PH1122 - Women's Health Flashcards
what factors increase the chance of a UTI
frequent or recent sexual activity, previous episodes of cystitis, the use of diaphragms or spermicidal agents, advancing age (e.g., postmenopausal), pregnancy, and diabetes can be risk factors.
how common is recurrent cystitis and what is the time frame for it ?
Recurrent cystitis (usually defined as three or more episodes in the past 12 months or two episodes in the past 6 months) is relatively common
What are reasons to refer with symptoms associated with cystitis ?
Duration Symptoms that have lasted longer than 5–7 days should be referred because of the risk that the woman might develop pyelonephritis.
Age of the patient Cystitis is unusual in children and should be viewed with caution. This might be a sign of a structural urinary tract abnormality. Referral is needed.
Older female patients (> 70 years) have a higher rate of complications associated with cystitis and are therefore best referred.
Presence of fever Referral is needed if the woman presents with fever associated with dysuria, frequency and urgency because fever is a sensitive indicator of an upper urinary tract infection.
Vaginal discharge If a patient reports vaginal discharge, the likely diagnosis is not cystitis but a vaginal infection.
Location of pain Pain experienced in the loin area suggests an upper urinary tract infection.
blood present in the urine requires further investigation
Suprapubic discomfort not associated with passing urine might also be present but is not common should also be referred.
Children <16 years Cystitis unusual in this age group
Patients with diabetes More likely to develop complications from a UTI
Duration >7 days Does not suggest an uncomplicated UTI
Vaginal discharge May indicate vaginitis
Women >70 years More susceptible to complicated UTIs and pyelonephritis; also, symptoms may be indicative of atrophic vaginitis
Pregnancy Pressure on the urinary tract caused by an infant makes management of UTIs more difficult and can increase the risk of pyelonephritis
Haematuria Blood may indicate a stone or a tumour
Immunocompromised More likely to develop complications from a UTI
Patients with associated fever and flank pain Suggestive of a complicated UTI and/or pyelonephritis
what are symptoms of cystitis ?
Cystitis is characterized by pain when passing urine and is associated with frequency, urgency, nocturia, and changes to urine’s appearance.
the patient might report only passing small amounts of urine, with pain worsening at the end of voiding urine.
usually SUDDEN ONSET
Suprapubic discomfort not associated with passing urine might also be present but is not common.
what are conditions to eliminate when suspecting cystitis.
Pyelonephritis
The most frequent complication of cystitis is when the invading pathogen involves the ureter or kidney by ascending from the bladder to these higher anatomical structures. The triad of flank pain, fever, and nausea and vomiting are typically associated with pyelonephritis. Onset is typically sudden. Pain relief can be offered, but a medical referral is needed to confirm the diagnosis, exclude pelvic inflammatory disease, and initiate appropriate treatment
Sexually transmitted diseases (STDs) can be caused by a number of pathogens; for example, Chlamydia trachomatis (most common but generally asymptomatic) and Neisseria gonorrhoea.
Symptoms are similar to those of acute uncomplicated cystitis in that pain and dysuria are experienced, but symptoms tend to be more gradual in onset and last for a longer period of time. In addition, up to 50% of people experience increased or altered vaginal discharge, and pyuria (pus in the urine) is usually present. Usually more common in younger people.
Oestrogen deficiency
Postmenopausal women experience thinning of the endometrial lining as a result of a reduction in the levels of circulating oestrogen in the blood. This increases the likelihood of irritation or trauma, leading to cystitis-like symptoms. If the symptoms are caused by intercourse, symptomatic relief can be gained with a lubricating product. Referral for possible topical oestrogen therapy would be appropriate if the symptoms recur.
Medicine-induced cystitis
Nonsteroidal antiinflammatory drugs (NSAIDs, especially tiaprofenic acid), allopurinol, danazol and cyclophosphamide have been shown to cause cystitis.
