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Dante Pascali MD FRCS(C) Urogynecology Divison Head Assistant Professor, University of Ottawa

Challenges in Treatments of Common Urogynecological Conditions Challenges in Obstetrics & Gynecology Kuwait Feb 8, 2017. Dante Pascali MD FRCS(C) Urogynecology Divison Head Assistant Professor, University of Ottawa Canada. Disclosures. Consultant for Pfizer, Astellas and Duchesnay.

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Dante Pascali MD FRCS(C) Urogynecology Divison Head Assistant Professor, University of Ottawa

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  1. Challenges in Treatments of Common Urogynecological Conditions Challenges in Obstetrics & GynecologyKuwait Feb 8, 2017 Dante Pascali MD FRCS(C) Urogynecology Divison Head Assistant Professor, University of Ottawa Canada

  2. Disclosures • Consultant for Pfizer, Astellas and Duchesnay.

  3. Objectives • Develop a better understanding of urogenital atrophy. • Review the work up and treatment of recurrent urinary tract infections. • Review the diagnosis and treatment of interstial cystitis

  4. Urogenital Atrophy • When tissues of the vagina become thinner because of the lack of estrogen. This results in itching, pain during sexual intercourse, and a greater frequency of vaginal infection. • “Genitourinary Symptoms of Menopause” (GSM)

  5. Urogenital atrophy: QOL • Negative effects: • self-esteem 1, 2 • physical activity level 1, 2 • sleep 1 • sexuality 3 • relationship with partner 3 1. Kelleher et al. Curr Opin Obstet Gynecol 1995;7(5):404-8. 2. van der Vaart et al. Neurourol Urodyn 2003;22(2):97-104. 3. Bachman. Int J Fertil Menopausal Stud 1995;40:16-22.

  6. Treatment The ideal option is: • effective • safe • convenient to use • acceptable to patient • inexpensive … because treatment is “forever”

  7. Atrophy: Estrogen • restoration of vaginal cytology 1 •  epithelial thickness 1 •  blood flow 2 •  vaginal fluid secretions 3 1. Semmens. Clin Pract Sex 1990;8(suppl):2-3. 2. Sarrel. Int J Impot Res 1998;10(suppl2):S91-3. 3. Rigg. Int J Fertil 1986;31(suppl3):29-34.

  8. Atrophy: Estrogen Routes of Administration • systemic (oral, transdermal) • local (vaginal) On adequate systemic doses: • 25 – 40 % had vaginal dryness Notelovitz. Int J Gynecol Obstet 1997(suppl1);59:S35-9. Smith & Studd. Br J Hosp Med 1993;49(11):799-808.

  9. Atrophy: Estrogen Vaginal Route • CEE cream • 0.5 gm cream (0.3 mg CEE) (1/4 new applicator) daily x 2 weeks, then 2-3 x week • sustained-release estradiol ring • 2 mg estradiol q 3 months • estradiol tablet • 10 μg estradiol daily x 2 weeks, then 2 x week

  10. Atrophy: Estrogen Clinical Efficacy • vaginal estrogen better than placebo • subjective RR > 90% • objective RR > 85% • no significant differences in efficacy between different products Suckling et al. Cochrane Database Syst Rev 2003;(4):CD001500. Cardozo et al. Obstet Gynecol 1998;92 (4):722-7.

  11. Atrophy: Estrogen Safety: CEE Cream • 0.5 gm cream (0.3 mg CEE) daily x 2 weeks, then 3 x week for 6 months • detectable estradiol levels in 5 /20 • biopsy at week 24 in 18 women • proliferative tissue: 1 /18 • no hyperplasia • no carcinoma Handa et al. Obstet Gynecol 1994;84:215-18.

  12. Atrophy: Estrogen Recommendation: Although systemic absorption of estrogen can occur with local preparations, there is insufficient data to recommend annual endometrial surveillance in asymptomatic women using vaginal estrogens in appropriate doses (LEVEL III - C). Farrell et al, SOGC Clinical Practice Guidelines 2004.

