This presentation from pelvic medicine specialist Michelle E. Van Kuiken, MD, will get primary care providers up to speed on the wide range of urinary disorders, with diagnostic criteria and treatment options for overactive bladder, recurrent UTIs and vaginal prolapse, among other conditions. Bonus: how to work up microscopic hematuria.
eso today we'll be talking about female pelvic health and incontinence s. I wanted to just quickly break down. Sort of. What is the distinction between urology Euro gynecology and F p m. R s? I know Sometimes there's confusion between the specialties and who to refer Certain patients to s o both specialties both urology and O b g y n have fellowship tracks that contrary to become female public medicine and reconstructive surgeons. Um, this happened about seven years ago in 2013 when the A, c, G and me developed it developed board accreditation for the actual subspecialty of f p m rs eso you were all just complete a two year fellowship training, um, and P f p m rs while you're about Ecologist completed three. And some of this is just accounting for the fact that urologist undergo initial longer surgical training. Um, at the fore end. Um, but in terms of what we treat, there's a lot of overlap from things including pelvic organ prolapse, urinary incontinence, both stress and urge, Um, some difficult torrey disorders on which I won't be covering today. Um, public pain. Recurrent U T I S O. There is quite a bit of overlap. I myself do see some male patients. Probably about 20 to 25% of my patient population is still male. But I focus most of my time on seeing female patients. Yeah, and I'm going away again. Sorry. So today we're gonna talk about a different variety of topics, including, you know, overactive bladder, urinary, incontinent stress. Urgent mixed. I want to go over briefly. The new microscopic he material guidelines that were just that just came out from the A way. This year, we'll talk briefly about public organ prolapse where current U T eyes and a really quick blurb on interstitial cystitis, bladder pain syndrome and the items that air start here. In this list our items that are available through the website there actually is an American Urologic Association stabilization guideline that's associated with these topics on there not just geared towards urologists or public medicine. Specialists are geared toward primary care providers as well. It could be a really great resource in knowing how to diagnose or work up a certain problem and even certain early on treatment algorithms that can be utilized s so I would encourage all of you on to go to the website. It's a way net dot org's slash guidelines. Where you have access to these guidelines, there's no password or anything additional needed to access these materials. Let's get this eso in terms of what I think are important aspects of history. Whenever seeing a female patient, I'd like to also obtain an O B G y n history. I'd like to know how many times they've been pregnant if they've had vaginal deliveries versus C section. If there was any trauma associated with those deliveries, have patients postmenopausal. I want to know, um, if they're using any vaginal estrogen products and for how long? If they're premenopausal, are they on any hormonal contraceptives? And if so, for how long? On these things can matter in terms of the vulva. Vaginal health patients and can sometimes play a role in their lower urinary tract symptoms. And, of course, they want to know if they've had any issue. My in surgeries, sexual history. I'd like to know if the patients are sexually active and if they are, if there's any pain or discomfort with sexual activity on. But I like to know where is the pain. Ondas the pain immediate or doesn't start or persist with sexual activity. And sometimes this can give us insight into if there might be some degree of baseline pelvic pain or pelvic floor dysfunction that would benefit from public for physical therapy. All patients when I see them, I like to ask if there's a sensation of pressure bulge or something that they could feel, um, coming out of the vagina. Um, this is a really This is the best question one can ask to screen for Pearl collapse, even without doing an exam. And women are usually fairly reliable historians. When it comes to answering this question, I also always ask all patients about bowel health. There's ah, known correlation between bowel disorders and a number of different lower urinary tract conditions, including overactive bladder and recurrent urinary tract infection. So I like to know how many bowel movements of patients having a week what their stool caliber is if they're hard and pellet like, are they soft? And oftentimes I'd like to know if patients are taking anything for their bowel health. Um, and if they're greater than 50 years old, I want to know when their last colonoscopy Waas, and I'm sure all of you are good at asking a lot of these questions as well. So other things I'd like to know when taking an adequate history are about back in spine issues. I'd like to know if they have any back pain. Hip pain. Have they had any prior back surgeries or trauma on? Do they have any lower extremities or neurologic complaints? Because all of these complaint and toe lower urinary tract health as well, So the first topic will cover a little more details Overactive bladder and