The technical name for the field of Urology is Genitourinary (GU). The urologists have traditionally provided health care to 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.

Females make up approximately 30% of our urological practice.

Women experience some of the same urologic diseases as do men, albeit with different incidence and prevalence; e.g.

  • Cancers (Adrenal, Kidney, Bladder and Urethral cancers).
  • Urinary stones.
  • Urinary infections.
  • Urinary injuries.
  • Voiding dysfunction.
  • However, with the exception of voiding dysfunction, the evaluation and management of the above disease are similar for both men and women.

What is female urology?

The subspecialty of female urology is concerned with the diagnosis and treatment of those urinary tract disorders other than these & that are unique & most prevalent in females. These include urinary incontinence and pelvic floor prolapse, voiding dysfunction, recurrent urinary tract infection, urethral syndrome and interstitial cystitis. Expert evaluation of these conditions include a complete history and physical exam & investigations. The department of Urology at Dr. Roychowdhury’s Institute of Urology offers a comprehensive evaluation and treatment plan for these female urologic disorders.

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. The new subspecialty of female urology will continue to expand and reach new horizons in the 21st Century.

Some common female urology problems are as follows:

  • Urinary tract infections (UTIs)
  • rinary incontinence
  • Voiding dysfunction
  • Urethral syndrome
  • Pregnancy & urinary tract
  • Interstitial cystitis

What is incontinence?

Incontinence is an involuntary loss of urine. It is further defined by type as either stress (leakage with straining, coughing, sneezing), urge, mixed, overflow, functional or reflex incontinence. Treatment is dependent on the type of incontinence. Current therapies include dietary changes, scheduled voiding, bladder retraining, pelvic muscle exercises, biofeedback, electrical stimulation therapy, medication, collagen implants and minimally invasive surgery.

What is voiding dysfunction?

Voiding dysfunction can take many forms. The main symptoms are urinary frequency, urgency, painful urination and/or incomplete bladder emptying. Treatment is aimed at decreasing or eliminating symptoms. Treatment may involve medication or pelvic floor relaxation exercises.

What is a recurrent urinary tract infection?

A recurrent urinary infection (UTI) may be generally defined as three or more infection within one year. This may be idiopathic (no obvious cause) or related to urological disorder such as stones, tumor, reflux (urine flows backwards toward the kidney) or ineffective bladder emptying. Treatment is aimed at identifying the cause and/or proper antibiotic therapy to break the cycle of recurrent infection.

What is urethral syndrome?

Urethral syndrome is a condition involving pain at the urethra that can occur during urination or without regard to urination. Treatment may consist of oral medication or local estrogen replacement therapy.

What is interstitial cystitis?

Interstitial Cystitis (IC) is a urologic syndrome characterized by excessive urinary urgency, frequency, nocturia (night-time urination) and pain in the lower abdomen and/or perineum. It can occur at any age, however, the median age at diagnosis is between 42 and 46 years.

In this article we will discuss only about recurrent UTI & incontinence in females.

URINARY TRACT INFECTION IN FEMALES

How common are UTIs?

Urinary Tract Infections account for approximately 7 million visits to physician offices and necessitate or complicate over 1 million hospital admissions in the United States annually. Indian statistics are not available. UTIs are more common in women than in men, except in the neonatal period.

Why are women more prone to UTIs than men?

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 aged 5-14 years have bacteria in the urine. This figure increases to about 4% by young adulthood.

How does bacteria get into the urinary tract?

Most bacteria enter the urinary tract from the fecal reservoir, entering the urethra, than 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.

What are the most common bacteria found in UTI’s?

As mentioned previously, most UTIs are caused by facultative anaerobes from the bowel flora. Escherichia coli is the most common cause of UT s, 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 responsible 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 aeruginoa, Providencia, and Staph epidermidis.

Are bladder infections and UTIs the same?

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.

How do you diagnose UTI?

For patients with urinary symptoms, the following should be done:

Microscopic urine analysis for bacteriuria, pyuria and hematuria should be
In addition, a urine culture should be done.
When localization is necessary, ureteral catheterization allows separation between upper & lower tracts and also separation of infection between

Are radiologic studies necessary for UTIs?

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 fungus infection; or persistent/recurrent UTIs. Patients with persistent pyelonephritis often have perinephritic or renal abscesses.

What are some of the useful radiology tests and how are they different?

These tests are as follow:

  • The IVP (Excretory Urogram) has been a routine examination to evaluate patients with complicated infections but is not required in uncomplicated
  • 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, pyelonephritis and perirenal abscesses.
  • The Computed Tomography (CT) offers the best anatomic detail, but the cost prevents it from being a screening procedure. It is more sensitive than the IVP/ultrasound in the diagnosis of renal and perirenal abscesses.

How do you treat UTIs?

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, and spinal cord injury.

What antibiotics do you use and how long do you treat UTIs?

The treatment is dictated by the category of infection. For uncomplicated lower tract infections such as cystitis, Trimethoprim — sulfamethoxazole or trimethoprim alone 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 and blood cultures.

What are recurrent UTIs and why is it important to distinguish between recurrence and reinfections?

Recurrent UTIs are usually new infections from bacteria outside the urinary tract (reinfection). Recurrent infections due to the re-emergence of bacteria from a site within the urinary tract (bacterial persistence) are uncommon. The distinction between reinfection and bacterial persistence is important in management because women with reinfection 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.

Does menopause cause increased UTIs?

Post-menopausal women do have frequent reinfection 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 micro flora 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 reinfection rate.

Are preventive antibiotics beneficial?

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.

What is urinary incontinence?

Urinary incontinence is defined as the uncontrollable loss of urine. It is the most common urologic disorder affecting both men and women in United States. Women are affected more than men in 3: 1 ratio.

Different types of incontinence

Urinary incontinence can be divided into seven categories as follows:

  • Urge incontinence
  • Stress incontinence
  • Unaware incontinence
  • Total incontinence/ continuous leakage
  • Nocturnal enuresis
  • Post void dribble
  • Extra urethral incontinence

What are the causes and symptoms of the different types of incontinence?

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 the bathroom every 1% – 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 result 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 result 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 occur in vesico-uretero or urethro vaginal fistula and ectopic ureter. The causes of these conditions are radiation congenital, trauma and post-surgical or obstetric injuries.

What should you do if you experience some of the above symptoms and incontinent of urine?

Urinary incontinence is often a 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 urologist experienced in managing urinary incontinency as soon as practical.

What’s involved in the diagnostic evaluation of urinary incontinence?

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 (Urodynamic)
  • Cystogram
  • Possible IVP

How do you treat urinary incontinence?

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.

Based on the result 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!

It is 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.

With today’s increased technology for diagnostic and understanding of the female anatomy and physiology and improved surgical skills, most surgery for urinary incontinence can be done through minimal (keyhole) incisions, with the majority of the work done transvaginally in a day surgery environment. As would be expected with minimal incision, the healing time is quicker and the return to normal activities is shortened.