INTRODUCTION — Urinary incontinence is the involuntary leakage of urine. Although it becomes more common as people get older, incontinence is not normal at any age. Many types of therapy are available for urinary incontinence. A brief review of the normal process of urination in adults will help in understanding both the causes and treatment of urinary incontinence.
NORMAL URINATION — Urine is produced by the kidneys and passes into a muscular sac called the urinary bladder. The urethra is the tube that leads from the bladder to the outside of the body (show figure 1).
A ring of muscles, called the urinary sphincter, surrounds the urethra. As the bladder fills with urine, complex nerve signals ensure that the sphincter muscles are contracted and the bladder muscle stays relaxed. This allows the bladder to fill with urine and prevents urine from leaking out.
When the bladder is nearing full, nerve signals are sent to the brain, letting the person know that the bladder is getting full. Additional nerve signals must be sent to begin urination. Some of these signals cause the bladder muscles to contract, which pushes urine into the urethra. At the same time, other signals cause the sphincter muscles to relax, which allows the urine to pass out of the body. Most individuals empty their bladder every three to five hours during the day and zero to one times during the night.
Simply put, four things can go wrong with this process: The bladder contracts when the person is not ready to urinate, called urge incontinence. This is the most common reason people have incontinence. The sphincter does not close properly or does not stay closed when there is increased pressure (as with a cough or sneeze), allowing urine to leak. This is called stress incontinence, and is a common reason for incontinence in women, especially women who have had children. The bladder is too weak to empty completely, causing leakage when the bladder is overly full. This is called overflow incontinence, and is uncommon. The urethra is obstructed, preventing urine from draining completely, which can also lead to overflow incontinence. This is common in men with an enlarged prostate.
Urine leakage also can occur when persons are unable to make it to the toilet on time when medical conditions, medications, and/or difficulty with thinking and immobility interfere with normal bladder and sphincter function and getting to a bathroom.
RISK FACTORS — The frequency of urinary incontinence increases with age, and it affects more women than men. About 10 to 30 percent of women and 1.5 to 5 percent of men up to age 64 have urinary incontinence. In those age 65 and older, 15 to 30 percent of individuals have incontinence. At least 50 percent of persons older than 65 who live in long-term care facilities (eg, nursing homes) have incontinence [1].
Urinary incontinence also has been associated with a number of conditions, including obesity (in women), high impact physical activities, heart failure, lung problems, smoking, chronic cough, depression, constipation, pregnancy, vaginal delivery, and problems with mobility.
TYPES OF URINARY INCONTINENCE
Urge incontinence — Urge incontinence occurs when the bladder contracts suddenly, so that a normal "urge" becomes more forceful "urgency", the strong, uncomfortable need to urinate. A person with urge incontinence will generally have an abrupt, overwhelming urge to urinate, followed by urine leakage that can range from a few drops to soaking. The urgency and leakage may occur in response to a stimulus, such as unlocking the door when returning home, going out in the cold, turning on the faucet, or washing hands.
There are many names that have been used for urge incontinence and the associated symptoms of urgency and frequency, including overactive bladder, detrusor instability or overactivity, and irritable or spastic bladder.
Some patients with overactive bladder have symptoms of urinary urgency and frequency during the daytime only, while other patients also have to urinate frequently during the night (called nocturia). Frequency is the complaint of needing to urinate more often than other people (normal is considered to be 8 times in 24 hours).
Factors that can lead to urge incontinence include age-related changes in the anatomy of the urinary tract and the physiology of urination, nervous system problems related to conditions such as stroke, or bladder irritation caused by inflammation.
Stress incontinence — Stress incontinence occurs when the urinary sphincter does not stay closed during an increase in pressure in the abdomen, leading to urine leakage. As an example, the increased pressure in the abdomen with coughing, sneezing, laughing, or running can cause episodes of stress incontinence in susceptible patients. Stress incontinence is the most common cause of urinary incontinence in younger women, the second most common cause in older women, and may occur in older men after certain types of prostate surgery.
Stress incontinence in women is most commonly caused by weakness in the muscles and other tissues that support the urethra. Less commonly, stress incontinence is caused by complete failure of the sphincter to close, a condition known as intrinsic sphincter deficiency (ISD). This can occur due to scarring from surgery or radiation therapy used for cancer treatment.
Mixed incontinence — Mixed incontinence is the combination of both urge and stress incontinence, and is most common in younger to middle aged women.
Incontinence associated with medical factors — Urinary incontinence can occur due to treatable factors and medical conditions (show table 1A-1B). As examples, medical conditions such as urinary tract infection or poorly-controlled diabetes may temporarily cause urinary leakage. Certain medications, excess fluid intake, fluid retention, and arthritis or other problems that cause difficulty in getting to the toilet are potentially treatable causes of incontinence.
Overflow incontinence — Overflow incontinence refers to leakage that occurs when the bladder fails to empty properly, either because of obstruction of the urethra or weak bladder muscle contractions. When the person tries to urinate, abnormally large amounts of urine remain in the bladder. There may be a weak stream, dribbling, and frequent urination. An element of stress incontinence may occur at the same time.
Overflow incontinence is relatively uncommon, but can occur in some older men in whom either benign or cancerous enlargement of the prostate (a gland that surrounds the urethra) causes marked narrowing of the urethra. It is uncommon in women.
DIAGNOSIS — One of the most important first steps in the diagnosis and treatment of urinary incontinence is for the patient to openly and honestly discuss their problem with a healthcare provider. Studies have shown that up to one-half of persons with incontinence do not discuss their problem with a healthcare professional. However, disclosing the problem to a clinician can lead to an accurate diagnosis and effective treatment.
A number of tools are available to help determine the cause of urinary incontinence.
History and physical examination — The history and physical examination are among the most important steps in the investigation and treatment of urinary incontinence. Patients should discuss the type of leakage (associated with urgency, increases in abdominal pressure, or without warning), when their leakage began, if it has worsened or improved over time, and if they have tried any self-management techniques or prescribed treatments. Patients should also mention if they have a problem with leakage of stool (fecal incontinence). A full physical examination includes a review of mental status (alert versus confused), nerve and heart function, genital or pelvic exam, and a rectal examination, all of which can provide clues about the cause(s) of incontinence.
Bladder diary — Patients may be asked to keep a bladder diary to measure the timing and amount of urine voided, frequency and amount of leakage, and any associated factors, such as coughing or sneezing (show figure 2A-2B). This provides useful information about the cause(s) and potential treatment of incontinence.
Office tests — Simple tests may be done during an office visit to determine the type of leakage a patient has, which can help to guide treatment decisions. The provider may ask the patient to cough vigorously to determine if leakage occurs (usually as a result of stress incontinence). They may measure the amount of urine left in the bladder after normal urination to determine how well the bladder empties; this is called the post void residual, and should be less than 50 cc (approximately 2 ounces). This can be done by inserting a catheter into the bladder after the patient voids, or by using a type of ultrasound (called a bladder scanner).
Laboratory tests — The clinician will request a urine test (urinalysis) to look for evidence of infection or blood in the urine. Blood tests may be ordered to measure the kidney function.
Urodynamic testing — Urodynamic testing examines the bladder, urethra, and urethral sphincter as the bladder is filled with water, when the bladder is full, and when the person coughs or bears down. Testing includes measurement of the bladder capacity (how much the bladder can hold), the pressures in the bladder and urethra, and how fast urine flows during urination. Urodynamic testing is not needed for all persons with incontinence, but may be recommended in certain situations, such as to confirm stress incontinence if surgery is planned.
TREATMENT — The treatment of urinary incontinence will depend, in part, upon the type and cause of the incontinence. In most cases, treatment begins with conservative therapies, such as changes in lifestyle and potentially reversible factors, behavioral treatments, or a pessary. If these therapies are inadequate, medication or surgery may be considered.
Before embarking on a treatment plan, the patient and clinician should discuss the goals of treatment in detail, as these will not be the same for every patient.
Treatments for stress and urge incontinence — The following treatments may be helpful for persons with stress, urge, or mixed incontinence.
Fluid management — Persons who drink large amounts of fluids (especially those containing caffeine) may find that cutting back decreases the frequency of their leakage. The body requires a certain amount of fluids to function; for most people, thirst is a good indicator of when fluids are needed. Persons who are older may need to make a special effort to drink enough as they may not become thirsty in the initial stages of dehydration.
Drinking excessive amounts of fluid is of little benefit despite the popular misconceptions that drinking water can "flush out toxins," improve skin health, or assist with weight loss. Between 32 and 64 ounces of fluid per day (from food and fluids) is sufficient for most people; more fluids may be needed for persons who are active and perspiring or when outdoor temperatures are high. Decreasing evening fluid intake (eg, no fluids after 6 to 7 P.M.) is advised for persons with frequent nighttime voids or overnight leakage.
Potentially reversible factors — Patients who take certain medications (such as diuretics ("water pills")), have swollen ankles or feet (edema), are diabetic and have elevated blood glucose levels, and those who have difficulty walking may be at increased risk for urinary incontinence. A variety of techniques can be used to reduce symptoms. Persons who take diuretics should take them at a time when there is easy access to a bathroom. Persons with edema should elevate their feet for several hours in the afternoon or evening, and may consider wearing graduated pressure stockings, or in some cases can take a diuretic in the afternoon. Some prescription drugs and over-the-counter medications (e.g., ibruprofen and other nonsteroidal anti-inflammatory agents) can worsen edema; check with your healthcare provider. these measures may help to reduce overnight frequency, urgency, and leakage. Persons with diabetes who have elevated blood glucose levels should work with their healthcare provider to reduce blood glucose. Elevated blood glucose levels cause the kidneys to produce more urine, which can increase frequency, urgency, and leakage. Persons who have difficulty walking should be evaluated for interventions such as physical therapy, which could improve mobility. These persons may benefit from a portable toilet that can be placed close to their bed or living area. Potential obstacles such as electrical cords, throw rugs, or furniture should be moved out of hallways and walkways.
Pelvic muscle exercises — Pelvic muscle exercises, also known as Kegel exercises, strengthen the muscles involved in closing the urethral sphincter. These are used primarily for stress incontinence but can also be used to control sudden urges in persons with urge incontinence (show figure 4). (See "Patient information: Pelvic muscle exercises").
Studies have shown that, when done correctly, pelvic muscle exercises can be effective in people with stress incontinence. Patients may benefit from a visit to a physical therapist, or a urology, gynecology, or geriatric nurse specialist for detailed instructions. Biofeedback may also help teach correct exercise technique.
Treatments for urge incontinence
Bladder irritants — Some foods and beverages are thought to contribute to frequency and urgency. This includes caffeinated beverages and alcohol, spicy foods, and acidic foods or beverages. While this has not been proven, it may be reasonable to see if eliminating one or all of these items helps.
Bladder retraining — Normally, a person should urinate approximately every three to four hours during the day; getting up once during the night to void is normal for older persons. Bladder retraining can help persons with urge incontinence by slowly increasing the amount of urine the bladder hold, and therefore the time interval between voids (show figure 5). This regimen retrains the nerves and pelvic muscles, which can improve control of bladder contractions. Patients are instructed to urinate at specific intervals through the day, starting with a small time interval. For example, a person who must currently void every 30 to 45 minutes would start by voiding every 45 minutes, whether there is an urge or not.
If the patient feels the need to urge sooner, they should not to run to the bathroom, but should stand still or sit down and concentrate on decreasing the urge, usually while doing several pelvic muscle contractions (see "Pelvic muscle exercises" above). Once the urge has decreased or passed, the patient can walk slowly to the bathroom to urinate. After one to two weeks, the time interval can be increased by 30 to 60 minute increments. The goal is to increase the voiding interval to a more normal pattern, approximately every 3 to 5 hours.
For patients with dementia or memory impairment, treatment focuses on encouraging the patient to use the toilet at regular intervals (usually every two to three hours) and providing positive feedback for successful toileting.
Constipation — Constipation can lead to fecal impaction (when stool collects and is difficult to pass from the rectum), which can increase symptoms of frequency and urgency. Patients can prevent constipation by increasing the amount of fiber in their diet to between 20 and 30 grams per day (show table 3A-3C). (See "Patient information: Constipation in adults").
Medications — When bladder retraining and fluid management alone are not successful in treating urge incontinence, medications can be added. Medicines that are available are called bladder relaxants or antimuscarinic agents. Medications work best when combined with behavioral therapy. In general, these drugs have similar effectiveness, but may differ somewhat on the type and severity of side effects, such as dry mouth, constipation, and heartburn.
Patients and their clinicians should wait at least 4 weeks to determine the response to a medication. A patient who does not respond to one drug may respond to another. Patients who take these medications for long periods of time need to practice good dental care because dry mouth can increase the risk of cavities. There is a small risk of urinary retention (causing the bladder to incompletely empty) with these medications, especially in older patients. Oxybutynin comes in three forms: immediate release (generic oxybutynin, taken two to three times daily), extended release (Ditropan XL®, taken once daily), and a patch (Oxytrol®, which is worn on the skin and changed twice weekly). The immediate release form is particularly useful for people who require protection at specific times (eg, when going out to dinner) since it begins to work quickly and wears off after about six hours. Side effects occur less frequently with Ditropan XL® and Oxytrol®. Tolterodine is available in an immediate release form (Detrol® 1 or 2 mg, taken twice daily) and extended release (Detrol LA®, 2 or 4 mg taken once daily). Side effects occur less frequently with Detrol LA®. Trospium (Sanctura®) is taken one or two times daily on an empty stomach, and is available in 20 mg. Solifenacin (Vesicare®) is taken once a day, and is available in 5 mg or 10 mg. Darifenacin (Enablex®) is taken once a day, and is available in 7.5 mg and 15 mg.
Treatments for stress incontinence
Weight reduction — Obesity can contribute to symptoms of stress or mixed incontinence. In persons who are obese, weight loss can significantly reduce episodes of leakage due to stress incontinence.
Medication — There is currently no medication available for treatment of stress incontinence. Use of oral estrogen in women was found to worsen stress incontinence. Whether topical estrogen cream can improve incontinence is controversial.
Vaginal pessaries — A vaginal pessary is a flexible device made of silicone that can be worn in the vagina (show figure 6). It is traditionally used for women with pelvic organ prolapse (when the bladder, vagina, uterus, or rectum bulge from the vagina), but specially designed stress incontinence pessaries are also available. These help to support the urethra during a cough or sneeze, and may reduce or eliminate stress or overflow incontinence (show figure 7). A pessary is a reasonable treatment for women who want to delay surgery and for those who prefer a non-surgical treatment. When fit properly, the woman will not feel the pessary.
The pessary must be removed and cleaned with soap and water periodically. In addition, there is a small risk that the pessary can cause irritation of the vaginal tissues. Most women who use a pessary see their healthcare provider every three to six months for an examination. Some women are able to learn how to insert and remove the pessary on their own; this is especially helpful for women who are sexually active.
Periurethral bulking injections — In selected women, stress urinary incontinence is caused by complete failure of the urethral sphincter muscles; this is called intrinsic sphincter deficiency (ISD). This may occur in women who have had previous pelvic surgery or radiation treatment and later developed scarring, but it can also occur in postmenopausal women who have severely thinned (atrophic) vaginal tissues. ISD leakage is typically continuous and can occur while sitting or standing quietly.
Women with ISD may gain some short term benefit from injection of material into the wall of the urethra to help keep the urethra closed. These are called periurethral bulking injections. Materials injected include collagen, Teflon®, silicone, and carbon-coated beads.
Surgical treatments for women — Surgery offers the highest cure rate of any treatment for stress urinary incontinence, even in elderly women. Cure rates vary by procedure and by length of time since surgery, although most procedures result in 85 to 95 percent of women being cured at six weeks after surgery; cure rates tend to decrease over time. Ideally, surgery should be reserved for women who have completed childbearing because pregnancy and childbirth can cause damage to the urethral supports, potentially causing incontinence to recur.
There are several surgical procedures for the treatment of SUI in women. The best procedure depends upon several factors. Each procedure has its own risks, benefits, complications, and chance of failure. Long-term outcomes are not always known because some procedures have not been used long enough to measure the incidence of incontinence 10 to 20 years after surgery; the risk of incontinence recurring at a later time is difficult to know in these situations. All of these issues should be discussed in detail with the surgeon.
Other measures
Pads — While pads are not a recommended treatment for incontinence, they are necessary for some persons who are unable or unwilling to use behavioral treatments, medications, or more invasive treatments, or who have incomplete relief of leakage despite treatment.
Pads and protective undergarments are available for both men and women in a large variety of sizes and absorbencies. The choice of garment depends upon the type, frequency, and volume of urinary incontinence leakage. Pads designed for menstrual bleeding may be insufficient for persons with sudden, large volume leakage. In addition, menstrual pads typically do not manage urine odor as well as incontinence products. Men may prefer a penile sheath to a pad; the sheath covers the penis like a condom, and is connected to a tube and bag that collects the urine.
These items are expensive and are usually not covered by insurance; in some states within the United States, Medicaid may cover pads for people of very limited income, while in other countries pads may be obtained for no or little cost through continence advisor nurses. Information on pad varieties and other urinary incontinence supplies is available from medical supply companies and urinary incontinence patient advocacy groups (see "Where to get more information" below). The U.S. National Association for Continence has an online tool that can help a patient to choose a protective garment based upon individual characteristics (www.nafc.org/productdiagnostic.asp).
For all protective products, it is important that the skin is kept dry and that odor is managed. Skin that is exposed to urine for long periods can cause skin irritation, and can potentially cause skin burns or infection. In addition to protecting the skin, patients may need protective products for their bed or other furniture.
Catheters — A catheter may be necessary in some patients who cannot empty their bladder completely or at all. Because catheters (especially those left in place for long periods) can cause urinary tract infections and other serious complications, they are usually a treatment of last resort.
A catheter may be inserted and left in the bladder, or may be inserted as needed to drain the bladder, and then removed. A healthcare provider can teach the patient or a family member how to perform catheterization at home.