urge urinary incontinence. Eso the official definition of this eyes the presence of urinary urgency. This is the key symptom, and this could be a accompanied by frequency in bacteria with her, without urged urinary incontinence. And this needs to be in the absence of urinary tract infection or other obvious pathology. So it really consists of these four key components, So the prevalence of O A B range is pretty widely anywhere from 7 to 20 per 7 27% in men and up to 43% of women. But we know urge your urge. Urinary incontinence is more common in women and a lot of this is just do thio anatomical differences between men and women. We also know that overactive bladder, which is symptom prevalence and severity, increased with age. However, all patients that present with new overactive bladder symptoms should get a. Your analysis and urine culture is part of the work up, especially if the onset of their symptoms were more acute nature to realize something like a urinary tract infection. In some cases, water cancer or C s of the water can present this way as well. So the ideologies of O A. B or many S o a lot of things different form abilities can contribute. Um, diabetes can cause Paula Yuria cause changes to the bladder things like obesity backwards spine issues, as we discussed in other neurologic conditions bowel dysfunction as we previously discussed general aging factors. So for men, there's components of BPH which can cause longstanding obstruction and over time, uh, instability of the truth, Sir. Muscle, which can cause over activity symptoms and women prolapse and incomplete emptying, can cause over activity of the bladder and also hormonal changes. We know that there are both estrogen and testosterone receptors in the lower urinary track. And as people age, there's less stimulation of the urethra and bladder. From these hormones on, there could be significant atrophy that can lead to symptoms, obviously, mobility issues as well. If patients can't make it to the restroom on time, they're gonna have accidents. So a B, um, is nice and that there is a riel tiered treatment approach for these patients, and this is available through the EU, a website. So first line our behavioral modifications, and this mostly consists of fluid management and pelvic floor muscle exercises. Second line are pharmacologic therapies, which include anti coal interjects in beta three agonists and third line therapy Zahra Procedural interventions, which are things that we can offer patients either in the office or in the operating room on these include Botox injections into the bladder or sacred or a modulation. So in terms of first line therapy for patients, they always like to get a sense of patients. Fluid management. Um, the average American, I would say, especially police. The patients I see tend to drink too much fluid every day, so I like to get a sense of how many total ounces or leaders are they drinking. And I like to get a sense of why patients are drinking the fluids that they're drinking. Um, you know, some patients will tell me, you know, I need to drink X amount of water a day. Otherwise I get leg cramps. Or, you know, if their patients that have other medical core abilities that necessitates that fluid, Um, that's great. Many patients will just, you know, drink out of boredom to prevent hunger. Um, for various other reasons. So I'd like to get a sense of why they're engaging in these behaviors. Ask about types of fluids so caffeinated beverages and alcohol could be diuretics. Caffeine is also a bladder irritant. I lost like to also ask about other types of foods that are high in acid and carbonated beverages because these could be bladder irritants, so limiting some of these could be very helpful for patients for patients, particularly with bacteria. I'd like to ask about timing of fluid intake. Um, I asked him, How long do they stopped drinking fluid before bed? I'll typically tell a patient with bacteria they should really try to limit their fluids after dinner time and at least 3 to 4 hours before bed. And if patients Aaron diuretics oftentimes elicit help from their PCP to maybe change the timing have that diuretic to be more favorable for the patient. Other first line therapies are Consider avoiding diary. I often use this in patients so they can monitor their ins and outs at home. One of the nice things about this is that it can provide both diagnostic and therapeutic benefit to patients. I think it's particularly helpful in patients who really are drinking too much fluid or fluids that could be irritating to the bladder because it helps them to recognize the pattern of their behavior and be more willing to make a change. Public floor muscle exercises can be done one of two ways. Um, I have some handouts that I provide to patients with instructions on how to perform these exercises. But if patients either have an exam or I don't think this is feasible or they just would prefer to work with someone, e se one end out, consider referral to physical therapist and also and finally, I'd like to assess for constipation. Onda treated present So second line management for overactive bladder, so they've already managed their fluids, They tried physical therapy and their constipation is managed. We consider anti Colin urge ICS eso anti coal interjects Um, there's a number of different medications in this category, but