POST MENOPAUSAL ENDOMETRIOSIS

FREQUENCY, DIAGNOSIS AND MANAGEMENT

Endometriosis a common gynaecological disorder occurring in 5 to 10% of the female population. It is a disease that affects younger women during their fertile life. It is supposed to be oestrogen dependent and therefore subsides after menopause. However it still occurs in 2.5 % of post menopausal women. Now there are millions and millions of postmenopausal women, and thousands are with Endometriosis, thus the gynaecologists often come across them. In recent times management of postmenopausal endometriosis is being considered. There is no clear cut pathogenesis on endometriosis. A very old retrograde menstruation theory does not explain all situations. In some case endometriosis has been seen in some 60 to 70 year old women, without any previous history. These lesions are deep, adhesive and sometimes far off from the pelvis. Besides retrograde menstruation, the other factors can be familial predisposition, genetic and epigenetic factors. It can also happen because of coelomic metaplasia, (meaning the bowel epithelium changes into endometriotic tissue) It can also arise from foetal remnants or abnormal oestrogen production from non ovarian tissues. Perhaps immune deficiency also plays a role it is believed that a hormone called Aromatase can convert the local testosterone into oestrogens and a de novo endometriosis arises. Levels of this hormones are higher in postmenopausal women . This can happen more often in obese women. No single theory can explain endometriosis especially when it happens for the first time. It often happens away from the pelvis on non gonodal (not gonads) such as, organs, kidney, ureter (the tube that connects the kidney to the bladder), appendix and bowel. Very rarely it is even reported on the skin. HRT is often responsible for postmenopausal endometriosis especially if oestrogen only therapy is used. Phytoestrogens (oestrogens from plant sources), these are over the counter drugs and their irregular use can reactivate endometriosis in post menopausal women who had it in younger years. Previous endometriosis can even become malignant if oestrogen only therapy is used in hysterectomised post menopausal women.

When women suffer, with pelvic pain, dyspareunia, Dyschezia (pain on bowel movement), abnormal bleeding, and known to have had endometriosis, has had surgical treatment, even if no history of endometriosis, always keep endometriosis in mind. Now if a woman is still having hot flushes, foggy head, lack of sleep and requests treatment for her problems; what can be offered to help her? After looking at her basic previous history, tests such as, a pelvic examination, cytology basic blood tests, maybe an ultrasound, a laparoscopy, if the pain is significant. If there are any significant findings, such as cysts on the ovary and deep infiltrating endometriosis, surgical treatment is advised. If there are no surgical findings medical treatment can be offered. This can be in the form of oestrogens, progesterone, and modified oestrogens called SERMS (modified oestrogens which act differently on different organs). If she still has her uterus and has recently become postmenopausal, concerned about pregnancy, she can try an oral contraceptive pill. Use a pill that best suits her. She can also try a group of hormones called GnRH analogues (these can lower the sex hormone levels). Tibolone, a synthetic steroid which acts as oestrogen, progesterone and testosterone, is a very useful drug. It helps with hot flushes, decreased libido and is very easy to take. It is a useful HRT for postmenopausal with endometriosis. It has a slightly increase risk of DVT.

Postmenopausal endometriosis is mostly recurrence or continuation of premenopausal endometriosis however there are cases reported which seem to arise new. There pathophysiology is difficult to understand.  Beside the explanations mentioned earlier it is also believed that an inflammatory  small cell protein involved in cell signalling called interlukin  play an important role by allowing ectopic endometrial cells to implant in different places and help them to grow. It is also suggested that stem cells modify as endometrial cells.

Conclusion: - Postmenopausal endometriosis is known to occur in about 2.5% of this group of women. It should always be kept in mind when postmenopausal women present with symptoms of pain and / or abnormal bleeding.

Since the postmenopausal endometriosis can be malignant, they can be surface ovarian cancers, endometrial and clear cell cancers; surgical treatment should be the first line of approach.  Many case reports where endometriosis is seen to occur outside the pelvis, such as the ureter, appendix, and bowel loops, and vagina. In one recent case report on the liver in which after surgical treatment, a SERM (conjugated equine oestrogens/ Bazidoxifene,) was used, as a modified HRT which preventing oestrogen acting on the endometrium (preventing the risk of endomtrial cancer), was used, and endometriosis completely resolved. I wonder if in future others will try to do this. Further research is needed to manage the postmenopausal Endometriosis and guidelines for surgical treatment and different newer HRT, will also be very welcome.

