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Chapter 6: Urinary tract infections 265

motivation of the patient. Systemic or topical oestro- Inspinalcordcompressionemergencydecompression
gen therapy may be of benefit. Imipramine (a mixed is essential (see page 000). In other neuropathic condi-
anticholinergic and α-agonist) has been used. Ring tions intermittent self-catheterisation is the preferred
pessaries are useful for those with uterine prolapse. treatment.
Surgery is effective but carries a significant morbidity. Patients who are unfit for TURP or are unable to

Using a transabdominal approach (but without enter- self-catheterise may require a long-term indwelling
ing the peritoneal cavity) stitches are placed through catheter.
the fascia at the level of the bladder neck or ure- Prevention of infection is important both by using
thra to hitch the urethra and bladder neck up and sterile catheters and possibly using prophylactic an-
forwards. These are sutured either to Cooper’s liga- tibiotics.
ment (a Burch colposuspension or urethropexy) or
to the periosteum of the pubic bone (a Marshall–
Marchetti–Krantz colposuspension). For vaginal cys- Urinary tract infections
toceles (where the bladder herniates into the vaginal
canal), a transvaginal approach may be used to re-
pair the cystocele but this is generally less effective. Urinary tract infections (UTIs)
Alternatively using both vaginal and transabdominal Definition
approaches a sling or sutures are used to lift the blad- An infection of the urinary tract which may be fur-
der neck or mid-urethra up to the rectus abdominis ther distinguished on the basis of anatomy, e.g. cystitis,
muscle. pyelonephritis. In females, vaginitis is another syndrome
Urge incontinence: unlike stress incontinence, be- which commonly overlaps.
haviouralandmedicaltherapiesarethemaintreatments.
Surgery (clam cystoplasty to increase the size of the blad-
Age
der using bowel) is rarely successful.
All ages
Behavioural therapy can be more effective than medi-

cation. In patients with cognitive awareness of bladder
Sex
filling and the ability to independently toilet, bladder
F > M
training is used to learn methods of deliberately sup-
pressing the urge to pass urine. In patients without
cognitive awareness or lack of motivation to remain Aetiology
dry, scheduled or prompted voiding reduces the num- Most frequently due to bacteria, in particular E. coli and
ber of episodes of incontinence, as well as the volumes Proteus mirabilis.Hospital acquired infections may be
passed when incontinent. due to other organisms such as Staphyloccoccus, Ente-
Drug therapy: Anticholinergics are the mainstay of
rococcus and Klebsiella. Less commonly, fungi (Candida
drug treatment (e.g. oxybutynin, tolterodine). These and Histoplasma capsulatum), parasites (the protozoan
tend to cause a dry mouth and may cause constipa- Trichomonas vaginalis and the fluke Schistosoma haema-
tion and/or urinary retention. Imipramine may also tobium) and very rarely viruses can cause UTIs.
be tried but tends to be avoided in the elderly due to
side effects. Pathophysiology
Combined stress and urge incontinence may be treated Bacterialvirulencefactors:Criticaltothepathogenesis
with behavioural therapy with or without medical ther- of bacteria is adherence to the uroepithelium as infec-
apy.Surgicaltreatmentappearstobelesseffectivethanin tions ascend from the urethral orifice to the bladder
pure stress incontinence. Overflow incontinence: Treat- and to the kidney in pyelonephritis. E. coli have spe-
ment is aimed at the underlying cause. cial fimbriae (also called pili) which permit adhesion.
If there is bladder outlet obstruction, either TURP or Other virulence factors include flagellae (to permit

incision of the bladder neck (or external sphincter) is mobility), production of enzymes such as haemolysin
used to reduce outlet obstruction. (E. coli and Proteus)which induces pore formation