Female urology

Petrou, Steven P.

doi:10.1590/S1677-55382004000400022

UROLOGICAL SURVEY

Female urology

Urinary urgency and frequency, and chronic urethral and/or pelvic pain in females. Can doxycycline help?

Burkhard FC, Blick N, Hochreiter WW, Studer UE

Department of Urology, University of Berne, Berne, Switzerland

J Urol. 2004; 172: 232-5

PURPOSE: Persistent urinary urgency and frequency, and chronic urethral and/or pelvic pain in women are often a diagnostic and therapeutic challenge. This can be frustrating for patients and physicians. The search for an infectious agent often proves futile and after multiple ineffective treatment regimens patients may be classified as having interstitial cystitis or referred to a psychiatrist as the last option. We evaluated whether treatment with doxycycline of the patient and her sexual partner would be beneficial.

MATERIALS AND METHODS: Women presenting with a history of urinary urgency and frequency, and chronic urethral and/or pelvic pain often associated with dyspareunia and/or a history of recurrent urinary tract infection were evaluated. Initial examinations included urethral and cervical/vaginal swabs, serum analysis, urine examination and culture, and bladder barbitage. A total of 103 women with a median age of 46 years (range 21 to 84) and with a median symptoms history of 60 months (range 3 to 480) were included. All patients had trigonal leukoplakia at cystoscopy, in 15% an infectious organism was identified and 30% had leukocyturia. All were treated with doxycyclines, and a vaginal antimicrobic and/or antimycotic agent following the same regimen, including treatment of the sexual partner.

RESULTS: After treatment with doxycycline 71% of the women were symptom-free or had a subjective decrease in symptoms.

CONCLUSIONS: Treatment with doxycycline is effective in more than two-thirds of patients complaining of persistent frequency and urgency, chronic urethral and/or pelvic pain, and dyspareunia as well as a history of recurrent urinary tract infections. In women with negative urinary cultures but a history of urgency/frequency probative treatment with doxycycline is justified and endoscopic findings may support the hypothesis of chronic infection. This should be done especially before contemplating psychiatric treatment or diagnosing the patient with interstitial cystitis. We attribute this high success rate to simultaneous treatment of the sexual partner, who may be an asymptomatic carrier, although this remains to be proved.

Editorial Comment

The authors review the efficacy of doxycycline therapy for one month on female patients with urinary urgency, frequency, chronic urethral and/or pelvic pain. Of note is that only 15% of the patients had an identified infectious organism. All patients have trigonal leukoplakia at cystoscopy. At the time of treatment with doxycycline the patient also underwent therapy with a vaginal antimicrobic and/or antimycotic agent. In addition, all sexual partners underwent synchronous therapy.

The use of antibiotics in the absence of a true positive culture is a therapy that many of us have tried, in both males and female. Who can say that he has never treated a man with prostatitis with long-term antibiotics in the absence of a positive culture and then experienced a positive clinical result. The subselection of patients to receive therapy with leukoplakia is interesting. Leukoplakia has been described and discussed previously in the literature (1). In addition, it was noted that the patients had synchronous therapy with a vaginal antimicrobic or antimycotic agent and had the sexual partners treated as well. It would be interesting to subdivide the success rates between those patients who had a sexual partner that was treated and those patients who did not have a sexual partner thus obviating the need for therapy for same. Potential difference in success rate would have perhaps shed light on the ping-pong reinoculation effect with a sexual partner versus a difficult primary problem of a non-infectious nature. In addition, that patients had a synchronous therapy with a vaginal antimicotic and/or antimycrobic agent does confuse the issue to a degree. Perhaps vaginal pathology was as much to blame for the troublesome symptoms as was a primary bladder difficulty. The efficacy of doxycycline may be multi-factorial including that it is the only medication in its class that is renally excreted thus potentially achieving excellent bladder urine levels. If increased serum antibiotic levels do lend themselves to an increased therapeutic effect, then direction instillation of antimicrobial solutions in the bladder should not be discounted or forgotten in this challenging patient population (2).

References

1. Petrou SP, Pinkstaff DM, Wu KJ; Bregg KJ: Leukoplakia of the bladder. Infections in Urology. 2003; 16: 95-105.

2. Arap M, Petrou SP: Efficacy of intermittent intravesical gentamicin sulfate solution for recalcitrant recurrent cystitis in women. Infections in Urology. 2003; 16: 45-8.

Dr. Steven P. Petrou

Associate Professor of Urology

Mayo Clinic College of Medicine

Jacksonville, Florida, USA

Does Valsalva leak point pressure predict outcome after the distal urethral polypropylene sling? Role of urodynamics in the sling era

Rodriguez LV, de Almeida F, Dorey F, Raz S

Departments of Urology, The Geffen School of Medicine at the University of California Los Angeles,

Los Angeles, California, USA

J Urol. 2004; 172: 210-4

PURPOSE: Recently sling procedures have been shown to be effective in the treatment of all types of incontinence. In this study we evaluated the role of preoperative Valsalva leak point pressure (VLPP) in predicting the outcome of sling surgery.

MATERIALS AND METHODS: We prospectively evaluated 174 consecutive patients who underwent a distal polypropylene sling procedure for the treatment of stress urinary incontinence (SUI). Using SEAPI scores patients were divided by VLPP into group 1-60 patients who did not leak on urodynamics, group 2-27 patients with VLPP greater than 80 cm H₂O, group 3-71 patients with VLPP 30 to 80 cm H₂O and group 4-16 patients with VLPP less than 30 cm H₂O. Surgical outcomes were determined by symptom, bother and quality of life questionnaires filled out by patients. The physicians were blinded to patient response.

RESULTS: Mean followup was 14.7 months (range 12 to 30) and mean patient age was 62 years (range 32 to 88). The groups were well matched before surgery with respect to age, number of previous surgeries, and severity of SUI symptoms and urge incontinence. The percentage of patients who were cured or improved was similar among groups. After surgery there was no statistical difference among patient mean self-reported symptoms of or bother from SUI or urge incontinence.

CONCLUSIONS: The distal urethral polypropylene sling provides similar symptom improvement in all patients regardless of preoperative VLPP. VLPP is helpful in the diagnosis of SUI but appears to be of minimal benefit in predicting the outcome of the distal urethral polypropylene sling procedure.

Editorial Comment

The authors review the Valsalva leak point pressures obtained preoperatively before the placement of a distal urethral polypropylene sling and then correlate those values with the outcome of sling surgery. This paper is well written and is of great value. It was noted that the valsalva leak point pressure was helpful in evaluating stress urinary incontinence but could not accurately predict which patients would be a surgical success or not. This further highlights the utility of the minimally invasive sling procedure as a therapeutic option for all degrees of stress urinary incontinence. The authors found that patients with lower valsalva leak point pressures were likely to have significantly more severe stress urinary incontinence symptoms. This finding has been noted before (1). The value and role of urodynamic testing in stress urinary incontinence has been a long time subject of discussion in the field of urology (2). This academic contribution continues that intellectual discourse.

References

1. Nitti VW, Combs AJ: The correlation of valsalva leak point pressure with subjective degree of stress urinary incontinence in women. J Urol. 1996; 155: 2815.

2. McGuire EJ, Lytton B, Kohorn EI, Pepe V: The value of urodynamic testing in stress urinary incontinence. J Urol. 1980; 124: 256-8.