BOY OR GIRL? IT DEPENDS ON THE MALE PARTNER

This story starts in 1962. I was a very young doctor, just started a new job at a newly opened Medical school as a lecturer. It was my very first day, at my first job after completing my training. Those days there was no ultrasound, not even an x-ray machine nearby. My registrar called me to this new admission in the labour ward a woman was in established labour, who had never seen a doctor throughout her entire pregnancy. She had an enormous belly. It was difficult to feel anything. I expected it to be a twin pregnancy with too much fluid. We had no idea about her blood count. She told us she is trying for a male child and already has six daughters .Within minutes of her arrival the first child was born, the second child was already in a big hurry to arrive in the world , her belly was still somewhat biggish, however I gave her the injections to prevent bleeding which  is given after twin birth, then suddenly I realised that there was another baby, I had never witnessed  a triplet birth and never thought of it, we rushed a bit, to save getting  this baby trapped  after the injection, but luckily this baby arrived safely. Guess what, all the babies were girls well formed all normal with good weights between 4.5 lbs to 5 lbs. I suddenly felt very sad. I did not know how to tell the parents I told them of a family who had 8 daughters hoping for a son one day they all became very successful doctors. Here with this lower middle class family I was worried about their feeding and schooling.  60 years on, since I still think of what happened to them. In some countries there is such a fanaticism about having a son to carry the family name. Sadly the women are always blamed however it is the fathers Y chromosome which is responsible for the sex of the baby. In humans there are two sex chromosomes X and Y. The females have XX and male are XY. When a baby is being formed, an X chromosome comes from the mother and Y from the father, if there is a Y chromosome then the baby will be male. There is a 50 /50 chance in nature what will happen.  There are a few theories. The sperm can be male or female depending on what a particular man has inherited. The male are divided as mm, mf, and ff, men with mm sperm will mostly have boys and ff will mostly have girls. This varies in different generations.  The female sperm is longer stronger and also lives longer so a few theories were suggested that if you want to have a female child work out your ovulation and refrain from having sex two to three days before that, by the time you ovulate your male sperms may have demised, and if you want a male child have sex as close to ovulation as possible the fast running sperm will be able to fertilize the egg. In the 21^st century ovulation can be worked out by temperature charts, and ultrasounds, even an artificial inoculation of sperm can be done on the precise day. This in my very brief experience proved excellent. In more sophisticated medical situations where sexing is required for prevention of sex linked diseases, a micro sort system is recommended in preference to per implantation biopsy and intra villous sampling. Stories also go about what position you adopt during sex for a boy or girl. Inherited billionaires have more boys. People who have more brothers have more sons and vice versa. How do we guess in modern times when everybody has only one or two siblings? To my way of thinking the ovulation technique seems more scientific. Poor King Henry the VIII was not aware of any of this, and that it was he who was responsible for the sex of his child and not his queens.

INTERSTITIAL CYSTITIS (IC) OR PAINFUL BLADDER SYNDROME

This is a poorly understood condition, which millions of people suffer from around the world. Two thirds of these are women.  Here we will focus mainly on women. They suffer from pain in the bladder area (that is why it is also called bladder pain syndrome or BPS). There is pain in the inner thighs, back ache, chronic pelvic pain, pain on passing urine, need to pass urine frequently without much urine in the bladder. There is no bladder infection. The problem must be going on from 6 weeks to 6 months. The Bladder is the bag where the urine collects from the kidneys, when it is full the brain sends a message to pass urine. Normally it is not painful; except when there is a bladder infection. However IC or BPS the frequency of going to the toilet 50 – 60 times during a 24hr period, middle of meetings or odd times makes sex life distorted, due to exaggeration of symptoms for several days following sex.  Even more pain during menstruation and any kind of stress, acidic type of food, strawberries, lemons, oranges, coffee, and chocolate.  It is commonly believed that cranberry juice helps urinary symptoms but in fact it makes IC worse all this makes life very difficult for women. There are many conditions, which cause symptoms similar to IC that women suffer with and some of these are Irritable bowel syndrome, Endometriosis, Sexually transmitted infections, kidney disease, bladder cancer or stone, chronic fatigue, fibromyalgia, multiple sclerosis, emotional behavioural and sexual dysfunction consequences.  Many of these are quite serious. What causes IC is not understood. There is some genetic predisposition, female sex, fair skin, red hair, chronic pain disorders, some kind of autoimmune problem (that is when the body attacks itself). Can it be Hormonal, as it is more common in females?  Is this a viral or unknown infection?  There are defects  seen in the bladder mucosa, it is not  clear, if it is the cause or the result of the disease, a leak  from these  areas  irritates the bladder by the substances in the urine.