WHEN TO SEEK HELP — Patients should seek help from their healthcare provider if they are bothered by urinary frequency or urgency or leakage, if they are awakened more than twice during the night to urinate, if urinary leakage occurs, if there is pain with urination, or if they notice blood in the urine.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
National Institute on Aging
(www.nia.nih.gov/)
National Association for Continence
1-800-BLADDER
(www.nafc.org)
Simon Foundation
(www.simonfoundation.org)
National Institute of Diabetes & Digestive & Kidney Diseases
(www.niddk.nih.gov/)
American Foundation for Urologic Disease
(www.afud.org)
For continence resources in other countries, go to Continence Worldwide
(www.continenceworldwide.com)
[1-5]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Herzog, AR, Fultz, NH. Prevalence and incidence of urinary incontinence in community-dwelling populations. J Am Geriatr Soc 1990; 38:273.
2. DuBeau, CE, Levy, B, Mangione, CM, Resnick, NM. The impact of urge urinary incontinence on quality of life: importance of patients' perspective and explanatory style. J Am Geriatr Soc 1998; 46:683.
3. Fantl, JA, Newman, DK, Colling, J, et al. Urinary Incontinence in Adults: Acute and Chronic Management. Clinical Practice Guideline, No. 2, 1996 Update, AHCPR Publication No. 96-0682. Public Health Service, Agency for Health Care Policy and Research, Rockville, MD. (Available at www.ahrq.gov/clinic/uiovervw.htm, accessed 9/7/2006).
4. Brown, JS, Bradley, CS, Subak, LL, et al. The sensitivity and specificity of a simple test to distinguish between urge and stress urinary incontinence. Ann Intern Med 2006; 144:715.
5. Wyman, JF, Choi, SC, Harkins, SW, et al. The urinary diary in evaluation of incontinent women: A test-retest analysis. Obstet Gynecol 1988; 71:812.
Monday, October 15, 2007
Urinary incontinence
INTRODUCTION — Urinary incontinence is the involuntary leakage of urine. Although it becomes more common as people get older, incontinence is not normal at any age. Many types of therapy are available for urinary incontinence. A brief review of the normal process of urination in adults will help in understanding both the causes and treatment of urinary incontinence.
NORMAL URINATION — Urine is produced by the kidneys and passes into a muscular sac called the urinary bladder. The urethra is the tube that leads from the bladder to the outside of the body (show figure 1).
A ring of muscles, called the urinary sphincter, surrounds the urethra. As the bladder fills with urine, complex nerve signals ensure that the sphincter muscles are contracted and the bladder muscle stays relaxed. This allows the bladder to fill with urine and prevents urine from leaking out.
When the bladder is nearing full, nerve signals are sent to the brain, letting the person know that the bladder is getting full. Additional nerve signals must be sent to begin urination. Some of these signals cause the bladder muscles to contract, which pushes urine into the urethra. At the same time, other signals cause the sphincter muscles to relax, which allows the urine to pass out of the body. Most individuals empty their bladder every three to five hours during the day and zero to one times during the night.
Simply put, four things can go wrong with this process: The bladder contracts when the person is not ready to urinate, called urge incontinence. This is the most common reason people have incontinence. The sphincter does not close properly or does not stay closed when there is increased pressure (as with a cough or sneeze), allowing urine to leak. This is called stress incontinence, and is a common reason for incontinence in women, especially women who have had children. The bladder is too weak to empty completely, causing leakage when the bladder is overly full. This is called overflow incontinence, and is uncommon. The urethra is obstructed, preventing urine from draining completely, which can also lead to overflow incontinence. This is common in men with an enlarged prostate.
Urine leakage also can occur when persons are unable to make it to the toilet on time when medical conditions, medications, and/or difficulty with thinking and immobility interfere with normal bladder and sphincter function and getting to a bathroom.
RISK FACTORS — The frequency of urinary incontinence increases with age, and it affects more women than men. About 10 to 30 percent of women and 1.5 to 5 percent of men up to age 64 have urinary incontinence. In those age 65 and older, 15 to 30 percent of individuals have incontinence. At least 50 percent of persons older than 65 who live in long-term care facilities (eg, nursing homes) have incontinence [1].
Urinary incontinence also has been associated with a number of conditions, including obesity (in women), high impact physical activities, heart failure, lung problems, smoking, chronic cough, depression, constipation, pregnancy, vaginal delivery, and problems with mobility.
TYPES OF URINARY INCONTINENCE
Urge incontinence — Urge incontinence occurs when the bladder contracts suddenly, so that a normal "urge" becomes more forceful "urgency", the strong, uncomfortable need to urinate. A person with urge incontinence will generally have an abrupt, overwhelming urge to urinate, followed by urine leakage that can range from a few drops to soaking. The urgency and leakage may occur in response to a stimulus, such as unlocking the door when returning home, going out in the cold, turning on the faucet, or washing hands.
There are many names that have been used for urge incontinence and the associated symptoms of urgency and frequency, including overactive bladder, detrusor instability or overactivity, and irritable or spastic bladder.
Some patients with overactive bladder have symptoms of urinary urgency and frequency during the daytime only, while other patients also have to urinate frequently during the night (called nocturia). Frequency is the complaint of needing to urinate more often than other people (normal is considered to be 8 times in 24 hours).
Factors that can lead to urge incontinence include age-related changes in the anatomy of the urinary tract and the physiology of urination, nervous system problems related to conditions such as stroke, or bladder irritation caused by inflammation.
Stress incontinence — Stress incontinence occurs when the urinary sphincter does not stay closed during an increase in pressure in the abdomen, leading to urine leakage. As an example, the increased pressure in the abdomen with coughing, sneezing, laughing, or running can cause episodes of stress incontinence in susceptible patients. Stress incontinence is the most common cause of urinary incontinence in younger women, the second most common cause in older women, and may occur in older men after certain types of prostate surgery.
Stress incontinence in women is most commonly caused by weakness in the muscles and other tissues that support the urethra. Less commonly, stress incontinence is caused by complete failure of the sphincter to close, a condition known as intrinsic sphincter deficiency (ISD). This can occur due to scarring from surgery or radiation therapy used for cancer treatment.
Mixed incontinence — Mixed incontinence is the combination of both urge and stress incontinence, and is most common in younger to middle aged women.
Incontinence associated with medical factors — Urinary incontinence can occur due to treatable factors and medical conditions (show table 1A-1B). As examples, medical conditions such as urinary tract infection or poorly-controlled diabetes may temporarily cause urinary leakage. Certain medications, excess fluid intake, fluid retention, and arthritis or other problems that cause difficulty in getting to the toilet are potentially treatable causes of incontinence.
Overflow incontinence — Overflow incontinence refers to leakage that occurs when the bladder fails to empty properly, either because of obstruction of the urethra or weak bladder muscle contractions. When the person tries to urinate, abnormally large amounts of urine remain in the bladder. There may be a weak stream, dribbling, and frequent urination. An element of stress incontinence may occur at the same time.
Overflow incontinence is relatively uncommon, but can occur in some older men in whom either benign or cancerous enlargement of the prostate (a gland that surrounds the urethra) causes marked narrowing of the urethra. It is uncommon in women.
DIAGNOSIS — One of the most important first steps in the diagnosis and treatment of urinary incontinence is for the patient to openly and honestly discuss their problem with a healthcare provider. Studies have shown that up to one-half of persons with incontinence do not discuss their problem with a healthcare professional. However, disclosing the problem to a clinician can lead to an accurate diagnosis and effective treatment.
A number of tools are available to help determine the cause of urinary incontinence.
History and physical examination — The history and physical examination are among the most important steps in the investigation and treatment of urinary incontinence. Patients should discuss the type of leakage (associated with urgency, increases in abdominal pressure, or without warning), when their leakage began, if it has worsened or improved over time, and if they have tried any self-management techniques or prescribed treatments. Patients should also mention if they have a problem with leakage of stool (fecal incontinence). A full physical examination includes a review of mental status (alert versus confused), nerve and heart function, genital or pelvic exam, and a rectal examination, all of which can provide clues about the cause(s) of incontinence.
Bladder diary — Patients may be asked to keep a bladder diary to measure the timing and amount of urine voided, frequency and amount of leakage, and any associated factors, such as coughing or sneezing (show figure 2A-2B). This provides useful information about the cause(s) and potential treatment of incontinence.
Office tests — Simple tests may be done during an office visit to determine the type of leakage a patient has, which can help to guide treatment decisions. The provider may ask the patient to cough vigorously to determine if leakage occurs (usually as a result of stress incontinence). They may measure the amount of urine left in the bladder after normal urination to determine how well the bladder empties; this is called the post void residual, and should be less than 50 cc (approximately 2 ounces). This can be done by inserting a catheter into the bladder after the patient voids, or by using a type of ultrasound (called a bladder scanner).
Laboratory tests — The clinician will request a urine test (urinalysis) to look for evidence of infection or blood in the urine. Blood tests may be ordered to measure the kidney function.
Urodynamic testing — Urodynamic testing examines the bladder, urethra, and urethral sphincter as the bladder is filled with water, when the bladder is full, and when the person coughs or bears down. Testing includes measurement of the bladder capacity (how much the bladder can hold), the pressures in the bladder and urethra, and how fast urine flows during urination. Urodynamic testing is not needed for all persons with incontinence, but may be recommended in certain situations, such as to confirm stress incontinence if surgery is planned.
TREATMENT — The treatment of urinary incontinence will depend, in part, upon the type and cause of the incontinence. In most cases, treatment begins with conservative therapies, such as changes in lifestyle and potentially reversible factors, behavioral treatments, or a pessary. If these therapies are inadequate, medication or surgery may be considered.
Before embarking on a treatment plan, the patient and clinician should discuss the goals of treatment in detail, as these will not be the same for every patient.
Treatments for stress and urge incontinence — The following treatments may be helpful for persons with stress, urge, or mixed incontinence.
Fluid management — Persons who drink large amounts of fluids (especially those containing caffeine) may find that cutting back decreases the frequency of their leakage. The body requires a certain amount of fluids to function; for most people, thirst is a good indicator of when fluids are needed. Persons who are older may need to make a special effort to drink enough as they may not become thirsty in the initial stages of dehydration.
Drinking excessive amounts of fluid is of little benefit despite the popular misconceptions that drinking water can "flush out toxins," improve skin health, or assist with weight loss. Between 32 and 64 ounces of fluid per day (from food and fluids) is sufficient for most people; more fluids may be needed for persons who are active and perspiring or when outdoor temperatures are high. Decreasing evening fluid intake (eg, no fluids after 6 to 7 P.M.) is advised for persons with frequent nighttime voids or overnight leakage.
Potentially reversible factors — Patients who take certain medications (such as diuretics ("water pills")), have swollen ankles or feet (edema), are diabetic and have elevated blood glucose levels, and those who have difficulty walking may be at increased risk for urinary incontinence. A variety of techniques can be used to reduce symptoms. Persons who take diuretics should take them at a time when there is easy access to a bathroom. Persons with edema should elevate their feet for several hours in the afternoon or evening, and may consider wearing graduated pressure stockings, or in some cases can take a diuretic in the afternoon. Some prescription drugs and over-the-counter medications (e.g., ibruprofen and other nonsteroidal anti-inflammatory agents) can worsen edema; check with your healthcare provider. these measures may help to reduce overnight frequency, urgency, and leakage. Persons with diabetes who have elevated blood glucose levels should work with their healthcare provider to reduce blood glucose. Elevated blood glucose levels cause the kidneys to produce more urine, which can increase frequency, urgency, and leakage. Persons who have difficulty walking should be evaluated for interventions such as physical therapy, which could improve mobility. These persons may benefit from a portable toilet that can be placed close to their bed or living area. Potential obstacles such as electrical cords, throw rugs, or furniture should be moved out of hallways and walkways.
Pelvic muscle exercises — Pelvic muscle exercises, also known as Kegel exercises, strengthen the muscles involved in closing the urethral sphincter. These are used primarily for stress incontinence but can also be used to control sudden urges in persons with urge incontinence (show figure 4). (See "Patient information: Pelvic muscle exercises").
Studies have shown that, when done correctly, pelvic muscle exercises can be effective in people with stress incontinence. Patients may benefit from a visit to a physical therapist, or a urology, gynecology, or geriatric nurse specialist for detailed instructions. Biofeedback may also help teach correct exercise technique.
Treatments for urge incontinence
Bladder irritants — Some foods and beverages are thought to contribute to frequency and urgency. This includes caffeinated beverages and alcohol, spicy foods, and acidic foods or beverages. While this has not been proven, it may be reasonable to see if eliminating one or all of these items helps.
Bladder retraining — Normally, a person should urinate approximately every three to four hours during the day; getting up once during the night to void is normal for older persons. Bladder retraining can help persons with urge incontinence by slowly increasing the amount of urine the bladder hold, and therefore the time interval between voids (show figure 5). This regimen retrains the nerves and pelvic muscles, which can improve control of bladder contractions. Patients are instructed to urinate at specific intervals through the day, starting with a small time interval. For example, a person who must currently void every 30 to 45 minutes would start by voiding every 45 minutes, whether there is an urge or not.
If the patient feels the need to urge sooner, they should not to run to the bathroom, but should stand still or sit down and concentrate on decreasing the urge, usually while doing several pelvic muscle contractions (see "Pelvic muscle exercises" above). Once the urge has decreased or passed, the patient can walk slowly to the bathroom to urinate. After one to two weeks, the time interval can be increased by 30 to 60 minute increments. The goal is to increase the voiding interval to a more normal pattern, approximately every 3 to 5 hours.
For patients with dementia or memory impairment, treatment focuses on encouraging the patient to use the toilet at regular intervals (usually every two to three hours) and providing positive feedback for successful toileting.
Constipation — Constipation can lead to fecal impaction (when stool collects and is difficult to pass from the rectum), which can increase symptoms of frequency and urgency. Patients can prevent constipation by increasing the amount of fiber in their diet to between 20 and 30 grams per day (show table 3A-3C). (See "Patient information: Constipation in adults").
Medications — When bladder retraining and fluid management alone are not successful in treating urge incontinence, medications can be added. Medicines that are available are called bladder relaxants or antimuscarinic agents. Medications work best when combined with behavioral therapy. In general, these drugs have similar effectiveness, but may differ somewhat on the type and severity of side effects, such as dry mouth, constipation, and heartburn.
Patients and their clinicians should wait at least 4 weeks to determine the response to a medication. A patient who does not respond to one drug may respond to another. Patients who take these medications for long periods of time need to practice good dental care because dry mouth can increase the risk of cavities. There is a small risk of urinary retention (causing the bladder to incompletely empty) with these medications, especially in older patients. Oxybutynin comes in three forms: immediate release (generic oxybutynin, taken two to three times daily), extended release (Ditropan XL®, taken once daily), and a patch (Oxytrol®, which is worn on the skin and changed twice weekly). The immediate release form is particularly useful for people who require protection at specific times (eg, when going out to dinner) since it begins to work quickly and wears off after about six hours. Side effects occur less frequently with Ditropan XL® and Oxytrol®. Tolterodine is available in an immediate release form (Detrol® 1 or 2 mg, taken twice daily) and extended release (Detrol LA®, 2 or 4 mg taken once daily). Side effects occur less frequently with Detrol LA®. Trospium (Sanctura®) is taken one or two times daily on an empty stomach, and is available in 20 mg. Solifenacin (Vesicare®) is taken once a day, and is available in 5 mg or 10 mg. Darifenacin (Enablex®) is taken once a day, and is available in 7.5 mg and 15 mg.
Treatments for stress incontinence
Weight reduction — Obesity can contribute to symptoms of stress or mixed incontinence. In persons who are obese, weight loss can significantly reduce episodes of leakage due to stress incontinence.
Medication — There is currently no medication available for treatment of stress incontinence. Use of oral estrogen in women was found to worsen stress incontinence. Whether topical estrogen cream can improve incontinence is controversial.
Vaginal pessaries — A vaginal pessary is a flexible device made of silicone that can be worn in the vagina (show figure 6). It is traditionally used for women with pelvic organ prolapse (when the bladder, vagina, uterus, or rectum bulge from the vagina), but specially designed stress incontinence pessaries are also available. These help to support the urethra during a cough or sneeze, and may reduce or eliminate stress or overflow incontinence (show figure 7). A pessary is a reasonable treatment for women who want to delay surgery and for those who prefer a non-surgical treatment. When fit properly, the woman will not feel the pessary.
The pessary must be removed and cleaned with soap and water periodically. In addition, there is a small risk that the pessary can cause irritation of the vaginal tissues. Most women who use a pessary see their healthcare provider every three to six months for an examination. Some women are able to learn how to insert and remove the pessary on their own; this is especially helpful for women who are sexually active.
Periurethral bulking injections — In selected women, stress urinary incontinence is caused by complete failure of the urethral sphincter muscles; this is called intrinsic sphincter deficiency (ISD). This may occur in women who have had previous pelvic surgery or radiation treatment and later developed scarring, but it can also occur in postmenopausal women who have severely thinned (atrophic) vaginal tissues. ISD leakage is typically continuous and can occur while sitting or standing quietly.
Women with ISD may gain some short term benefit from injection of material into the wall of the urethra to help keep the urethra closed. These are called periurethral bulking injections. Materials injected include collagen, Teflon®, silicone, and carbon-coated beads.
Surgical treatments for women — Surgery offers the highest cure rate of any treatment for stress urinary incontinence, even in elderly women. Cure rates vary by procedure and by length of time since surgery, although most procedures result in 85 to 95 percent of women being cured at six weeks after surgery; cure rates tend to decrease over time. Ideally, surgery should be reserved for women who have completed childbearing because pregnancy and childbirth can cause damage to the urethral supports, potentially causing incontinence to recur.
