Operational Obstetrics & Gynecology - 2nd Edition: The Health Care of Women in Military Settings
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Painful urination is one of the classical symptoms of bladder infection, along with frequency, urgency and sometimes hematuria. Such an infection can be confirmed by a positive urine culture (>100,000 colonies/ml), or strongly supported by a positive "dipstick" (for bacteria or leukocyte esterase) and a clinically tender bladder (normally the bladder is not the least bit tender).Bladder infections are treated with broad-spectrum oral antibiotics (Gantrisin, Bactrim DS, ampicillin, Keflex, Macrodantin, etc.). Immediate relief of symptoms will occur with Pyridium 200 mg PO TID for 2 days.
In operational settings, cystitis is often treated on the basis of symptoms and without confirming with cultures or dipsticks. A woman complaining of urgency, frequency and dysuria very likely has cystitis. With only limited resources, the main goal is to quickly treat any possible UTI's, return the patient to full duty, and avoid the much more serious problem of pyelonephritis.
Should symptoms persists despite a course of broad spectrum antibiotics, a careful examination should be made and further testing is appropriate.
Bladder infections among women in operational settings are common:
- Because of the difficulty in urinating (undressing in field environments, limited sanitation, etc.), many women will intentionally dehydrate, simply to avoid having to urinate. When successful, this dehydration leads to urinary stasis, predisposing them toward bladder infection.
- To further avoid urinating in field settings, many women will try to hold their urine as long as possible. This, too, leads to urinary stasis and predisposes towards UTIs.
Read more about urination issues in field settings.
Urinary frequency and burning in a patient with a history of exposure to gonorrhea suggests gonorrheal urethritis.The urethra is normally not tender.
Should the urethra be tender, particularly if combined with a purulent discharge, urethritis should be suspected.
Paraurethral abscesses (infected Skene's glands), and eversion of urethral epithelium are often found.
This diagnosis is confirmed by gram-negative intracellular diplococci on Gram Stain or positive culture on Thayer-Martin media (chocolate agar).
Should the operational environment disallow this precise workup, treatment is often provided on the basis of clinical suspicion and symptoms, or after a failed course of broad-spectrum antibiotics provided for a suspected UTI.
Treatment is:
- Cefixime 400 mg orally in a single dose, OR
- Ceftriaxone 125 mg IM in a single dose, OR
- Ciprofloxacin 500 mg orally in a single dose, OR
- Ofloxacin 400 mg orally in a single dose,
PLUS
- Azithromycin 1 g orally in a single dose, OR
- Doxycycline 100 mg orally twice a day for 7 days.
Sexual partners also need to be treated. Skene's abscesses should have I&D followed by daily packing with iodoform gauze for 2-4 days.
These patients complain of symptoms suggesting cystitis (frequency, burning, and urgency), but the urine culture is negative and they do not improve on conventional antibiotic therapy.A purulent discharge from the urethra may or may not be present, but the urethra is tender to touch.
Cultures from the urethra may be positive for chlamydia, Mycoplasma or Ureaplasma, but will be negative for gonorrhea.
Treatment may be started on the basis of clinical suspicion alone.
Treatment is:
- Azithromycin 1 g orally in a single dose, OR
- Doxycycline 100 mg orally twice a day for 7 days, OR
- Erythromycin base 500 mg orally four times a day for 7 days, OR
- Erythromycin ethylsuccinate 800 mg orally four times a day for 7 days, OR
- Ofloxacin 300 mg twice a day for 7 days, OR
- Erythromycin base 250 mg orally four times a day for 14 days, OR
- Erythromycin ethylsuccinate 400 mg orally four times a day for 14 days.
Preferred treatment (CDC) for an initial outbreak is:
- Acyclovir 400 mg orally three times a day for 7-10 days, OR
- Acyclovir 200 mg orally five times a day for 7-10 days, OR
- Famciclovir 250 mg orally three times a day for 7-10 days, OR
- Valacyclovir 1 g orally twice a day for 7-10 days.
Read more about Herpes Vulvitis
Painful urination may also be a symptom of other gynecologic disease, not specifically related to the bladder. Endometriosis, for example, may initially present as painful urination with a tender bladder which does not respond to typical antibiotic therapy and all urine cultures will be negative.
Read more about Yeast Read more about Trichomonas
The overwhelming number of patients complaining of urinary frequency will have one of the following problems:
- Bladder infection (accompanied by dysuria).
- Excessive fluid intake (particularly just before bedtime).
- Increased stress.
- Some pelvic mass which is pressing on the bladder
Evaluation of urinary frequency involves asking the patient about her fluid intake habits and recent exposure to stress. A physical exam determines the presence or absence of:
- Bladder tenderness (suggesting cystitis or endometriosis)
- Pelvic mass (suggesting ovarian cyst, pregnancy, or fibroids)
In situations where the diagnosis is unclear, a urine culture or urine "dipstick" for bacteria, nitrates or leukocyte esterase may be helpful in identifying infection. A pregnancy test is sometimes enlightening.
