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.
Should symptoms persists despite a course of broad spectrum antibiotics, a careful examination should be made and further testing is appropriate.
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.
Recommended Regimens (CDC 2002)
Alternative Regimens (CDC 2002)
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.
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.
Recommended Regimens (CDC 2002)
Alternative Regimens (CDC 2002)
Recommended Regimens for an Initial Infection (CDC 2002)
Recommended Regimens for Recurrence (CDC 2002)
Recommended Regimens for Supressive Therapy (CDC 2002)
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.
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:
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 2.5 mg 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.
Blood in the Urine
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 wont 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.
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.
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:
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. Smooth muscle relaxants may also be helpful.
Unpredictable Urine Loss
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.
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).
Severe, acute, colicky, unilateral flank pain usually marks the passing of a kidney stone. The pain is:
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 patients 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.
OB-GYN 101: Introductory
Obstetrics & Gynecology
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