all of them essentially have the same mechanism of action and side effect. Profile eso any patient. I'm starting on anti Colin Ergic. I canceled them on the common risks, which were constipation and dry mouth. And there is some data that shows us a risk of long term cognitive side effects. But this is a little bit unproven and that these medications were using elderly patients who are more likely to develop cognitive side effects or cognitive issues down the line anyway. So it's a little bit unclear if this is actually a true cause. It effect, um, there really only contra indication eyes, narrow angle glaucoma and to use with caution and patients with delayed gastric emptying in history of urinary retention. Although anti coal energetic, actually causing urinary retention too naive patient, it's fairly rare. So there are six different anti coal interjects on the market on oftentimes, which one I choose to use heavily depends on what a patient's insurance is willing to cover, Um, in terms of my preferences for anti coal interjects, um, there is so the top four are our tertiary amines. And so these tend to have a little bit higher side of prepped effect profile and a little bit more potential cognitive side effect in elderly patient, the bottom two medications or Quaternary amines thes have less. Um, they cross the blood brain barrier less easily on DSO. I feel more inclined to prescribe them for patients in whom I'm concerned about those issues I'm in. Those two are trophy, um into our venison. Um, in terms of the other anti coal interjects above, um, Togias, in my experience, tends to have the least of the constipation dry mouth side effects. So the other category medication is a beta three agonists. Eso. This acts on the ADR allergic receptors in the bladder to promote bladder. Relax ation. There's only one medication on the market currently in this class, and that's mere Petric. Although there is another medication, um, currently in development called by Baghran that will compete with barometric, hopefully soon on to lower the cost of this medication. So common headaches are usually side effects are sorry are usually headache, but there's no constipation or dry mouth associate with this medication. So for patients with intolerable side effects, anti coal energy fix, this could be a really great alternative. There is a risk of cardiac side effects in susceptible patients. So patients who have poorly controlled hypertension or known uh, issues with Procardia they need to be monitored. And usually when I start a patient on Mayor Patrick, I'll recheck their blood pressure. At four weeks, I've never seen a patient who has well controlled blood pressure have an issue with this, just something to be aware of. And as I mentioned, because there's no generic and no competitors on the market, it can often times be available, um, expensive for patients. And we have to fight insurance companies to get it paid for. So when prescribing these medications, especially when when it comes to anti coal, interjects. If there's an extended release version available, you should prescribe this to minimize side effects. And if a patient is doing well on the medication and their symptoms of urgency, frequency knocked iria or urgent continents for improved, you should try to manage the side effects of constipation action when dry mouth before switching them to another medication. An official trial should last about 4 to 8 weeks, but most patients should really know within, you know, 2 to 4 weeks whether or not it's going to really be effective for them. Um, if there's minimal efficacy, there is utility and trying Thio. Try a second anti Colin ergic, Um, and finally, one of the new updates in the more recent anyway, um, overactive Bladder guidelines says we can now consider a combination of an anti coal energy with a beta three agonists. Optimize the efficacy of both medications. So this is just a quick screenshot of that guideline that's available on the Net soundboard website. So for overactive bladder therapies, third line so lets you have a patient who's failed their 1st and 2nd line medication options s. Oh, this is a great time to refer the patient s so we can offer them various treatment modalities in the office. So the first of those is Botox injections into the bladder. This is a procedure that we can do in the office. Well, generally and still intra vesicles light a cane to help provide some pre procedural animal Judea. Um, we inject, starting with a dose of 100 units of Botox. The effects usually last 6 to 9 months. There's a fairly common risk of U T I about 20 to 25% after the procedure. So I council patients about that and a quoted rate of urinary retention of about 6% in the literature. Although in my experience, the rate of this is actually far lower in the properly selected patient, probably closer to 1 to 2%. So patients need to be willing to self cath. So neuromodulation, um, is another third line therapy, and this comes in two different flavors. So the first is posterior tibial nerve stimulation. So this is an in office therapy very similar to acupuncture. A needless placed, a two posterior tibial nerve just above the medial malley olis. Uh, the nervous stimulated for 30 minutes at a time for a total of 12 sessions. A nice thing about this therapy is it's a really low risk therapy eso for patients who cannot