1. Diagnose UTI and distinguish uncomplicated from complicated UTI.

2. List risk factors associated with UTI.

3. Prescribe appropriate therapy for women with uncomplicated UTI.

4. Identify women with vulvodynia or vestibulodynia.

5. Prescribe treatment for women with vulvar disorders.

Recurrent Urinary Tract Infection
Jeffrey A. Waxman, MD, Assistant Professor, Departments of Surgery and Pediatrics, Division of Urology, Scott & White Memorial Hospital, Texas A&M University Health Science Center College of Medicine, Temple, TX

General considerations: by age 24 yr, nearly one-third of women have had urinary tract infection (UTI) requiring treatment; ≈50% of women experience UTI during lifetime; estimated annual cost of community-acquired UTI >$1.5 billion; data show—among sexually active coeds, incidence ≈70 infections per 100 person- years, and ≈50 infections per 100 person-years among women enrolled in health maintenance organization (HMO); use of diaphragm and spermicide and recent intercourse significant risks; among surveyed women >18 yr of age, ≈1 in 10 reported one presumed UTI in previous year; highest incidence among women 18 to 24 yr of age; most women reporting UTI in last year also reported 2 episodes in lives

Definitions: complicated UTI—uncommon; structural or functional abnormality (eg, kidney stones, congenital anatomic abnormality); when to suspect complicated UTI—male sex, advanced age, presentation in emergency department, nosocomial infection, pregnancy, indwelling urinary catheter, recent genitourinary instrumentation, functional or anatomic abnormality of urinary tract, childhood UTIs, recent antimicrobial use; uncomplicated UTI—accounts for most cases of UTI; no structural or functional abnormality

Diagnosis: distinguishing between complicated and uncomplicated UTI determines evaluation, and influences selection of antibiotic and duration of therapy; symptoms—dysuria, urgency, and frequency most common symptoms; nocturia, voiding small volumes (frequently), incontinence, pain, and cloudy urine (however, undissolved phosphates most common cause of cloudy urine); history—poor predictor of bacteriuria; study shows ≈50% of patients with urgency, frequency, and dysuria had >105 colony forming units (CFUs) per milliliter on culture; urinalysis—pyuria highly sensitive, but less specific; could indicate inflammatory conditions (eg, vaginitis); >10 white blood cells per high power field ≈80% accurate; pyuria affected by dilutional state of urine, degree of inflammatory response, sample contamination, and laboratory technique; hematuria—seen in ≈50% of patients with acute cystitis; monitor patient after treatment to ensure hematuria resolved; bacteriuria—may not be evident unless colony count >30,000 CFU/mL; urine culture—gold standard of >105 CFU/mL based on studies of women with asymptomatic bacteriuria; data show nearly one-third of symptomatic women have colony counts between 102 and 104 CFU/mL; treatment justified even with bacterial count <105 CFU/mL if patient symptomatic; differential diagnosis—urethritis (if patient sexually active), vaginitis, interstitial cystitis, hypoestrogenic changes and atrophic vaginitis, neoplasm; urinalysis and culture not necessary in all patients with symptoms; patient-initiated treatment—data show no adverse events among women who self-diagnose and self-treat UTI; recommended for healthy patient without comorbidities experiencing recurrent UTIs; provide patient with prescription for antibiotic and refills to have on hand at first symptom of UTI

Risk factors: physical—congenital abnormalities; urinary obstruction; estrogen deficiency; urogenital surgery; diabetes; behavioral—frequent sexual intercourse; new or multiple sexual partners; diaphragm or spermicide use; recent antibiotic use; consumption of carbonated beverages; factors not associated—tampon use; voiding before or after intercourse; diet; direction of wiping after bowel movement; predisposing factors—colonization of organisms occurs at vaginal introitus; in some patients, epithelial cells promote adherence of bacteria at vaginal introitus; treatment clears organism from bladder, but vaginal introitus remains colonized, serving as source of reinfection; dynamic process that accounts for majority of patients presenting with uncomplicated UTI; continuous antibiotic prophylaxis shown highly effective

Treatment: Infectious Diseases Society of America guidelines for uncomplicated bacterial cystitis—single-dose therapy generally less effective than same antimicrobial used for longer durations (3-5 days); 3-day treatment as effective as same agent given for longer duration; advantages of short course of antimicrobial therapy—better compliance; less expense; diminished impact on normal fecal flora; trimethoprim-sulfamethoxazole (TMP/ SMZ)—available as generic; 3-day course considered standard therapy in most instances; trimethoprim 100 mg bid option for patient allergic to sulfonamides; efficacy likely similar to fluoroquinolones; resistance rates to TMP/SMZ—rising; know resistance patterns in community; resistance among Escherichia coli isolates cause acute uncomplicated cystitis; TMP/SMZ might not be option if resistance rate in community >20%; increased resistance rates also seen with ampicillin; with nitrofurantoin (eg, Macrodantin) resistance rates flat but rising; bacteriostatic antibiotic (not bactericidal); prescribe 7 days of therapy (not 3-5) when using nitrofurantoin; resistance rates rising with fluoroquinolones; amoxicillin plus potassium clavulanate (co-amoxiclav; Augmentin)—data show not as effective as ciprofloxacin for treating acute uncomplicated cystitis; cephalexin—good choice for patient allergic to penicillin; fosfomycin (Monurol)—powder dissolved in water; highly active against gram-negative rods; effective against E coli and enterococci; not approved against Staphylococcus saprophyticus; single dose provides 1 to 3 days of therapeutic levels; advise patient that improvement in frequency and urgency may not be immediate

