Urinary Tract Infections in Women

Urinary tract infection is a common and important infection in women. The pathophysiology, diagnostic methods, and current treatment regimens are outlined with special consideration for premenopausal, postmenopausal, and pregnant women.     

Urinary Tract Infection as a Single Presenting Sign of Multiple Vaginal Foreign Bodies: Case Report and Review of the Literature

BackgroundVaginal foreign bodies in children usually present with foul-smelling discharge and/or vaginal bleeding. Rarely, these basic clinical diagnostic signs are not present.CaseWe report on a 5½-year-old girl with recurrent lower urinary tract infection as the sole presentation of multiple vaginal foreign bodies. Ultrasound of the lower urinary tract was inconclusive, and cystography indicated for recurrent urinary tract infections was declined by the patient in an outpatient setting. Cystography under general anesthesia raised the suspicion of foreign vaginal objects, and the definitive diagnosis was made by vaginoscopy. The relevant literature covering this subject is reviewed.ConclusionHigh level of suspicion and strict basic diagnostic protocol are the most important steps for a timely diagnosis of this condition.     

Pitfalls in diagnosis and management of distal vaginal agenesis: 10-year experience at a single centre

Objective

To discuss common pitfalls in diagnosis and management of distal vaginal agenesis, and summarize 10 years of experience among 11 patients using an interposition full-thickness graft and fibrin glue.

Study design

Eleven patients with distal vaginal agenesis were evaluated and managed with an interposition full-thickness graft to bridge the gap between the upper vagina and the introitus. Associated renal abnormalities and complications including infection, total lack of skin graft take, stress urinary incontinence, partial graft loss, vaginal stricture and graft uptake were all investigated.

Results

The mean age of the patients was 12.91 (standard deviation 1.22) years. All patients had primary amenorrhoea, cryptomenorrhea, and cyclical or constant pelvic pain. None of the patients had associated urological abnormalities, and there were no cases of infection, total lack of skin graft take, stress urinary incontinence, partial graft loss or vaginal stricture. Graft uptake was 100% in 10 of the 11 patients. Four patients have subsequently married and report a satisfactory sex life.

Conclusion

Accurate diagnosis of distal vaginal agenesis and careful pre-operative set-up, including evaluation of associated anomalies, bowel preparation, available vaginal stents and a multidisciplinary approach for the potential need for grafts, may be key to success.     

A scored form of the Bristol Female Lower Urinary Tract Symptoms questionnaire: data from a randomized controlled trial of surgery for women with stress incontinence

OBJECTIVE: Lower urinary tract symptoms are common among older women. The Bristol Female Lower Urinary Tract Symptoms (BFLUTS) questionnaire was designed to assess a wide range of symptoms, including incontinence, and impact on sexual function and quality of life. This paper describes development and validation of a scored form BFLUTS questionnaire. STUDY DESIGN: Baseline and 6-month follow-up data from a randomized trial compared tension-free vaginal tape with colposuspension for 344 women with urodynamically proven stress incontinence. Problematic and responsive items were identified and subjected to factor analysis to develop a scoring system. RESULTS: Three domains were identified to assess symptoms: incontinence (5 items); voiding (3 items); and filling (4 items); with additional subscales for sexual function (2 items) and quality of life (5 items). All scales have simple additive scores. CONCLUSION: A scored form of the BFLUTS questionnaire is now available and should be useful in research and clinical practice in urology and gynecology.     

Urinary Tract Injuries in Laparoscopic Hysterectomy: A Systematic Review

The aim of this review was to estimate the incidence of urinary tract injuries associated with laparoscopic hysterectomy and describe the long-term sequelae of these injuries and the impact of early recognition. Studies were identified by searching the PubMed database, spanning the last 10 years. The key words “ureter” or “ureteral” or “urethra” or “urethral” or “bladder” or “urinary tract” and “injury” and “laparoscopy” or “robotic” and “gynecology” were used. Additionally, a separate search was done for “routine cystoscopy” and “gynecology.” The inclusion criteria were published articles of original research referring to urologic injuries occurring during either laparoscopic or robotic surgery for gynecologic indications. Only English language articles from the past 10 years were included. Studies with less than 100 patients and no injuries reported were excluded. No robotic series met these criteria. A primary search of the database yielded 104 articles, and secondary cross-reference yielded 6 articles. After reviewing the abstracts, 40 articles met inclusion criteria and were reviewed in their entirety. Of those 40 articles, 3 were excluded because of an inability to extract urinary tract injuries from total injuries. Statistical analysis was performed using a generalized linear mixed effects model. The overall urinary tract injury rate for laparoscopic hysterectomy was 0.73%. The bladder injury rate ranged from 0.05% to 0.66% across procedure types, and the ureteral injury rate ranged from 0.02% to 0.4% across procedure type. In contrast to earlier publications, which cited unacceptably high urinary tract injury rates, laparoscopic hysterectomy appears to be safe regarding the bladder and ureter.     