tolerate medication who don't want to undergo any other type of procedure. Um, it's really just the discomfort from the needle, the concert that it's time consuming. So for a young patient, someone that you know is working. It's often inconvenient to come to the office for 30 minutes for 12 weeks in a row for this therapy. Um, there are some implantable Pts devices that are being developed. But I don't have experience with these as of yet, So are other neuromodulation option on a sacred neuromodulation. So this is an implantable device that we placed the S three nerve root for Amina eso the pros of this or that it provides constant stimulation. The patient isn't needing to come to the office and it also has adjustable setting. So if the patient experiences decreased efficacy over time, we are able to make adjustments for them. The cons originally were that the device was not Marie compatible. So this really limited its utility in patients who needed frequent memories, especially RMS population. However, interstellar Medtronic, the company who makes this device, has recently come out with an emery compatible device. So this is no longer an issue, and these devices do need to have the battery changed periodically anywhere from 3 to 7 years, depending on the amount of stimulation of patient is using thing. This has done procedurally in the operating room under a Mac sedation. So stress, urinary incontinence, um so stressed during. And continents, as you know, is lots of bureau of activities that increase intra abdominal pressure. So these air things like cough, sneeze, laugh, exercise jumping, rising from sitting to stand. Depending on the definition used, it's actually quite common. Andi up to 14% of all women in the United States will undergo some type of procedure for stress urinary incontinence in their lifetime. So ideologies, vaginal childbirth and increasing parody, or the number one risk factor for stress incontinence. But I also seen the Liberace women who come in with stress incontinence, also women with pelvic floor dysfunction. Whether that's higher, low tone will sometimes see young female athlete patients with these issues. Really, the diagnosis is simple. Um, you can really assess for the presence of stress and continents with a well taken history. But then, on exam, the objective demonstration of stress and continents by any means, whether they're standing, squatting supine with a comfortably full bladder is all you need to make the diagnosis. So in terms of how we treated, it's entirely patient driven eso. Depending on the severity of the continents, the degree of their father and their treatment goals, we can offer them either conservative or non surgical therapies and surgical therapies. So for conservative options, there's behavioral management. Eso again. Pelvic floor muscle exercises are physical. Therapy can be helpful for patients with more severe stress and continents. This probably isn't a great long term solution for them, and it may not provide them sufficient relief. I also tell patients to monitor their fluid in cape in, taken, encouraged, timed, avoiding. You know, if a patient is emptying their bladder more frequently, they may be less inclined to have accidents. They can also use an intra vaginal device. Um, that provides extrinsic compression of the urethra. And this comes in two different varieties. Um, so one of them is available over the counter. This is the poison Presa on this particular product is great for a patient that has light, predictable leakage. So if you have a patient that tells you, she leaks, you know when she goes to her Zumba class. But really not at other times, this is a great product that could be used. It can be inserted at times when they're worried about leakage, Um, and then they can remove it. They can only use it for up to 12 hours at a time. It's also good for patients who are hesitant about surgery. Don't mind using a vaginal device. Um, cons. Again for younger patients, it's not absorptive during Menzies and for an older patient, and it may be uncomfortable of significant vaginal atrophy. Is president So finally, we have our procedural options for stress urinary incontinence. So the first of these could be done in the office, and this is urethra bulking injections. Um, so this procedure is good for patients with mild to moderate and continents, or for older patients who may have significant anesthetic risks or don't desire a procedure in the operating room. Um, the pros of this procedure a downer that it's in office on bits, well tolerated, pretty low risk. However, it only lasts for about 6 to 12 months, and most patients at that time we'll have a decline in the efficacy and will require a repeat injection. So for younger patients or patients with more severe and continents, or who want a longer term solution for their incontinence. Sling surgery is really the gold standard. Um, there are a variety of different ways that this is performed. Eso one is the mid urethral sling. Um, this was first introduced in 1996 in the form of the retro pubic mid urethral sling. A number of years later, they came out with the transit operator Sling and you can see in the picture on the right the two different ways that this latest placed all the slings are made out of polypropylene mesh, which is the same message material that's used for things like inguinal