Urogynecological Risk Assessment in Postmenopausal Women
About 25% of post-menopausal women are affected by urogenital atrophy even if they are on HRT. Genital atrophy was evident in 34% of patients referred to a specialist menopause clinic and dyspareunia was present in 40% of sexually active group, of which the majority was superficial dyspareunia. Vaginal discomfort, post-coital bleeding and itching are other common presenting complaints and can affect QoL significantly. Atrophic urethritis and trigonitis can present with bladder pain, dysuria, urgency and frequency in the absence of infection. These symptoms can be effectively treated by systemic as well as vaginal estrogens, with the latter being preferred modality unless there are other indications for systemic estrogen replacement. A wide variety of different vaginal estrogen preparations are available and it may take several months for the full beneficial effects to be noted.. Treatment should be continued on a small maintenance dose to prevent recurrence of symptoms. There is no limit on the duration of treatment and no requirement for additional progestogen in non-hysterectomized women.
One of the challenges faced by urogynecologists is painful bladder syndrome/interstitial cystitis (PBS/IC), which often presents with symptoms of OAB and/or RUTI. PBS is defined by the International Continence Society 'as suprapubic pain related to bladder filling, accompanied by increased daytime and night-time frequency in the absence of proven UTI or other obvious pathology'. The prevalence of PBS/IC symptoms was found to be 2.3% in the age group <65 years, which increased to 4% in those aged 80 years and above.
The cause of PBS/IC is unknown although it is thought to be multi-factorial and an association with other causes of chronic pain syndromes has been reported. As it is mainly a diagnosis of exclusion, urinalyses, urodynamics, cystoscopy with bladder distension and bladder biopsy are commonly performed investigations, although their relevance and validity have been challenged. The classical cystoscopic finding of Hunner's ulcers is not commonly found and the cystoscopic findings are often not diagnostic for PBS/IC.
The disease has an unpredictable waxing-waning course and like any other chronic pain syndrome, also has a strong placebo effect. Bladder training, dietary modifications with avoidance of cheese, chocolate, caffeine, citrus fruits, tomato, carbonated drinks, spices, beer, wine and smoking cessation have been advocated (level of evidence 5).
In the absence of any single standard effective treatment for PBS/IC, various oral medications such as sodium pentosan polysulfate (PPS), amitriptyline, cimetidine, gabapentin and hydroxyzine have been used with varying success to treat the bladder pain. Bladder distension has also been found to be effective in 20–30% patients although the results may not last beyond 3–6 months. Bladder instillation (intravesical therapy) with dimethyl sulfoxide (DMSO), Bacillus Calmette-Guerin (BCG), heparin, hyaluronic acid and lidocaine, have been used but the available studies are limited and a Cochrane review did not find any robust evidence supporting their use. Further research is needed in this field to guide clinical practice.
The involvement of the chronic pain team and a multimodal, multidisciplinary approach is useful as in any other chronic pain condition. Surgical options are the last resort and are beyond the scope of discussion of this article. There is no cure at present for this chronic inflammatory condition and all treatment is directed to reducing the severity of symptoms. Patient education and involvement in their own care as well as support from friends, relatives and support groups are the cornerstones of management of this challenging condition. The Interstitial Cystitis Association is a valuable resource for these patients.
Urogenital Atrophy
About 25% of post-menopausal women are affected by urogenital atrophy even if they are on HRT. Genital atrophy was evident in 34% of patients referred to a specialist menopause clinic and dyspareunia was present in 40% of sexually active group, of which the majority was superficial dyspareunia. Vaginal discomfort, post-coital bleeding and itching are other common presenting complaints and can affect QoL significantly. Atrophic urethritis and trigonitis can present with bladder pain, dysuria, urgency and frequency in the absence of infection. These symptoms can be effectively treated by systemic as well as vaginal estrogens, with the latter being preferred modality unless there are other indications for systemic estrogen replacement. A wide variety of different vaginal estrogen preparations are available and it may take several months for the full beneficial effects to be noted.. Treatment should be continued on a small maintenance dose to prevent recurrence of symptoms. There is no limit on the duration of treatment and no requirement for additional progestogen in non-hysterectomized women.
One of the challenges faced by urogynecologists is painful bladder syndrome/interstitial cystitis (PBS/IC), which often presents with symptoms of OAB and/or RUTI. PBS is defined by the International Continence Society 'as suprapubic pain related to bladder filling, accompanied by increased daytime and night-time frequency in the absence of proven UTI or other obvious pathology'. The prevalence of PBS/IC symptoms was found to be 2.3% in the age group <65 years, which increased to 4% in those aged 80 years and above.
The cause of PBS/IC is unknown although it is thought to be multi-factorial and an association with other causes of chronic pain syndromes has been reported. As it is mainly a diagnosis of exclusion, urinalyses, urodynamics, cystoscopy with bladder distension and bladder biopsy are commonly performed investigations, although their relevance and validity have been challenged. The classical cystoscopic finding of Hunner's ulcers is not commonly found and the cystoscopic findings are often not diagnostic for PBS/IC.
The disease has an unpredictable waxing-waning course and like any other chronic pain syndrome, also has a strong placebo effect. Bladder training, dietary modifications with avoidance of cheese, chocolate, caffeine, citrus fruits, tomato, carbonated drinks, spices, beer, wine and smoking cessation have been advocated (level of evidence 5).
In the absence of any single standard effective treatment for PBS/IC, various oral medications such as sodium pentosan polysulfate (PPS), amitriptyline, cimetidine, gabapentin and hydroxyzine have been used with varying success to treat the bladder pain. Bladder distension has also been found to be effective in 20–30% patients although the results may not last beyond 3–6 months. Bladder instillation (intravesical therapy) with dimethyl sulfoxide (DMSO), Bacillus Calmette-Guerin (BCG), heparin, hyaluronic acid and lidocaine, have been used but the available studies are limited and a Cochrane review did not find any robust evidence supporting their use. Further research is needed in this field to guide clinical practice.
The involvement of the chronic pain team and a multimodal, multidisciplinary approach is useful as in any other chronic pain condition. Surgical options are the last resort and are beyond the scope of discussion of this article. There is no cure at present for this chronic inflammatory condition and all treatment is directed to reducing the severity of symptoms. Patient education and involvement in their own care as well as support from friends, relatives and support groups are the cornerstones of management of this challenging condition. The Interstitial Cystitis Association is a valuable resource for these patients.
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