Urinary culture and morbidity in gynecological surgery

Three hundred women undergoing gynecological surgery were evaluated as regards post-operative morbidity and its relationship to urinary tract infections. The incidence of pre-operative positive urine cultures was 6.3%. This was almost tripled post-operatively. Post operative morbidity was found in 39% of the cases with the highest rate following vaginal surgery. Urinary tract infection was thought to be the cause in 20% of the cases, wound infection in 42% and unknown among 36% of the cases. It was found that the pre- and post-operative urine cultures were poorly related to morbidity and it was particularly noted that 41% of patients who had positive post-operative cultures suffered no morbidity at all. It was concluded that the mere finding of positive post-operative urine cultures may not have accounted for the morbidity in some of the cases and the need for further search of the cause is discussed.     

间歇性导尿在宫颈癌根治术后患者膀胱功能恢复及预防泌尿系统感染的应用研究

目的:分析间歇性导尿在宫颈癌根治术后患者膀胱功能恢复及预防泌尿系统感染的临床意义。方法:选取中国人民解放军总医院妇产科2014年1月—2016年12月收治的早期宫颈癌(FIGOⅠA期、ⅠB期、ⅡA期)手术后残余尿量不合格患者182例,于手术后第10天拔除尿管,测残余尿量≥100 mL者为不合格。随机分为观察组(89例)和对照组(93例),观察组采用间歇性导尿及个体化精准护理,对照组采用留置尿管及常规护理。记录2组患者一般情况,比较2组患者残余尿量合格需要的时间和泌尿系统感染情况。结果:2组患者年龄、手术方式、FIGO分期、残余尿量分级比较差异无统计学意义(均P>0.05)。残余尿量100~200 mL、201~350 mL者中,观察组残余尿量合格需要的时间少于对照组,差异有统计学意义(均P<0.001),观察组泌尿系统感染发生率低于对照组,差异有统计学意义(均P<0.05)。结论:间歇性导尿能够促进宫颈癌根治术后患者膀胱功能恢复、降低泌尿系统感染发生率,该方法操作简便、患者易接受、临床效果满意,适合推广应用。     

阴道无张力尿道中段悬吊带术后尿潴留发生及危险因素研究

目的:确定阴道无张力尿道中段悬吊带术(TVT)后尿潴留的发生率,探讨影响膀胱排空功能障碍的相关因素及其防治措施。方法:回顾性分析136例行TVT手术患者的病例资料,其中97例同时行子宫切除或阴道壁修补术等其他妇科手术,术后第2天测残余尿,记录患者临床资料。结果:17例术后发生尿潴留,恢复时间平均为5.2天,13例术后1周内恢复正常排尿功能,2周内全部恢复正常。单因素分析显示年龄、产次及最大尿流率(≤20 ml/s)两组间差异有显著性,多因素分析显示只有最大尿流率有统计学意义(OR=0.076,P=0.040)。结论:行TVT术后发生尿潴留的患者大多在1周之内膀胱排空功能恢复正常,术前最大尿流率值对预测术后尿潴留发生有价值。     

Successful Pregnancy Following Surgery in the Obstructed Uterus in a Uterus Didelphys with Unilateral Distal Vaginal Agenesis and Ipsilateral Renal Agenesis: Case Report and Literature Review

SynopsisAfter surgical correction of unilateral distal vaginal agenesis, the obstructed didelphic uterus was able to harbor 2 subsequent pregnancies.BackgroundThere was a congenital anomaly syndrome of uterus didelphys, unilateral distal vaginal aplasia, and ipsilateral renal aplasia. Intuition suggests that later pregnancy would be in the unobstructed uterus.ObjectiveThe purpose is to report pregnancy occurring twice in a previously obstructed didelphic uterus after surgical correction.CaseA girl aged 13 years, 8 months presented with the syndrome of didelphic uterus, upper right hematocolpos, and right renal aplasia. Right vaginal marsupialization was done. Subsequently, she had 2 pregnancies in the right didelphic uterus.ConclusionPregnancy occurred in the obstructed uterus despite a large hematometra, extensive right pelvic peritoneal endometriosis, and hematocolpos. The surgeon should make every effort to preserve the obstructed uterus.     

Prepubertal Bleeding as a Presenting Symptom of Von Willebrand Disease: A Case Report

BackgroundVon Willebrand disease (VWD) affects approximately 1% of the population and is often diagnosed after the presentation of mucocutaneous bleeding.CaseA 7-year-old girl with eczema and constipation presented to clinic reporting vaginal bleeding. External genital examination findings were normal, and results of a workup for precocious puberty were negative. Vaginoscopy revealed an atypical appearance with increased vascularity and friability. Oral mucosal bleeding at the time of extubation prompted additional workup and hematology referral, which led to diagnosis of type I VWD.Summary and ConclusionIt is important to keep bleeding disorders on the differential, for unexplained prepubertal vaginal bleeding, to aid in prompt diagnosis.     