Many researchers believe that a substance called, antiproliferative factor (Substance that can interfere with healing, APF) found in the urine of people, with IC hinders the healing of the damaged mucosa of the bladder. In fact these researchers are seeking to use APF as a biomarker for IC. Many other conditions need to be excluded before we start thinking of IC. Some of these are, as already mentioned others can be radiation treatment, drugs that may have caused allergy to the bladder, pelvic floor disorders, damage or entrapment of pelvic nerves, vulvodynia, (pain in the vulval area without any obvious infection or skin disease) prolapse of pelvic organs, vulval or vaginal or cervical pathology, pelvic masses such as ovarian disease, and trigger points causing pain tenderness and muscle spasm.  

For making a diagnosis history is very important. It must be going on for 6 weeks to 6 months, take a family history, any radiation any drugs or any other problems. It is most important to exclude any bladder infection at present and during this time. Do a urine culture and urine cytology, this will exclude any infection or cancer cells. A clinical pelvic examination can exclude any prolapse, vaginal, vulval, uterine and often ovarian pathology.  In IC the bladder base is tender on an internal examination. Another test that is that can be performed is called Urodynamics. This can measure the bladder pressure and its capacity, women with IC start feeling the pain very soon after it starts to fill and get a desire to pass urine. The other test that is done by a few   doctors but not recommended by everyone is a Potassium solution test. In this test, water is used to fill the bladder followed by a potassium solution and in women with IC; filling with potassium solution is very painful. The other test called a Cystoscopy needs to be done by a specialist gynaecologist, urologist or urogynaecologist. In this test the bladder is instilled with fluid and then examined by a Fibroptic light with a Telescope. 

This shows petechial haemorrhages in the bladder wall (small pinpoint bleeding, also called Glomerulations) in different quadrants of the bladder, reddened mucosa, submucosal bleeding, and mucosal disruption, oedema with or without bleeding. This is diagnostic of some forms of IC. Depending on these finding IC is classified into four grades. Then, there are striking reddened patches on the bladder wall called Hunners ulcers. 

This finding also suggests another type of IC. Hunners areas, decreases the bladder capacity due to fibrosis and is more distressing than the one with minute haemorrhages.  A bladder biopsy is taken from these ulcers; this shows inflammation, mast cells that can cause severe allergic reaction, fibrosis and granulation. There is a questionnaire about pelvic pain frequency (PPF) and urgency of micturition which is filled by the client and if the score is 10 or more it is in favour of IC. It has been shown that the Clinicians under diagnose IC by a large percentage because they do not always think of IC in women suffering from chronic pelvic pain.
This  is  difficult  to  understand  what  causes  all  these  problems? The main question is; what is the solution? This depends on the age, severity, and how much stress is it causing and interfering with the quality of life.  

For a start, self help is required, stop the trigger factors, stress, foods that upset IC, smoking, meditation, yoga, planned breaks for toilet, gentle stretching exercises and restrict drinks before bed time. Physiotherapy for pelvic floor muscles, psychotherapy, proper bladder retraining.  Some drugs such as simple paracetamol, non steroidal anti inflammatory drugs (NSAIDS), antihistamines (anti allergy drugs) and antidepressants have all   been tried. Some tablets that help to relax the bladder are tried in more serious cases

There is one special tablet called, Pentosan Polysulphate Sodium which is an oral medication which is tried in many clinics. It takes 2-6 months to help.  Pain relief takes the longest time .First it is tried for 3 months and then for further 3 months. Its side effects are minimal nausea, headaches, dyspepsia and liver dysfunction, these are all reversible. They probably act by mast cell deregulation, immunological and neurological effects. These down regulate the activity of the sensory fibres that take the pain sensation to the brain. There are also drugs that are instilled into the bladder weekly for 6-8 weeks and then 2-5 weeks to relieve the pain and relax the bladder for three months. These are called Dimetylsulfoxide (DMSO). Some clinicians mix Heparin and Lidocaine( a local anaesthetic) for better relief of symptoms. Nerve stimulation technique is also tried by a Tens Machine, or Sacral Nerve Stimulation by a device similar to a Pacemaker called InterStim.