hernias and ventral hernias. Um, there's a lot of data out there now about the concerns with for mesh trans vaginally. However, this is for trans vaginal mess for prolapse, where the FDA has removed all these products from the market and it does not apply to mid urethral sling mesh. There's a lot of data surrounding the safety of these products. The other type of selling weaken places. A pube, a vaginal sling. Eso This is, um, sort of the original sling that existed before the major thrill sling. It's been largely supplanted by the use of mid urethral sling however, it still could be used in various patients on for patients who have aversion to mesh. Who had prior your referral issues where it might be concerned about mesh placement. And we can use either. A small strip usually had a one centimeter and with strip of rectus, abdominal fashion or fashion a lot of from the leg. Both of these procedures are thought to be equally efficacious. They just carry a slightly different side effect profile. So in terms of mixed urinary incontinence, this describes of why a majority of the woman we see I try to determine which one is worse. You know, I'll ask the patient. Is it, you know, running to the bathroom and not being able to make it on time? Is that more bothersome? That's more urge. Or is it that you know you can't let your grandchild or engage in physical activities because you're leaking physical exam is often very helpful, um, to help us figure this out. But if it still remains unclear, if the patients of poor historian we can proceed with your a dynamic testing to really give us an overall better picture of what's going on with the patients lower urinary tract, and this can be used for both diagnostic and counseling purposes. Uh huh. So to summarize overactive bladder and continents. You know, first line therapy for all these conditions for me includes fluid management time, Wooding public floor muscle exercises either on their own or with referral to a public for physical therapist. And I also treat constipation. I put a star by this because it's not officially part of the guidelines, but it's definitely a part of my treatment algorithm and very helpful. And it's also important to rule out u T i or underlying he material that may be contributing to these conditions. Second line therapies, um, for O A b. Urgent continents or mixed and continents or anti coal interjects and our beta three agonists. And, of course, please consider referral for any patient whose were factory to the above or desires. Further intervention would be happy to see them. So moving on to microscopic he materia. I wanted to talk about this today because there is the new AU, a guideline that just came out in May of 2020. I think it's really important for anyone you know. Screening patients are seeing patients with microscopic he materia to know the changes to these guidelines. So microscopic materia is very, very common. Depending on the population you look at, the prevalence ranges pretty widely from about 2.5% to 31%. And he material workups account for a lot of what urologists see about 20% of all referrals. So, of course, I think we're most worried about when we see microscopic material is a possible underlying malignant ideology, the most common of which we bladder cancer but could also be renal cell carcinoma or upper tract your Theo carcinoma. But there are a number of benign ideologies as well that could contribute whether that's urinary tract infection, natural a thigh assist BPH over vaginal atrophy, congenital reasons or medical renal disease can all be benign causes of microscopic materia. So going back to the 2012 guideline, which we're all I think pretty familiar with, and I see most primary care providers fairly adherent to this. Um, it was designed because at the time there was wide variation and how different providers were working at microscopic material, both primary care providers and urologists. The concern was, is that about 3% of all patients with microscopic material were found to be harboring a nun. Derlei Neurologic malignancy. However, when you risk stratified populations that can vary greatly from anywhere from 0% talk to 26% depending on risk factors. And so, really, when they created this guideline, they wanted to standardize the diagnostic approach to avoid misdiagnosis of an underlying malignancy. And so what they did is they created a very streamlined approach. Any patient with 3 to 5 r B. C s on a single year analysis who's 35 years old should get the same work up that work up is a CT euro graham. If the patient's renal function and allergies tolerate Anastas Capi other imaging modalities that you can consider RMR, you're a gram or a renal ultrasound with retrograde biography. But the problem with this guideline is it didn't allow for any risk stratification. So you end up seeing a lot of really low risk patients who are getting, you know, cat scans unnecessarily. So the new guideline, the big changes that were made to it is that it really now allows for a risk stratified approach toe work up and it also takes into account possible benign gynecologic causes in women which were largely overlooked in the initial guideline. So what are considered some of the risk factors for your ethereal carcinoma? So increasing age, male sex, history of smoking or current smoking? The degree of micro he materia the