Urinary Tract Infection, Lower (Cystitis, Urethritis)

- An inflammation of the bladder or urethra.

Causes and Incidence Most urinary tract infections (UTIs) are caused by gram-negative bacteria, with Escherichia coli accounting for approximately 80% of cases. Staphylococcus, Klebsiella, Proteus, Enterobacter, and mixed infections account for most of the remainder. The infecting bacteria are commonly normal intestinal and fecal flora. Interference in urine flow dynamics puts an individual at greater risk; such individuals include those with underlying obstructions (strictures, calculi, tumors, prostatic hypertrophy), neurogenic bladder, vesicourethral reflux, and diabetes or renal disease; those who are sexually active or pregnant; and those undergoing medical or surgical procedures, such as catheterization or cystoscopy. Women are 10 times more likely than men to have a UTI because of anatomic construction of the female urinary system. Approximately 20% of women have at least one UTI in their lifetime.

Disease Process Bacteria invade the urethra and bladder when the body defense mechanisms (regular emptying and cleansing of the lower urinary tract by urine flow) are diminished or absent. When urine flow is impeded or interrupted, or when the bladder is retaining residual and static urine, bacteria can ascend the urethra, move into the bladder mucosa, colonize, and multiply; this sets up the inflammatory process.

Symptoms Common signs and symptoms include pain; burning on urination; frequency; urgency; nocturia; cloudy, foul-smelling urine; and hematuria.

Potential Complications The major complications include damage and scarring to the lining of the urinary tract with recurrent infection and ascension of the infection to the kidneys, causing pyelonephritis.

Diagnostic Tests The diagnosis is based on the history and on urine culture and sensitivity to identify the causative agent and its response to a given antiinfective drug. A complete urodynamic workup may be done in those with recurrent infection or to identify factors contributing to infection, such as obstruction, stricture, and detrusor abnormality.

Treatments

Surgery
Revision of abnormalities in urinary tract.

Drugs
Antiinfective drugs (3to 5-day course) to kill pathogen and render urine sterile.

General
Repeat of culture about 14 days after start of drug therapy; increased fluid intake; evaluation of voiding patterns, sexual practices, and hygiene practices for possible preventive measures.

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- An allergic reaction that produces wheals and erythema in the dermis (urticaria) or the dermis and subcutaneous structures (angioedema).

Causes and Incidence Urticaria and angioedema are caused by an allergen that provokes a histamine-mediated response. Common allergens include drugs, insect bites or stings, miscellaneous environmental factors, desensitization injections, and foods (eggs, shellfish, nuts, fruits). About 20% of the general population have an episode of urticaria or angioedema at some time. The peak incidence occurs in adults in their 30s.

Disease Process A histamine response to the allergen induces vascular changes that result in vasodilation and itching. The histamine-mediated response also causes endothelial cells to contract, which allows vascular cells to leak between the cells via the vessel wall to form a wheal on the skin. A more diffuse swelling of subcutaneous tissue accompanies angioedema and is typically seen in the hands, feet, face, and upper airways.

Symptoms Pruritus is followed by the appearance of wheals 1 to 5 cm in diameter. These may enlarge and develop a clear center and erythematous border. The wheals may occur singly or in crops. They may appear in one site, remain for several hours, disappear, and then appear in a new site. Angioedema involves edema of subcutaneous tissues, and the wheals are typically larger. Respiratory distress and stridor may be seen if the upper airways are affected.

Potential Complications Skin abrasion and secondary infection may occur as a result of scratching, and laryngeal edema may occur in angioedema.

Diagnostic Tests The diagnosis is made by history and clinical examination. Other tests are unnecessary unless the urticaria is chronic and has no apparent allergic cause. In such cases underlying disease (e.g., lymphoma, polycythemia, systemic lupus erythematosus) should be ruled out.

Treatments

Surgery – None.

Drugs
Antihistamines to control histamine response; epinephrine subcutaneously for wheals and by mist for pharyngeal or laryngeal edema.

General
Identification and elimination of allergens; avoidance of scratching.

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- Abnormal uterine bleeding not associated with recognizable organic lesion, inflammation, ovulation, or pregnancy.

Causes and Incidence Dysfunctional uterine bleeding (DUB) usually results from an imbalance in the hormone-endometrium relationship when unopposed estrogen stimulates the endometrium. Contributing factors include polycystic ovaries, anovulation, obesity, nulliparity, and use of exogenous estrogen. Variation in uterine bleeding is the most frequently encountered health problem in women, and DUB is the most common cause of abnormal bleeding. It is typically seen at the extremes of reproductive life, with 50% of cases occurring after 45 years of age and another 20% in adolescence.