In some cases surgery is tried by electro  cautery or laser for  the bladder ulcers, resection of  the  abnormal area, Sub mucosal   injection. In rare situations enlarging the bladder size by using the gut is performed, but this does not help with pain. Extremely rare situations bladder is replaced by a bowel loop. There are many such techniques; this requires very special surgeons and special care of the urinary diverted loops or opening stoma. On a simpler front acupuncture and herbal remedies are tried.

Interstitial cystitis is a very stressful condition which mainly affects women causing pain, urgency and frequency of micturition in absence of any infection of the blabber or any other discernible pathology. There is no definitive treatment for IC. It cannot be cured. A combination of treatments goes a long way to relieve symptoms. Treatment is generally started in simple ways.  Progressively more and more complicated procedures are performed to help a very distressed woman.

PELVIC ORGAN PROLAPSE (POP)

Pelvic organ prolapse simply means that the pelvic organs descend into the vagina. This includes bladder (cystocele ) rectum (rectocele), uterus and bowel (enterocele ). All of these are not seen all the time in the same person, different combinations of POP is present in different women. It is also classified in degrees depending how far down it has come , when it is a bit in the vagina it is first degree , when it is at the opening of the vagina it is second degree, when it is outside it is called third degree, when it hangs totally outside it is called procendentia .

Globally one in five female suffers from it. However women do not complain about it, perhaps they are embarrassed about it and do not know that it can be treated. In developing countries almost 50% of women suffer due to difficult child birth at home. The main cause of POP is child birth, chronic cough, smoking, constipation, obesity, and hormone deficiency at during and after menopause. It can be occupational due to standing too long and heavy lifting all the time. POP in women who have never had a child is very rare; it is usually due to developmental defects either in the pelvis or the spine. Women who have POP also suffer from urinary problems such as leakage of urine (incontinence) and even faeces.

The symptoms women experience is a feeling of pressure in the vagina and with a finger they can feel a lump. Other symptoms are, pain on standing, backache, belly ache, difficult sex, urinary and bowel problems. Often in very severe cases the pelvic organs constantly hang out. Treatment can be started very soon after child birth with pelvic floor muscle exercises. In fact in many places when maternal health is taken seriously they are taught to the mother at the time of discharge. The most common is called Kegal exercise which has been going on for generations.  Perhaps some women may remember being told about it, when they had their baby. Changes in life style factors is also important,  such as avoiding constipation, smoking,  being overweight, proper eating habits, use of oestrogens if women are in the menopausal age group.  The other non surgical treatment is pessaries.

These help to keep the pelvic organs pushed inside.  They need to be changed every three to six months. Sometimes the women can do it themselves but it is best if a clinician can do it, so that they can look for any infection, ulceration and can do cervical smear when required. This treatment is ok when the women do not wish for operative treatment or are unfit for it or often too old.

Operative Treatment

This depends on several factors; how old is the women, what is the actual problem, for example a cystocele and what else, most importantly is the preservation of the uterus required or is it a nulliparous POP? (This means a woman has never had a child). The operations are cystocele and, rectocele repair or both and repair for descending cervix.  If it is a nulliparae’s prolapse the cervix is lifted up by different types of sling operation, hitching it to sacral promontory of the spine. These were invented by Indian gynaecologists as this is common in India.

Some other sling operations are also performed if there are urinary and bowel problems. I will discuss these in my next blog. Side effects of these operations are they can recur in 20-30% of women, especially after a child birth and soon after repair, or a POP can come up in another place. If the rectocele repair becomes tight it causes painful sex and bowel problems. In older women when preservation of uterus is not desired a vaginal hysterectomy with the repair for other defects is performed. Following these operations a catheter is left in the urinary bladder while the tissues heal.  Women are usually in hospital for 2-5 days.

One very last operation is the total vaginal fusion. This is done when intercourse is never desired and the uterus is absent. A slightly modified operation called La forts operation was once performed in 1877 and then it sort of died out.  Now it is coming back as women are living longer. This is a very simple operation with a success rate of 90%.  It can be performed under local anaesthesia. Hospital stay of 2 -3days, hardly any complication rate and satisfaction rate of women is very high. With changing demographic this is more often required.