There are several surgical procedures for the treatment of SUI in women. The best procedure depends upon several factors. Each procedure has its own risks, benefits, complications, and chance of failure. Long-term outcomes are not always known because some procedures have not been used long enough to measure the incidence of incontinence 10 to 20 years after surgery; the risk of incontinence recurring at a later time is difficult to know in these situations. All of these issues should be discussed in detail with the surgeon.
Other measures
Pads — While pads are not a recommended treatment for incontinence, they are necessary for some persons who are unable or unwilling to use behavioral treatments, medications, or more invasive treatments, or who have incomplete relief of leakage despite treatment.
Pads and protective undergarments are available for both men and women in a large variety of sizes and absorbencies. The choice of garment depends upon the type, frequency, and volume of urinary incontinence leakage. Pads designed for menstrual bleeding may be insufficient for persons with sudden, large volume leakage. In addition, menstrual pads typically do not manage urine odor as well as incontinence products. Men may prefer a penile sheath to a pad; the sheath covers the penis like a condom, and is connected to a tube and bag that collects the urine.
These items are expensive and are usually not covered by insurance; in some states within the United States, Medicaid may cover pads for people of very limited income, while in other countries pads may be obtained for no or little cost through continence advisor nurses. Information on pad varieties and other urinary incontinence supplies is available from medical supply companies and urinary incontinence patient advocacy groups (see "Where to get more information" below). The U.S. National Association for Continence has an online tool that can help a patient to choose a protective garment based upon individual characteristics (www.nafc.org/productdiagnostic.asp).
For all protective products, it is important that the skin is kept dry and that odor is managed. Skin that is exposed to urine for long periods can cause skin irritation, and can potentially cause skin burns or infection. In addition to protecting the skin, patients may need protective products for their bed or other furniture.
Catheters — A catheter may be necessary in some patients who cannot empty their bladder completely or at all. Because catheters (especially those left in place for long periods) can cause urinary tract infections and other serious complications, they are usually a treatment of last resort.
A catheter may be inserted and left in the bladder, or may be inserted as needed to drain the bladder, and then removed. A healthcare provider can teach the patient or a family member how to perform catheterization at home.
WHEN TO SEEK HELP — Patients should seek help from their healthcare provider if they are bothered by urinary frequency or urgency or leakage, if they are awakened more than twice during the night to urinate, if urinary leakage occurs, if there is pain with urination, or if they notice blood in the urine.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
National Institute on Aging
(www.nia.nih.gov/)
National Association for Continence
1-800-BLADDER
(www.nafc.org)
Simon Foundation
(www.simonfoundation.org)
National Institute of Diabetes & Digestive & Kidney Diseases
(www.niddk.nih.gov/)
American Foundation for Urologic Disease
(www.afud.org)
For continence resources in other countries, go to Continence Worldwide
(www.continenceworldwide.com)
[1-5]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Herzog, AR, Fultz, NH. Prevalence and incidence of urinary incontinence in community-dwelling populations. J Am Geriatr Soc 1990; 38:273.
2. DuBeau, CE, Levy, B, Mangione, CM, Resnick, NM. The impact of urge urinary incontinence on quality of life: importance of patients' perspective and explanatory style. J Am Geriatr Soc 1998; 46:683.
3. Fantl, JA, Newman, DK, Colling, J, et al. Urinary Incontinence in Adults: Acute and Chronic Management. Clinical Practice Guideline, No. 2, 1996 Update, AHCPR Publication No. 96-0682. Public Health Service, Agency for Health Care Policy and Research, Rockville, MD. (Available at www.ahrq.gov/clinic/uiovervw.htm, accessed 9/7/2006).
4. Brown, JS, Bradley, CS, Subak, LL, et al. The sensitivity and specificity of a simple test to distinguish between urge and stress urinary incontinence. Ann Intern Med 2006; 144:715.
5. Wyman, JF, Choi, SC, Harkins, SW, et al. The urinary diary in evaluation of incontinent women: A test-retest analysis. Obstet Gynecol 1988; 71:812.
NORMAL URINATION — Urine is produced by the kidneys and passes into a muscular sac called the urinary bladder. The urethra is the tube that leads from the bladder to the outside of the body (show figure 1).
A ring of muscles, called the urinary sphincter, surrounds the urethra. As the bladder fills with urine, complex nerve signals ensure that the sphincter muscles are contracted and the bladder muscle stays relaxed. This allows the bladder to fill with urine and prevents urine from leaking out.
When the bladder is nearing full, nerve signals are sent to the brain, letting the person know that the bladder is getting full. Additional nerve signals must be sent to begin urination. Some of these signals cause the bladder muscles to contract, which pushes urine into the urethra. At the same time, other signals cause the sphincter muscles to relax, which allows the urine to pass out of the body. Most individuals empty their bladder every three to five hours during the day and zero to one times during the night.
Simply put, four things can go wrong with this process: The bladder contracts when the person is not ready to urinate, called urge incontinence. This is the most common reason people have incontinence. The sphincter does not close properly or does not stay closed when there is increased pressure (as with a cough or sneeze), allowing urine to leak. This is called stress incontinence, and is a common reason for incontinence in women, especially women who have had children. The bladder is too weak to empty completely, causing leakage when the bladder is overly full. This is called overflow incontinence, and is uncommon. The urethra is obstructed, preventing urine from draining completely, which can also lead to overflow incontinence. This is common in men with an enlarged prostate.
Urine leakage also can occur when persons are unable to make it to the toilet on time when medical conditions, medications, and/or difficulty with thinking and immobility interfere with normal bladder and sphincter function and getting to a bathroom.
RISK FACTORS — The frequency of urinary incontinence increases with age, and it affects more women than men. About 10 to 30 percent of women and 1.5 to 5 percent of men up to age 64 have urinary incontinence. In those age 65 and older, 15 to 30 percent of individuals have incontinence. At least 50 percent of persons older than 65 who live in long-term care facilities (eg, nursing homes) have incontinence [1].
Urinary incontinence also has been associated with a number of conditions, including obesity (in women), high impact physical activities, heart failure, lung problems, smoking, chronic cough, depression, constipation, pregnancy, vaginal delivery, and problems with mobility.
TYPES OF URINARY INCONTINENCE
Urge incontinence — Urge incontinence occurs when the bladder contracts suddenly, so that a normal "urge" becomes more forceful "urgency", the strong, uncomfortable need to urinate. A person with urge incontinence will generally have an abrupt, overwhelming urge to urinate, followed by urine leakage that can range from a few drops to soaking. The urgency and leakage may occur in response to a stimulus, such as unlocking the door when returning home, going out in the cold, turning on the faucet, or washing hands.
There are many names that have been used for urge incontinence and the associated symptoms of urgency and frequency, including overactive bladder, detrusor instability or overactivity, and irritable or spastic bladder.
Some patients with overactive bladder have symptoms of urinary urgency and frequency during the daytime only, while other patients also have to urinate frequently during the night (called nocturia). Frequency is the complaint of needing to urinate more often than other people (normal is considered to be 8 times in 24 hours).
Factors that can lead to urge incontinence include age-related changes in the anatomy of the urinary tract and the physiology of urination, nervous system problems related to conditions such as stroke, or bladder irritation caused by inflammation.
Stress incontinence — Stress incontinence occurs when the urinary sphincter does not stay closed during an increase in pressure in the abdomen, leading to urine leakage. As an example, the increased pressure in the abdomen with coughing, sneezing, laughing, or running can cause episodes of stress incontinence in susceptible patients. Stress incontinence is the most common cause of urinary incontinence in younger women, the second most common cause in older women, and may occur in older men after certain types of prostate surgery.
Stress incontinence in women is most commonly caused by weakness in the muscles and other tissues that support the urethra. Less commonly, stress incontinence is caused by complete failure of the sphincter to close, a condition known as intrinsic sphincter deficiency (ISD). This can occur due to scarring from surgery or radiation therapy used for cancer treatment.
Mixed incontinence — Mixed incontinence is the combination of both urge and stress incontinence, and is most common in younger to middle aged women.
Incontinence associated with medical factors — Urinary incontinence can occur due to treatable factors and medical conditions (show table 1A-1B). As examples, medical conditions such as urinary tract infection or poorly-controlled diabetes may temporarily cause urinary leakage. Certain medications, excess fluid intake, fluid retention, and arthritis or other problems that cause difficulty in getting to the toilet are potentially treatable causes of incontinence.
Overflow incontinence — Overflow incontinence refers to leakage that occurs when the bladder fails to empty properly, either because of obstruction of the urethra or weak bladder muscle contractions. When the person tries to urinate, abnormally large amounts of urine remain in the bladder. There may be a weak stream, dribbling, and frequent urination. An element of stress incontinence may occur at the same time.
Overflow incontinence is relatively uncommon, but can occur in some older men in whom either benign or cancerous enlargement of the prostate (a gland that surrounds the urethra) causes marked narrowing of the urethra. It is uncommon in women.
DIAGNOSIS — One of the most important first steps in the diagnosis and treatment of urinary incontinence is for the patient to openly and honestly discuss their problem with a healthcare provider. Studies have shown that up to one-half of persons with incontinence do not discuss their problem with a healthcare professional. However, disclosing the problem to a clinician can lead to an accurate diagnosis and effective treatment.
A number of tools are available to help determine the cause of urinary incontinence.
History and physical examination — The history and physical examination are among the most important steps in the investigation and treatment of urinary incontinence. Patients should discuss the type of leakage (associated with urgency, increases in abdominal pressure, or without warning), when their leakage began, if it has worsened or improved over time, and if they have tried any self-management techniques or prescribed treatments. Patients should also mention if they have a problem with leakage of stool (fecal incontinence). A full physical examination includes a review of mental status (alert versus confused), nerve and heart function, genital or pelvic exam, and a rectal examination, all of which can provide clues about the cause(s) of incontinence.
Bladder diary — Patients may be asked to keep a bladder diary to measure the timing and amount of urine voided, frequency and amount of leakage, and any associated factors, such as coughing or sneezing (show figure 2A-2B). This provides useful information about the cause(s) and potential treatment of incontinence.
Office tests — Simple tests may be done during an office visit to determine the type of leakage a patient has, which can help to guide treatment decisions. The provider may ask the patient to cough vigorously to determine if leakage occurs (usually as a result of stress incontinence). They may measure the amount of urine left in the bladder after normal urination to determine how well the bladder empties; this is called the post void residual, and should be less than 50 cc (approximately 2 ounces). This can be done by inserting a catheter into the bladder after the patient voids, or by using a type of ultrasound (called a bladder scanner).
Laboratory tests — The clinician will request a urine test (urinalysis) to look for evidence of infection or blood in the urine. Blood tests may be ordered to measure the kidney function.
Urodynamic testing — Urodynamic testing examines the bladder, urethra, and urethral sphincter as the bladder is filled with water, when the bladder is full, and when the person coughs or bears down. Testing includes measurement of the bladder capacity (how much the bladder can hold), the pressures in the bladder and urethra, and how fast urine flows during urination. Urodynamic testing is not needed for all persons with incontinence, but may be recommended in certain situations, such as to confirm stress incontinence if surgery is planned.
TREATMENT — The treatment of urinary incontinence will depend, in part, upon the type and cause of the incontinence. In most cases, treatment begins with conservative therapies, such as changes in lifestyle and potentially reversible factors, behavioral treatments, or a pessary. If these therapies are inadequate, medication or surgery may be considered.
Before embarking on a treatment plan, the patient and clinician should discuss the goals of treatment in detail, as these will not be the same for every patient.
Treatments for stress and urge incontinence — The following treatments may be helpful for persons with stress, urge, or mixed incontinence.
Fluid management — Persons who drink large amounts of fluids (especially those containing caffeine) may find that cutting back decreases the frequency of their leakage. The body requires a certain amount of fluids to function; for most people, thirst is a good indicator of when fluids are needed. Persons who are older may need to make a special effort to drink enough as they may not become thirsty in the initial stages of dehydration.
Drinking excessive amounts of fluid is of little benefit despite the popular misconceptions that drinking water can "flush out toxins," improve skin health, or assist with weight loss. Between 32 and 64 ounces of fluid per day (from food and fluids) is sufficient for most people; more fluids may be needed for persons who are active and perspiring or when outdoor temperatures are high. Decreasing evening fluid intake (eg, no fluids after 6 to 7 P.M.) is advised for persons with frequent nighttime voids or overnight leakage.
Potentially reversible factors — Patients who take certain medications (such as diuretics ("water pills")), have swollen ankles or feet (edema), are diabetic and have elevated blood glucose levels, and those who have difficulty walking may be at increased risk for urinary incontinence. A variety of techniques can be used to reduce symptoms. Persons who take diuretics should take them at a time when there is easy access to a bathroom. Persons with edema should elevate their feet for several hours in the afternoon or evening, and may consider wearing graduated pressure stockings, or in some cases can take a diuretic in the afternoon. Some prescription drugs and over-the-counter medications (e.g., ibruprofen and other nonsteroidal anti-inflammatory agents) can worsen edema; check with your healthcare provider. these measures may help to reduce overnight frequency, urgency, and leakage. Persons with diabetes who have elevated blood glucose levels should work with their healthcare provider to reduce blood glucose. Elevated blood glucose levels cause the kidneys to produce more urine, which can increase frequency, urgency, and leakage. Persons who have difficulty walking should be evaluated for interventions such as physical therapy, which could improve mobility. These persons may benefit from a portable toilet that can be placed close to their bed or living area. Potential obstacles such as electrical cords, throw rugs, or furniture should be moved out of hallways and walkways.
Pelvic muscle exercises — Pelvic muscle exercises, also known as Kegel exercises, strengthen the muscles involved in closing the urethral sphincter. These are used primarily for stress incontinence but can also be used to control sudden urges in persons with urge incontinence (show figure 4). (See "Patient information: Pelvic muscle exercises").
Studies have shown that, when done correctly, pelvic muscle exercises can be effective in people with stress incontinence. Patients may benefit from a visit to a physical therapist, or a urology, gynecology, or geriatric nurse specialist for detailed instructions. Biofeedback may also help teach correct exercise technique.
Treatments for urge incontinence
Bladder irritants — Some foods and beverages are thought to contribute to frequency and urgency. This includes caffeinated beverages and alcohol, spicy foods, and acidic foods or beverages. While this has not been proven, it may be reasonable to see if eliminating one or all of these items helps.
Bladder retraining — Normally, a person should urinate approximately every three to four hours during the day; getting up once during the night to void is normal for older persons. Bladder retraining can help persons with urge incontinence by slowly increasing the amount of urine the bladder hold, and therefore the time interval between voids (show figure 5). This regimen retrains the nerves and pelvic muscles, which can improve control of bladder contractions. Patients are instructed to urinate at specific intervals through the day, starting with a small time interval. For example, a person who must currently void every 30 to 45 minutes would start by voiding every 45 minutes, whether there is an urge or not.
If the patient feels the need to urge sooner, they should not to run to the bathroom, but should stand still or sit down and concentrate on decreasing the urge, usually while doing several pelvic muscle contractions (see "Pelvic muscle exercises" above). Once the urge has decreased or passed, the patient can walk slowly to the bathroom to urinate. After one to two weeks, the time interval can be increased by 30 to 60 minute increments. The goal is to increase the voiding interval to a more normal pattern, approximately every 3 to 5 hours.
For patients with dementia or memory impairment, treatment focuses on encouraging the patient to use the toilet at regular intervals (usually every two to three hours) and providing positive feedback for successful toileting.
Constipation — Constipation can lead to fecal impaction (when stool collects and is difficult to pass from the rectum), which can increase symptoms of frequency and urgency. Patients can prevent constipation by increasing the amount of fiber in their diet to between 20 and 30 grams per day (show table 3A-3C). (See "Patient information: Constipation in adults").
Medications — When bladder retraining and fluid management alone are not successful in treating urge incontinence, medications can be added. Medicines that are available are called bladder relaxants or antimuscarinic agents. Medications work best when combined with behavioral therapy. In general, these drugs have similar effectiveness, but may differ somewhat on the type and severity of side effects, such as dry mouth, constipation, and heartburn.
Patients and their clinicians should wait at least 4 weeks to determine the response to a medication. A patient who does not respond to one drug may respond to another. Patients who take these medications for long periods of time need to practice good dental care because dry mouth can increase the risk of cavities. There is a small risk of urinary retention (causing the bladder to incompletely empty) with these medications, especially in older patients. Oxybutynin comes in three forms: immediate release (generic oxybutynin, taken two to three times daily), extended release (Ditropan XL®, taken once daily), and a patch (Oxytrol®, which is worn on the skin and changed twice weekly). The immediate release form is particularly useful for people who require protection at specific times (eg, when going out to dinner) since it begins to work quickly and wears off after about six hours. Side effects occur less frequently with Ditropan XL® and Oxytrol®. Tolterodine is available in an immediate release form (Detrol® 1 or 2 mg, taken twice daily) and extended release (Detrol LA®, 2 or 4 mg taken once daily). Side effects occur less frequently with Detrol LA®. Trospium (Sanctura®) is taken one or two times daily on an empty stomach, and is available in 20 mg. Solifenacin (Vesicare®) is taken once a day, and is available in 5 mg or 10 mg. Darifenacin (Enablex®) is taken once a day, and is available in 7.5 mg and 15 mg.
Treatments for stress incontinence
Weight reduction — Obesity can contribute to symptoms of stress or mixed incontinence. In persons who are obese, weight loss can significantly reduce episodes of leakage due to stress incontinence.
Medication — There is currently no medication available for treatment of stress incontinence. Use of oral estrogen in women was found to worsen stress incontinence. Whether topical estrogen cream can improve incontinence is controversial.
Vaginal pessaries — A vaginal pessary is a flexible device made of silicone that can be worn in the vagina (show figure 6). It is traditionally used for women with pelvic organ prolapse (when the bladder, vagina, uterus, or rectum bulge from the vagina), but specially designed stress incontinence pessaries are also available. These help to support the urethra during a cough or sneeze, and may reduce or eliminate stress or overflow incontinence (show figure 7). A pessary is a reasonable treatment for women who want to delay surgery and for those who prefer a non-surgical treatment. When fit properly, the woman will not feel the pessary.