Whenever infection is suggested, a course of oral broad-spectrum antibiotics is advised. If no infection is apparent and the patient acknowledges large fluid intake, reducing the intake some may be helpful. (don't over-react to this...too little fluid intake can be a problem also.)
If the patient has had a trial of antibiotics, and/or has a negative culture, it is certainly worth trying low dose anticholinergics (like 2.5mg Ditropan 2-3 times per day) for the stress component. In young women, it is often NOT a pelvic mass or infection: it is often just stress.
There are a wealth of reasons for grossly visible blood in the urine. In women of child-bearing age, not postpartum and not menstruating, the most frequent is cystitis or a bladder infection. Such an infection is usually accompanied by urinary frequency and painful urination. The bladder is tender to palpation and urine culture will be positive (>100,000 colonies/ml). Urine "dipstick" will be positive for bacteria, nitrates and leukocyte esterase in the typical case.Treatment involves an oral broad-spectrum antibiotic (Gantrisin, Bactrim, ampicillin, Keflex, Macrodantin, etc.).
If all symptoms resolve and the hematuria does not return, no further evaluation is necessary. If the hematuria does not disappear or if the patient has repeated episodes of hematuria, then urologic consultation will be necessary to look for other causes of hematuria (renal stones, renal cell cancer, bladder cancer, endometriosis, etc.)
This is usually a symptom of either a urinary tract infection (cystitis) or a vaginal infection.Examining the patient to determine the presence or absence of Gardnerella, trichomonads, yeast, or a lost tampon may be helpful in excluding vaginal problems. A urine culture or urine "dipstick" for bacteria, nitrates or leukocyte esterase may be helpful in eliminating a bladder infection as the cause of the problem.
Certain foods are associated with an unusual odor in the urine (asparagus), as are certain antibiotics (ampicillin).
If the patient cannot urinate at all, she will be in extreme distress with a distended, tender bladder.Insert a Foley catheter and allow the urine to begin draining. After the first 500 cc of urine has drained, clamp the Foley to temporarily stop draining for 5-10 minutes before allowing another 500 cc to drain. Continue to drain the urine in 500 cc increments until empty. Severe bladder cramps may occur if the entire bladder is drained at one time of a large amount (>1000 cc) of urine. (Severe bladder cramps may occur anyway.)
After the bladder is drained, leave the Foley catheter in place for a day or two to allow the bladder's muscular wall to regain its' normal tone. If there is more than about 700 cc in someone, you should leave the Foley 5 days. If truly overstretched, the bladder won’t recover its tone in 48 hours.
Try to determine why the patient couldn't void. She may have recent trauma to the perineum or vagina, which caused swelling in the area of the bladder or urethra, obstructing flow. She may have a pelvic mass (ovarian cyst, uterine fibroids, pregnancy, etc.) which has distorted the anatomy and functionally blocked the urethra. She may have herpes and cannot urinate because of the severe pain, which is caused by urine flowing over open ulcers.
Outside of postpartum or post-surgical circumstances, being unable to urinate is very rare in women, and not a good sign. Urinary retention is a common presentation of MS. If it does not respond to 5 days of Foley placement, urologic consultation/evaluation is needed. .
After a day or two, remove the Foley catheter. Usually the patient will be able to urinate normally again. If there is any doubt, catheterize her for "residual volumes."(RV) After she urinates, insert a catheter to completely empty the bladder. If the RV is less than 50 cc, no further catheterization is necessary. If the RV is greater than 50 cc, continue to catheterize her after each urination until the RV is less than 50 cc. If the RV is quite large (>300 cc), then the bladder has probably not regained its normal tone and you should simply leave the Foley catheter in place for a few more days.
There are four primary forms of urinary incontinence:
- 1) Loss of urine when coughing, sneezing or straining ("stress urinary incontinence").
2) Sudden, involuntary loss of urine accompanied by urgency (unstable bladder, irritable bladder, detrusor dyssynergia).
3) Involuntary loss of urine upon rising or standing.
4) Involuntary loss of urine at unpredictable times, not associated with urgency, frequency or other activities.
Loss of urine when straining (stress urinary incontinence) affects nearly all women at some time in their life.If a woman's bladder is full enough and she strains hard enough, some urine will escape, due to the shortness of her urethra, the fragility of the normal continence mechanism, and its vulnerability to trauma during intercourse and childbirth.
Genuine stress incontinence which occurs more or less daily and requires the patient to wear a pad to avoid soiling her clothing will require gynecologic or urologic consultation and usually surgery to repair the anatomic defect.