persistence of micro he materia in history of Grossi Materia And also, as I mentioned earlier, our initial work up for overactive bladder of a patient has some new onset, you know, irritated lower urinary tract symptoms. That can be a respect, er history of radiation history of cycle fast for my family history, etcetera. So what does this? What does this risk stratification look like? Eso this again is available on the A website. The full guideline in terms of you know who falls into the low intermediate and high risk so important you notice in our first line that they're now does allow for gender specific stratification of of risk for a malignancy. So now any woman less than 60 years of age if she's a never smoker, his own Onley 3 to 10, you know RBC's per high power field and no risk factors can either undergo no work up or work up with just a cyst, Oscar P and renal ultrasound. And I think this is really helpful, Um, and in helping to avoid unnecessary radiation in contrast, exposure in patients, um, who are otherwise low risk. I think important things to consider if you look in our high risk category are history of gross, he materia um, And so the important point is that it is that it really doesn't apply to Grossi Materia, And this is also true of patient is on blood thinners. And one of the reasons why I like to point this out in particularly in relation to women is that women are often diagnosed with later stage bladder cancer with poor prognosis, because Grossi material is often ascribed to benign causes such as U. T. I. And it's not uncommon to see women who have received multiple rounds of antibiotics for presumed u T I prior to the referral to the urologist. So if a woman has grossly material and has classic U T I symptoms, urgency, frequency pain and a positive urine culture, that's one thing. But if woman has painless grossi material or grossly material with little discomfort in a negative culture that should automatically prompt quick referral. And if you have any questions about this at all, just refer them to a urologist. Eso The summary of this is basically now we have these great new guidelines that allow for risk stratify approach toe work up. You know, that takes into account things like smoking history, sex, degree of hue, material and family history. We decrease the costs and risks of C T. You're you're a gram. And remember, grocery materia is always high risk in merits complete work up. So the current U T I, um, is probably one of the more difficult things Thio see and treat, Um, simply because it is quite common on. We often don't have a great explanation for why certain women are more at risk. It's estimated up. The 60% of women will experience one u T I. In their lifetime on 2040 to 40% of women will have at least one recurrent episode, and upto half of those women will experience multiple recurrent episodes and meet the definition for recurrent u T. I. And this is an expensive problem on. I'm sure something that all of you see earlier routinely. So the EU A also just came out with a guideline in 2019 in regards to recurrent urinary tract infections. And so if you look towards the bottom of the slide, you'll see, really, the definition of a current you're a tract infection is to separate culture proven episodes of acute bacterial cystitis, um, within six months or three within one year. So in younger women, this is usually a pretty easy problem to diagnose and treat, you know d serious central to the diagnosis. I mean, it's pretty accurate, especially in the absence of vaginal pathology on Women may also have frequency, urgency, strength area and plus or minus he materia on, and they may give that the history was related to intercourse. But in older patients, I find that u T I could become much more complicated, often because their symptoms are a lot less clear because things like frequency urgency to Syria, foul smelling urine can often be chronic problems in these patients. We also know that bacteria area increases in the elderly patient, and so just because they have a positive urine culture, does that mean it's necessarily a true urinary tract infection. And finally, in these elderly women, often getting a clean catch specimen is often nearly impossible relating to a lot of an atomic factors. Vaginal atrophy can cause significant recession of the urethra, and so it's likely to be contaminated, especially if a paper patients in a diaper or hasn't continent issues. Um, so both the American Geriatric Society and the Infectious Disease Society of America agree that evaluation for urinary tract infection should be reserved when there's an acute onset or change in symptoms in the elderly patients, you know. So they have new burning or, you know, fever, new grocery material worsening of thes pre existing symptoms. Those would be a reason to check a culture and treat of positive. So when it comes to how I conservatively managed women with recurrent U. T. I E. S, there's a fairly straightforward algorithm that I follow. So if a patient has u T, I disassociated with intercourse where the patient is pre or post and post menopausal post coital antibiotics are usually an initial, um, way to go, and I usually use Nitra for Antonen 50 mg, um, like nitro Toronto in a lot for the urinary tract has low tissue penetration in other areas. On mostly concentrates in the urine. If the patient is