The pessary must be removed and cleaned with soap and water periodically. In addition, there is a small risk that the pessary can cause irritation of the vaginal tissues. Most women who use a pessary see their healthcare provider every three to six months for an examination. Some women are able to learn how to insert and remove the pessary on their own; this is especially helpful for women who are sexually active.
Periurethral bulking injections — In selected women, stress urinary incontinence is caused by complete failure of the urethral sphincter muscles; this is called intrinsic sphincter deficiency (ISD). This may occur in women who have had previous pelvic surgery or radiation treatment and later developed scarring, but it can also occur in postmenopausal women who have severely thinned (atrophic) vaginal tissues. ISD leakage is typically continuous and can occur while sitting or standing quietly.
Women with ISD may gain some short term benefit from injection of material into the wall of the urethra to help keep the urethra closed. These are called periurethral bulking injections. Materials injected include collagen, Teflon®, silicone, and carbon-coated beads.
Surgical treatments for women — Surgery offers the highest cure rate of any treatment for stress urinary incontinence, even in elderly women. Cure rates vary by procedure and by length of time since surgery, although most procedures result in 85 to 95 percent of women being cured at six weeks after surgery; cure rates tend to decrease over time. Ideally, surgery should be reserved for women who have completed childbearing because pregnancy and childbirth can cause damage to the urethral supports, potentially causing incontinence to recur.
There are several surgical procedures for the treatment of SUI in women. The best procedure depends upon several factors. Each procedure has its own risks, benefits, complications, and chance of failure. Long-term outcomes are not always known because some procedures have not been used long enough to measure the incidence of incontinence 10 to 20 years after surgery; the risk of incontinence recurring at a later time is difficult to know in these situations. All of these issues should be discussed in detail with the surgeon.
Other measures
Pads — While pads are not a recommended treatment for incontinence, they are necessary for some persons who are unable or unwilling to use behavioral treatments, medications, or more invasive treatments, or who have incomplete relief of leakage despite treatment.
Pads and protective undergarments are available for both men and women in a large variety of sizes and absorbencies. The choice of garment depends upon the type, frequency, and volume of urinary incontinence leakage. Pads designed for menstrual bleeding may be insufficient for persons with sudden, large volume leakage. In addition, menstrual pads typically do not manage urine odor as well as incontinence products. Men may prefer a penile sheath to a pad; the sheath covers the penis like a condom, and is connected to a tube and bag that collects the urine.
These items are expensive and are usually not covered by insurance; in some states within the United States, Medicaid may cover pads for people of very limited income, while in other countries pads may be obtained for no or little cost through continence advisor nurses. Information on pad varieties and other urinary incontinence supplies is available from medical supply companies and urinary incontinence patient advocacy groups (see "Where to get more information" below). The U.S. National Association for Continence has an online tool that can help a patient to choose a protective garment based upon individual characteristics (www.nafc.org/productdiagnostic.asp).
For all protective products, it is important that the skin is kept dry and that odor is managed. Skin that is exposed to urine for long periods can cause skin irritation, and can potentially cause skin burns or infection. In addition to protecting the skin, patients may need protective products for their bed or other furniture.
Catheters — A catheter may be necessary in some patients who cannot empty their bladder completely or at all. Because catheters (especially those left in place for long periods) can cause urinary tract infections and other serious complications, they are usually a treatment of last resort.
A catheter may be inserted and left in the bladder, or may be inserted as needed to drain the bladder, and then removed. A healthcare provider can teach the patient or a family member how to perform catheterization at home.
WHEN TO SEEK HELP — Patients should seek help from their healthcare provider if they are bothered by urinary frequency or urgency or leakage, if they are awakened more than twice during the night to urinate, if urinary leakage occurs, if there is pain with urination, or if they notice blood in the urine.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
National Institute on Aging
(www.nia.nih.gov/)
National Association for Continence
1-800-BLADDER
(www.nafc.org)
Simon Foundation
(www.simonfoundation.org)
National Institute of Diabetes & Digestive & Kidney Diseases
(www.niddk.nih.gov/)
American Foundation for Urologic Disease
(www.afud.org)
For continence resources in other countries, go to Continence Worldwide
(www.continenceworldwide.com)
[1-5]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Herzog, AR, Fultz, NH. Prevalence and incidence of urinary incontinence in community-dwelling populations. J Am Geriatr Soc 1990; 38:273.
2. DuBeau, CE, Levy, B, Mangione, CM, Resnick, NM. The impact of urge urinary incontinence on quality of life: importance of patients' perspective and explanatory style. J Am Geriatr Soc 1998; 46:683.
3. Fantl, JA, Newman, DK, Colling, J, et al. Urinary Incontinence in Adults: Acute and Chronic Management. Clinical Practice Guideline, No. 2, 1996 Update, AHCPR Publication No. 96-0682. Public Health Service, Agency for Health Care Policy and Research, Rockville, MD. (Available at www.ahrq.gov/clinic/uiovervw.htm, accessed 9/7/2006).
4. Brown, JS, Bradley, CS, Subak, LL, et al. The sensitivity and specificity of a simple test to distinguish between urge and stress urinary incontinence. Ann Intern Med 2006; 144:715.
5. Wyman, JF, Choi, SC, Harkins, SW, et al. The urinary diary in evaluation of incontinent women: A test-retest analysis. Obstet Gynecol 1988; 71:812.
Pelvic muscle exercises
INTRODUCTION — The pelvic muscles work to control the release of urine. Like other muscles, they can become weakened over time as a result of childbirth, surgery, and aging. People with bladder control problems can improve urinary control through pelvic muscle exercises (also called Kegel exercises).
WHO SHOULD USE PELVIC MUSCLE EXERCISES? — Pelvic muscle exercises are best for people with mild to moderate stress urinary incontinence (leaking urine with coughing, laughing, sneezing) or urge incontinence (leaking after a sudden urge to void).
These exercises may be less helpful for people with severe stress incontinence, and not helpful at all for people with other types of urinary incontinence, including overflow incontinence (when the bladder cannot empty completely and leaks when it becomes overly full). (See "Patient information: Urinary incontinence").
People who want to use pelvic muscle exercises should speak to their healthcare provider to determine if the exercises would be helpful, and also to receive instructions about how to perform the exercises correctly.
PELVIC MUSCLE EXERCISE TECHNIQUE The first step is to identify the correct muscles to contract. Women can do this by placing a finger in the vagina and squeezing the vaginal muscles around their finger. The muscles of the buttocks, abdomen, and thighs should not be used.
Another way is for a woman to imagine that she is sitting on a marble. Imagine using the vaginal muscles to gently lift the marble off the chair.
Some clinicians teach this exercise by having the patient stop the urine stream during urinating, but this is NOT recommended. Second, hold the pelvic muscle contraction approximately 8 to 10 seconds, and then relax the muscles; adequate relaxation is as important as contraction. In the beginning, it may not be possible to hold the contraction for more than one second.
Perform 8 to 12 contractions followed by relaxation three times. Try to do this every day, but no less than three or four times a week The exercise regimen should be continued for at least 15 to 20 weeks. Over time, try to hold the contraction harder and for a longer time. These exercises need to be continued indefinitely to have a lasting effect, similar to other forms of exercise.
In patients whose muscles are weak, the exercises should initially be done while lying down. As the muscles become stronger, the exercises may be done while sitting or standing.
Contract these muscles during activities that can cause urine leakage, such as during physical exercise, lifting, coughing or sneezing.
Some patients benefit from working with a physical therapist or nurse to receive more detailed instructions and to ensure that the correct technique is used. In addition, these providers may use biofeedback to improve exercise technique and strength; this provides a visual demonstration of how well the muscles contract and relax. A computer monitor shows as the muscles contract and relax, and also indicates if the wrong muscles are used.
RESULTS — Studies have shown that, if done correctly, pelvic muscle exercises can be effective in people with stress incontinence because the exercises improve muscle strength. This strength can also be used to stop a sudden urge to void that may result in urine leakage. If there is a sudden sense of urgency that may cause urine leakage, patients are advised to sit or stand still and contract the pelvic muscles. After the urge diminishes, the patient can then proceed to the toilet.
Most people notice an improvement after three to four months. It is important to continue the exercises in order to maintain bladder control. Patients with mild fecal leakage (leakage of stool) may have improvement in the amount and frequency of fecal leakage as well.
If these exercises are not helpful, please speak with a healthcare provider. Other muscle training and rehabilitation techniques, medical treatments, and surgical treatments are available and may be recommended.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
Mayo Clinic
(www.mayoclinic.com)
American Academy of Family Physicians
(www.familydoctor.org)
The National Institute of Diabetes and Digestive and Kidney Diseases
(www.kidney.niddk.nih.gov/kudiseases/pubs/exercise_ez/)
National Association for Continence
1-800-BLADDER
(www.nafc.org)
Simon Foundation
(www.simonfoundation.org)
American Foundation for Urologic Disease
(www.afud.org)
[1]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Hay-Smith, E, Dumoulin, C. Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database Syst Rev 2006; :CD005654.
WHO SHOULD USE PELVIC MUSCLE EXERCISES? — Pelvic muscle exercises are best for people with mild to moderate stress urinary incontinence (leaking urine with coughing, laughing, sneezing) or urge incontinence (leaking after a sudden urge to void).
These exercises may be less helpful for people with severe stress incontinence, and not helpful at all for people with other types of urinary incontinence, including overflow incontinence (when the bladder cannot empty completely and leaks when it becomes overly full). (See "Patient information: Urinary incontinence").
People who want to use pelvic muscle exercises should speak to their healthcare provider to determine if the exercises would be helpful, and also to receive instructions about how to perform the exercises correctly.
PELVIC MUSCLE EXERCISE TECHNIQUE The first step is to identify the correct muscles to contract. Women can do this by placing a finger in the vagina and squeezing the vaginal muscles around their finger. The muscles of the buttocks, abdomen, and thighs should not be used.
Another way is for a woman to imagine that she is sitting on a marble. Imagine using the vaginal muscles to gently lift the marble off the chair.
Some clinicians teach this exercise by having the patient stop the urine stream during urinating, but this is NOT recommended. Second, hold the pelvic muscle contraction approximately 8 to 10 seconds, and then relax the muscles; adequate relaxation is as important as contraction. In the beginning, it may not be possible to hold the contraction for more than one second.
Perform 8 to 12 contractions followed by relaxation three times. Try to do this every day, but no less than three or four times a week The exercise regimen should be continued for at least 15 to 20 weeks. Over time, try to hold the contraction harder and for a longer time. These exercises need to be continued indefinitely to have a lasting effect, similar to other forms of exercise.
In patients whose muscles are weak, the exercises should initially be done while lying down. As the muscles become stronger, the exercises may be done while sitting or standing.
Contract these muscles during activities that can cause urine leakage, such as during physical exercise, lifting, coughing or sneezing.
Some patients benefit from working with a physical therapist or nurse to receive more detailed instructions and to ensure that the correct technique is used. In addition, these providers may use biofeedback to improve exercise technique and strength; this provides a visual demonstration of how well the muscles contract and relax. A computer monitor shows as the muscles contract and relax, and also indicates if the wrong muscles are used.
RESULTS — Studies have shown that, if done correctly, pelvic muscle exercises can be effective in people with stress incontinence because the exercises improve muscle strength. This strength can also be used to stop a sudden urge to void that may result in urine leakage. If there is a sudden sense of urgency that may cause urine leakage, patients are advised to sit or stand still and contract the pelvic muscles. After the urge diminishes, the patient can then proceed to the toilet.
Most people notice an improvement after three to four months. It is important to continue the exercises in order to maintain bladder control. Patients with mild fecal leakage (leakage of stool) may have improvement in the amount and frequency of fecal leakage as well.
If these exercises are not helpful, please speak with a healthcare provider. Other muscle training and rehabilitation techniques, medical treatments, and surgical treatments are available and may be recommended.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
Mayo Clinic
(www.mayoclinic.com)
American Academy of Family Physicians
(www.familydoctor.org)
The National Institute of Diabetes and Digestive and Kidney Diseases
(www.kidney.niddk.nih.gov/kudiseases/pubs/exercise_ez/)
National Association for Continence
1-800-BLADDER
(www.nafc.org)
Simon Foundation
(www.simonfoundation.org)
American Foundation for Urologic Disease
(www.afud.org)
[1]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Hay-Smith, E, Dumoulin, C. Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database Syst Rev 2006; :CD005654.
Gonorrhea
INTRODUCTION — Gonorrhea is a sexually transmitted infection that can affect both men and women. Approximately 700,000 people are infected with gonorrhea every year in the United States, although only about half of those people are tested and receive treatment. Gonorrhea has potentially serious consequences, particularly in women and newborns of infected mothers.
CAUSES — Gonorrhea is caused by a bacterium known as Neisseria gonorrhoeae. It is too tiny to be seen by the naked eye. Gonorrhea is usually spread from one person to another during sexual intercourse; it is not transmitted via inanimate objects, like toilet seats.
A person can become infected when the bacteria invades mucous membranes of the mouth, throat, anus, urethra (where urine exits), and vagina. Ejaculation is not necessary to spread the infection. Risk factors for infection include a new sexual partner or multiple sexual partners, and a previous history of gonorrhea.
SYMPTOMS — Symptoms of gonorrhea depend upon a person's gender and the area that is infected. However, some people have no symptoms at all. This potentially allows the disease to be spread from person to person before it is detected.
Both men and women can develop infection of the urethra (where urine exits), throat, and rectum. In women, infection can also occur in the cervix, uterus, fallopian tubes, and ovaries (show figure 1). Infection in men can affect the prostate and the epididymis (show figure 2). In both men and women, the infection can affect several areas at once.
Women — In women, the most common site of infection is the cervix. Cervical infection causes no symptoms in about 50 percent of cases. If symptoms do occur, a woman may notice vaginal itching, abnormal vaginal discharge, or vaginal bleeding between menstrual periods. Infection of the urethra can cause burning during urination.
The anus and rectum can also become infected, which causes no symptoms in most cases. When present, symptoms include anal itching, rectal discharge, rectal fullness, and painful defecation. Even women who do not engage in rectal intercourse can become infected in this area due to contact with vaginal secretions.
Rarely, a woman's Bartholin's glands and Skene's glands can become infected (show figure 3). The primary symptom is vaginal discomfort. Infection of the throat and mouth may cause a sore throat, but usually causes no symptoms at all.
Men — While women often have no symptoms of gonorrhea, 90 percent of men do experience symptoms, including painful urination and a milky penile discharge. Epididymal infection can develop, causing pain and swelling in one testicle.
Infection of the rectum can develop among men who have sex with men. Symptoms include a rectal discharge, rectal fullness, constipation, and pain. Symptoms usually develop within four to eight days of infection, although it can be up to 30 days in some men.
DIAGNOSIS — Gonorrhea can be identified using several methods, all of which require that the person visit a healthcare provider's office or clinic. Testing may be done because the person has symptoms or as a part of a general check up.
The usual method of testing for gonorrhea gives results within hours. Testing can be done with a swab of the cervix or urethra, as well as with a urine sample.
Other sexually transmitted infections — A person who is found to have an STI, or has a partner with an STI, should consider testing for other STIs, including HIV, Chlamydia, hepatitis B, trichomoniasis, and syphilis. (See "Patient information: Testing for HIV", see "Patient information: Chlamydia" and see "Patient information: Hepatitis B").
Women are advised to have an annual cervical cancer screening (Pap smear), which can detect precancerous or abnormal changes related to a sexually transmitted virus, the human papilloma virus. (See "Patient information: Screening for cervical cancer").
Men or women who use intravenous drugs or have sexual intercourse with a partner who is at risk for hepatitis C should consider testing for this infection. (See "Patient information: Hepatitis C").
Testing is also available for herpes simplex virus, although this is not usually performed unless there are symptoms or risk factors for infection. (See "Patient information: Genital herpes").
COMPLICATIONS — If untreated, gonorrhea can lead to serious complications in both men and women, including joint infections and arthritis. Women can develop pelvic inflammatory disease while men can develop epididymitis. People with gonorrhea are also at higher risk of becoming infected with HIV. (See "Patient information: Joint infection" and see "Patient information: Symptoms of HIV infection").
Pelvic inflammatory disease (PID) occurs in women when gonorrhea spreads from the cervix to the uterus and fallopian tubes. This can cause abdominal or pelvic pain, pain during intercourse, and occasionally, chronic pelvic pain. PID occurs in 10 to 40 percent of women with cervical gonorrhea, which can scar the fallopian tubes and lead to infertility and an increased risk of ectopic pregnancy. (See "Patient information: Chronic pelvic pain in women").
Epididymitis can occur in men with untreated gonorrhea, and can lead to infertility as a result of scarring of the epididymis. The epididymis collects sperm after it leaves the testis.
Infants infected with gonorrhea during birth can develop a serious eye infection, which can potentially cause blindness. As a result, pregnant women are routinely tested for gonorrhea during pregnancy and infants are routinely given a one-time eye treatment with antibiotic ointment immediately after birth.
TREATMENT — Treatment of gonorrhea is the same for women and men. Most experts recommend a one-time antibiotic treatment, such as an injection of ceftriaxone, or an oral dose of cefixime. This is a new recommendation, made in 2007, due to increasing rates of resistance to another type of antibiotic called quinolones (for example, ciprofloxacin, ofloxacin). Pregnant women with uncomplicated gonorrhea can be safely treated with either ceftriaxone or cefixime.
Alternate medications are available for persons who are allergic to the above medications, including an oral medication called azithromycin. Resistant strains of gonorrhea are increasing in some areas of the world (including the United States). The Centers for Disease Control and Prevention (CDC) monitors drug resistance rates (www.cdc.gov/std/gisp).
