, eg, heart failure, diabetes with impaired renal function; does patient have condition that affects nerve con­trol of bladder function, eg, multiple sclerosis (MS)

History and physical examination (men): general examination; obtain sense of prostate size; focused neurologic examination; dipstick urinalysis; concerns include  —  UTI; prostatitis; stress incontinence (uncommon unless man has had bladder or prostate surgery); neurogenic bladder (in MS); bladder outlet obstruction after surgery; medica­tions

Bladder diary: ask patient to keep 3-day bladder diary; single day sufficient to determine whether frequency associ­ated with excessive consumption of water; confirm by measurement of specific gravity of urine; pearl  —  most peo­ple do not need more than 5 to 6 8-oz glasses of water daily

National Institute for Health and Clinical Excellence (NICE) practice recommendation: diagnose OAB in men and women with complete medical history, focused physical examination, and 3-day bladder diary; invasive testing not necessary before beginning conservative treatment

Red flags: women  —  persistent hematuria; UTI; suspected malignancy; pain; associated bowel dysfunction, eg, con­stipation, fecal incontinence (consider neurologic condition); fistula; failure to respond to therapy; men  —  failure to respond to treatment; hematuria without infection; prostate nodule or urethral obstruction (consider tumor); neuro­logic condition; history of pelvic surgery

Treatment

Algorithm: if symptoms suggest OAB  —  obtain patient history; perform focused physical examination; obtain urinal­ysis; if no infection or pathology, treat as OAB

Treatment goal: OAB, especially wet type, chronic condition, and symptoms do not usually resolve completely; ac­tively involve patient in setting realistic goals (eg, reduction from 3 wet episodes daily to 1 per day); work and ef­fort required on patient’s part; medications may have adverse effects

Behavior and lifestyle modification: determine how much fluid patient ingesting (bladder diary); improve tone of pelvic floor muscles (especially in women with SUI) by use of Kegel exercises; bladder retraining using timed or prompted voiding; general exercise and weight loss; reduction or cessation of use of nicotine and caffeine; patients may improve without intervention because waxing and waning characteristic of natural history of many urinary conditions; in general, behavioral interventions produce »20% improvement over time; try behavioral approaches for few weeks; if no improvement, suggest medication

Antimuscarinic agents: most common medications for OAB; do not change irritability of bladder, but control condi­tion, resulting in improved QOL (exact mechanism of action unknown); 5 subtypes; different manufacturers tar­get different subtypes; all appear equally effective; pearl  —  trospium (eg, Sanctura) not absorbed into central nervous system, so preferable for elderly patients in whom confusion may be concern

Side effects: dry mouth; constipation; blurred vision; cardiovascular adverse effects (rare); urinary retention (in men); cognitive impairment in elderly; most patients find tolerability better with extended-release formulations

Dosing: tailor treatment to side effect profile of drug and specific characteristics of patient; begin with low dose and titrate slowly; »4 wk-trial necessary to determine efficacy; if first drug ineffective, try another; side effects mod­erate with time

Outcome: 50% of patients see dramatic results; 50% find side effects unacceptable; behavior modification com­bined with medication gives significantly better response than either alone

Other options: b-blockers in men; topical estrogen in women (oral estrogens may make incontinence worse); injec­tion of toxin (eg, botulinum toxin) into bladder to reduce muscle tone and irritability; neuromodulation  —  patient wears device that stimulates sacral nerve; improved symptom relief; possible placebo effect; desmopressin or va­sopressin (experimental)  —  to reduce urine production

Evidence-based practice recommendations: bladder training and other lifestyle modifications should be offered as first-line treatment for women with OAB with or without incontinence; add antimuscarinic agent with MUI; trial of oxybutynin, propiverine, tolterodine, or trospium should be given to patients with significant urgency with or with­out urge incontinence; dose should be titrated to minimize adverse effects

Asymptomatic Bacteriuria and Urinary Tract
Infections in Older Adults

Preeti N. Malani, MD, Clinical Associate Professor, Department of Internal Medicine, University of Michigan Health System, Ann Arbor

Myths about UTIs: all patients need urinalysis and urine culture; all bacteriuria with pyuria equals UTI and requires antibiotics; antimicrobials beneficial and produce good outcomes

Asymptomatic bacteriuria (AB): absence of UTI signs or symptoms; typical pathogens (not contaminants); urine appropriately collected and not stored at room temperature

Colony counts: clean catch (women)  —  2 consecutive specimens with same organism, >10⁵ CFU/mL; clean catch (men)  —  single specimen, >10⁵ CFU/mL; catheterized specimen  —  single specimen, >10² CFU/mL

Pathophysiology: strains of bacteria that grow rapidly and survive in urinary tract without causing symptoms

Risk factors: sexual activity; women at higher risk than men; older women at higher risk than younger women; insti­tutionalization; decreased functional status; incontinence; invasive instrumentation, eg, indwelling catheter; altered anatomy or other cause of urinary stasis, eg, prostatic hypertrophy in men; previous antimicrobial use

Prevalence: young girls, £1%; premenopausal women, 5%; pregnant women, 2% to 7%; diabetic women, 8% to 14%; community-dwelling men >75 yr, 6% to 15%; community-dwelling women >80 yr of age, 20%; elderly in nursing home, 15% to 50%; hemodialysis patients, 28%; patients with spinal cord injury, >50%