POP is a big subject now so much so that it has become a separate speciality within the field of gynaecology. There should   be more public awareness so that the women are not hesitant to ask for help in early stages of POP problems.

ADENOMYOSIS: ENDOMETRIOSIS OF THE UTERUS

Eva is 37 years of age has 2 children; 6 and 4. For many months she had been having very heavy and painful periods. She was unable to cope with her day to day life; her quality of life was getting progressively worse. She went to see her GP, and complained to him about all her problems. He asked her if she had any difficulty with her bowel and urination, she immediately answered yes. I have pain both on urinating and bowel action and also frequency of passing urination. When the GP examined her he noticed that she was looking pale, he could feel her enlarged uterus on abdominal examination and confirmed this on pelvic examination, that it was about the size of 12 -14 weeks of pregnancy it was hard and tender. The uterine size is expressed with reference to the size of pregnancy; however during pregnancy it is soft. He did her haemoglobin, this was low 9.6gm (Normally it is about 11-12). He was an experienced GP, and gave her a diagnosis of a uterine Fibroid or a condition called Adenomyosis.

Adenomyosis is a condition in which the endometrial cells grow within the uterine muscle layers. It can be scattered in the muscle or form a mass like effect, unlike fibroids it does not have a capsule or an outer cover. It is believed that it affects up to 65% of females in their life time. A few decades ago it was thought that it does not affect young women who have had no children. Recently with the improvement in diagnosing Adenomyosis (ADENO) with Ultrasound and MRI it is believed that 35% of women suffering from ADENO are nulliparae’s (women who have never had a pregnancy), in fact in English medical literature some cases had been reported in adolescent girls. One third of the females suffering from ADENO have no symptoms. Others suffer from heavy painful menstrual periods, lower abdominal pain, and pain on intercourse, passing urine and on bowel actions. It also causes infertility, miscarriages and even premature birth. If associated with polycystic ovarian syndrome it is even worse due to high oestrogen levels. This makes IVF difficult due to altered uterine shape, uterine peristalsis, and makes embryo implantation difficult; a toxic and altered hormonal environment makes it further worse.

One problem is that it is a long disease, which lasts for years almost up to menopause. It often becomes mild after menopause or goes away. I have removed some very enlarged painful uteri, in post menopausal women.   A patient’s medical history and a clinical pelvic examination give a good clue to its diagnosis. Blood tests can be done to assess a woman’s condition. New high resolution ultrasound and MRI give a precise diagnosis. MRI is an expensive test and not always available ultrasound is nearly as good. In recent times it has been advised to always keep AENO in mind if you have a young adolescent girl with intractable pain and painful period, please do an ultrasound.

Why does ADENO happen? It can be due to trauma to the myometrial and endometrial zone during child birth, an operation such as curettage, caesarean, this is a process of tissue injury repair. The endometrium invades into the myometrium.  The other theory is that, stem or embryonic cells change into endometrial cells and make these endometrial nests or even masses.

The treatment of ADENO initially conservative especially if the woman is young and fertility is an issue.  Antinflamatory tablets are given during periods so that they help pain and excessive bleeding, its effect are minimal to moderate. Next in the line of treatment are hormones, they are either given to make the periods milder or stop them completely.  They all have their side effects and most of them stop fertility, however the good thing is that all of them are temporary.  Let’s start from oral contraceptive pills, then progesterone tablets or injections and vaginal rings. These also give Adenomyosis time to heal, but how much it does; we do not know.  When they are stopped the problem starts again. Another treatment is a progesterone implant a small rod implanted in your upper arm under the skin it lives there for 3 years. It can cause some irregular spotting, prevents pregnancy.  One of the good hormone is Danazol tablets, or danazol loaded intrauterine device which fitted in your uterus for 6 months.  This has a great advantage that a woman can still achieve a pregnancy while she is using this.  A strong hormone treatment is Gonnadotrophin releasing Hormone (GnRH). This is given as an injection every at 1 to 3 monthly intervals. This suppresses our pituitary gland, thus our ovaries, hence no more periods. This cannot be a very long term treatment; it causes side effects like menopause. Add on treatments are given for these.  One serious side effect is the loss of bone density. In contrast to this, a group of drugs called Aromatase inhibitors which stop the formation of oestrogens in the body from other hormones that exist in the body fat. They are also found to be useful particularly in obese women where extra oestrogen is formed in the body fat. GnRH is unable to do this.