Patients infected with gonorrhea are sometimes also infected with Chlamydia. For this reason, some clinicians will recommend treatment for both infections at once. (See "Patient information: Chlamydia").
Treatment of sexual partners — Current or recent sexual partners of a person diagnosed with gonorrhea should also be treated, especially since that person may not have any symptoms. Furthermore, an untreated partner can reinfect the patient. The traditional approach has been for the patient to notify their partner that a clinic visit is necessary, where the partner can be tested and treated if needed. In contrast, some clinics have a policy of offering two prescriptions - one for the patient and one for the partner.
In order to prevent reinfection, sexual contact should be avoided until both partners have been treated and all symptoms have resolved. It is possible to become infected with gonorrhea more than once.
Test of cure — Patients who finish the recommended treatment regimen do not need to be retested. However, a person who continues to have symptoms should be reevaluated; further testing may be recommended.
PREVENTION — The most effective way to prevent gonorrhea is to avoid sexual intercourse. Because this is not practical for many people, the following tips are recommended: Use a latex condom with every act of sexual intercourse. Discuss routine testing for sexually transmitted infections with a healthcare provider. Persons in a long-term, mutually monogamous relationship are at a lower risk of infections than those with multiple sexual partners or multiple short-term relationships. See a healthcare provider if there are signs or symptoms of gonorrhea. Avoid sexual intercourse if either partner notes abnormal genital discharge, burning with urination, or a genital rash or sore.
SUMMARY Gonorrhea is a sexually transmitted infection that can be spread during sexual intercourse. A man does not have to ejaculate to spread the infection (see "Causes" above). Some people have symptoms (pain while urinating, discharge from the penis or vagina), while others have no symptoms at all. The infection can be spread from one person to another before it is diagnosed (see "Symptoms" above). Testing for gonorrhea is done in a medical office or clinic. Testing can be done with a swab of the penis or cervix or with a urine sample (see "Diagnosis" above). If untreated, gonorrhea can lead to serious complications in both men and women. In addition, people with gonorrhea are at higher risk of becoming infected with HIV (see "Complications" above). Gonorrhea can be cured with an antibiotic. Sexual partners of a person with gonorrhea should also be treated. Sex should be avoided until both partners have been treated. (see "Treatment" above). Using a latex condom reduces the risk of becoming infected with gonorrhea. Regular testing for sexually transmitted infections is recommended, especially before having sex with a new partner. Sex should be avoided if either partner has abnormal discharge from the penis or vagina, burning with urination, or a genital rash or sore (see "Prevention" above).
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
National Institute of Allergy and Infectious Diseases
(www.niaid.nih.gov/factsheets/stdgon.htm)
Centers for Disease Control and Prevention
(www.cdc.gov/std/Gonorrhea/STDFact-gonorrhea.htm)
American Social Health Association
(www.ashastd.org/stdfaqs/gonorrhea.html)
[1-3]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Choudhury, B, Risley, CL, Ghani, AC, et al. Identification of individuals with gonorrhoea within sexual networks: a population-based study. Lancet 2006; 368:139.
2. Workowski, KA, Berman, SM. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep 2006; 55:1.
3. Cook, RL, Hutchison, SL, Ostergaard, L, et al. Systematic review: noninvasive testing for Chlamydia trachomatis and Neisseria gonorrhoeae. Ann Intern Med 2005; 142:914.
CAUSES — Gonorrhea is caused by a bacterium known as Neisseria gonorrhoeae. It is too tiny to be seen by the naked eye. Gonorrhea is usually spread from one person to another during sexual intercourse; it is not transmitted via inanimate objects, like toilet seats.
A person can become infected when the bacteria invades mucous membranes of the mouth, throat, anus, urethra (where urine exits), and vagina. Ejaculation is not necessary to spread the infection. Risk factors for infection include a new sexual partner or multiple sexual partners, and a previous history of gonorrhea.
SYMPTOMS — Symptoms of gonorrhea depend upon a person's gender and the area that is infected. However, some people have no symptoms at all. This potentially allows the disease to be spread from person to person before it is detected.
Both men and women can develop infection of the urethra (where urine exits), throat, and rectum. In women, infection can also occur in the cervix, uterus, fallopian tubes, and ovaries (show figure 1). Infection in men can affect the prostate and the epididymis (show figure 2). In both men and women, the infection can affect several areas at once.
Women — In women, the most common site of infection is the cervix. Cervical infection causes no symptoms in about 50 percent of cases. If symptoms do occur, a woman may notice vaginal itching, abnormal vaginal discharge, or vaginal bleeding between menstrual periods. Infection of the urethra can cause burning during urination.
The anus and rectum can also become infected, which causes no symptoms in most cases. When present, symptoms include anal itching, rectal discharge, rectal fullness, and painful defecation. Even women who do not engage in rectal intercourse can become infected in this area due to contact with vaginal secretions.
Rarely, a woman's Bartholin's glands and Skene's glands can become infected (show figure 3). The primary symptom is vaginal discomfort. Infection of the throat and mouth may cause a sore throat, but usually causes no symptoms at all.
Men — While women often have no symptoms of gonorrhea, 90 percent of men do experience symptoms, including painful urination and a milky penile discharge. Epididymal infection can develop, causing pain and swelling in one testicle.
Infection of the rectum can develop among men who have sex with men. Symptoms include a rectal discharge, rectal fullness, constipation, and pain. Symptoms usually develop within four to eight days of infection, although it can be up to 30 days in some men.
DIAGNOSIS — Gonorrhea can be identified using several methods, all of which require that the person visit a healthcare provider's office or clinic. Testing may be done because the person has symptoms or as a part of a general check up.
The usual method of testing for gonorrhea gives results within hours. Testing can be done with a swab of the cervix or urethra, as well as with a urine sample.
Other sexually transmitted infections — A person who is found to have an STI, or has a partner with an STI, should consider testing for other STIs, including HIV, Chlamydia, hepatitis B, trichomoniasis, and syphilis. (See "Patient information: Testing for HIV", see "Patient information: Chlamydia" and see "Patient information: Hepatitis B").
Women are advised to have an annual cervical cancer screening (Pap smear), which can detect precancerous or abnormal changes related to a sexually transmitted virus, the human papilloma virus. (See "Patient information: Screening for cervical cancer").
Men or women who use intravenous drugs or have sexual intercourse with a partner who is at risk for hepatitis C should consider testing for this infection. (See "Patient information: Hepatitis C").
Testing is also available for herpes simplex virus, although this is not usually performed unless there are symptoms or risk factors for infection. (See "Patient information: Genital herpes").
COMPLICATIONS — If untreated, gonorrhea can lead to serious complications in both men and women, including joint infections and arthritis. Women can develop pelvic inflammatory disease while men can develop epididymitis. People with gonorrhea are also at higher risk of becoming infected with HIV. (See "Patient information: Joint infection" and see "Patient information: Symptoms of HIV infection").
Pelvic inflammatory disease (PID) occurs in women when gonorrhea spreads from the cervix to the uterus and fallopian tubes. This can cause abdominal or pelvic pain, pain during intercourse, and occasionally, chronic pelvic pain. PID occurs in 10 to 40 percent of women with cervical gonorrhea, which can scar the fallopian tubes and lead to infertility and an increased risk of ectopic pregnancy. (See "Patient information: Chronic pelvic pain in women").
Epididymitis can occur in men with untreated gonorrhea, and can lead to infertility as a result of scarring of the epididymis. The epididymis collects sperm after it leaves the testis.
Infants infected with gonorrhea during birth can develop a serious eye infection, which can potentially cause blindness. As a result, pregnant women are routinely tested for gonorrhea during pregnancy and infants are routinely given a one-time eye treatment with antibiotic ointment immediately after birth.
TREATMENT — Treatment of gonorrhea is the same for women and men. Most experts recommend a one-time antibiotic treatment, such as an injection of ceftriaxone, or an oral dose of cefixime. This is a new recommendation, made in 2007, due to increasing rates of resistance to another type of antibiotic called quinolones (for example, ciprofloxacin, ofloxacin). Pregnant women with uncomplicated gonorrhea can be safely treated with either ceftriaxone or cefixime.
Alternate medications are available for persons who are allergic to the above medications, including an oral medication called azithromycin. Resistant strains of gonorrhea are increasing in some areas of the world (including the United States). The Centers for Disease Control and Prevention (CDC) monitors drug resistance rates (www.cdc.gov/std/gisp).
Patients infected with gonorrhea are sometimes also infected with Chlamydia. For this reason, some clinicians will recommend treatment for both infections at once. (See "Patient information: Chlamydia").
Treatment of sexual partners — Current or recent sexual partners of a person diagnosed with gonorrhea should also be treated, especially since that person may not have any symptoms. Furthermore, an untreated partner can reinfect the patient. The traditional approach has been for the patient to notify their partner that a clinic visit is necessary, where the partner can be tested and treated if needed. In contrast, some clinics have a policy of offering two prescriptions - one for the patient and one for the partner.
In order to prevent reinfection, sexual contact should be avoided until both partners have been treated and all symptoms have resolved. It is possible to become infected with gonorrhea more than once.
Test of cure — Patients who finish the recommended treatment regimen do not need to be retested. However, a person who continues to have symptoms should be reevaluated; further testing may be recommended.
PREVENTION — The most effective way to prevent gonorrhea is to avoid sexual intercourse. Because this is not practical for many people, the following tips are recommended: Use a latex condom with every act of sexual intercourse. Discuss routine testing for sexually transmitted infections with a healthcare provider. Persons in a long-term, mutually monogamous relationship are at a lower risk of infections than those with multiple sexual partners or multiple short-term relationships. See a healthcare provider if there are signs or symptoms of gonorrhea. Avoid sexual intercourse if either partner notes abnormal genital discharge, burning with urination, or a genital rash or sore.
SUMMARY Gonorrhea is a sexually transmitted infection that can be spread during sexual intercourse. A man does not have to ejaculate to spread the infection (see "Causes" above). Some people have symptoms (pain while urinating, discharge from the penis or vagina), while others have no symptoms at all. The infection can be spread from one person to another before it is diagnosed (see "Symptoms" above). Testing for gonorrhea is done in a medical office or clinic. Testing can be done with a swab of the penis or cervix or with a urine sample (see "Diagnosis" above). If untreated, gonorrhea can lead to serious complications in both men and women. In addition, people with gonorrhea are at higher risk of becoming infected with HIV (see "Complications" above). Gonorrhea can be cured with an antibiotic. Sexual partners of a person with gonorrhea should also be treated. Sex should be avoided until both partners have been treated. (see "Treatment" above). Using a latex condom reduces the risk of becoming infected with gonorrhea. Regular testing for sexually transmitted infections is recommended, especially before having sex with a new partner. Sex should be avoided if either partner has abnormal discharge from the penis or vagina, burning with urination, or a genital rash or sore (see "Prevention" above).
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
National Institute of Allergy and Infectious Diseases
(www.niaid.nih.gov/factsheets/stdgon.htm)
Centers for Disease Control and Prevention
(www.cdc.gov/std/Gonorrhea/STDFact-gonorrhea.htm)
American Social Health Association
(www.ashastd.org/stdfaqs/gonorrhea.html)
[1-3]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Choudhury, B, Risley, CL, Ghani, AC, et al. Identification of individuals with gonorrhoea within sexual networks: a population-based study. Lancet 2006; 368:139.
2. Workowski, KA, Berman, SM. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep 2006; 55:1.
3. Cook, RL, Hutchison, SL, Ostergaard, L, et al. Systematic review: noninvasive testing for Chlamydia trachomatis and Neisseria gonorrhoeae. Ann Intern Med 2005; 142:914.
Pelvic muscle exercises
INTRODUCTION — The pelvic muscles work to control the release of urine. Like other muscles, they can become weakened over time as a result of childbirth, surgery, and aging. People with bladder control problems can improve urinary control through pelvic muscle exercises (also called Kegel exercises).
WHO SHOULD USE PELVIC MUSCLE EXERCISES? — Pelvic muscle exercises are best for people with mild to moderate stress urinary incontinence (leaking urine with coughing, laughing, sneezing) or urge incontinence (leaking after a sudden urge to void).
These exercises may be less helpful for people with severe stress incontinence, and not helpful at all for people with other types of urinary incontinence, including overflow incontinence (when the bladder cannot empty completely and leaks when it becomes overly full). (See "Patient information: Urinary incontinence").
People who want to use pelvic muscle exercises should speak to their healthcare provider to determine if the exercises would be helpful, and also to receive instructions about how to perform the exercises correctly.
PELVIC MUSCLE EXERCISE TECHNIQUE The first step is to identify the correct muscles to contract. Women can do this by placing a finger in the vagina and squeezing the vaginal muscles around their finger. The muscles of the buttocks, abdomen, and thighs should not be used.
Another way is for a woman to imagine that she is sitting on a marble. Imagine using the vaginal muscles to gently lift the marble off the chair.
Some clinicians teach this exercise by having the patient stop the urine stream during urinating, but this is NOT recommended. Second, hold the pelvic muscle contraction approximately 8 to 10 seconds, and then relax the muscles; adequate relaxation is as important as contraction. In the beginning, it may not be possible to hold the contraction for more than one second.
Perform 8 to 12 contractions followed by relaxation three times. Try to do this every day, but no less than three or four times a week The exercise regimen should be continued for at least 15 to 20 weeks. Over time, try to hold the contraction harder and for a longer time. These exercises need to be continued indefinitely to have a lasting effect, similar to other forms of exercise.
In patients whose muscles are weak, the exercises should initially be done while lying down. As the muscles become stronger, the exercises may be done while sitting or standing.
Contract these muscles during activities that can cause urine leakage, such as during physical exercise, lifting, coughing or sneezing.
Some patients benefit from working with a physical therapist or nurse to receive more detailed instructions and to ensure that the correct technique is used. In addition, these providers may use biofeedback to improve exercise technique and strength; this provides a visual demonstration of how well the muscles contract and relax. A computer monitor shows as the muscles contract and relax, and also indicates if the wrong muscles are used.
RESULTS — Studies have shown that, if done correctly, pelvic muscle exercises can be effective in people with stress incontinence because the exercises improve muscle strength. This strength can also be used to stop a sudden urge to void that may result in urine leakage. If there is a sudden sense of urgency that may cause urine leakage, patients are advised to sit or stand still and contract the pelvic muscles. After the urge diminishes, the patient can then proceed to the toilet.
Most people notice an improvement after three to four months. It is important to continue the exercises in order to maintain bladder control. Patients with mild fecal leakage (leakage of stool) may have improvement in the amount and frequency of fecal leakage as well.
If these exercises are not helpful, please speak with a healthcare provider. Other muscle training and rehabilitation techniques, medical treatments, and surgical treatments are available and may be recommended.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
Mayo Clinic
(www.mayoclinic.com)
American Academy of Family Physicians
(www.familydoctor.org)
The National Institute of Diabetes and Digestive and Kidney Diseases
(www.kidney.niddk.nih.gov/kudiseases/pubs/exercise_ez/)
National Association for Continence
1-800-BLADDER
(www.nafc.org)
Simon Foundation
(www.simonfoundation.org)
American Foundation for Urologic Disease
(www.afud.org)
[1]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Hay-Smith, E, Dumoulin, C. Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database Syst Rev 2006; :CD005654.
WHO SHOULD USE PELVIC MUSCLE EXERCISES? — Pelvic muscle exercises are best for people with mild to moderate stress urinary incontinence (leaking urine with coughing, laughing, sneezing) or urge incontinence (leaking after a sudden urge to void).
These exercises may be less helpful for people with severe stress incontinence, and not helpful at all for people with other types of urinary incontinence, including overflow incontinence (when the bladder cannot empty completely and leaks when it becomes overly full). (See "Patient information: Urinary incontinence").
People who want to use pelvic muscle exercises should speak to their healthcare provider to determine if the exercises would be helpful, and also to receive instructions about how to perform the exercises correctly.
PELVIC MUSCLE EXERCISE TECHNIQUE The first step is to identify the correct muscles to contract. Women can do this by placing a finger in the vagina and squeezing the vaginal muscles around their finger. The muscles of the buttocks, abdomen, and thighs should not be used.
Another way is for a woman to imagine that she is sitting on a marble. Imagine using the vaginal muscles to gently lift the marble off the chair.
Some clinicians teach this exercise by having the patient stop the urine stream during urinating, but this is NOT recommended. Second, hold the pelvic muscle contraction approximately 8 to 10 seconds, and then relax the muscles; adequate relaxation is as important as contraction. In the beginning, it may not be possible to hold the contraction for more than one second.
Perform 8 to 12 contractions followed by relaxation three times. Try to do this every day, but no less than three or four times a week The exercise regimen should be continued for at least 15 to 20 weeks. Over time, try to hold the contraction harder and for a longer time. These exercises need to be continued indefinitely to have a lasting effect, similar to other forms of exercise.
In patients whose muscles are weak, the exercises should initially be done while lying down. As the muscles become stronger, the exercises may be done while sitting or standing.
Contract these muscles during activities that can cause urine leakage, such as during physical exercise, lifting, coughing or sneezing.
Some patients benefit from working with a physical therapist or nurse to receive more detailed instructions and to ensure that the correct technique is used. In addition, these providers may use biofeedback to improve exercise technique and strength; this provides a visual demonstration of how well the muscles contract and relax. A computer monitor shows as the muscles contract and relax, and also indicates if the wrong muscles are used.
RESULTS — Studies have shown that, if done correctly, pelvic muscle exercises can be effective in people with stress incontinence because the exercises improve muscle strength. This strength can also be used to stop a sudden urge to void that may result in urine leakage. If there is a sudden sense of urgency that may cause urine leakage, patients are advised to sit or stand still and contract the pelvic muscles. After the urge diminishes, the patient can then proceed to the toilet.
Most people notice an improvement after three to four months. It is important to continue the exercises in order to maintain bladder control. Patients with mild fecal leakage (leakage of stool) may have improvement in the amount and frequency of fecal leakage as well.