Lesser degrees of stress incontinence can be treated by:
- Kegel exercises (periodic tightening of the muscles of the pelvic floor 10-15 times a day for 4 weeks).
- Frequent emptying of the bladder and "double voiding" (re-emptying the bladder 10-15 minutes after the initial void) to keep the bladder as empty as possible.
- Elimination of caffeine, alcohol and tobacco (common bladder irritants) which may aggravate the incontinence.
- A course of oral antibiotics to eliminate the chance that a sub-clinical cystitis is aggravating the incontinence.
Women with an "irritable bladder" will complain that when they suddenly get the urge to urinate, they must find a bathroom within 1-2 minutes or else they will actually lose urine involuntarily.Evaluation of the irritable bladder will require gynecologic consultation, but a number of simple things can be done to relieve the symptoms while awaiting consultation. Eliminating caffeine, alcohol, and tobacco from the diet will reduce the stimulation of the bladder wall. "Double voiding" (emptying the bladder, waiting 10-15 minutes and then emptying the bladder again) will help fully empty the bladder and will reduce the stimulus. A course of oral antibiotic may eliminate any subclinical infection.
Involuntary loss of urine upon standing or arising suggests the presence of a urethral diverticulum. This outpouching of the urethra collects and holds urine, releasing it at unpredictable times. Specialized instruments are needed to visualize most urethral diverticula and patients with this type of complaint should be evaluated through a gynecology or urology consultation. Nothing short of surgery is likely to help this particular problem.
Unpredictable loss of urine not associated with urgency or activity suggests a neurologic cause. Such conditions as multiple sclerosis, spinal cord tumors, spinal disk compression and other neurologic problems should be considered. If a patient has a single episode of this type of urine loss, she can simply be reassured, but if she notes an on-going or worsening problem with this type of urine loss, careful neurologic evaluation should be performed.
There are three primary reasons for urinary urgency:
- 1) Cystitis (bladder infection)
2) Irritable bladder (unstable bladder, detrusor dyssynergia)
3) Stress
In women of child-bearing age, cystitis is the most frequent cause of this distressing symptom in which a patient suddenly has a powerful urge to urinate. Bladder infection is usually accompanied by urinary frequency and painful urination. The bladder is tender to palpation and urine culture is positive (>100,000 colonies/ml). Urine "dipstick" will be positive for bacteria, nitrates and leukocyte esterase in the typical case.
Treatment involves an oral broad-spectrum antibiotic (Gantrisin, Bactrim, ampicillin, Keflex, Macrodantin, etc.). If all symptoms resolve, no further evaluation is necessary. Persistent symptoms will usually necessitate a gynecologic or urologic consultation.
Women with an "irritable bladder" will complain that when they suddenly get the urge to urinate, they must find a bathroom within 1-2 minutes or else they will actually lose urine involuntarily. Evaluation of the irritable bladder will require gynecologic consultation, as described above.
Stress
Stress is commonly encountered in military settings. While the stressor cannot always be reduced, the body's reaction to the stressor can, sometimes, be modified. Women who suffer from stress-induced urgency may benefit from counseling and stress-reduction techniques.
A kidney infection.These infections are characterized by CVA pain or tenderness, chills, fever, lassitude, and sometimes nausea and vomiting. They may be preceded by cystitis or may come without warning.
Treatment is vigorous antibiotic therapy (frequently IV antibiotics because of the seriousness of the illness) and brisk fluid intake (IV or PO).
Kidney stones are common. While occurring more frequently among men than women, they still represent a significant cause of abdominal pain. A distal ureteral stone, especially in the intramural tunnel of the bladder often causes severe frequency/urgency patterns of urination. The dehydration, which often accompanies deployment, predisposes military members to formation of stones.
Severe, acute, colicky, unilateral flank pain usually marks the passing of a kidney stone. The pain is:
- Unrelieved by position,
- Generally accompanied by gross or microscopic hematuria, and
- May produce nausea and vomiting.
While passing stones is very unpleasant for the patient, it is not life threatening. Only in the event of upper tract infection or a solitary kidney is the obstruction associated with a passing stone a true medical emergency. In the absence of these two factors, the goal of treatment is pain relief and hydration.
Appropriate work-up of kidney stones depends on the patient presentation and available facilities. In the absence of fever or other evidence of UTI, treat the patient empirically with IV hydration and IV pain medications (Torodol or morphine). Oral pain medication is usually appropriate following this therapy.
If the patient does not pass a stone, an intravenous pyelogram (IVP) within 30 days of presentation is considered timely unless the patient’s condition deteriorates. If the diagnosis is in question, a spiral CT scan is the diagnostic tool of choice, as abnormalities other than kidney or ureteral stones are often visible. An IVP, however, provides functional as well as diagnostic information, and the diuresis from the contrast load may encourage passing of the stone. The only equipment required is plain radiography, which is much more likely to be available in a deployed setting.