postmenopausal, Andi have recurrent urinary tract infections. Vaginal estrogen is a must. This is one of the only evidence based strategies that we have to prevent urinary tract infections and postmenopausal women. And it's all now so it's use is supported by the new American urologic Associate ID station guideline in terms of starting patients on it in terms of whether to use a cream, a suppository or a ring. Sometimes this will depend on the patient's ability to administer the product, but also on what their insurance again is willing to cover. Estrogen, unfortunately, has some coverage issues, which is both very frustrating to me and the patient. Whenever I start vaginal estrogen, I started daily for two weeks in the night transition to 2 to 3 nights weekly. When giving the cream, I'll usually tell women to apply a fingertip size amount, um, to their fingers. So about a half a grand to a gram, I have tell them toe open up. The vaginal enteritis just flop a little bit in there. They don't need to use the applicator that could be cumbersome for all patients. I consider a cranberry supplement, plus or minus demon knows there is good evidence. Although mixed for cranberry supplement use, one brand that I often recommend is called a Laura. I didn't include it here because it uses the necessary pro anthro CNN or pack content that's known to be efficacious in preventing UT ice in de Manos. There is, um, good. I'll be a limited data on its efficacy, especially for recurrent E. Coli U T I. On it's fairly safe and well tolerated. Again. If the patient's constipated, I treat it and I do a daily bowel regimen with me. Relax. And if the patient also complaints of despair Ania, I consider a public for, um, physical therapy referral. I think Thio some extent women with recurrent urinary tract infections may also have some degree of public pain and pelvic floor dysfunction. Um and so I will refer them if this is also present s. So this is a screenshot of the AU, a guideline and recurrent urinary tract infections. It's available on the website. Eso finally was gonna talk about pelvic organ prolapse. Um, so this is, you know, one of my favorite things to see and treat. Um, so the definition obviously prolapse of the vaginal vault, uterus, bladder or rectum that results from pelvic floor laxity. This can come in a variety of different flavors. Um, can be just a pickle in nature. So just uterus Patients may have anterior posterior prolapse associated with it as well. Um, ideology. Increasing vaginal parody patients with connective tissue disorders. There definitely is a strong family history associated with prolapse for reasons that are not entirely clear on and also patients who give a history of chronic straining. So these patients may have a history of chronic constipation or difficult Torrey dysfunction, Um, associate it as well, but it really is unclear why some women are affected more than others. So the classic symptoms or the bulge symptoms, which is, as I mentioned earlier in our screening questions, or the most predictive of actually seeing a perhaps on the exam so patients may complain of feeling pelvic pressure or see or feel something falling out of the vagina. Classic story is, I was patients will say, You know, I was watching myself in the shower. I felt something, Um, that's usually the first time that they'll notice it. For some patients, it can happen more acutely, and it could be worrisome to them, and I provide them reassurance. One thing that is usually not associate with prolapse is pelvic pain, so patients can have discomfort or pressure. But pain is generally not a symptom of prolapse urinary symptoms, so patients can have overactive bladder frequency urgency. Um, but they may, conversely, have issues with difficulties empty and due to Qingqing of the urethra from a prolapse, so they may have elevated residuals with a weak stream and hesitancy. This may predispose them to issues with the current urinary tract infections on. They may have difficulty Torrey symptoms so incomplete evacuation or needing to splint meeting but pushing the fingers or the parent knee, um, to help completely evacuate the battles. So when treating patients with public Korean prolapse, I first and foremost like to provide them with reassurance on assuring them that, you know, this is a quality of life issue. I think a lot of women coming concerns that they have a pelvic mass or something more serious. Maybe going on, eh? So I like to let them know that this is not something that is life threatening but definitely can be quality of life altering so we can offer women a variety of strategies. Observation. There's some data that shows, depending at the time of the presentation, Um, perhaps isn't necessarily going to continue to progress, but it does. In the majority of women, we can manage them with a past Serie, which is something that we offer in our office. We will fit women and insert them with it, Um, and also surgical correction of their prolapse. So pestering management is something that I really enjoy using in a variety of different patients. For various reasons, I think pastoring management could be great both in the short and the long term. So for women who come in and they have had, you know, they have very symptomatic per lapse, but perhaps they're not optimized for surgery or can't have surgery for whatever