Top Female Urology Problems and Effective Treatments

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Difficulty emptying the bladder, referred to as voiding disorders, is an issue for patients of all ages but is particularly common in young girls. Dr. Agrawal says these types of problems often arise from poor toileting habits, like not relaxing and then trying to force the urine out. “For the most part, these are things that are easily fixable,” he says. Bedwetting problems, also referred to as nocturnal enuresis, happen when children do not receive the right signals to wake up from sleep and urinate in the bathroom, Dr. Agrawal says. By adolescence, the problem usually goes away naturally. That said, there are consequences to this type of problem, such as sleep alarms. In these cases, the doctor can insert a bladder catheter and drain urine more frequently to limit the bladder capacity and avoid bedwetting. Dr. Vikas Agrawal, a urogynecologist affiliated with Sharp Grossmont Hospital, says that female urology focuses on common problems that typically affect women. As mothers, daughters, and grandmothers move through various stages of life, especially pregnancy, we often encounter new and sometimes embarrassing or uncomfortable situations. The good news is that many of these problems are very treatable. “We see a wide variety of issues in female urology, problems that span the entire spectrum of a woman’s life cycle,” Dr. Agrawal says. “From little kids who have voiding disorders to school-age girls who have bedwetting problems and then hitting puberty – girls who might have urinary tract infections and other issues. As women get older, they can have menopausal issues. During their childbearing years, there are specific issues they can face.”

Overview of the Female Urinary System

Women usually have urinary problems after childbirth and when they are about to have menopause. The decrease in estrogen at this time reduces the amount of prostatic fluid that is expelled during sexual intercourse. This reduces the acidity in the bladder, thereby contributing to the growth of bacteria, increasing the risk of bladder and kidney infections.

In addition, sexual activity can lead to the spreading of harmful bacteria in the female urinary system and, in rare cases, to kidney infections. It is important to treat urinary infections in a timely fashion and prevent their reoccurrence in order to avoid the possibility of the spread of infection to the kidney. Women lose an excellent quantity of calcium when they have frequent bouts of incontinence, and some specialists say that kidney infections are often the result of incontinence.

In general, women are more likely to have urinary problems than men are because women have a shorter urethra that is located closer to the rectum and the exterior genital mucous, allowing bacteria in these areas to more easily gain access to the urinary tract. Numerous cases of kidney and bladder infections, as well as incontinence, originate because of frequent infections.

The urinary system is involved in the formation and excretion of urine. This system encompasses the kidneys (which produce urine), the ureters (which help to transport urine from the kidneys to the bladder), the bladder (which stores the urine), and the urethra (which helps to eliminate urine). In women, the uterus and the pelvic floor muscles have a close relationship to the urinary system.

Common Urological Issues in Women (female urology)

This chapter offers a descriptive overview of the urological issues that exist in women. We also describe the unique urological issues that occur in women as they age and offer sexual counseling to account for the plethora of comorbidities and life changes that can occur for women that attempt to engage in sexual intercourse after this type of surgery. A wide variety of treatment options exist for all of these common female urological issues, and this chapter offers detailed options in treatment strategy, including conservative and surgical options for urinary incontinence and pelvic organ prolapse that depend on a structured conversation that occurs between the clinician and the patient after the patient’s medical history and goals of treatment are considered. In addition, various treatment options are offered for urinary tract infections and interstitial cystitis that are also dependent on the level of invasiveness that patients are willing to consider. Finally, chapter 2 discover the unique problems that exist with respect to surgical treatment of female urethral diverticula, while offering patients a low-pressure approach to the treatment of small diverticula. Overall, this chapter and the remaining contents of this e-book provide a comprehensive review of the treatment strategies that currently exist for women who are interested in dealing with their common urological issues while also accounting for the various risks and benefits of treatment.

Due to the many differences between the male and female anatomy, the health risks for women compared to men are starkly different. The urinary system is just one anatomical area in which men and women are unique, and due to these anatomical variances, common urological problems exist more prominently in women. This e-book delves in-depth into all of the unique urological issues that can exist in women, including urinary incontinence, pelvic organ prolapse, urinary tract infections, and interstitial cystitis, while also focusing on some of the unique challenges that exist in treating these types of urological issues in women due to the preponderance of comorbidities such as osteoarthritis.

