INTRODUCTION — Exposure to blood or other bodily fluids can cause many serious infections, including the human immunodeficiency virus (HIV, the virus that causes AIDS). While most people are not exposed to these fluids, a number of situations can arise where exposures may occur, such as finding a syringe with needle, helping an injured person, or being the victim of an assault or rape.
Experts have worked to determine the best advice for these situations. It is important to note that the guidelines are based on studies of exposures within the healthcare system, from needlestick and other exposures of healthcare workers.
Although more than 200 different diseases can be transmitted from exposure to blood, the most serious infections are hepatitis B virus (HBV), hepatitis C virus (HCV), and HIV. Fortunately, the risk of acquiring any of these infections is low. This topic review discusses the definition of exposure, the risk of infection, and treatment and follow up recommendations for non-healthcare workers.
DEFINITION OF EXPOSURE — In order to be exposed to a bloodborne pathogen, an individual must have contact with blood, a visibly bloody fluid (eg, phlegm or urine containing blood), or another bodily fluid (eg, semen or vaginal secretions) that contain a virus. The blood or fluid must come in direct contact with some part of the person's body. A virus can enter the body through the bloodstream or mucous membranes, which include the eye, mouth, or genitals. Contact with skin that is intact (without new cuts, scraps, or rashes) poses little to no risk of infection.
Thus, exposure to a bloodborne pathogen is possible after: A percutaneous (through the skin) injury such as a needlestick or cut with a sharp object Contact with a mucous membrane (including exposure through sexual intercourse, especially if an ulcer is present or trauma to vaginal tissues occurs) or non-intact skin
INFECTION AFTER EXPOSURE
Needlestick — Of the viruses that may be transmitted through the blood or bodily fluids, hepatitis B virus (HBV) is the most infectious. A healthcare worker who sustains a needlestick with blood from a known HBV-infected patient has between a 6 and 30 percent chance of developing HBV. The risk of HCV and HIV in the same situation is 1.8 and 0.3, respectively. Other factors influence the risk of becoming infected, including the amount of blood or bodily fluid involved, the depth of penetration, and the amount of virus in the source's blood or body fluid.
Mucous membrane — The risk of becoming infected from a mucous membrane exposure is more difficult to define. When healthcare workers were followed after mucous membrane exposure to HIV, no cases of HIV were identified among those who had been exposed. However, no other explanation for HIV has been found in a few cases where mucous membrane exposure occurred in a work setting. This has led most experts to believe that the risk of acquiring HIV following a mucous membrane exposure is far less than 0.3 percent, but the risk is not zero.
One versus multiple exposures — There is also a difference in terms of risk if the individual has a one-time exposure or has multiple exposures. Thus, the risk of infection for the victim of a single sexual assault is far less than that of a regular sexual partner of an infected person.
POST-EXPOSURE RECOMMENDATIONS — The first and most important measure to take following exposure to blood or bodily fluids is to wash the area well with soap and water. Crime victims are exceptions to this rule since washing may destroy important evidence for criminal prosecution. Recommendations to prevent infection after exposure depend upon the risk of a specific virus being present:
Hepatitis B — The risk of becoming infected with hepatitis B is greater than the risk of other infections. Fortunately, there is an effective vaccine that can help to prevent infection.
Hepatitis B vaccine — The vaccine may be administered to individuals who are exposed to blood, even if the blood is not known to carry HBV. The vaccine should be given at the time of exposure, and repeated one month and six months later to achieve full protection. (See "Patient information: Hepatitis B").
Many people have previously been given the series of three HBV vaccines. In this case, some experts recommend a single booster dose of the vaccine.
Hepatitis B immune globulin — If the source of the blood is known to be positive for HBV, treatment with hepatitis B immune globulin (HBIG) is recommended. HBIG contains antibodies that provide temporary protection against the infection. HBIG is an injection, which should be given as soon as possible after exposure, preferably within 24 hours. The first dose of hepatitis B vaccine should be given at the same time. HBIG is not needed if a person was previously vaccinated with HBV vaccine.
Hepatitis C — HCV can cause a form of hepatitis that leads to chronic liver disease. There is no known way to prevent this infection following exposure. Blood tests should be done immediately after exposure to measure liver function and test for the presence of hepatitis C; the tests should be repeated after four to six weeks and again after four to six months, or sooner if symptoms of hepatitis develop. Symptoms of hepatitis C include loss of appetite, nausea, abdominal pain, darkening of urine, light stools, or jaundice (yellowing of the skin or whites of the eye). (See "Patient information: Hepatitis C").
Human immunodeficiency virus (HIV) — Treatments are available to reduce the risk of becoming infected with HIV after exposure. One retrospective study suggested that the use of an anti-HIV medication, zidovudine (ZDV), reduced the already low risk of healthcare workers becoming infected with HIV by about 81 percent. The risk of becoming infected with HIV as a result of other types of exposure (eg, trauma, rape) is probably even lower than that of a healthcare worker.
However, unlike in healthcare settings, it is often difficult after a rape or trauma if the blood or bodily fluid contains HIV. If the source of the exposure is known, an attempt can be made to test the person for HIV. However, treatment is available even if the source's HIV status cannot be determined.