Disease Process Unopposed estrogen stimulation often causes an endometrial hyperplasia. The endometrium becomes thickened by the estrogen, and when it can no longer be maintained, the endometrial lining sloughs in an incomplete and irregular pattern, leading to irregular, prolonged bleeding.

Symptoms The main sign is painless, irregular, heavy vaginal bleeding. Midcycle spotting, oligomenorrhea, or amenorrhea may also be present.

Potential Complications Anemia is the chief complication.

Diagnostic Tests The diagnosis is made on the basis of the history, a pelvic examination, and laparoscopy to rule out other bleeding disorders or underlying disorders. Endometrial biopsy can rule out cancer.

Treatments

Surgery
Laser ablation or fulguration of endometriosis; presacral neurectomy when bleeding is severe and does not respond to other treatment.

Drugs
Combination contraceptives to control bleeding.

General
Iron replacement or packed cells for associated anemia; adequate nutritional intake; cessation of extreme exercise schedules.

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- Adenocarcinomas account for most endometrial cancer; other tumor types include adenoacanthoma and clear cell and squamous cell tumors.

Causes and Incidence The cause of endometrial cancer has not yet been firmly established although a long-established link exists to hormone-related disorders. However, approximately 40% of endometrial tumors appear to be autonomous with no known etiology. Associated risk factors include adenomatous hyperplasia of the endometrium, menstrual irregularities, delayed menopause, infertility, diabetes or hypertension, and a history of breast or ovarian cancer.
Endometrial cancer is the most common of the gynecologic malignancies, with more than 31,000 new cases a year in the United States. This cancer is found primarily in postmenopausal women between 55 and 60 years of age. The women tend to be from highly industrialized countries, and the prevalence has increased sharply.

Disease Process Cells begin as endometrial hyperplasia and change to cancer cells, beginning in the fundus of the uterus and spreading to the entire endometrium. The tumor may then extend down the endocervical canal and involve the cervix and vagina. It also spreads through the uterine wall to the abdominal cavity and adjacent structures and metastasizes to the pelvic and paraaortic lymph nodes, lungs, bone, and brain.

Symptoms The only significant clinical sign of endometrial cancer is inappropriate uterine bleeding. Approximately one third of postmenopausal women who experience such bleeding have endometrial cancer.

Potential Complications Advanced disease leads to complications such as bowel obstruction, ascites, and respiratory distress, and the prognosis is poor.

Diagnostic Tests A Papanicolaou smear is helpful but undependable, because 30% to 40% of smears yield false-negative results. Malignant cells on endometrial biopsy and fractional curettage yield a definitive diagnosis.

Treatments

Surgery
Hysterectomy

Drugs
Chemotherapy for recurrent lesions and metastasis; hormones (e.g., progestin) to treat metastasis or precancerous lesions.

General
Radiation as adjunct to surgery and palliation; counseling for body image and sexual functioning alterations.

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- Well-circumscribed, nonencapsulated, benign tumors of the uterus.

Causes and Incidence The etiology is unclear, but the tumors tend to grow in response to excess estrogen levels and shrink after menopause. Fibroids are the most common pelvic neoplasm and occur in about 30% of women over age 35. In the United States, the incidence is higher in black women.

Disease Process Fibroids arise from the smooth muscle within the myometrium of the uterus. They may be seen on the intramural, submucosal, or subserous surface of the uterus or in the musculature of the cervix or broad ligaments. Tumor growth often outstrips blood supply, causing the tumor to hyalinize. The hyaline tissue may then liquefy and calcify.

Symptoms Most fibroids are asymptomatic. Symptoms, when present, include prolonged or excessive menstrual bleeding with no change in the cycle interval. Pain, heaviness, or tenderness in the lower abdomen may also be present.

Potential Complications Complications include hemorrhage, torsion and infection, adhesions, and infertility.

Diagnostic Tests The diagnosis is made on abdominal and bimanual palpation of the uterus. Ultrasound scanning may be used to distinguish endometriosis from leiomyomas. Cytologic tests and cervical biopsy may be done to rule out cancer.

Treatments

Surgery
Hysteroscopic or laparoscopic myomectomy to preserve uterus for childbearing; hysterectomy to control heavy bleeding.

Drugs – None.

General
Ongoing gynecologic examinations to monitor fibroids.

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