Urinary problems are the most frequently encountered complaints of the gynaecological patients visiting the outpatient department. Several causes contribute to the varied presentations and types of the urinary problems. The establishment of a proper diagnosis involves a detailed history, meticulous examination and a complete urological investigation. Common urinary problems that patients present with include Urinary Tract Infections (UTI), retention of urine, difficulty in micturition, painful micturition, increased frequency of micturition, difficulty in controlling urination, involuntary passage of urine on cough or sneeze, abdominal pain associated with micturition and increased night frequency of micturition. Let’s concentrate on a few of these complaints in this article.
Urinary Tract Infection (UTI)
It can be an infection in any part of the urinary system from kidneys to ureters to bladder and/or urethra. Most common method of infection in women is ascending from the urethra into the bladder, due to anatomical reasons – urethra is shorter in females than males, and is closer to vagina and anus. Some factors like poor personal hygiene, sexual intercourse, catheterization, pregnancy, and menopause make women more susceptible to UTIs. Symptoms and signs of UTI are painful micturition, increased frequency, urgency (strong urge to urinate), burning sensation, cloudy or blood stained urine, foul smelling urination, mild fever and/or passage of frequent small amounts of urine; if the infection reaches the kidney- high fever with or without chills, nausea, vomiting and pain in back radiating on one side. Diagnosis is made by characteristic symptoms and by urinary examination- urine may contain pus and organisms. Culture and microscopy of the discharge helps in establishing the diagnosis.
Treatment consists of administration of large quantities of fluids, at least 2.5 litres/24 hours, especially in cases of cystitis (inflammation of bladder) and appropriate antibiotics. Patients are advised to avoid all irritants like deodorants, vaginal contraceptives and douches. Alkaline drinks and citrates are helpful. Menopausal women may benefit by supplementing oestrogen (hormonal) creams to improve the atrophic (thin and shrunk tissue) state of vagina and urethra. Some preventive measures can be followed to avoid UTI: like use a 100% cotton inner wear, maintain proper personal hygiene, urinate after intercourse, use proper antibiotics as advised, cranberry juice can help in decreasing number of UTIs, have plenty of oral fluids, use lubricated condoms without spermicide creams and most importantly proper toilet training should be followed.
Coming to the next common urinary problems which most women elicit in their history either as chief complaint or on enquiring include frequency of micturition, urgency to urinate and/or inability to control urination or involuntary passage of urine (incontinence). Incontinence affects nearly 400 million people worldwide. Studies have found the incidence as high even in younger population, affecting nearly 24% women between ages 18-44 years. Urinary incontinence is a worldwide problem and the burden is expected to grow with an ageing population with longer life span and availability of better healthcare facilities. In women, pregnancy, childbirth, and menopause are major reasons for increased prevalence of incontinence. Although Urinary Incontinence is not a life threatening problem, it negatively affects the quality of life; may cause emotional problems like depression, anxiety, stress, and embarrassment in public impacting their travel, exercises, and sexual activity as well. Thus it is an important public health problem which needs to be addressed not just medically, but socially also. The common causes which are postulated to precipitate urinary incontinence are genital prolapse (weakening of genital tissues leading to their prolapse outside the vagina), type of childbirth, and longer duration of delivery, number of children, urogenital infections, and injuries to the genital regions, genetics and menopause.
Stress Urinary Incontinence (SUI) is the commonest cause of urinary incontinence noted worldwide. SUI is involuntary loss of urine from the urethra when there is increase in intra- abdominal pressure, which occurs during physical activities like coughing, sneezing, running, lifting heavy weight or exercise. Diagnosis is made during detailed history of the symptoms, along with important past history relating to injury to the genital tract (example during child birth); followed by meticulous examination of the patient in supine (lying down), standing, and squatting positions. Urodynamic tests focus on the bladder’s ability to hold urine and empty steadily and completely, that is, a study that assesses how the bladder and urethra are performing their job of storing and releasing urine. Sonography and cystoscopy (a tube with a camera and light to visualize the inside of the bladder) are other tests which may be individualized as per the patients. Treatment options for Stress Urinary Incontinence are non-surgical and surgical.
Non- surgical therapies include behavioural therapy like bladder training, fluid, and diet modification, Kegel’s exercises and Pelvic floor muscle training and drug therapy. However, surgical therapy is well established and over 200 different surgical procedures are described. Most effective and durable long term therapies are Surgical. The goal of the surgical treatment is to provide sufficient urethral support to prevent urine from leaking in cases of increased intra-abdominal pressure. When determining the optimal surgery for a patient, factors to be considered include type of SUI, bladder capacity, severity of the problem, associated other conditions which may require concomitant surgery (like prolapse). There are many modifications since the advent of surgeries for SUI, to name the most common ones performed- Kelly’s plication, retropubic suspension ( Burch colposuspension), Laparoscopic Procedures, Trans Vaginal needle suspension procedures, sling surgery ( mid- urethral polypropylene mesh, Tension free Vaginal Tape, Trans Obturator Tape), bulking agents, etc. Sling surgeries are the most popular and easy to perform surgeries. The choice of the surgery depends on the cause of urinary incontinence and thus to ensure optimal efficacy of the selected procedure with reduction in risk of complications, careful patient selection is a must.
The other common complaints are increased frequency of urination- day and/or night, inability to reach the washroom when there an urge to pass urine (urgency) and inability to hold the urine before reaching the toilet with some amount of leakage of urine (urge incontinence). In these patients detailed history especially of any associated medical conditions (like diabetes, high blood pressure on treatment) is vital. Urinary infection is also ruled out in patients with these complaints. After the diagnosis is confirmed, the treatment is mainly pharmacological and non-surgical. The underlying medical condition should be addressed along with the treatment for the urinary complaints; minimizing the side effect profile of these medicines. The treatment is always individualized depending on the severity of the problems. When patients have mixed symptoms along with SUI, non-surgical or pharmacological methods are preferred as first line treatment followed by surgery for SUI ( if needed).Thus, to conclude, urinary symptoms are commonly encountered problems in gynaecological practice and it is of utmost importance to
focus on its prevention along with treatment, eliminating their negative effects on the quality of life.
About the Author
Dr. Nishita Shah has completed her MBBS, DNB, ICOG fellowship in Reproductive Medicine (Mumbai). She is practicing Gynaecologist, with special interests in Urogynaecology and Infertility. She has been the Youth Council Member in Mumbai Obstetrics and Gynaecological Society for over five years. Dr. Nishita works as Consultant Obstetrician & Gynaecologist at Opera House, Kemps Corner, Colaba; Hospital Attachments: Bhatia hospital, St. Elizabeth’s Hospital, Surya Mother and Childcare Hospital, Shanti Nursing Home (Ghatkopar), Apollo Spectra hospital, K. J. Somaiya Hospital. She has five years of experience in practice, and has won prizes and awards at National and International Conferences for various paper and video presentations. Nishita has authored and co-authored chapters in different textbooks and publications in journals.