  13. Atrophy: Other Options Vaginal moisturizer • polycarbophil gel: Replens™ Vaginal lubricants • KY Jelly ™ • Astroglide™ • Gyne-Moistrin™ NOT A TREATMENT just a coping strategy

  14. Polycarbophil Gel Clinical Efficacy • one applicator 3 x week x 12 weeks •  vaginal fluid 1, 2 •  elasticity 1 •  vaginal pH 1 • no cytologic epithelial change 3 1. Nachtigill. Fertil Steril 1994;61(1):178-80. 2. Bygdeman & Swahn. Maturitas 1996;23(3):259-63. 3. van der Laak. J Clin Path 2002;55(6):446-51.

  15. Regular intercourse maintains normal vaginal blood flow ? Smoking cessation smokers have a higher incidence of atrophy as compared to non-smokers Atrophy: Other Options Leiblum et al. JAMA 1983;249(16):195-8. Kalogeraki et al. In Vivo 1996:10(6):597-600. Karamanidis et al. Clin Exp Obst Gynecol 2001;28(4):274-6.

  16. Atrophy: Other Options No proven symptom benefit • soy isoflavones • Black Cohosh • progesterone cream • Vitamin E Upmalis et al. Menopause 2000;7(4):236-42.

  17. Vaginal energy-based therapy • Radio-frequency or laser energy to the various layers of the vaginal tissue, stimulating collagen regeneration contracture of elastin fibers and neovascularization. • Patients report subjective improvement in symptoms in small case controlled studies • Decreased pH and increased lactobacilli as vaginal flora returns to premenopausal state Pitsouni et al, Maturitas, 2016

  18. Future studies • VELAS – Vaginal Erbium Laser Academy Study • Multicentre Trial • 3 treatments • 1500 post-menopausal patients • Gambracciani et al.

  19. Urinary tract infections • URINALYSIS • Bacteriuria • Hematuria • Pyuria

  20. Microbiology • Escherichia coli is the pathogen in 80 to 85% of uncomplicated UTIs. • Staphylococcus saprophyticus is the cause of most others. • Proteus mirabilis, Klebsiella & Enterococci less common.

  21. Clinical features • Dysuria,frequency,urgency, suprapubic pain,&/or hematuria. • Urethritis & vaginitis may present with dysuria (need to R/O STIs), Hx of new partner, discharge, pruritis , dyspareunia. External dysuria in the absence of frequency & urgency. • Fever(>38 °C), flank pain, CVA tenderness & nausea or vomiting suggest upper tract infection.

  22. Antibiotic resistance E.coli from uncomplicated cystitis: • 30% are resistant to ampicillin and sulfonamides. • Increasing resistance to trimethoprim and/or TMP-SMX varies according to region, ranges from 10 to 22% in the US, in Europe 9 to 15%. • Resistance to nitrofurantoin among E.coli is < 5%.

  23. Short Course vs. Prolonged Treatment • Several studies have confirmed the effectiveness of three day regimens of trimethoprim, TMP-SMX, or a fluoroquinolone for the treatment of acute uncomplicated cystitis. • A meta-analysis that included 32 trials show that three day therapy was similar to prolonged therapy(>= 5 days). • There are no published data in adults that demonstrate nitrofurantoin to be as effective in a single or a 3 day regimen as TMP-SMX, or fluoroquinolone, it should be given for a minimal of 7 days .

  24. Recurrent UTI •  3 UTI / yr • 2 Types: • Bacterial Persistence • Reinfection

  25. Management • Behavioral Modification • Postcoital voiding • Frequent urination (hydration) • Hygiene • Dietary • Cranberry Juice • Vitamin C • Prophylactic antibiotics • Low dose continuous • Intermittent (self-start) • Postcoital

  26. Cranberry Juice • Cranberries contain compounds that: • prevent bacteria (E.coli) from adhering to uro-epithelial cells • cause bacteria to be flushed & prevent colonization • (fructose & polymeric compound of unknown nature) • Blueberries also contain polymeric compound • Cranberry: • 200-350 ml 1-3x per day or 1 tablet BID • Decreased incidence of UTI vs. placebo Kontiokari et al. BMJ 2001;322(7302):1571.