Urinary Tract Infections (UTIs) female urology problems

When a urinary tract infection enters your system, it’s usually not a big deal because it’s a pretty common ailment and easy to treat. But since it is an infection, UTIs are nothing to mess with and can potentially be serious if left untreated. According to Doctor Lamia Kadir with the University of California, Berkeley’s unit of student health and counseling services, you contract a UTI when “bacteria from the bowel can find their way into the bathroom, and they are basically going against the natural flow of the urine and moving up through the urinary system.” Not everyone gets a UTI but according to Kadir, there are certain factors that put people at risk. Women are definitely more prone to the infection. They “have much shorter urethras than males, so the bacteria can reach their target more quickly.” In addition, women who are sexually active or who use diaphragms may be more likely to get a UTI due to the irritation the intercourse or diaphragms can cause to the area around the urethra.

Urinary tract infections involve one or more structures of the urinary tract. They are one of the most common female urology problems. Symptoms include pain or burning when you urinate, fever, blood or pus in your urine, night sweats, and being unable to hold your urine. Treatment options include getting adequate rest, drinking more fluids, and urinating every 2 to 3 hours and wiping from front to back. Other treatments include taking antibiotics and soaking in a warm bathtub. You can reduce your risk of urinary tract infections by drinking water and avoiding dehydrating substances, taking preventative antibiotics on a regular basis, and gently cleansing yourself immediately after sex. You should call your healthcare provider if you have severe pain in your lower back, high fever, chills, abdominal pain, or blood in your urine.

Overactive Bladder (OAB)

It is necessary to stress that to make the diagnosis of OAB, the main symptom should be urinary urgency and not urinary incontinence. As a consequence of the problems, the patient presents with the main symptom of OAB, feeling urgency. The clinical history is crucial. Some patients do not have urinary incontinence; they search for the bathroom many times because they feel urinary urgency. If the physician asks whether the patient has involuntary urine loss and the patient agrees, it is not enough to make the diagnosis of OAB, even when the symptom of urgency is present. Urinary incontinence and pelvic floor symptoms should be checked with additional specific questions, and an example of that is a request for a connection between sneezing and incontinence. Sexual function should be explored, and the presence of sexual problems is an independent risk factor, highlighting another area of the patient’s symptoms. Dryness of the vaginal wall is common in these patients, and a good clinical history would be important in addressing the patient’s overall condition. She would understand that her physician is interested in the patient’s general situation. The patient has the right to ask questions; while people are individual, with common abnormalities or symptoms, they have the right to know the answers, allowing discussion with their physician. The aim of this is to make the patients totally involved in their own OAB symptom control accounts and to invest in treatment according to their preferences.

Overactive bladder (OAB) is defined as a group of urinary symptoms that include urgency, with or without urge incontinence (the complaint of involuntary leakage accompanied by or immediately preceded by urgency), frequency, and nocturia. In an overactive bladder, the new bladder sensation should be experienced as a strong need to void. This would result in events like loss of urine if voiding is not organized by the patient. Spontaneous contraction frequently leads to a sudden and urgent rise in vesicle pressure preceding loss of urine and usually accompanies a strong and uncomfortable desire to void.

Stress Urinary Incontinence (SUI)

A study of SUI prevalence rates has shown that in women, the problem occurs in 39% of cases aged 40-44 years and 63% of cases aged 70-74 years. During normal physical exertion, such as laughing, sneezing, coughing, lifting heavy items, or jumping, some women begin to suffer involuntary urine loss. The prevalence of SUI in women of childbearing age is less often observed. Pregnant women with symptoms of SUI are defined by medical staff as having different and additional factors that might lead to the emergence and exacerbation of the symptoms. The risk factors for SUI include age, childbirth, predisposition (genetic contribution, family history), menopause, morphological and functional differences of the lower urinary tracts, presence of pelvic organ prolapses, obesity, and diseases of the lower urinary tracts. The treatment of SUI is based on non-pharmacological and pharmacological methods (local or systemic pools, electro-stimulation, reinforced and implanted slings, bulking agents, trans-boundary botulism toxins). Only lifestyle changes have a pronounced value for women with SUI. Therefore, it becomes necessary to switch to doing physical exercises intended for women, to…