An present an intrauterine device containing Levonorgestal is found to be the best reversible treatment of Adeno. It prevents fertility and can be used repeatedly, after every 3-5 years.  The failure rate of treating symptoms is only 20 percent. There is a smaller IUD now available and can be tried in adolescents. Local excision of adenomyosis has been tried, but it is not easy and long term results are a bit questionable and unsatisfactory. The treatment of ADENO depends on, if fertility is to be preserved. Hysterectomy is the best treatment, although uterine artery embolization and endometrial ablation is also tried with some success.  As long as a patient agrees to surgery, a hysterectomy can be performed abdominally, vaginally or laparascopically and now even robotically.

Generally ovaries do not need to be removed.  In some very difficult cases it is found to spread into the bladder and bowel.

Adenomyosis is a difficult and painful condition from which women used to suffer a lot in the past, but the new techniques of diagnosis and treatment have helped the gynaecologist in its management.  

CAUSES OF HOT FLUSHES AND NIGHT SWEATS

Most women in their life time experience hot flushes and sweating at night or even during the day. When peri menopausal, menopausal and post menopausal; it is estimated that this happens in about 15% of women throughout their lives. This can be very uncomfortable and very embarrassing depending on where you are and what you are doing at the time. The simple answer is to wear light clothing, give up smoking if you are a smoker, try HRT if it is ok for you, or natural remedies.

There are many other endocrine conditions which cause hot flushes and sweating, overactive Thyroid (this controls our body function and is located in the neck). If the hot flushes are not controlled by menopausal treatment, have your thyroid tested. It is common to have thyroid disorders during menopausal years, and the treatments are simple.

There are few other endocrine causes which can cause these symptoms, these are 1) Pheochromocytoma, this is a tumour of the Adrenal gland, 2) Carcinoid syndrome, is a complex syndrome arising from the appendix. This can occur at any age and will have many other symptoms associated with it. Often if someone is diabetic and is on insulin or diabetic drugs, sweating can happen due to low blood sugar, this is a serious problem and can be life threatening. Treatment is simple, sugar drinks or a glass of fruit juice with some food.

Various infections also cause sweating; some of these are very serious, such as Tuberculosis, Osteomylitis (bone infection), Endocarditis (infection of heart valves), HIV, Abscesses formation, Malaria and other infections.

Cancer also causes sweating and fever. Lymphomas are more common to do so.

Certain drugs particularly antidepressants are known to cause sweating.

Stroke and Heart Attacks can cause severe sweating.

Many disorders of the nervous system also cause sweating

My idea of giving women this list is to make them aware of the many causes of sweating. Most of these can happen suddenly and at different age groups, along with many other symptoms, so take notice and do not ignore them.

URINARY TRACT INFECTIONS IN FEMALES

Urinary tract infections (UTI’s) are a very common problem in women and young female children. What is a urinary tract in humans? It consists of two kidneys on either side of our spine in our abdomen. Two tubes called the ureters run one from each kidney into a bag called the urinary bladder. In the female a small tube called the urethra opens to the outside from where females pass urine. In men it is different, it is long and on the way it is connected to other tubes. 

Of all the urinary tract infections that happen 80% happen in women. According to one study almost 50% of women have had at least one UTI in their lives by the time they are 50. UTI’s when simple are confined to the urinary bladder  this is called cystitis.  In some women and children it happens repeatedly than it becomes more significant. It can even travel to the kidney, and it is called pyelonephritis, it can become more serious. In even more neglected cases it can cause serious infection in parts of the body, so do not ignore UTI’s or simple bladder infections. What causes UTI’s so commonly in women. It is because our urethra is small, it is close to the rectum, and bacteria easily travel to the urethra and causes infection. It is also possible that local hygiene is not so good. Women often need a catheter after an operation, during labour, or other times if they are unable to pass urine. Other causes can be obesity, unprotected sex with an infected person. Some diseases such as Diabetes, Multiple Sclerosis, Parkinson’s Disease and some local abdominal diseases such as  Fibroids (a benign uterine tumour ), Endometriosis, Ovarian Cysts, Vaginal Infections, Kidney or Bladder Stones and using local contraceptives such as Vaginal Foam and a Diaphragm. Menopausal and post menopausal women are also very prone to UTI’s due to lack of protection from Oestrogens. Chemotherapy and commercial personal hygiene products. Malformations of the UT may be a cause of UTI’s. This will show in childhood and often recurrent.