Continuous antibiotic prophylaxis: one dose of antibiotic every night; decreases opportunity for infectious organisms to multiply and cause infection; duration of therapy ≈6 mo; continue for another interval if problem persists; excellent protection rates with antibiotic agents taken postcoitally; recommended for patient having 2 symptomatic UTIs in 6-mo interval or 3 symptomatic episodes in 1 yr; low-dose prophylaxis not mandatory, woman can self-treat when symptomatic; prophylaxis effective against acute uncomplicated cystitis, even if used for ≤5 yr; small likelihood patient will develop resistance to antibiotic used prophylactically

Cranberry juice: condensed tannins (proanthocyanidins) in cranberries and blueberries prevent uropathogens from adhering to cell surface of endothelium; data show 20% fewer UTIs in older women drinking cranberry juice, compared to those in placebo or lactobacillus groups; no data whether supplement as effective as juice

Estrogen: supports colonization of vaginal vault by lactobacilli; acidifies vaginal vault, inhibiting growth of uropathogens; reduced level of lactobacilli in menopause; more alkaline vaginal vault allows for adherence of E coli; data show significant reduction in number of UTIs in postmenopausal women using topical estrogen, compared to placebo group; stimulates growth of lactobacilli and reacidifies vaginal vault; options—topical conjugated estrogens cream; vaginal ring; estradiol vaginal tablets (eg, Vagifem); applying topical estrogen— one-half of applicator 3 times weekly (eg, Monday, Wednesday, and Friday) for 1 mo, then ≈2 times weekly, or with finger dispense enough cream to cover fingertip; apply to labia, vulva, and inside vagina toward urethra; initially, when epithelium thin, apply several times weekly, then follow maintenance dosage of 2 to 3 times weekly; use in patients with breast cancer—topical estrogens act locally, with minimal absorption into systemic circulation; consultation with patient’s oncologist before initiating treatment recommended

Management strategy: determine whether infection complicated or uncomplicated; acute uncomplicated cystitis—no fever or pyelonephritis; obtain allergy history; if recent microbiologic test results available, presume patient has reinfection; look at resistances and sensitivities and treat accordingly; consider risk factors for resistance (eg, current or recent use of TMP/SMZ or other antimicrobial agent); consider resistance rates in community; treat with TMP/SMZ if community resistance rate low; if community resistance rate high, use alternative (eg, nitrofurantoin for 7 days, single-dose fosfomycin, or 3- to 5-day course of fluoroquinolone; complicated—obtain culture; tailor therapy to culture result; treat on basis of previous microbiologic or patient factors

Urology referral: patients with persistent infection; patient with multiple infections caused by same organism; pyelonephritis; infection with urea-splitting bacteria

Vulvar Pain Syndromes
Tracey Maurer, MD, Clinical Assistant Professor, Obstetrics and Gynecology, University of Vermont College of Medicine, Burlington; Attending Physician, Fletcher Allen Health Center, Williston, VT

General considerations: growing awareness about genital pain in women; data show—50% of women complain of some form of dyspareunia during lifetime; prevalence 30%, and 3% to 7% of women report current problem; equally distributed among Hispanic, black, and white women (populations studied); prevalence highest among women 18 to 25 yr of age and lowest among women >35 yr of age

Definition: vulvar discomfort; most often described as burning pain, occurring in absence of relevant visible findings or specific, clinically identifiable or neurologic disorder (International Society for the Study of Vulvovaginal Disease, 2004); diagnosis requires ruling out other causes; vulvodynia—generalized pain of vulva; unprovoked pain; chronic daily vulvar pain; worsened with touch; vestibulodynia—localized pain of vulval vestibule; pain provoked (eg, pelvic examination, sexual intercourse, tampon placement); variability in diagnoses

Etiology: unknown; studies show no relation to inflammatory process; some studies show increased nerve density in area of vestibule; pelvic floor dysfunction; possible immunologic changes; subclinical sensitivity seen systemically; risk factors—nothing definitive; recurrent infections; oral contraceptives (OCs); physical, sexual, and emotional abuse; comorbid conditions (eg, interstitial cystitis, irritable bowel syndrome and fibromyalgia)

Physical examination: vulvodynia—burning, stinging, irritation, rawness; vestibulodynia—localized pain; redness at vestibule just outside hymenal ring may or may not be seen; touch with cotton swab elicits extreme pain; conditions to rule out—infection (eg, yeast, desquamative inflammatory vaginitis; must be treated before vestibulodynia diagnosed); cancer; dermatologic conditions; biopsy abnormal-looking tissue; dysplasia can present with localized pain or itching (dysplasia often not revealed without use of acetic acid on area); neurologic causes—pudendal nerve neuralgia (pain worse with sitting, relief with standing and lying down); disc herniation or compression; pelvic floor dysfunction (good starting point for treatment); postherpetic neuralgia

Treatment: vulvodynia—oral pain-blocking medications (eg, amitriptyline, gabapentin [eg, Neurontin]); nerve blocks; pelvic floor therapy (strongly recommended); diet modification controversial; psychotherapy (helps patient deal with pain and relationship issues); vestibulodynia—topical gabapentin placed on painful area better than oral form; pelvic floor therapy; vestibulectomy (treatment with highest rate of success); psychotherapy

Questions: antifungal treatment—patient with vulvodynia or vestibulodynia can have adverse reaction to antifungal agents; discontinue if burning reported; selective serotonin reuptake inhibitors (SSRIs)—ongoing studies; none show SSRIs more useful than amitriptyline or gabapentin; referral to physical therapy—be sure physical therapist knowledgeable about treating pelvic floor dysfunction; vaginal dilators—may be helpful after pain relieved so patient can resume sexual activity; amitriptyline dosage—start with 10 mg and increase by 10 mg every week until maximum dosage of 30 mg achieved; gabapentin—300 mg at night; increase by 300 mg every week or so; most patients tolerate 600 to 900 mg daily (can be divided between morning and night or taken all at night)