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Urogynecology Clinical Pearls ACP Meeting 2013 Richmond, VA C. Sage Claydon, MD, FACOG

Urogynecology Clinical Pearls ACP Meeting 2013 Richmond, VA C. Sage Claydon, MD, FACOG Female Pelvic Medicine and Reconstructive Surgery. Good help to those in need. Disclosures. Astellas: Vesicare, Myrbetriq Speaker Bureau . Case 1: Recurrent UTI’s 55yo PMP c/o dysuria & frequency .

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Urogynecology Clinical Pearls ACP Meeting 2013 Richmond, VA C. Sage Claydon, MD, FACOG

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  1. Urogynecology Clinical Pearls ACP Meeting 2013 Richmond, VA C. Sage Claydon, MD, FACOG Female Pelvic Medicine and Reconstructive Surgery Good help to those in need

  2. Disclosures • Astellas: Vesicare, Myrbetriq • Speaker Bureau

  3. Case 1: Recurrent UTI’s55yo PMP c/o dysuria & frequency • 4th episode in 9 months Responds to Abx, but gets yeast infections UTI’s when first married • PMHx: Denies Kidney stones, DM, HSV or HIV • Ucx’s: Ecoli, Klebsiella, Ecoli • PSHx: TVT last year • ROS: dryness with intercourse • PE: • Neuro: nl, BMI 29 • Pelvic: no sub-urethral mass, PVR 50cc+vaginal atrophy, no prolapse past hymen. • Udip: glu -, nit +, LE+, RBC+

  4. How do you treat her UTI’s? TMP-SMX x 7 days, then: • Daily cranberry juice • Refer to a Specialist (imaging & cystoscopy) • Daily low-dose antibiotics & PRN Diflucan • Teach her to “self-cath”

  5. What do we know so far ? • 4th episode in 9 months Responds to Abx, but gets yeast infections UTI’s when first married • PMHx: Denies Kidney stones, DM, HSV or HIV • Ucx’s: Ecoli, Klebsiella, Ecoli • PSHx:TVT last year • ROS:dryness with intercourse • PE: • Neuro: nl, BMI 29 • Pelvic: no sub-urethral mass, PVR 50cc+vaginal atrophy, no prolapse past hymen. • Udip: glu -, nit +, LE+, RBC+

  6. Recurrent urinary tract infection Scholes, J infect Dis 2000 Raz, Clin Infect Dis 2000 Ejrnaes Dan Bull Med 2011 Definition: 3 positive cultures in 12 months or 2 in 6 months • Etiology: - Host factors - Genetics, behavioral and anatomic • Bacterial Virulence

  7. Prophylaxis Strategies without Antibiotics Bachmann, Menopause 2009 Ochoa-Brust, Acta Ob. Gyn. Scand 2007, Jepson, Cochrane Syst Rev. 2012, Beerepoot, Arch. Int Med 2011, Tammen, BJU 1990 Beerepoot, Arch. Int Med 2012 • Boost Host Defense – Vaginal Estrogen - 10ug 3x/week pill, finger tip cream 0.3mg – Vitamin C 100mg daily – maybe – Cranberry products – maybe pills not juice – Immuno-active prophylaxis not available in USA • Alter the bacteria – Probiotics & lactobacillus – maybe

  8. Low dose suppression for 3 - 6 months - 50% recurrence after stopping - Increased Abx resistance Post-coital - Single dose - Nitrofurantoin, trimethoprim (tmp), fosfomycin Self-start (7-day course) Prophylaxis Strategies with Antibiotics Mazzulli C J Uol 2012 Wein 2007

  9. Recurrent UTIPearls Lee, Cochrane Syst. Rev. 2012 • Methenamine Hippurate - Effective in patients without renal tract anomalies - Bacterial static; dose dependant on Urine pH - No resistance • Daily Nitrofurantoin suppression - Associated with peripheral neuropathy & pulmonary fibrosis • Don’t treat new infections with same Abx used for suppression

  10. Case 2: Nocturia:66yo WF c/o urinary incontinence worse at night • Wakes 3 - 4x • Often leaks on the way to the toilet • Feels she empties • Denies prior treatment or daytime leaking • PMHx: HTN • ROS: Hot Flashes • Meds: HCTZ q am, ASA • PE: BMI 33, U dip: glu -, nit - • Neuro, Pulm, CV: nl • Pelvic: small urethral caruncle and vaginal atrophy, no prolapse past hymen • Ext: B ankle edema