Interstitial Cystitis (IC)

At present, the cause of IC is not known. Evidence suggests that different factors may trigger IC symptoms in each individual, and these factors may include any combination and degree of pelvic floor abnormalities, allergic response (both allergy to certain foods and allergens outside the body), or infection. In recent years, there has been interest in the possible role of the immune system in causing IC. The structure of the normal bladder wall has been compared by microscope in people with and without IC. People with IC showed changes in the glycosaminoglycans (GAGs) that form a natural protective mucous layer in the bladder, which normally prevents toxic substances in urine from coming into contact with the sensitive nerve endings in the bladder wall. It is believed this damage to the GAG layer allowed substances like potassium ions, and also toxic urinary chemicals, to pass through and irritate the bladder wall cells, causing the symptoms of IC.

Interstitial cystitis is a condition that produces many of the same symptoms as a urinary tract or bladder infection, including frequent bathroom trips, urgency, and pain, but it is not caused by an infection.

A feeling that your bladder is never completely empty. Pain or feelings of pressure in the perineum, which is the area between the vagina and the anus. Pain or feelings of pressure in the lower abdomen. Pain during sexual intercourse. Bladder pain or discomfort when the bladder fills and relief when the bladder empties. Frequent urination—every 30 minutes or more regularly through the day and night.

Pelvic Organ Prolapse (POP)

The symptoms of POP can include a sensation that something down there is coming out, urinary incontinence, vaginal spotting or bleeding, urinary tract infections, and constipation, to name a few. If your gynecologist determines that you have a mild form of POP, the treatment of choice for a woman who is interested in not becoming pregnant in the future is an outpatient procedure that involves placing a permanent shelf called Prolift surgically inside your vaginal canal and attached to some of the muscles there to create support. If you elect to become pregnant in the future, the Prolift shelf can be removed to permit the normal descent of the pressure in the vaginal canal that occurs with childbirth, and then it can be reinserted after your baby is born. Another less invasive treatment is pessaries. These are devices that may take several trial runs to figure out the exact right fit. They must be placed inside the vagina and removed during the day every night. They come in a wide array of shapes, sizes, and some have knobs that stick out that are designed to help keep it in place. This is called the Hodge pessary.

Pelvic organ prolapse (POP) occurs when one or more organs in the pelvis, such as the vagina, bladder, small intestine, uterus, and rectum, fall or slide into the vaginal canal. Mild cases of POP do not cause discomfort or distress and can often be treated with pelvic floor exercises. Unfortunately, as the prolapse becomes more severe, a woman’s quality of life can be adversely affected, as she will experience significant discomfort and disturbed bowel and urinary function. Risk factors for POP include a strong family history of POP, increasing age, pelvic surgery, connective tissue disorders, and constipation with straining.

Diagnostic Tools and Procedures

What is cystoscopy?

Cystoscopy is a procedure that is performed in a hospital or doctor’s office with the same type of equipment that is used to do a Pap smear. The provider would explain to the nurse, “I have a female patient in room three who is having frequent infections of her bladder.” Cystoscopy is a test to look inside the bladder and make sure nothing is wrong inside the bladder causing the bladder infection. The patient usually takes a prescription antibiotic before and after the cystoscopy to avoid any chance of an infection after the procedure. The healthcare provider enters the urethra with a tiny camera that sends a picture of the inside of the bladder onto a computer screen so they can see what is going on inside the bladder, and check to see if the bladder empties well. In the end, it is a simple, quick check that can be useful in finding the cause of some bladder complaints.

How is urodynamics performed?

Urodynamics is a more complicated test done to look at bladder pressures and see how the bladder empties and fills. This testing uses both water and saline to fill the bladder. It is a good test to find out why you have loss of bladder control. People often ask if urodynamics is painful. The answer is, it can be. Urodynamics is a procedure that is performed in the hospital or a doctor’s office. When urodynamics is first discussed, it may sound scary or too painful to consider. A healthcare provider or nurse experienced in urodynamics should explain what to expect during this procedure. Many times, the idea of urodynamics is more scary than the actual procedure.