If these exercises are not helpful, please speak with a healthcare provider. Other muscle training and rehabilitation techniques, medical treatments, and surgical treatments are available and may be recommended.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
Mayo Clinic
(www.mayoclinic.com)
American Academy of Family Physicians
(www.familydoctor.org)
The National Institute of Diabetes and Digestive and Kidney Diseases
(www.kidney.niddk.nih.gov/kudiseases/pubs/exercise_ez/)
National Association for Continence
1-800-BLADDER
(www.nafc.org)
Simon Foundation
(www.simonfoundation.org)
American Foundation for Urologic Disease
(www.afud.org)
[1]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Hay-Smith, E, Dumoulin, C. Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database Syst Rev 2006; :CD005654.
Gonorrhea
INTRODUCTION — Gonorrhea is a sexually transmitted infection that can affect both men and women. Approximately 700,000 people are infected with gonorrhea every year in the United States, although only about half of those people are tested and receive treatment. Gonorrhea has potentially serious consequences, particularly in women and newborns of infected mothers.
CAUSES — Gonorrhea is caused by a bacterium known as Neisseria gonorrhoeae. It is too tiny to be seen by the naked eye. Gonorrhea is usually spread from one person to another during sexual intercourse; it is not transmitted via inanimate objects, like toilet seats.
A person can become infected when the bacteria invades mucous membranes of the mouth, throat, anus, urethra (where urine exits), and vagina. Ejaculation is not necessary to spread the infection. Risk factors for infection include a new sexual partner or multiple sexual partners, and a previous history of gonorrhea.
SYMPTOMS — Symptoms of gonorrhea depend upon a person's gender and the area that is infected. However, some people have no symptoms at all. This potentially allows the disease to be spread from person to person before it is detected.
Both men and women can develop infection of the urethra (where urine exits), throat, and rectum. In women, infection can also occur in the cervix, uterus, fallopian tubes, and ovaries (show figure 1). Infection in men can affect the prostate and the epididymis (show figure 2). In both men and women, the infection can affect several areas at once.
Women — In women, the most common site of infection is the cervix. Cervical infection causes no symptoms in about 50 percent of cases. If symptoms do occur, a woman may notice vaginal itching, abnormal vaginal discharge, or vaginal bleeding between menstrual periods. Infection of the urethra can cause burning during urination.
The anus and rectum can also become infected, which causes no symptoms in most cases. When present, symptoms include anal itching, rectal discharge, rectal fullness, and painful defecation. Even women who do not engage in rectal intercourse can become infected in this area due to contact with vaginal secretions.
Rarely, a woman's Bartholin's glands and Skene's glands can become infected (show figure 3). The primary symptom is vaginal discomfort. Infection of the throat and mouth may cause a sore throat, but usually causes no symptoms at all.
Men — While women often have no symptoms of gonorrhea, 90 percent of men do experience symptoms, including painful urination and a milky penile discharge. Epididymal infection can develop, causing pain and swelling in one testicle.
Infection of the rectum can develop among men who have sex with men. Symptoms include a rectal discharge, rectal fullness, constipation, and pain. Symptoms usually develop within four to eight days of infection, although it can be up to 30 days in some men.
DIAGNOSIS — Gonorrhea can be identified using several methods, all of which require that the person visit a healthcare provider's office or clinic. Testing may be done because the person has symptoms or as a part of a general check up.
The usual method of testing for gonorrhea gives results within hours. Testing can be done with a swab of the cervix or urethra, as well as with a urine sample.
Other sexually transmitted infections — A person who is found to have an STI, or has a partner with an STI, should consider testing for other STIs, including HIV, Chlamydia, hepatitis B, trichomoniasis, and syphilis. (See "Patient information: Testing for HIV", see "Patient information: Chlamydia" and see "Patient information: Hepatitis B").
Women are advised to have an annual cervical cancer screening (Pap smear), which can detect precancerous or abnormal changes related to a sexually transmitted virus, the human papilloma virus. (See "Patient information: Screening for cervical cancer").
Men or women who use intravenous drugs or have sexual intercourse with a partner who is at risk for hepatitis C should consider testing for this infection. (See "Patient information: Hepatitis C").
Testing is also available for herpes simplex virus, although this is not usually performed unless there are symptoms or risk factors for infection. (See "Patient information: Genital herpes").
COMPLICATIONS — If untreated, gonorrhea can lead to serious complications in both men and women, including joint infections and arthritis. Women can develop pelvic inflammatory disease while men can develop epididymitis. People with gonorrhea are also at higher risk of becoming infected with HIV. (See "Patient information: Joint infection" and see "Patient information: Symptoms of HIV infection").
Pelvic inflammatory disease (PID) occurs in women when gonorrhea spreads from the cervix to the uterus and fallopian tubes. This can cause abdominal or pelvic pain, pain during intercourse, and occasionally, chronic pelvic pain. PID occurs in 10 to 40 percent of women with cervical gonorrhea, which can scar the fallopian tubes and lead to infertility and an increased risk of ectopic pregnancy. (See "Patient information: Chronic pelvic pain in women").
Epididymitis can occur in men with untreated gonorrhea, and can lead to infertility as a result of scarring of the epididymis. The epididymis collects sperm after it leaves the testis.
Infants infected with gonorrhea during birth can develop a serious eye infection, which can potentially cause blindness. As a result, pregnant women are routinely tested for gonorrhea during pregnancy and infants are routinely given a one-time eye treatment with antibiotic ointment immediately after birth.
TREATMENT — Treatment of gonorrhea is the same for women and men. Most experts recommend a one-time antibiotic treatment, such as an injection of ceftriaxone, or an oral dose of cefixime. This is a new recommendation, made in 2007, due to increasing rates of resistance to another type of antibiotic called quinolones (for example, ciprofloxacin, ofloxacin). Pregnant women with uncomplicated gonorrhea can be safely treated with either ceftriaxone or cefixime.
Alternate medications are available for persons who are allergic to the above medications, including an oral medication called azithromycin. Resistant strains of gonorrhea are increasing in some areas of the world (including the United States). The Centers for Disease Control and Prevention (CDC) monitors drug resistance rates (www.cdc.gov/std/gisp).
Patients infected with gonorrhea are sometimes also infected with Chlamydia. For this reason, some clinicians will recommend treatment for both infections at once. (See "Patient information: Chlamydia").
Treatment of sexual partners — Current or recent sexual partners of a person diagnosed with gonorrhea should also be treated, especially since that person may not have any symptoms. Furthermore, an untreated partner can reinfect the patient. The traditional approach has been for the patient to notify their partner that a clinic visit is necessary, where the partner can be tested and treated if needed. In contrast, some clinics have a policy of offering two prescriptions - one for the patient and one for the partner.
In order to prevent reinfection, sexual contact should be avoided until both partners have been treated and all symptoms have resolved. It is possible to become infected with gonorrhea more than once.
Test of cure — Patients who finish the recommended treatment regimen do not need to be retested. However, a person who continues to have symptoms should be reevaluated; further testing may be recommended.
PREVENTION — The most effective way to prevent gonorrhea is to avoid sexual intercourse. Because this is not practical for many people, the following tips are recommended: Use a latex condom with every act of sexual intercourse. Discuss routine testing for sexually transmitted infections with a healthcare provider. Persons in a long-term, mutually monogamous relationship are at a lower risk of infections than those with multiple sexual partners or multiple short-term relationships. See a healthcare provider if there are signs or symptoms of gonorrhea. Avoid sexual intercourse if either partner notes abnormal genital discharge, burning with urination, or a genital rash or sore.
SUMMARY Gonorrhea is a sexually transmitted infection that can be spread during sexual intercourse. A man does not have to ejaculate to spread the infection (see "Causes" above). Some people have symptoms (pain while urinating, discharge from the penis or vagina), while others have no symptoms at all. The infection can be spread from one person to another before it is diagnosed (see "Symptoms" above). Testing for gonorrhea is done in a medical office or clinic. Testing can be done with a swab of the penis or cervix or with a urine sample (see "Diagnosis" above). If untreated, gonorrhea can lead to serious complications in both men and women. In addition, people with gonorrhea are at higher risk of becoming infected with HIV (see "Complications" above). Gonorrhea can be cured with an antibiotic. Sexual partners of a person with gonorrhea should also be treated. Sex should be avoided until both partners have been treated. (see "Treatment" above). Using a latex condom reduces the risk of becoming infected with gonorrhea. Regular testing for sexually transmitted infections is recommended, especially before having sex with a new partner. Sex should be avoided if either partner has abnormal discharge from the penis or vagina, burning with urination, or a genital rash or sore (see "Prevention" above).
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
National Institute of Allergy and Infectious Diseases
(www.niaid.nih.gov/factsheets/stdgon.htm)
Centers for Disease Control and Prevention
(www.cdc.gov/std/Gonorrhea/STDFact-gonorrhea.htm)
American Social Health Association
(www.ashastd.org/stdfaqs/gonorrhea.html)
[1-3]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Choudhury, B, Risley, CL, Ghani, AC, et al. Identification of individuals with gonorrhoea within sexual networks: a population-based study. Lancet 2006; 368:139.
2. Workowski, KA, Berman, SM. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep 2006; 55:1.
3. Cook, RL, Hutchison, SL, Ostergaard, L, et al. Systematic review: noninvasive testing for Chlamydia trachomatis and Neisseria gonorrhoeae. Ann Intern Med 2005; 142:914.
CAUSES — Gonorrhea is caused by a bacterium known as Neisseria gonorrhoeae. It is too tiny to be seen by the naked eye. Gonorrhea is usually spread from one person to another during sexual intercourse; it is not transmitted via inanimate objects, like toilet seats.
A person can become infected when the bacteria invades mucous membranes of the mouth, throat, anus, urethra (where urine exits), and vagina. Ejaculation is not necessary to spread the infection. Risk factors for infection include a new sexual partner or multiple sexual partners, and a previous history of gonorrhea.
SYMPTOMS — Symptoms of gonorrhea depend upon a person's gender and the area that is infected. However, some people have no symptoms at all. This potentially allows the disease to be spread from person to person before it is detected.
Both men and women can develop infection of the urethra (where urine exits), throat, and rectum. In women, infection can also occur in the cervix, uterus, fallopian tubes, and ovaries (show figure 1). Infection in men can affect the prostate and the epididymis (show figure 2). In both men and women, the infection can affect several areas at once.
Women — In women, the most common site of infection is the cervix. Cervical infection causes no symptoms in about 50 percent of cases. If symptoms do occur, a woman may notice vaginal itching, abnormal vaginal discharge, or vaginal bleeding between menstrual periods. Infection of the urethra can cause burning during urination.
The anus and rectum can also become infected, which causes no symptoms in most cases. When present, symptoms include anal itching, rectal discharge, rectal fullness, and painful defecation. Even women who do not engage in rectal intercourse can become infected in this area due to contact with vaginal secretions.
Rarely, a woman's Bartholin's glands and Skene's glands can become infected (show figure 3). The primary symptom is vaginal discomfort. Infection of the throat and mouth may cause a sore throat, but usually causes no symptoms at all.
Men — While women often have no symptoms of gonorrhea, 90 percent of men do experience symptoms, including painful urination and a milky penile discharge. Epididymal infection can develop, causing pain and swelling in one testicle.
Infection of the rectum can develop among men who have sex with men. Symptoms include a rectal discharge, rectal fullness, constipation, and pain. Symptoms usually develop within four to eight days of infection, although it can be up to 30 days in some men.
DIAGNOSIS — Gonorrhea can be identified using several methods, all of which require that the person visit a healthcare provider's office or clinic. Testing may be done because the person has symptoms or as a part of a general check up.
The usual method of testing for gonorrhea gives results within hours. Testing can be done with a swab of the cervix or urethra, as well as with a urine sample.
Other sexually transmitted infections — A person who is found to have an STI, or has a partner with an STI, should consider testing for other STIs, including HIV, Chlamydia, hepatitis B, trichomoniasis, and syphilis. (See "Patient information: Testing for HIV", see "Patient information: Chlamydia" and see "Patient information: Hepatitis B").
Women are advised to have an annual cervical cancer screening (Pap smear), which can detect precancerous or abnormal changes related to a sexually transmitted virus, the human papilloma virus. (See "Patient information: Screening for cervical cancer").
Men or women who use intravenous drugs or have sexual intercourse with a partner who is at risk for hepatitis C should consider testing for this infection. (See "Patient information: Hepatitis C").
Testing is also available for herpes simplex virus, although this is not usually performed unless there are symptoms or risk factors for infection. (See "Patient information: Genital herpes").
COMPLICATIONS — If untreated, gonorrhea can lead to serious complications in both men and women, including joint infections and arthritis. Women can develop pelvic inflammatory disease while men can develop epididymitis. People with gonorrhea are also at higher risk of becoming infected with HIV. (See "Patient information: Joint infection" and see "Patient information: Symptoms of HIV infection").
Pelvic inflammatory disease (PID) occurs in women when gonorrhea spreads from the cervix to the uterus and fallopian tubes. This can cause abdominal or pelvic pain, pain during intercourse, and occasionally, chronic pelvic pain. PID occurs in 10 to 40 percent of women with cervical gonorrhea, which can scar the fallopian tubes and lead to infertility and an increased risk of ectopic pregnancy. (See "Patient information: Chronic pelvic pain in women").
Epididymitis can occur in men with untreated gonorrhea, and can lead to infertility as a result of scarring of the epididymis. The epididymis collects sperm after it leaves the testis.
Infants infected with gonorrhea during birth can develop a serious eye infection, which can potentially cause blindness. As a result, pregnant women are routinely tested for gonorrhea during pregnancy and infants are routinely given a one-time eye treatment with antibiotic ointment immediately after birth.
TREATMENT — Treatment of gonorrhea is the same for women and men. Most experts recommend a one-time antibiotic treatment, such as an injection of ceftriaxone, or an oral dose of cefixime. This is a new recommendation, made in 2007, due to increasing rates of resistance to another type of antibiotic called quinolones (for example, ciprofloxacin, ofloxacin). Pregnant women with uncomplicated gonorrhea can be safely treated with either ceftriaxone or cefixime.
Alternate medications are available for persons who are allergic to the above medications, including an oral medication called azithromycin. Resistant strains of gonorrhea are increasing in some areas of the world (including the United States). The Centers for Disease Control and Prevention (CDC) monitors drug resistance rates (www.cdc.gov/std/gisp).
Patients infected with gonorrhea are sometimes also infected with Chlamydia. For this reason, some clinicians will recommend treatment for both infections at once. (See "Patient information: Chlamydia").
Treatment of sexual partners — Current or recent sexual partners of a person diagnosed with gonorrhea should also be treated, especially since that person may not have any symptoms. Furthermore, an untreated partner can reinfect the patient. The traditional approach has been for the patient to notify their partner that a clinic visit is necessary, where the partner can be tested and treated if needed. In contrast, some clinics have a policy of offering two prescriptions - one for the patient and one for the partner.
In order to prevent reinfection, sexual contact should be avoided until both partners have been treated and all symptoms have resolved. It is possible to become infected with gonorrhea more than once.
Test of cure — Patients who finish the recommended treatment regimen do not need to be retested. However, a person who continues to have symptoms should be reevaluated; further testing may be recommended.
PREVENTION — The most effective way to prevent gonorrhea is to avoid sexual intercourse. Because this is not practical for many people, the following tips are recommended: Use a latex condom with every act of sexual intercourse. Discuss routine testing for sexually transmitted infections with a healthcare provider. Persons in a long-term, mutually monogamous relationship are at a lower risk of infections than those with multiple sexual partners or multiple short-term relationships. See a healthcare provider if there are signs or symptoms of gonorrhea. Avoid sexual intercourse if either partner notes abnormal genital discharge, burning with urination, or a genital rash or sore.
SUMMARY Gonorrhea is a sexually transmitted infection that can be spread during sexual intercourse. A man does not have to ejaculate to spread the infection (see "Causes" above). Some people have symptoms (pain while urinating, discharge from the penis or vagina), while others have no symptoms at all. The infection can be spread from one person to another before it is diagnosed (see "Symptoms" above). Testing for gonorrhea is done in a medical office or clinic. Testing can be done with a swab of the penis or cervix or with a urine sample (see "Diagnosis" above). If untreated, gonorrhea can lead to serious complications in both men and women. In addition, people with gonorrhea are at higher risk of becoming infected with HIV (see "Complications" above). Gonorrhea can be cured with an antibiotic. Sexual partners of a person with gonorrhea should also be treated. Sex should be avoided until both partners have been treated. (see "Treatment" above). Using a latex condom reduces the risk of becoming infected with gonorrhea. Regular testing for sexually transmitted infections is recommended, especially before having sex with a new partner. Sex should be avoided if either partner has abnormal discharge from the penis or vagina, burning with urination, or a genital rash or sore (see "Prevention" above).
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
National Institute of Allergy and Infectious Diseases
(www.niaid.nih.gov/factsheets/stdgon.htm)
Centers for Disease Control and Prevention
(www.cdc.gov/std/Gonorrhea/STDFact-gonorrhea.htm)
American Social Health Association
(www.ashastd.org/stdfaqs/gonorrhea.html)
[1-3]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Choudhury, B, Risley, CL, Ghani, AC, et al. Identification of individuals with gonorrhoea within sexual networks: a population-based study. Lancet 2006; 368:139.
2. Workowski, KA, Berman, SM. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep 2006; 55:1.
3. Cook, RL, Hutchison, SL, Ostergaard, L, et al. Systematic review: noninvasive testing for Chlamydia trachomatis and Neisseria gonorrhoeae. Ann Intern Med 2005; 142:914.
Genital herpes
WHAT IS GENITAL HERPES? — Genital herpes is a common sexually transmitted disease that is caused by the herpes simplex virus. It is estimated that at least one in five adults in the United States is infected with the virus, but many people have no symptoms and do not realize that they are infected.