Vaginitis
Vaginitis exhibits similar symptoms to cystitis in that dysuria, nocturia and frequency are common. Bleeding or spotting may also be present. It can be caused by direct irritation (e.g., use of vaginal sprays and toiletries). All patients should be questioned about an associated vaginal discharge. The presence of vaginal discharge is highly suggestive of vaginitis.
what can be used to treat cystitis ?
Alkalinizing agents are used to return the urine pH back to normal, thus theoretically relieving symptoms of dysuria. However, they have little trial data to support their use.
Potassium citrate
Sodium citrate (Cymalon, CanesOasis, Cystitis Relief, Care Cystitis Relief)
What non pharmacological advise can be given to a patient with cystitis ?
Fluid intake Patients should be advised to drink about 5 L of fluid during every 24-hour period. This will help promote bladder voiding, which is thought to help flush bacteria out of the bladder.
Product taste The taste of potassium citrate mixture is unpleasant. Patients should be advised to dilute the mixture with water to make the taste more palatable
what is the dose for medication used to treat cystitis ?
All marketed products are presented as a 2-day treatment course and taken three times a day, although potassium citrate can be bought as a ready-made solution (the dosage is 10 mL three times a day, diluted well with water). They have very few side effects and can be given safely with other prescribed medication, although, in theory, products containing potassium should be avoided in patients taking angiotensin-converting enzyme (ACE) inhibitors, potassium-sparing diuretics and spironolactone.
What are key symptoms of thrush that help differentiate it with other conditions ?
Symptoms of pruritus, burning and discharge are possible in all three common causes of vaginal discharge; therefore, no one symptom can be relied on with 100% certainty to differentiate among thrush, bacterial vaginosis and trichomoniasis. However, certain symptom clusters are strongly suggestive of a particular diagnosis.
Discharge Any discharge with a strong odour should be referred. Bacterial vaginosis and trichomoniasis are associated with a fishy odour. Discharge in bacterial vaginosis tends to be grey-white and trichomoniasis greenish-yellow. By contrast, discharge associated with thrush is often described as curdlike or cottage cheese–like, with little or no odour. Note that the physiological discharge is clear and odourless but can cause slight staining of underwear.
Age Thrush can occur in any age group, unlike bacterial vaginosis and trichomoniasis, which are rare in premenarchal girls. In addition, trichomoniasis is also rare in women >60 years.
Pruritus Vaginal itching tends to be most prominent in thrush compared with bacterial vaginosis and trichomoniasis, where itch is slight or absent.
Onset In thrush, the onset of symptoms is sudden, whereas in bacterial vaginosis and trichomoniasis onset tends to be less sudden.
The defining feature of thrush is vulval itching. Vulval soreness and irritation are also common. Discharge occurs only in about 20% of patients and, if present, has little or no odour and is described as resembling cottage cheese or is curd-like. Symptoms are generally acute in onset.
What conditions need to be eliminated when suspecting thrush ?
Bacterial vaginosis Many patients are asymptomatic but, when symptoms occur, the condition is characterized by a thin white discharge with a strong fishy odour. Odour is worse after sexual intercourse and may worsen during menses. Itching and soreness are not usually present. The exact cause of bacterial vaginosis is unknown but results from an overgrowth of anaerobic bacteria and reduction in lactobacilli concentration. Gardnerella vaginalis is often implicated. Certain risk factors include change in sexual partner, multiple sexual partners, low social class and race (more common in African and African American women). It may remit and relapse for several months. OTC products are marketed, such as a product to differentiate between thrush and bacterial vaginosis (Canestest), and works on changes in pH levels (> 4.5 can suggest bacterial vaginosis); Canesbalance is marketed for its treatment because it alters pH back to normal physiological levels. However, this should not be recommended because treatment requires antibiotics (oral metronidazole, 400 mg, twice daily for 5–7 days or local application of metronidazole or clindamycin).
Trichomoniasis
Trichomoniasis, a protozoan infection ( Trichomonas vaginalis ), is primarily transmitted through sexual intercourse. Up to 50% of patients are asymptomatic. If symptoms are experienced, approximately 30% experience a profuse, frothy, greenish-yellow and fishy-smelling discharge. Other symptoms include vulvar itching and soreness, vaginal spotting, dysuria, and lower abdominal pain. Referral for metronidazole (400 mg bd for 5–7 days) is required.