Urinalysis and Culture

For microscopic urine examination, a given quantity of urine (10 – 20 mL) is centrifuged and then some fields submitted to microscopic analysis. Some centers are now using dedicated computer systems with varying sensitivity in different setups. The dipstick test is a paper dipstick impregnated with multiple reagents at specific sites. Tests evaluate the concentration of ions such as sodium and potassium, concentration of urinary waste products such as urea-derived ammonia, protein concentration, and possibly blood and glycosuria. The methods have high sensitivity in the presence of significant disease and have correctly classified most cases of gross hematuria. However, their specificity is generally poor and, by current technology, they cannot avoid serial collection to be able to monitor the basic functions of kidneys such as sodium physiology, renal concentration, and capability of excretion of urinary waste products.

This is one of the most critical components of urological evaluation. It is done by collecting a clean catch, midstream urine specimen. Clean catch means wiping the two or three possible sites of contamination and collecting fresh urine before it becomes contaminated with vaginal discharge or environmental debris. A midstream collection means that the first urine stream should not be collected and the container should not be touched by the urine stream or the patient. Basic urinalysis consists of a visual observation of color, turbidity, and presence of blood, protein, and lots of leukocytes. The container should be labeled to indicate the type and method of storage and the time and source of the specimen.

Cystoscopy

Before the cystoscopy is done, the patient will be given a prescription for Levaquin or Cipro, potent and painless antibiotics, to take the night before. She will go to the office with an empty bladder. At the office, the patient will be lying down on a table with her feet up in stirrups. Dr. Wu then gently cleans the vulva and puts a lubricated numbing lubricant in the vagina and a jelly or numbing mousse in the urethra. While the patient is waiting for the numbing to take place, she should be taking some big deep breaths of air to relax herself. The actual insertion and removal of the cystoscope is less than one minute! It is not painful and there is no lasting discomfort! Dr. Wu will describe how the patient’s bladder looks in real time, including how she ought to be emptying her bladder better.

Cystoscopy is a procedure through which the physician can look into the bladder. The cystoscope is a long, thin tube with a camera on the end that is inserted through the urethra and into the bladder. If there are abnormal-looking areas, a biopsy can be taken with a small forceps inserted through the scope. The biopsies are sent to the lab for diagnosis. Dr. Wu is an expert with the cystoscope. She is experienced in giving patients a minimum of discomfort, both physically and financially (she will always take sufficient time and never rush through the exam). Dr. Wu will completely and accurately discuss all the findings of the cystoscopy, including showing the patient how certain findings look in her bladder by taking digital photos.

Urodynamic Testing

The urodynamic tests that your physician might perform to further evaluate any incontinence symptoms you may have include filling cystometrography (CMG), pressure flow study, and post-void residual measurement (PVR). The information that can be obtained from these tests can help to inform the most appropriate treatment for you, if needed. In particular, these studies can be used to identify the reasons for your voiding and urine storage symptoms, and to serve as objective measures of your voiding symptoms and their potential causes. These studies can be used after a simple medical history and a physical exam have been performed.

One of the basic tests used most frequently to evaluate the causes of voiding dysfunction is called urodynamic testing. Urodynamic testing involves the use of a few short office procedures in which the functions of filling and emptying of a bladder are precisely measured. By undergoing these tests, one can even help understand the reasons why a woman may fail to empty her bladder, and this information can help in deciding which intervention to use to correct her problem. In some cases, urodynamic testing is not recommended before initiating treatment. This may be true in a woman who has only occasional episodes of incontinence that are easily controllable by using simple treatment (e.g., dietary changes, Kegel exercises).

Treatment Options for Female Urology Problems

For women with overactive bladder syndrome, bladder retraining, biofeedback, and pelvic floor exercises can be used to temporarily help symptoms. A pessary can be used to push up the bladder to reduce urinary incontinence. Medications such as anticholinergic drugs and beta-3 adrenergic receptor agonists can be administered. If drugs have no lasting effect, onabotulinumtoxinA or sacral neuromodulation may be considered as a third line of treatment. Sacral anterior root stimulation or other types of nerve stimulation are also options. Severe stress urinary incontinence may be treated by a urethral injection with an implant material. Urethral slings or retropubic suspension systems may be used to treat stress void incontinence. If conservative treatments fail, surgical treatments such as upper urethral surgery can be considered for stress-related incontinence.