Genital herpes is a lifelong condition that, at the present time, cannot be cured. However, the infection can be managed with medication and self-care measures. Infected individuals are encouraged to talk to their sexual partner and use condoms and take other preventive measures; genital herpes can be spread even when there are no visible ulcers or blisters.
Being diagnosed with genital herpes can be an emotional and distressing experience, and it is important for patients to speak with their healthcare provider about how to manage symptoms and avoid passing the virus to their sexual partner. Counseling and support groups can also be beneficial to individuals living with genital herpes infection.
Cause — Genital herpes is caused by infection with the herpes simplex virus (HSV, usually type 2 (HSV-2)). It can also be caused by herpes simplex virus type 1 (HSV-1), the most common cause of oral herpes (cold sores on the mouth and lips).
The virus can be passed from one person to another during oral, anal, or vaginal sex, even if the person with herpes has no visible ulcers or sores.
SIGNS AND SYMPTOMS — Many people infected with genital herpes never experience symptoms. The symptoms of genital herpes can vary widely depending on whether an individual is experiencing an initial or recurrent episode.
Initial episode — For most people, the first herpes outbreak is the most severe, and symptoms tend to be more severe in women than men. The first outbreak usually occurs within a few weeks of infection with the virus. Symptoms tend to resolve within two to three weeks.
The signs of an initial (or primary) episode of genital herpes include multiple blisters in the genital area. For women, the sites most frequently involved includes the vagina, vulva, buttocks, anus, and thighs; for men, the penis, scrotum, anus, buttocks and thighs may be affected. Signs and symptoms typically include blisters that become painful ulcers. Blisters on the penis and outer labia may crust over and heal. New lesions may develop for up to 5 to 7 days after the first group appears. Some individuals also get blisters in non-genital areas such as the mouth and lips. There may also be tender, swollen lymph nodes in the groin, painful urination, and flu-like symptoms such as joint pain, fever, and headache.
A small percentage of people develop additional non-genital symptoms, including meningitis (inflammation of the tissue covering the brain and spinal cord) and an inability to urinate (from the effects of the virus on the nervous system). The virus can also cause proctitis (inflammation of the rectum or anus), particularly in men who have sex with men.
Latent stage — After the initial outbreak, the virus travels to a bundle of nerves at the base of the spine, where it remains inactive for a period of time. This is called the latent stage. Patients have no symptoms during this stage.
Recurrent episodes — Many people experience recurrent episodes of genital herpes, which occur when the virus travels through nerves to the skin's surface, causing an outbreak of ulcers. These recurrent episodes tend to be milder than the initial outbreak, and some recurrences cause no noticeable symptoms at all. When blisters are present, they are usually present for a shorter duration, about 10 days on average.
Ulcers may develop in the same area as during the first outbreak, or may appear in other areas. Sexual contact in the area where herpes lesions develop is not necessary; for example, it is possible to have lesions around the anus without having had anal sex.
Likelihood of recurrence — Recurrence is more common in individuals infected with HSV-2 compared to those with HSV-1. In one study of individuals infected with HSV-2, 89 percent had one recurrence over the 13 months following the initial episode, 38 percent had up to six recurrences, and 20 percent had more than ten [1]. The likelihood of an individual experiencing recurrences appears to be related to the length and severity of the person's initial episode.
However, it is also possible to have a recurrence many years (20 to 40 years) after the initial HSV infection was acquired. This type of delayed herpes outbreak can be especially distressing for those who never had symptoms during the initial infection, and it may cause concern about the sexual activities of past or present sexual partner(s).
Prodrome — As many as 50 percent of people with recurrences experience mild symptoms before a recurrent outbreak; these may include itching, tingling, or pain in the buttocks, legs, and hips. Recurrences tend to become less frequent and less severe after the first year.
Triggers for recurrence — Illness, stress, sunlight, birth control pills, and fatigue can trigger recurrent herpes outbreaks. Menstruation in women may also trigger an outbreak.
Shedding stage — Viral shedding means that the virus is present in the urinary and genital tract. During this period, often called asymptomatic shedding or asymptomatic reactivation (because no ulcers are present), the infection can be transmitted between sexual partners. Shedding of HSV-2 occurs approximately 20 percent of the time (an average of 72 days per year), mostly before, during, or after ulcers are present. The virus is shed on 3 percent of days when there are no signs or symptoms of the virus. Some people with HSV shed virus more frequently than others.
DIAGNOSIS — The diagnosis of genital herpes is based on an individual's history of possible exposure to the virus, the presence of characteristic signs and symptoms, and the results of diagnostic tests. A careful diagnosis is especially important for distinguishing genital herpes from other sexually transmitted diseases, particularly those that also produce genital ulcers, such syphilis and chancroid.
Along with a patient's history and physical symptoms, several diagnostic tests may be used to diagnose genital herpes. These tests can usually confirm infection and identify which virus (HSV-1 or HSV-2) is responsible. They can also detect asymptomatic shedding in individuals with known infection, although routine testing for this purpose is not usually performed.
Culture test — A culture test determines if herpes simplex virus is present on the skin and in secretions from the urinary and genital tracts. This is the test most commonly used to diagnose genital herpes; however, this test detects the virus in only about 50 percent of individuals with genital ulcers. The culture test is more likely to detect the virus when ulcers are new and open, as compared to when they are older and healing. Therefore, it is important to see a healthcare provider within 48 hours of the first symptoms. The test is also more sensitive in individuals experiencing an initial episode of genital herpes than in individuals experiencing a recurrent episode.
Blood test — Blood tests are often used when a person believes he or she may have been exposed to the herpes virus in the past, but has no visible ulcers. A blood test can detect antibodies (proteins that are produced by the body in response to a foreign substance) to HSV-1 and HSV-2. Having a positive test for these antibodies indicates that an individual has been infected with the virus at some time in the past, although it is usually not possible to know when or from whom the virus was transmitted.
Because the antibody response takes time, the results of this test may be negative during the first episode of genital herpes. Within three to four months after an initial episode, HSV antibodies can usually be detected. The antibody test remains positive for life.
Blood tests may be helpful for couples in which one person has a history of genital herpes and the other does not. It is possible for a person to have HSV antibodies (indicating past infection), even if they have no memory or history of genital herpes.
Determining the type of herpes (1 or 2) can also help to predict the likelihood of future recurrences, given that type 2 recurs more frequently than type 1 (see "Likelihood of recurrence" above).
Polymerase chain reaction (PCR) test — The polymerase chain reaction (PCR) test is a very sensitive test for identifying the herpes virus in cells and secretions from the urinary and genital tracts. The PCR test is more sensitive than the culture test, but is not routinely used due to it's higher cost.
TRANSMISSION AND RISK FACTORS
Transmission between sexual partners — The herpes virus is most often transmitted between partners during oral, anal, or vaginal sex. It is possible for a person to develop genital herpes after exposure to a cold sore on an infected person's lip during oral sex; in this case, genital herpes may be due to infection with HSV-1. Transmission from person to person can occur even if there are no visible ulcers, as a result of asymptomatic viral shedding. However, the risk of transmission is much greater when a person has signs or symptoms of active infection. Individuals do not need to be concerned about the possibility of viral transmission from environmental surfaces (door knobs, toilet seats, utensils, bed sheets).
The risk of transmission from an infected male to an uninfected female partner is slightly higher than the risk of transmission from an infected female to an uninfected male partner. The risk of infection is also higher in men or women who receive anal sex.
If both sexual partners have the same type of herpes virus (eg, HSV-1 or HSV-2), there is no risk of repeated transmission. It is possible for a person with one type of herpes virus to become infected with the other type; for this reason, testing to determine virus type is important.
One study examined rates of genital herpes transmission in heterosexual couples in whom only one partner was initially infected [2]. Over one year, the virus was transmitted to the other partner in 10 percent of couples. In 70 percent of cases, infection occurred at a time when there were no symptoms.
Transmission of HSV may occur within a short time in new sexual relationships. In one study of 199 patients with newly acquired HSV genital infection, the average time from the first sexual encounter to the time a person was infected with HSV was 3.5 months (range 1.5 to 10 months) [3].
Pregnancy and herpes — Women who have a first outbreak of genital herpes near the time of delivery are at risk of transmitting herpes to their newborn.
Women who acquire genital herpes before becoming pregnant are not likely to pass the virus to the baby. However, it is possible for this to happen, particularly if the mother has symptoms of pain or burning, or has active lesions at the time of delivery. In patients with one or more recurrences during pregnancy, preventive antiviral therapy with acyclovir should be considered. A caesarean delivery is usually recommended in women who experience an outbreak of symptoms at the time of labor.
Since genital herpes in infants is a very serious condition, women should inform their healthcare provider if they have a history of the infection. Women with no history of genital herpes whose partner has a history of cold sores (generally HSV-1) or genital herpes (generally HSV-2) should avoid oral, vaginal, and anal sex during the last trimester of pregnancy. In this situation, condoms are recommended during the entire pregnancy. Careful planning during the pregnancy and precautions during pregnancy and at the time of delivery can reduce the likelihood of transmission and allow for a normal birth.
GENITAL HERPES AND HIV — Individuals with genital herpes are at an increased risk of acquiring HIV. During an outbreak, blisters and ulcers make it easier for a partner's genital fluids to enter the body. Therefore, if a person with herpes is exposed to HIV through sexual contact while herpetic lesions are present, HIV can more easily travel through the skin.
TREATMENT — Although there is no cure for genital herpes, the infection can be managed with antiviral drug therapy and self-care measures. A summary of the antiviral medications is available in table 1 (show table 1).
Antiviral drug therapy — Several antiviral drugs are available for treating genital herpes. There are two regimens of drug therapy for genital herpes: episodic therapy and suppressive therapy.
Episodic therapy — Episodic therapy is treatment with antiviral drugs as soon as the symptoms of genital herpes begin. The medication is stopped after 7 to 10 days. Antiviral medications can alleviate pain, reduce the healing time of ulcers, and shorten the duration of viral shedding (the time during which the virus can be transmitted to a partner).
Episodic therapy is usually recommended for individuals who have fewer than six recurrences each year. Unfortunately, episodic treatment does not reduce the frequency of recurrences. Antiviral treatment of recurrent episodes is most likely to be effective if started within 24 hours of the first symptoms.
Suppressive therapy — Suppressive therapy refers to the continuous use of antiviral drugs, even when there are no symptoms. Suppressive therapy increases the time between recurrences, decreases the number of recurrences, shortens the duration of symptoms during a recurrence, and can reduce the risk of transmission of HSV to an uninfected partner.
Suppressive therapy is usually recommended for HSV-positive individuals who have six or more recurrences each year and those with a weakened immune system due to the human immunodeficiency virus (HIV), use of immune-suppressing drugs, or other factors.
Suppressive therapy may also be considered for people who are in a sexual relationship with a partner who does not have a history of genital herpes or antibodies to HSV-1 or 2 (as determined by blood testing). This approach has been demonstrated to reduce transmission to the susceptible person by approximately one-half.
Antiviral medications — Three antiviral medications are used to treat genital herpes: acyclovir, famciclovir, and valacyclovir. They are usually taken by mouth (in pill form). Acyclovir (Zovirax®) — Acyclovir (Zovirax®) is the oldest and least expensive antiviral medication. It usually requires more frequent dosing than famciclovir and valacyclovir. It is available in pill, liquid, and injectable forms. Famciclovir (Famvir®) — Famciclovir (Famvir®) is another drug available for the treatment of genital herpes. It is usually taken two or three times per day. Valacyclovir (Valtrex®) — Valacyclovir (Valtrex®) may be more convenient than acyclovir and famciclovir because it is taken one to two times per day.
Self-care measures — In addition to antiviral medications, local treatments may be used to relieve the pain of a herpes outbreak. Sitting in a few inches of cool water (called a sitz bath) can temporarily decrease pain. This can be done in a bathtub or a specially designed sitz bath, available at most pharmacies without a prescription. Women who are having trouble urinating may find it helpful to urinate in the sitz bath or at the end of a warm bath. Soaps and bubble baths should be avoided. It is important to keep the genital area clean and dry, and to avoid tight or irritating underwear and clothing.
Acetaminophen (Tylenol®) or ibuprofen (Advil®) may also help relieve the pain of genital ulcers. Over-the-counter creams and ointments are generally not recommended.
COUNSELING AND SUPPORT — The diagnosis of genital herpes can cause feelings of shame, fear, and distress. While these reactions are normal, it is important to remember that genital herpes is a manageable condition. Education is important for infected individuals and their partner to know what to expect and how to protect themselves.
Many patients find that counseling, either with their family healthcare provider or a mental health professional, is helpful in dealing with the issues that come with a diagnosis of genital herpes. Counseling may be especially important for people who have tested positive for the virus but have not developed symptoms, as these individuals may have difficulty understanding the impact of the disease in the absence of any physical signs.
There are many genital herpes support groups in the United States and worldwide; these provide a safe environment for people to share their experiences and feelings, and also to access accurate information about the disease. Infected individuals are encouraged to speak with their healthcare provider or visit the websites listed below (see "Where to get more information" below).
PREVENTION — Because all sexually active persons are at some risk of acquiring genital herpes, it is important to communicate with a sexual partner before the first sexual encounter. Discussing herpes can be uncomfortable and embarrassing, but it ensures that both partners understand the possibility of transmitting the infection through sexual activity. Regular testing for sexually transmitted diseases is also recommended, especially if one or both partners has other sexual partners.
After being diagnosed with genital herpes, it is still possible to have a safe and healthy sex life; however, it is important to take precautions. Use of a latex condom with every sexual encounter can reduce the risk that an infected male will pass the herpes virus to an uninfected male or female partner. Condoms are less effective in preventing an infected woman from transmitting the virus to an uninfected man, although there is probably some benefit. Even when a person is symptom-free, use of a condom is recommended. Sex should be avoided any time genital ulcers are present. Oral sex should be avoided if there are ulcers or blisters around the mouth, as a person with the oral form of herpes can give a partner genital herpes by performing oral sex.
SUMMARY Genital herpes is an infection that is spread during sex. Symptoms of genital herpes include blisters in the genital area (eg, penis, buttocks, anus, vulva). The blisters become painful ulcers. Some people have no symptoms at all. Many people have an outbreak of genital herpes more than once in their life. Later outbreaks can also cause blisters and painful ulcers. Outbreaks may occur frequently (eg, once per month) or rarely (eg, once per ten years). Sometimes, outbreaks are triggered by illness, stress, sunlight, birth control pills, or being tired. Several tests are available to diagnose genital herpes. Some tests use blood while others require a swab of the blister. It is possible to spread herpes even if there are no visible ulcers. It is not possible to catch herpes by touching a surface (door knobs, toilet seat, bed sheets). It is possible to spread herpes from the mouth (from a cold sore) to the genitals. Several medications are available to treat genital herpes (acyclovir, valacyclovir, and famciclovir). These drugs help to speed healing of ulcers and lower the risk of spreading the virus. Some people take the medicine every day to prevent future outbreaks or prevent spread to their sex partner. There are ways to lower the risk of being infected with genital herpes. Men should use a latex condom every time they have sex. Sex (oral, vaginal, and anal) is not recommended if a person has blisters or ulcers.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
Centers for Disease Control and Prevention (CDC)
Phone: (404) 639-3534
Toll-free: (800) 311-3435
(www.cdc.gov)
National Institute of Allergy and Infectious Diseases
(www.niaid.nih.gov/)
Herpes Resource Center
American Social Health Association
Phone: (800) 230-6039
(www.ashastd.org)
[1,2,4-12]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Benedetti, J, Corey, L, Ashley, R. Recurrence rates in genital herpes after symptomatic first-episode infection. Ann Intern Med 1994; 121:847.
2. Mertz, GJ, Benedetti, J, Ashley, R, et al. Risk factors for the sexual transmission of genital herpes. Ann Intern Med 1992; 116:197.
3. Wald, A, Krantz, E, Selke, S, et al. Knowledge of partners' genital herpes protects against herpes simplex virus type 2 acquisition. J Infect Dis 2006; 194:42.
4. Fleming, DT, McQuillan, GM, Johnson, RE, et al. Herpes simplex virus type 2 in the United States, 1976 to 1994. N Engl J Med 1997; 337:1105.
5. Centers for Disease Control and Prevention, Division of Sexually Transmitted Diseases. Sexually Transmitted Diseases Surveillance, Other Sexually Transmitted Diseases, 2003 (www.cdc.gov/std/stats/03pdf/otherSTDs.pdf).
6. Corey, L, Adams, HG, Brown, ZA, Holmes, KK. Genital herpes simplex virus infections: Clinical manifestations, course, and complications. Ann Intern Med 1983; 98:958.
7. Kimberlin, DW, Rouse, DJ. Clinical practice. Genital herpes. N Engl J Med 2004; 350:1970.
8. Douglas, JM, Critchlow, C, Benedetti, J, et al. A double-blind study of oral acyclovir for suppression of recurrences of genital herpes simplex virus infection. N Engl J Med 1984; 310:1551.
9. Sacks, SL. Famciclovir suppression of asymptomatic and symptomatic recurrent anogenital herpes simplex virus shedding in women: a randomized, double-blind, double-dummy, placebo-controlled, parallel-group, single-center trial. J Infect Dis 2004; 189:1341.
10. Fife, KH, Barbarash, RA, Rudolph, T, et al. Valaciclovir versus acyclovir in the treatment of first-episode genital herpes infection: Results of an international, multicenter, double-blind, randomized clinical trial. Sex Transm Dis 1997; 24:481.
11. Bodsworth, NJ, Crooks, RJ, Borelli, S, et al. Valaciclovir versus aciclovir in patient initiated treatment of recurrent genital herpes: A randomised, double blind clinical trial. Genitourin Med 1997; 73:110.
12. Corey, L, Wald, A, Patel, R, et al. Once-daily valacyclovir to reduce the risk of transmission of genital herpes. N Engl J Med 2004; 350:11.