Chlamydia
Most people with chlamydial infection are asymptomatic but, when symptoms are experienced, the patient may complain of purulent or mucopurulent discharge, dysuria, urinary frequency, and intermenstrual or postcoital bleeding.
Cystitis
Dysuria can affect up to one in three women with a vaginal infection. Other symptoms such as nocturia and urgency will be more prominent in cystitis, and discharge is uncommon.
Atrophic vaginitis
Symptoms consistent with thrush in postmenopausal women, especially vaginal itching and burning, may be due to atrophic vaginitis. However, clinically significant atrophic vaginitis is uncommon in postmenopausal women and should be referred to rule out malignancy.
There are also several factors that predispose women to thrush and require consideration before initiating treatment.
Medicine-induced thrush
Corticosteroids, immunosuppressants and medications affecting the oestrogen status of the patient (e.g., oral contraceptives, hormone replacement therapy, tamoxifen, raloxifene), can predispose women to thrush. This is also true with the use of broad-spectrum antibiotics, and it is not unusual to see a patient prescribed an antibiotic and treatment for thrush at the same time.
Diabetes
Patients with poorly controlled diabetes (type 1 or 2) are more likely to suffer from thrush because hyperglycaemia can enhance production of protein surface receptors on C. albicans organisms. This hinders phagocytosis by neutrophils, thus making thrush more difficult to eliminate.
Pregnancy
Hormonal changes during pregnancy will alter the vaginal environment and have been reported to make eradication of Candida more difficult. Topical agents are safe and effective in pregnancy, but OTC-licensed indications state that patients should be treated by a doctor or midwife; therefore, these patients should be referred to the doctor.
How should you treat someone suffering from recurrent thrush ?
After treatment, a minority of patients will present with recurrent symptoms (four or more episodes per year). This may be due to poor adherence, misdiagnosis, resistant strains of Candida, undiagnosed diabetes, or the presence of a mixed infection. Such cases are outside the remit of community pharmacy and have been shown to be difficult to treat. Often, specialist care is needed through a genitourinary medicine clinic.
When would you refer a patient with symptoms related to thrush ?
Discharge that has a strong smell- Thrush has no or little odour and therefore this suggests other causes, such as bacterial vaginosis or trichomoniasis
Women <16 and >60 years-Thrush is unusual in these age groups
Patients with diabetes-Might suggest poor diabetic control
OTC medication failure
Patients predisposed to thrush
Recurrent attacks- Suggests underlying problem or misdiagnosis
What OTC medication can be used to treat thrush ?
Topical imidazoles and one systemic triazole (fluconazole) are available OTC to treat vaginal thrush. They are potent and selective inhibitors of fungal enzymes necessary for the synthesis of ergosterol, which is needed to maintain the integrity of cell membranes.
Imidazoles and triazoles have proven and comparable efficacy, with clinical cure rates between 85% and 90%. Additionally, cure rates between single- or multiple-dose therapy and multiple-day therapy show no differences
What are some common side effects and drug interactions of imidazoles and fluconazole ?
Imidazole - Vaginal irritation
Drug interaction - NONE
Fluconazole- GI disturbances, headache, rash
Drug interactions- Anticoagulants, ciclosporin, rifampicin, phenytoin, tacrolimus
How should people be advised to use a pessary for thrush ?
Because the dosage is at night, patients should be advised to use the pessary when in bed.
• 1.
Wash your hands.
• 2.
Pull out the plunger from the applicator.
• 3.
Remove the pessary from the packaging and place firmly into the applicator (the end of the applicator needs to be gently squeezed to allow the pessary to fit).
• 4.
Lying on your back, with knees drawn towards the chest, insert the applicator as deeply as is comfortable into the vagina.
• 5.
Slowly press the plunger of the applicator until it stops.
• 6.
Remove and dispose of the applicator.
• 7.
Remain on your back for as long as possible.