To treat urinary incontinence effectively, doctors consider a person’s age, how active they are, and the severity of the incontinence among other factors. Bladder training and pelvic exercises to strengthen the muscles that are used to stop urination can help. Another common treatment for urinary incontinence is medication such as anticholinergics. Severe stress urinary incontinence may be treated by a urethral sling or a pelvic laparoscopic sling. Implants can be placed under the urethra to provide support and prevent urine leakage. Injections of certain medications into the area of the urethra may also be an option. Plant-based creams and pessaries may be used to treat mild to moderate vaginal atrophy. Some women with urinary incontinence may benefit from surgical treatment options.

Medications

Antibiotics can effectively treat an infection in the urinary tract, such as in the bladder or kidneys. Unlike common thought, antibiotics do not work to treat asymptomatic bacteria in the urine in most women, particularly if symptom-free. Clinical symptoms of a urinary tract infection usually include urgent and frequent urination, burning with urination, and blood in the urine. Urologists use antibiotics frequently to treat problems also such as urinary tract infections and inflammation in the bladder. The best treatment of long-term antibiotic use for a chronic urinary tract pathology, such as chronic infection or inflammation in the bladder, is to use a medicine that dissolves in the urine that fills the bladder but does not dissolve into the bloodstream.

First, there are the overactive bladder (OAB) drugs which treat the symptoms of OAB, including urgent and frequent urination and urinary incontinence. The second medication primarily used for stress incontinence is duloxetine, which increases urethral sphincter activity through the nervous system. I have found such medicines to be most helpful when needed in combination with at least one other treatment of pelvic floor physical therapy, medications, in-office procedures, surgery, or a combination of these. With combination treatment, women are less likely to need the medication forever.

Behavioral Therapies

Pelvic floor muscle training

Available in video form, real-time, and electrically stimulating types, PFM training is thought to strengthen both the fast and slow PFM components, increase the duration of fast firing, and improve continence. It can be conducted independently but may require occasionally meeting with a physical therapist. Patients generally begin with first-trimester type muscle exercises that continue over 8–12 weeks. These can amount to as many as two hours per day. Muscle training is dependent on proper breathing, position, and Balkan tip use as well as optimal Popenhagen position and timing. The instructed contractions must be intensity controlled, coordinated, and fast, and must produce involuntary contraction. Patients can also utilize feedback for properly trained sphincteric performance. When a woman unable to even feel her PFM, it can affect the therapy, just controlling the pressure for 10 times, or visually and auditorily stimulating them. Acoustic diaries generally show improvement and enable women to perform PFM contractions better. Urethral pressure and surface electromyography testing can help select proper exercises and make outcomes better.

Due to social stigma and privacy concerns, many patients and physicians prefer behavioral treatments for incontinence as the first-line therapy. Many studies have proven the effectiveness of these techniques. Prior to initiating one of these programs, patients should undergo urethral pressure and surface electromyography to rule out over- or under-active pelvic floor muscle, so as to provide more personalized training sessions. Overall, proper motivation and support from family and friends can prevent induce further emotional difficulty.

Surgical Interventions

Surgical interventions for these cases usually provide complete or at least near complete relief. However, the surgical pain and potential time off work may seem inhibiting to some women. This is usually balanced by the disruption that the symptoms are impacting on their functionality and comfort. If these patients have been through many failed surgical trials in the past, they will be skeptical. Management of this frustration is crucial in a successful patient consultation. The operation varies according to the organ involved (bladder, bowel, peritoneum) and the specificity of the OAB symptoms of being associated with ciber myofascial pain (using trigger point needling at the time of treatment).

Reduction in painful urination in women can be accomplished with simple surgical aids. These can include a bladder lift operation to reduce stress incontinence syndrome. However, these are all aggressive approaches aimed at altering the anatomy of the treatment in order to achieve improvement. Patients should be aware that while a large decrement in their discomfort can be achieved with surgical procedures, the anatomical alteration can have a negative impact on continence desire (risk of retention due to poor bladder contractility post mesh sling).


      

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