Genital herpes is a lifelong condition that, at the present time, cannot be cured. However, the infection can be managed with medication and self-care measures. Infected individuals are encouraged to talk to their sexual partner and use condoms and take other preventive measures; genital herpes can be spread even when there are no visible ulcers or blisters.
Being diagnosed with genital herpes can be an emotional and distressing experience, and it is important for patients to speak with their healthcare provider about how to manage symptoms and avoid passing the virus to their sexual partner. Counseling and support groups can also be beneficial to individuals living with genital herpes infection.
Cause — Genital herpes is caused by infection with the herpes simplex virus (HSV, usually type 2 (HSV-2)). It can also be caused by herpes simplex virus type 1 (HSV-1), the most common cause of oral herpes (cold sores on the mouth and lips).
The virus can be passed from one person to another during oral, anal, or vaginal sex, even if the person with herpes has no visible ulcers or sores.
SIGNS AND SYMPTOMS — Many people infected with genital herpes never experience symptoms. The symptoms of genital herpes can vary widely depending on whether an individual is experiencing an initial or recurrent episode.
Initial episode — For most people, the first herpes outbreak is the most severe, and symptoms tend to be more severe in women than men. The first outbreak usually occurs within a few weeks of infection with the virus. Symptoms tend to resolve within two to three weeks.
The signs of an initial (or primary) episode of genital herpes include multiple blisters in the genital area. For women, the sites most frequently involved includes the vagina, vulva, buttocks, anus, and thighs; for men, the penis, scrotum, anus, buttocks and thighs may be affected. Signs and symptoms typically include blisters that become painful ulcers. Blisters on the penis and outer labia may crust over and heal. New lesions may develop for up to 5 to 7 days after the first group appears. Some individuals also get blisters in non-genital areas such as the mouth and lips. There may also be tender, swollen lymph nodes in the groin, painful urination, and flu-like symptoms such as joint pain, fever, and headache.
A small percentage of people develop additional non-genital symptoms, including meningitis (inflammation of the tissue covering the brain and spinal cord) and an inability to urinate (from the effects of the virus on the nervous system). The virus can also cause proctitis (inflammation of the rectum or anus), particularly in men who have sex with men.
Latent stage — After the initial outbreak, the virus travels to a bundle of nerves at the base of the spine, where it remains inactive for a period of time. This is called the latent stage. Patients have no symptoms during this stage.
Recurrent episodes — Many people experience recurrent episodes of genital herpes, which occur when the virus travels through nerves to the skin's surface, causing an outbreak of ulcers. These recurrent episodes tend to be milder than the initial outbreak, and some recurrences cause no noticeable symptoms at all. When blisters are present, they are usually present for a shorter duration, about 10 days on average.
Ulcers may develop in the same area as during the first outbreak, or may appear in other areas. Sexual contact in the area where herpes lesions develop is not necessary; for example, it is possible to have lesions around the anus without having had anal sex.
Likelihood of recurrence — Recurrence is more common in individuals infected with HSV-2 compared to those with HSV-1. In one study of individuals infected with HSV-2, 89 percent had one recurrence over the 13 months following the initial episode, 38 percent had up to six recurrences, and 20 percent had more than ten [1]. The likelihood of an individual experiencing recurrences appears to be related to the length and severity of the person's initial episode.
However, it is also possible to have a recurrence many years (20 to 40 years) after the initial HSV infection was acquired. This type of delayed herpes outbreak can be especially distressing for those who never had symptoms during the initial infection, and it may cause concern about the sexual activities of past or present sexual partner(s).
Prodrome — As many as 50 percent of people with recurrences experience mild symptoms before a recurrent outbreak; these may include itching, tingling, or pain in the buttocks, legs, and hips. Recurrences tend to become less frequent and less severe after the first year.
Triggers for recurrence — Illness, stress, sunlight, birth control pills, and fatigue can trigger recurrent herpes outbreaks. Menstruation in women may also trigger an outbreak.
Shedding stage — Viral shedding means that the virus is present in the urinary and genital tract. During this period, often called asymptomatic shedding or asymptomatic reactivation (because no ulcers are present), the infection can be transmitted between sexual partners. Shedding of HSV-2 occurs approximately 20 percent of the time (an average of 72 days per year), mostly before, during, or after ulcers are present. The virus is shed on 3 percent of days when there are no signs or symptoms of the virus. Some people with HSV shed virus more frequently than others.
DIAGNOSIS — The diagnosis of genital herpes is based on an individual's history of possible exposure to the virus, the presence of characteristic signs and symptoms, and the results of diagnostic tests. A careful diagnosis is especially important for distinguishing genital herpes from other sexually transmitted diseases, particularly those that also produce genital ulcers, such syphilis and chancroid.
Along with a patient's history and physical symptoms, several diagnostic tests may be used to diagnose genital herpes. These tests can usually confirm infection and identify which virus (HSV-1 or HSV-2) is responsible. They can also detect asymptomatic shedding in individuals with known infection, although routine testing for this purpose is not usually performed.
Culture test — A culture test determines if herpes simplex virus is present on the skin and in secretions from the urinary and genital tracts. This is the test most commonly used to diagnose genital herpes; however, this test detects the virus in only about 50 percent of individuals with genital ulcers. The culture test is more likely to detect the virus when ulcers are new and open, as compared to when they are older and healing. Therefore, it is important to see a healthcare provider within 48 hours of the first symptoms. The test is also more sensitive in individuals experiencing an initial episode of genital herpes than in individuals experiencing a recurrent episode.
Blood test — Blood tests are often used when a person believes he or she may have been exposed to the herpes virus in the past, but has no visible ulcers. A blood test can detect antibodies (proteins that are produced by the body in response to a foreign substance) to HSV-1 and HSV-2. Having a positive test for these antibodies indicates that an individual has been infected with the virus at some time in the past, although it is usually not possible to know when or from whom the virus was transmitted.
Because the antibody response takes time, the results of this test may be negative during the first episode of genital herpes. Within three to four months after an initial episode, HSV antibodies can usually be detected. The antibody test remains positive for life.
Blood tests may be helpful for couples in which one person has a history of genital herpes and the other does not. It is possible for a person to have HSV antibodies (indicating past infection), even if they have no memory or history of genital herpes.
Determining the type of herpes (1 or 2) can also help to predict the likelihood of future recurrences, given that type 2 recurs more frequently than type 1 (see "Likelihood of recurrence" above).
Polymerase chain reaction (PCR) test — The polymerase chain reaction (PCR) test is a very sensitive test for identifying the herpes virus in cells and secretions from the urinary and genital tracts. The PCR test is more sensitive than the culture test, but is not routinely used due to it's higher cost.
TRANSMISSION AND RISK FACTORS
Transmission between sexual partners — The herpes virus is most often transmitted between partners during oral, anal, or vaginal sex. It is possible for a person to develop genital herpes after exposure to a cold sore on an infected person's lip during oral sex; in this case, genital herpes may be due to infection with HSV-1. Transmission from person to person can occur even if there are no visible ulcers, as a result of asymptomatic viral shedding. However, the risk of transmission is much greater when a person has signs or symptoms of active infection. Individuals do not need to be concerned about the possibility of viral transmission from environmental surfaces (door knobs, toilet seats, utensils, bed sheets).
The risk of transmission from an infected male to an uninfected female partner is slightly higher than the risk of transmission from an infected female to an uninfected male partner. The risk of infection is also higher in men or women who receive anal sex.
If both sexual partners have the same type of herpes virus (eg, HSV-1 or HSV-2), there is no risk of repeated transmission. It is possible for a person with one type of herpes virus to become infected with the other type; for this reason, testing to determine virus type is important.
One study examined rates of genital herpes transmission in heterosexual couples in whom only one partner was initially infected [2]. Over one year, the virus was transmitted to the other partner in 10 percent of couples. In 70 percent of cases, infection occurred at a time when there were no symptoms.
Transmission of HSV may occur within a short time in new sexual relationships. In one study of 199 patients with newly acquired HSV genital infection, the average time from the first sexual encounter to the time a person was infected with HSV was 3.5 months (range 1.5 to 10 months) [3].
Pregnancy and herpes — Women who have a first outbreak of genital herpes near the time of delivery are at risk of transmitting herpes to their newborn.
Women who acquire genital herpes before becoming pregnant are not likely to pass the virus to the baby. However, it is possible for this to happen, particularly if the mother has symptoms of pain or burning, or has active lesions at the time of delivery. In patients with one or more recurrences during pregnancy, preventive antiviral therapy with acyclovir should be considered. A caesarean delivery is usually recommended in women who experience an outbreak of symptoms at the time of labor.
Since genital herpes in infants is a very serious condition, women should inform their healthcare provider if they have a history of the infection. Women with no history of genital herpes whose partner has a history of cold sores (generally HSV-1) or genital herpes (generally HSV-2) should avoid oral, vaginal, and anal sex during the last trimester of pregnancy. In this situation, condoms are recommended during the entire pregnancy. Careful planning during the pregnancy and precautions during pregnancy and at the time of delivery can reduce the likelihood of transmission and allow for a normal birth.
GENITAL HERPES AND HIV — Individuals with genital herpes are at an increased risk of acquiring HIV. During an outbreak, blisters and ulcers make it easier for a partner's genital fluids to enter the body. Therefore, if a person with herpes is exposed to HIV through sexual contact while herpetic lesions are present, HIV can more easily travel through the skin.
TREATMENT — Although there is no cure for genital herpes, the infection can be managed with antiviral drug therapy and self-care measures. A summary of the antiviral medications is available in table 1 (show table 1).
Antiviral drug therapy — Several antiviral drugs are available for treating genital herpes. There are two regimens of drug therapy for genital herpes: episodic therapy and suppressive therapy.
Episodic therapy — Episodic therapy is treatment with antiviral drugs as soon as the symptoms of genital herpes begin. The medication is stopped after 7 to 10 days. Antiviral medications can alleviate pain, reduce the healing time of ulcers, and shorten the duration of viral shedding (the time during which the virus can be transmitted to a partner).
Episodic therapy is usually recommended for individuals who have fewer than six recurrences each year. Unfortunately, episodic treatment does not reduce the frequency of recurrences. Antiviral treatment of recurrent episodes is most likely to be effective if started within 24 hours of the first symptoms.
Suppressive therapy — Suppressive therapy refers to the continuous use of antiviral drugs, even when there are no symptoms. Suppressive therapy increases the time between recurrences, decreases the number of recurrences, shortens the duration of symptoms during a recurrence, and can reduce the risk of transmission of HSV to an uninfected partner.
Suppressive therapy is usually recommended for HSV-positive individuals who have six or more recurrences each year and those with a weakened immune system due to the human immunodeficiency virus (HIV), use of immune-suppressing drugs, or other factors.
Suppressive therapy may also be considered for people who are in a sexual relationship with a partner who does not have a history of genital herpes or antibodies to HSV-1 or 2 (as determined by blood testing). This approach has been demonstrated to reduce transmission to the susceptible person by approximately one-half.
Antiviral medications — Three antiviral medications are used to treat genital herpes: acyclovir, famciclovir, and valacyclovir. They are usually taken by mouth (in pill form). Acyclovir (Zovirax®) — Acyclovir (Zovirax®) is the oldest and least expensive antiviral medication. It usually requires more frequent dosing than famciclovir and valacyclovir. It is available in pill, liquid, and injectable forms. Famciclovir (Famvir®) — Famciclovir (Famvir®) is another drug available for the treatment of genital herpes. It is usually taken two or three times per day. Valacyclovir (Valtrex®) — Valacyclovir (Valtrex®) may be more convenient than acyclovir and famciclovir because it is taken one to two times per day.
Self-care measures — In addition to antiviral medications, local treatments may be used to relieve the pain of a herpes outbreak. Sitting in a few inches of cool water (called a sitz bath) can temporarily decrease pain. This can be done in a bathtub or a specially designed sitz bath, available at most pharmacies without a prescription. Women who are having trouble urinating may find it helpful to urinate in the sitz bath or at the end of a warm bath. Soaps and bubble baths should be avoided. It is important to keep the genital area clean and dry, and to avoid tight or irritating underwear and clothing.
Acetaminophen (Tylenol®) or ibuprofen (Advil®) may also help relieve the pain of genital ulcers. Over-the-counter creams and ointments are generally not recommended.
COUNSELING AND SUPPORT — The diagnosis of genital herpes can cause feelings of shame, fear, and distress. While these reactions are normal, it is important to remember that genital herpes is a manageable condition. Education is important for infected individuals and their partner to know what to expect and how to protect themselves.
Many patients find that counseling, either with their family healthcare provider or a mental health professional, is helpful in dealing with the issues that come with a diagnosis of genital herpes. Counseling may be especially important for people who have tested positive for the virus but have not developed symptoms, as these individuals may have difficulty understanding the impact of the disease in the absence of any physical signs.
There are many genital herpes support groups in the United States and worldwide; these provide a safe environment for people to share their experiences and feelings, and also to access accurate information about the disease. Infected individuals are encouraged to speak with their healthcare provider or visit the websites listed below (see "Where to get more information" below).
PREVENTION — Because all sexually active persons are at some risk of acquiring genital herpes, it is important to communicate with a sexual partner before the first sexual encounter. Discussing herpes can be uncomfortable and embarrassing, but it ensures that both partners understand the possibility of transmitting the infection through sexual activity. Regular testing for sexually transmitted diseases is also recommended, especially if one or both partners has other sexual partners.
After being diagnosed with genital herpes, it is still possible to have a safe and healthy sex life; however, it is important to take precautions. Use of a latex condom with every sexual encounter can reduce the risk that an infected male will pass the herpes virus to an uninfected male or female partner. Condoms are less effective in preventing an infected woman from transmitting the virus to an uninfected man, although there is probably some benefit. Even when a person is symptom-free, use of a condom is recommended. Sex should be avoided any time genital ulcers are present. Oral sex should be avoided if there are ulcers or blisters around the mouth, as a person with the oral form of herpes can give a partner genital herpes by performing oral sex.
SUMMARY Genital herpes is an infection that is spread during sex. Symptoms of genital herpes include blisters in the genital area (eg, penis, buttocks, anus, vulva). The blisters become painful ulcers. Some people have no symptoms at all. Many people have an outbreak of genital herpes more than once in their life. Later outbreaks can also cause blisters and painful ulcers. Outbreaks may occur frequently (eg, once per month) or rarely (eg, once per ten years). Sometimes, outbreaks are triggered by illness, stress, sunlight, birth control pills, or being tired. Several tests are available to diagnose genital herpes. Some tests use blood while others require a swab of the blister. It is possible to spread herpes even if there are no visible ulcers. It is not possible to catch herpes by touching a surface (door knobs, toilet seat, bed sheets). It is possible to spread herpes from the mouth (from a cold sore) to the genitals. Several medications are available to treat genital herpes (acyclovir, valacyclovir, and famciclovir). These drugs help to speed healing of ulcers and lower the risk of spreading the virus. Some people take the medicine every day to prevent future outbreaks or prevent spread to their sex partner. There are ways to lower the risk of being infected with genital herpes. Men should use a latex condom every time they have sex. Sex (oral, vaginal, and anal) is not recommended if a person has blisters or ulcers.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
Centers for Disease Control and Prevention (CDC)
Phone: (404) 639-3534
Toll-free: (800) 311-3435
(www.cdc.gov)
National Institute of Allergy and Infectious Diseases
(www.niaid.nih.gov/)
Herpes Resource Center
American Social Health Association
Phone: (800) 230-6039
(www.ashastd.org)
[1,2,4-12]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Benedetti, J, Corey, L, Ashley, R. Recurrence rates in genital herpes after symptomatic first-episode infection. Ann Intern Med 1994; 121:847.
2. Mertz, GJ, Benedetti, J, Ashley, R, et al. Risk factors for the sexual transmission of genital herpes. Ann Intern Med 1992; 116:197.
3. Wald, A, Krantz, E, Selke, S, et al. Knowledge of partners' genital herpes protects against herpes simplex virus type 2 acquisition. J Infect Dis 2006; 194:42.
4. Fleming, DT, McQuillan, GM, Johnson, RE, et al. Herpes simplex virus type 2 in the United States, 1976 to 1994. N Engl J Med 1997; 337:1105.
5. Centers for Disease Control and Prevention, Division of Sexually Transmitted Diseases. Sexually Transmitted Diseases Surveillance, Other Sexually Transmitted Diseases, 2003 (www.cdc.gov/std/stats/03pdf/otherSTDs.pdf).
6. Corey, L, Adams, HG, Brown, ZA, Holmes, KK. Genital herpes simplex virus infections: Clinical manifestations, course, and complications. Ann Intern Med 1983; 98:958.
7. Kimberlin, DW, Rouse, DJ. Clinical practice. Genital herpes. N Engl J Med 2004; 350:1970.
8. Douglas, JM, Critchlow, C, Benedetti, J, et al. A double-blind study of oral acyclovir for suppression of recurrences of genital herpes simplex virus infection. N Engl J Med 1984; 310:1551.
9. Sacks, SL. Famciclovir suppression of asymptomatic and symptomatic recurrent anogenital herpes simplex virus shedding in women: a randomized, double-blind, double-dummy, placebo-controlled, parallel-group, single-center trial. J Infect Dis 2004; 189:1341.
10. Fife, KH, Barbarash, RA, Rudolph, T, et al. Valaciclovir versus acyclovir in the treatment of first-episode genital herpes infection: Results of an international, multicenter, double-blind, randomized clinical trial. Sex Transm Dis 1997; 24:481.
11. Bodsworth, NJ, Crooks, RJ, Borelli, S, et al. Valaciclovir versus aciclovir in patient initiated treatment of recurrent genital herpes: A randomised, double blind clinical trial. Genitourin Med 1997; 73:110.
12. Corey, L, Wald, A, Patel, R, et al. Once-daily valacyclovir to reduce the risk of transmission of genital herpes. N Engl J Med 2004; 350:11.
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