reason. Um, sooner rather than later, we can place a pet Serie for acute symptom relief, and this could be used as a bridge to surgery on I tell women just because I'm placing a pest serie in you today, it doesn't mean that you can't have a surgery six months, one year, two years from now, eh? So it can be a nice bridging strategy for some women. It can also be used as a long term strategy. Is a permanent solution for women that wish to avoid surgery or not. Candidates for surgery Passengers can be managed different ways. Eso in a patient who's younger or dexterous, the patient can take the passer in and out themselves. They can wash it on their own. And then this actually allows us to be able to see the patients much less frequently so we can space out there. Follow up, sometimes is annually is sufficient for women who self manage, suppress Aries or there's provider maintenance. And so this is what we do for women who are older or unable to take out their customers on their own. We'll start them on, you know, seeing them more frequently, and usually then weaken space them out anywhere from 3 to 4 months for routine surveillance. Visits will take the past three out, do a vaginal cleaning and expect Expect inspection. I apologize andan exam. And finally, there's surgical management of prolapse on. This comes again in a variety of different flavors. So we have reconstructive versus obliterated procedures. So reconstructive, meaning that we restore the length of the vaginal canal both based on the patient's preference or if they have desire for future penetrative intercourse versus obliterate Ivo. One procedure that's been around for very for many years. It has great durability is a cultural crisis. Things is an ideal procedure in a patient who's elderly. Um, it's a short operative time and has great outcomes and satisfaction rates. We can perform our prolapse repairs either via an abdominal or vaginal approach. I mean, we can use either mesh augments versus native tissue on, and we can perform uterine sparing versus uterine removal surgeries. And so these are all different options that I discussed with women based on their goals. Um, there's been an increase in the number of women lately who want to leave their uterus of the time of prolapse repair. And there's actually good data not to support this practice, whether it's in the form of an abdominal Sagara culpa pack. See where we cannot pecks the uterus, um, to the sacrum, as seen in this picture, although this one the uterus, has been removed. We can also do vaginal uterine sparing procedures. Um, And again, when we perform a vaginal procedure, we do not place mesh because the data has shown that this is unsafe and can harm women and has now been banned by the FDA. All of the procedures, whether vaginal or abdominal, reconstructive or obliterate Ivo I've are generally considered minimally invasive. And most of these patients can go home either the same day or the next day. So, in summary, public organ prolapse the quality of life condition. If you have any women with these complaints, I'm happy to see them for their initial exam on guy. We can offer them a wide array of surgical and nonsurgical management options. Toe fit their treatment goals. Eso just to re summarize what we talked about today in terms of our conservative management strategies for any patient who presents with lower urinary tract symptoms, I think these are all things that can be safely instituted, whether you're seeing a patient either in person or via a virtual visit. And those are things like Avoid that, you know, fluid management and avoidance of dietary triggers. Um, bowel regimen, Vaginal estrogen in postmenopausal women, referral to public for physical therapy and considering a trial of beta three agonists, or anti colon ergic. And this is essentially a you know, some combination of these items I'll use for any patient with directive, bladder incontinence or bladder pain syndromes, because there does tend to be a lot of overlapping pathology. Um, in regards to these and finally for recurrent u T. I already went through this, but just to summarize it again for you. T I associate with intercourse postcoital antibiotics. All postmenopausal patients should be given vaginal estrogen, and I believe I didn't mention before. One concern that often comes up that the patient has a history of breast cancer, um, patients who have a history of breast cancer. The data has shown that there is absolutely no increased risk of either causing breast cancer or recurrence of breast cancer and women with a personal history of breast cancer. There is, actually now some also Cem data that's coming out, that it shows that that's also applies to women with a history of gynecologic malignancies, so even and women who have had treated uterine or ovarian malignancies. They can also use vaginal estrogen in all patients. I consider use of cranberry, and demand knows if they're constipated, I treat it. And if they have pain, I referring to public for Petey. Um, and if for any reason, anybody needs a patient to be seen either the same day or urgently, um, I would ask you to screenshot this essay that you can call our office to expedite any referrals and happy to see any patient that has any acute concerns on Dhere. Some information regarding our practice managers.
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