Microbiology: men  —  gram-negative bacilli, eg, Escherichia coli, Klebsiella, Proteus, enterococci, coagulase-nega­tive staphylococci; women  —  E coli, other gram-negative bacteria, coagulase-negative staphylococci; group B streptococci, enterococci; genitourinary abnormalities  —  type of bacteria less predictable; indwelling catheters  —  Pseudomonas aeruginosa, Proteus, other gram-negative bacteria

Epidemiology

Women: no role for screening or treatment of AB; increased risk for symptomatic UTI over time; treatment does not reduce frequency of symptomatic infection or recurrent AB; antibiotics sterilize urine in most patients, but AB re­curs in »50% by 1 yr (no difference in recurrence rate between treated and untreated women); not associated with long-term adverse events

Men: no role for screening or treatment of AB; diabetes does not seem to increase prevalence; treatment of AB does not prevent symptomatic infections

Community-dwelling elderly: no role for screening or treatment of AB; no increased risk for adverse outcomes; no difference in number of symptomatic UTIs; AB transient, recurs after therapy, and can lead to resistance

Elderly in health care facilities: still no role for screening or treatment; several studies show no benefit from treat­ment; AB recurs after treatment, and antimicrobial resistance emerges; studies of nursing home residents  —  treatment results in no change in mortality or symptoms (eg, chronic incontinence), or symptomatic UTIs; drug re­actions and resistance increase

Populations that benefit from treatment of AB: pregnant women, because risk for pyelonephritis extremely high; patients undergoing urologic procedures; renal transplant patients (possibly); short-term catheter use  —  risk for UTI increased; most patients develop bacteriuria, and rate higher with longer catheter use; study found »90% of bacteriuria asymptomatic; no benefit to treating candiduria in patients with catheters; study  —  women bacteriuric 48 hr after catheter removal; no symptomatic UTIs in those treated; 17% of those not treated developed symptoms (2B evidence); long-term catheter use  —  in 1982 study, patients with AB treated with cephalexin; 12- to 44- wk follow-up found no reductions in bacteria, no difference in symptomatic UTIs or fever, no reduction in antibiotic use, and 75% incidence of resistance; pyuria  —  white blood cells often found in urine of asymptomatic patients; pyuria can be present without bacteriuria, but bacteriuria seldom present without pyuria (negative predictive value 96%)

Symptomatic bacteriuria: symptoms of cystitis and dysuria; frequency; pain; urgency (not side effect of diuretic or symptom of UUI); symptoms of pyelonephritis; new or worsening incontinence; of itself, cloudy or foul-smelling urine not considered symptom

Symptomatic UTI and sepsis in elderly: UTI most common cause of gram-negative sepsis in elderly; sepsis  —uncommon (»5 episodes per 100 patient-years); 16% mortality; incidence increased with underlying diseases, in­dwelling catheter, and non-E coli infection

Management of UTI in older adults: verify that symptoms referable to genitourinary tract; perform urinalysis; if significant pyuria present, culture urine and check susceptibility; begin empiric oral or intravenous (IV) antibiotics; assess clinical response; re-culture if symptoms recur; if relapse with same organism, assess anatomy and look for calculi; correct underlying conditions; avoid unnecessary instrumentation; drug therapy  —  avoid fluoroquinolones and extended treatment; cephalexin sometimes useful; avoid nitrofurantoin in elderly (does not enter urine; can cause toxicity)

Recurrent UTIs in postmenopausal women: risk factors include history of premenopausal UTIs, urologic factors (eg, incontinence), pelvic floor abnormalities, ABO nonsecretor status; work-up  —  history; thorough urologic and gynecologic examination; urodynamic cystoscopy often not helpful; management  —  behavior changes; timed void­ing; topical intravaginal estrogen cream shown in study to significantly reduce incidence of symptomatic UTI (0.5 per patient-year with treatment vs 5 per patient-year in placebo group); some evidence supports use of cranberry cocktail or pills for prevention (not treatment) of UTIs in young women

Question: antibiotics prophylaxis  —  not recommended

Suggested Reading

Abrams P: Describing bladder storage function: overactive bladder syndrome and detrusor overactivity.  Urology 62:28, 2003; Abrams P et al: The standardization of terminology in lower urinary tract function: report from the standardization sub-committee of the International Continence Society. Urology 61:37, 2003; Cheung WW et al: Prevalence, evaluation and management of overac­tive bladder in primary care. BMC Fam Pract 10:8, 2009; Colodner R et al: Risk factors for community-acquired urinary tract infec­tion due to quinolone-resistant E. coli. Infection 36:41, 2008; Coyne KS et al: The impact of overactive bladder, incontinence and other lower urinary tract symptoms on quality of life, work productivity, sexuality and emotional well-being in men and women: re­sults from the EPIC study. BJU Int 101:1388, 2008; MacDiarmid S et al: Overactive bladder in women: symptom impact and treat­ment expectations. Curr Med Res Opin 21:1413, 2005; Novara G et al: A systematic review and meta-analysis of randomized controlled trials with antimuscarinic drugs for overactive bladder. Eur Urol 54:740, 2008; Nygaard I et al: Reproducibility of the seven-day voiding diary in women with stress urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct 11:15, 2000; Orr PH et al: Febrile urinary infection in the institutionalized elderly. Am J Med 100:71, 1996; Raz et al: Recurrent urinary tract infections in postmenopausal women. Clin Infect Dis 30:152, 2000; Rosenberg MT et al: A practical guide to the evaluation and treatment of male lower urinary tract symptoms in the primary care setting. Int J Clin Pract 61:1535, 2007