A Rare and Extreme Case of Vulvar Swelling in the Setting of Nephrotic Syndrome in a Prepubertal Girl

BackgroundWe present a rare case of severe vulvar edema secondary to steroid-refractory nephrotic syndrome in a prepubertal girl.CaseThe patient is an 8-year-old girl who presented during nephrotic syndrome relapse. She exhibited severe mons pubis and labial edema. She was treated with local symptomatic measures such as sitz baths, barrier ointment, and labial sling, with minimal relief. Improvement ultimately occurred after bilateral nephrectomy.Summary and ConclusionVulvar edema is rare in prepubertal girls. In this case, the edema was secondary to steroid-refractory nephrotic syndrome and was not responsive to local treatment measures. There is a paucity of data on effective treatment of vulvar edema in young girls. Our goal is to raise awareness of such pathology, which might lead to development of uniform guidelines for treatment of this condition.     

Implementation of a Clinical Protocol to Reduce Urinary Tract Infections Among Women With Urinary Retention After Pelvic Reconstructive Surgery: A Prospective Quality Improvement Study

ObjectiveWe implemented and assessed a clinical practice quality improvement protocol aimed at decreasing postoperative urinary tract infections (UTIs) among patients with transurethral catheters.MethodsThis was a quality improvement study with pre- and post-intervention comparisons. Patients requiring postoperative transurethral catheters underwent 3 interventions: (1) shortening the time from surgery to repeat voiding trials to 3–5 days for pelvic reconstructive surgeries and to 1–3 days for mid-urethral slings, (2) avoiding routine urine cultures at the time of voiding trials, and (3) recommending 2 L of water intake daily until 3 days after the voiding trial. The primary outcome was the percentage of patients receiving antibiotics for UTIs within 6 weeks. Secondary outcomes included rates of failing office voiding trials, UTI symptoms/cultures, adherence to hydration, and health care resource utilization.ResultsWe included 31 patients before and 40 patients after the intervention. The 2 cohorts had similar demographic and clinical characteristics. Among patients requiring catheterization, rates of antibiotic treatment for UTIs decreased from 65% to 40% after the intervention (P = 0.04). UTI symptoms and urine cultures sent for analysis decreased significantly (P = 0.04 and P = 0.005, respectively). There was high adherence (84%) to increased hydration. Rates of failing office voiding trials remained similar. The number of phone calls decreased by 43% (P = 0.003), and there was no increase in office or emergency department visits. Multivariate regression showed that UTIs were 2.04 times more likely before than after the intervention.ConclusionOur quality improvement intervention was practical to implement and effective in reducing postoperative UTIs among patients with urinary catheters.     

A randomized, double-blind, placebo-controlled comparison of the effect of nitrofurantoin monohydrate macrocrystals on the development of urinary tract infections after surgery for pelvic organ prolapse and/or stress urinary incontinence with suprapubic catheterization

OBJECTIVE: The purpose of this study was to determine if antibiotic prophylaxis with nitrofurantoin monohydrate macrocrystals (study drug) after pelvic organ prolapse and/or urinary incontinence surgery with suprapubic catheterization (SPC) decreases urinary tract infection (uti) compared with placebo in a randomized, double-blind, multicenter trial. STUDY DESIGN: Six centers participated in this study. After a negative preoperative urine culture, history, surgical and postoperative course, urine culture and symptoms at SPC removal, and at 6 to 8 weeks postoperative, any other UTI and adherence were recorded. To demonstrate a 50% decrease in the bacteruria rate from 20%, with 80% power and alpha of 0.05, 438 patients were required. Data were evaluated with Student t test and Fisher exact test. RESULTS: Of 449 patients enrolled, 211 randomized to study drug, and 224 randomized to placebo. No pre- or perioperative differences existed between groups (all P>.05). Antibiotic prophylaxis decreased positive urine cultures compared with placebo (46% vs 61%, P=.002), symptomatic UTI at SPC removal (7.2% vs 19.8%, P=.001), and any other symptomatic UTI 6 to 8 weeks postoperatively (18.9% vs 32.6%, P=.002). Antibiotic prophylaxis did not decrease symptomatic UTI at the 6- to 8-week postoperative visit (1.8% vs 5.4%, P=.10). CONCLUSION: Antibiotic prophylaxis with nitrofurantoin monohydrate macrocrystals decreases UTI compared with placebo after pelvic organ prolapse and/or urinary incontinence surgery with suprapubic catheterization.     

Fibroid Arising in a Mullerian Duct Remnant and Presenting as a Pelvic Mass in a Patient with Vaginal Agenesis: An Unusual Finding

EDITORIAL COMMENT: We accepted this case because of its anecdotal interest and also to stress the message that a pelvic mass in a woman with known Mullerian tract anomalies merits an intravenous pyelogram to check on the presence and positions of kidneys and ureters before laparotomy is performed to remove the tumour. The histology report of the tumour gave the reviewer a moment of anxiety when 'the duct-like structure lined by tubal epithelium' was described!
Authors reply: The authors were well aware of the risk of pelvic kidney being involved. Unfortunately an adequate IVP was unable to be obtained in this particular centre. We improvised by identifying 2 kidneys in normal position by ultrasound scan.
Summary: We report a case of vaginal agenesis associated with a large fibroid arising from a Müllerian duct remnant. Vaginal agenesis is rare and infrequently encountered by gynaecologists. Its association with a pelvic mass is even more uncommon, and a medline search by the authors has failed to uncover another reported case. We provide the clinical details of this case and discuss the differential diagnoses.