  27. Antimicrobial prophylaxis • The choice of antibiotic should be based on susceptibility of the strains causing the previous UTIs & any history of drug allergy. • Before any prophylaxis is initiated eradication of the previous infection must be ensured by obtaining a negative culture 1 to 2 weeks after treatment.

  28. Postcoital prophylaxis • May be more efficient & acceptable method in women whose UTI appears to be related to intercourse. • In a randomized trial, postcoital cipro was as effective as daily cipro in sexually active women. • The preferred regimen is a single dose of cephalexin 250mg or nitrofurantoin 50mg.

  29. Self-treatment • Three studies have shown that UTI can be accurately diagnosed by women 85 to 95% of the time. • This strategy should be restricted to women who have documented UTIs, motivated, compliant, and have good relationship with their MD.

  30. Prophylaxis in post menopausal women • In one randomized ,double blind, placebo-controlled trial of 95 post menopausal women with recurrent UTI, intravaginal estriol cream for 8 months significantly reduced the incidence of UTI compared to placebo (0.5 vs. 5.9 episode per patient per year).

  31. Estrogen Observations • restoration of vaginal flora •  vaginal pH Raz & Stamm. N Eng J Med 1993;329:753-6.

  32. Estrogen Clinical Efficacy • 5.9 UTI/yr placebo versus 0.5 UTI/yr intravaginal estriol 1 • increased interval time before next UTI (estradiol ring versus placebo) 2 • benefit of estrogen over placebo (OR 2.51, CI 1.48-4.25) 3 1. Raz & Stamm. N Eng J Med 1993;329:753-6. 2. Eriksen. Am J Obstet Gynecol 1999;180(5):1072-9. 3. Cardozo et al. Int J Urogynecol Pelvic Floor Dysfunct 2001;12(1):15-20.

  33. Interstitial Cystitisshould be suspected in : • Hx of recurrent UTI with negative cultures. • Dx of OAB with no incontinence & not responding to anticholinergics. • Pain or frequency with sexual activity. • Chronic pelvic pain.

  34. PUF questionnaire • Validated pelvic pain and urgency/frequency patient symptom scale • Total score ranges from 1 to 35. PUF score correlates +ve PST. A total score of 10-14 = 74% likelihood of positive PST; 15-19 = 76%; 20+ = 91% potassium positive

  35. PUF Scale

  36. Potassium sensitivity test (PST) • A +ve PST is a definitive evidence of IC in a patient with –ve culture & no Hx of Ca , radiation, or chemical cystitis, but a –ve test doesn’t R/O the possibility, 20 to 25 % of IC test -ve because the intermittent nature of IC. • PST is the only diagnostic test for IC. • PST 78% sensitive & 98% specific.

  37. Cystoscopy & biopsy • Positive cystoscopic findings are only seen advanced disease , thus it is no longer considered gold standard for diagnosis & is not mandatory. • Cystoscopy has 60% rate of under diagnosis it’s done to exclude other pathology. • There are no histological pathognomonic features of IC, therefore biopsy is not recommended.

  38. Urodynamic Studies • Optional , not specific for diagnosis of IC • Findings include sensory urgency <125 cc & decreased functional capacity <300 cc. • Involuntary contractions occur in 25-28% of patients.

  39. Treatment of IC • Refer to an expert. • Dietary modification. • Tricyclic antidepressants. • Antihistamine Tx. • Cysta-Q Tx (quercetin, bromelain and papain) • Pentosan polysulfate sodium (Elmiron) • Bladder hydrodistension • Intravesical DMSO or heparin

  40. Take Home Message • Local estrogen can significantly improve QOL. • Local estrogen is safe and efficacious. • Recurrent urinary tract infections should be treated with a step-wise approach. • IC is a difficult diagnosis to make, but has several viable treatment options.

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