  11. What would you do next ? • Prescribe an Anti-muscarinic • Change the timing of her diuretic • Ask her to keep a 3-day Voiding Diary and return next week • Start her on HRT • Refer her for sleep studies

  12. Voiding Diary • Frequency 6 (< 8) • Avg. voided volume 10oz (8 -12) • Max functional capacity 16oz (13-16) • ≠ Overactive Bladder (OAB)

  13. Voiding Diary • Nocturnal urine volume 74% (< 33%) of 24-hr urine output • Voids 3 times after going to bed • Nocturnal Polyuria

  14. Voiding Diary • 74% total urine output after going to bed • Leaks with activity when bladder very full • Nocturnal Polyuria & • Stress Incontinence

  15. Nocturia Appell Neurol Urodyn 2008 Vaughan Int J Clin Pract 2010 Asplund BJU 2005 • Waking from sleep to void • Loss of sleep affects health and QOL - mood, memory, fall risk • Differential Diagnosis Includes: - OAB, Polyuria, Sleep disturbance (hot flashes, husband, hound), Reduced bladder capacity

  16. Nocturnal Polyuria Van Kerrebroeck BJU Int 2002 Yoshimura Int J Urol 2004 Appell Neurol Urodyn 2008 • Defined as nocturnal urine volume > 33% of total 24-hr urine output • Numerous causes - 3rd space fluid re-absorption, Sleep Apnea, diuretics, CHF, DM, CRF • Common with age >65

  17. Pearl: Nocturnal Polyuria • Voiding Diary to diagnose & to direct treatment • Start with behavior modification: • Restrict fluid after 7pm & increase am fluid • Compression hose • Change diuretic to afternoon • Treat associated conditions: C-PAP • Weight loss

  18. Nocturnal Polyuria Medications Brubaker Int Urogyn J 2007 Kang Int Neurourol J 2012 • Anti-muscarinics not effective • DDAVP nasal spray - Start 10ug hs titrate to 40ug - Women require smaller dose than men - Monitor Na weekly x 4 weeks for hyponaturea

  19. Case 3: Urinary Incontinence65yo c/o urinary incontinence for 1 year • +Frequency, nocturia • Can’t predict it • Leaks with coughing and jumping • Denies PMH • Neuro and Pelvic exam nl

  20. What is her diagnosis? • Stress Incontinence • Overactive bladder (urge incontinence) • Mixed Incontinence • Overflow Incontinence

  21. Distinguishing betweenSUI, OAB-wet and mixed incontinence

  22. Voiding Diary • Average voided volume - about 1cup • Average maximum void - about 2 cups • OAB patients • void more often • smaller volumes • SUI / overflow patients • voids vary • Polydypsia/ diuretics • void more often • normal volumes

  23. Mixed IncontinencePearls • Treat the most bothersome symptom 1st • Physical Therapy will help OAB and SUI • Anti-muscarinics may decrease urgency and frequency. But patients will lose more urine with each “stress leak” because the bladder is holding more • If vaginal atrophy consider vaginal ERT

  24. Case 4: Dyspareunia35yo c/o new onset painful intercourse Pain with coitus “kind of just inside & also deep”. Some aching after. Better with NSAIDs. Happily married. Regular periods, mild dysmenorrhea, condoms for contraception, never used tampons, frequency x 2 weeks. Denies: vaginal discharge, dryness & dysuria. PMHx: SVD x 2 ROS: neg constitutional, slipped on the ice 2 weeks ago

  25. QUIZ: 4Your differential includes all except? • Psychosomatic • Endometriosis • Pelvic prolapse • Vaginal/Pelvic Infection • Pulled/strained muscle

  26. Physical Exam: EGBUS: no lesions, adenopathy or masses. neg touch test Speculum: normal, slightly tender but doesn’t reproduce pain, mild cystocele & rectocele Uterus: mobile non-tender, no uterosacral ligament nodularity Adnexa: no masses or tenderness Pelvic floor muscles: L OI & Coccygeus reproduce pain

  27. Dyspareunia

  28. Dyspareunia Pearls • If vestibule is tender – Lidocaine jelly applied to vestibule can help complete the exam • PFM spasm can cause frequency and dyspareunia • Prolapse doesn’t cause pelvic pain or pain with intercourse

  29. Thank you Success: At age 4 success is. . . Not piddling in your pants.  At age 12 success is . . . Having friends.  At age 17 success is . . . Having a driver's license.  At age 35 success is . . . Having money. At age 50 success is . . . Having money. At age 70 success is . . . Having a drivers license.  At age 75 success is . . . Having friends.  At age 80 success is . . . Not piddling in your pants. 

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