What are the symptoms of UTI’S?

Rarely there are any symptoms, mostly women have frequent moments of passing urine and it is painful to do so. There is back ache (where kidneys are located), pain in the stomach and on the side of the abdomen. There can be nausea, vomiting, fever and even diarrhoea. The urine can be smelly and may contain blood. A young child will have all these problems. She may refuse to eat. The best thing is to go to the doctor. They can do a dip test with a strip in urine to confirm  infection and send a urine sample collected after wiping the vagina called the mid stream urine, for culture and appropriate antibiotics are started immediately. The symptoms improve within two days. If this does not happen the ABS are changed as the urine culture report will tell the doctor about the infecting bacteria and the suitable Antibiotic. A urine culture is also done after treatment to ensure that the infection has cleared. If a woman or children have recurrent infections, many other tests are done. These are an ultrasound, tests for STD’s,  a Cystoscopy meaning there by looking with a telescopic light inside the urinary bladder. Also make sure that the child is not being molested by anyone. Children sometimes have a problem that when they pass urine some urine goes back into their ureter. (The tube connecting kidney to the bladder) This requires surgical treatment. If this is not done the kidneys maybe damaged.

Women and girls who get repeated UTI’s should address their life style factors. Drink plenty of water, do not wear tight clothing, and do not wear anybody else’s clothes. Avoid grapefruit and cranberry juice that is recommended on social media for UTI’s. Use correct and safe contraceptives. Always have safe sex. Keep good hygiene for external parts of the body, when wiping bottom, wipe from top to the bottom.

         For women who get recurrent UTI’s meaning they have 2 episodes in 6 months or 3 in a year, Prophylactic treatments are required; with Postcoital Antibiotics, Continuous Low Dose Antibiotics and treatment for any voiding problems such as prolapse management of serious infections such as Aids, Antibiotics with UT instrumentation such as catheters.   

        

         Pregnancy and UTI’S

         In pregnancy UTI’s are important. In fact in all pregnant mothers a urine test is done and if there is bacteria even in absence of infection this is treated. UTI’s in pregnancy an cause premature  labour and due to  abdominal pressure, the infection can quickly go into the kidney causing pylonephritis. The women become very sick, symptoms become more severe, they are given intravenous antibiotics. They need to be hospitalized. If UTI’s happen again during pregnancy a woman is given prophylactic ABS for the rest of her pregnancy.

In UTI’s in addition to ABS we use urinary antiseptics they help and prevent bacteria, if the infection is simple and in the bladder alone for prophylaxis. In these situations we need to watch the sensitivity of bacteria so that the resistance bacteria do not develop,which will be impossible to treat. This is one big disadvantage of using prophylaxis.

Besides UTI’s there are a few other common problems with URINARY TRACT which are not strictly infection. One of them is called Interstitial Cystitis (IC) or Bladder Pressure Pain. This is a painful condition without infection. It is poorly understood, difficult to diagnose and treat. It is believed that there is some defect in the bladder lining which is irritated by food, sex and some vulval hygiene products. Diagnosis is made by using a cystoscopy in which they use a potassium solution for bladder wash this causes pain in women with IC. Treat is not very effective, women need a lot of psychological help, nonsteroidal anti inflammatory tablets, antihistamines and tricyclic anti depressants. In USA, FDI has allowed one oral drug Pontosan polysulfate to a maximum of six months. Change of life style factor is also recommended. Other urinary problem often in the elderly is over sensitive bladder when you need to go to the toilet frequently but there is no UTI. For this, one has to do pelvic floor exercises, bladder training, scheduled toilet trips, absorbent pads or underwear. Local oestrogen cream may help and intermittent catheterisation which in itself can be risky.  Usually the bacteria in UTI’s is ECOLI, which comes from our bowel but in unusual circumstances and in nursing homes they can be more serious and  difficult to treat, these are Proteus , Pseudomonas , Klebsella and bacteria from STD’s

Urinary tract system in our body is very important, as it gets rid of all the waste products from our body. If kidneys fail humans are on death bed. Special attention should be paid to all our Urinary tract problems particularly in children, women, pregnancy and the elderly. Never ignore blood in the urine, rarely can it be due to UTI’s but it can be a sign of cancer. Women do die from UT cancers.