The benefits of post-exposure treatment (eg, reduced risk of infection) must be weighed against the risks (eg, side effects of treatment, interactions with other medications, cost of treatment). All women of childbearing age should be tested for pregnancy before beginning treatment. Anyone who was exposed to potentially infected blood or bodily fluids should be tested for HIV at the time of exposure (baseline) and at six weeks, three months, and six months postexposure (show table 1).
Recommendations — Experts from the United States Center for Disease Control recommend use of medications to reduce the risk of HIV infection if all of the following criteria are met: Exposure occurred less than 72 hours previously One or more of the following areas were exposed: the vagina, rectum, eye, mouth, or other mucous membrane, open skin, through the skin (eg, from a sharp or needle) One or more of the following bodily fluids was involved in the exposure: blood, semen, vaginal secretions, rectal secretions, breast milk, or any body fluid that is visibly contaminated with blood
However, the CDC also recommends that each situation be considered on an individual basis; preventive treatment may be recommended to people who do not meet these criteria in some situations. In all situations, regardless of whether treatment is used, it is important to follow strategies to prevent further spread of the potential infection (see "Protecting others after exposure" below).
The CDC recommends NOT using preventive treatment when: the exposure occurred more than 72 hours prior; when the exposure is to intact skin; or when the exposure fluid is urine, nasal secretions, saliva, sweat, or tears, and is not visibly contaminated with blood.
Anyone who is exposed to blood or bodily fluids should consult with a healthcare provider if symptoms of fever, swollen lymph nodes (glands), sore throat, skin lesions, muscle or joint pain, diarrhea, headache, nausea/vomiting, or weight loss develop. The usual time from HIV exposure to the first symptoms of HIV is two to four weeks. (See "Patient information: Symptoms of HIV infection").
Treatment regimen — Postexposure prevention treatment should be started as soon as possible after exposure, within a few hours rather than days. Animal studies suggest that the longer treatment is delayed, the less effective it is. Preventive treatment should not be given if more than 72 hours have elapsed since exposure.
The Centers for Disease Control and Prevention (CDC) recommends a combination of two or three medications to prevent developing HIV after exposure; the best regimen should be determined by a healthcare provider who is experienced with HIV prevention and treatment regimens (show table 2). The optimal length of preventive treatment is unknown, although four weeks is generally recommended.
It is important to be aware of the potential side effects of these drugs, possible interactions with other medications, and the proper timing of doses. Because there are a variety of medications and combinations, it is best to discuss these issues with the person who prescribes them. In all cases, it is crucial to take all of the medication exactly as directed.
FOLLOW-UP
Testing — Follow-up testing for HBV, HCV, and HIV should be performed after possible exposure (see above for specific recommendations on frequency of testing). For people receiving HBV vaccine, return appointments to complete the vaccine series are crucial.
People exposed to a bloodborne pathogen via sexual intercourse are often tested for other sexually transmitted diseases (STDs). In particular, blood tests for syphilis and cultures for gonorrhea and chlamydia are usually performed immediately after exposure and four to six weeks later (show table 1).
Anxiety — It is common to feel anxious or scared after being exposed to blood or bodily fluids.
These fears are normal but may interfere with a person's ability to concentrate on normal day to day responsibilities.
However, the risk of becoming infected with hepatitis B, C, and HIV is small in most cases. Following the steps outlined here and the advice provided by healthcare personnel can further decrease this risk. Counseling may be helpful for people who have difficulty coping, especially during the first few weeks and months after exposure.
PROTECTING OTHERS AFTER EXPOSURE — Anyone exposed to a bloodborne pathogen should understand how to prevent spreading their potential infection to others (for example, family, sexual partner or breastfeeding child) during the follow-up period, especially during the first six months after exposure; this is when most people who are infected with HIV become antibody positive.
Precautions should include abstaining from sexual intercourse or using condoms every time. Condoms reduce, but do not completely eliminate, the chances of transmitting HBV, HCV, or HIV infection to others. Women who have been exposed to blood or body fluids from a person known to be infected should avoid becoming pregnant during this time. In addition, individuals who have been exposed to HIV-infected fluids should not donate blood, plasma, organs, tissue, or semen during the follow-up period. Women who are breastfeeding may consider stopping temporarily. To maintain a supply of breastmilk, it is acceptable to pump milk and then dump it.
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)
Toll-free: (800) 311-3435
(www.cdc.gov)
[1-8]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Bamberger, JD, Waldo, CR, Gerberding, JL, Katz, MH. Postexposure prophylaxis for human immunodeficiency virus (HIV) infection following sexual assault. Am J Med 1999; 106:323.
2. Beck-Sague, CM, Solomon, F. Sexually transmitted diseases in abused children and adolescent and adult victims of rape: review of selected literature. Clin Infect Dis 1999; 28 Suppl 1:S74.
3. Fong, C. Post-exposure prophylaxis for HIV infection after sexual assault: when is it indicated?. Emerg Med J 2001; 18:242.
4. Lurie, P, Miller, S, Hecht, F, Chesney, M. Postexposure prophylaxis after nonoccupational HIV exposure: clinical, ethical, and policy considerations. JAMA 1998; 280:1769.
5. Tokars, JI, Marcus, R, Culver, DH, et al. Surveillance of HIV infection and zidovudine use among health care workers after occupational exposure to HIV-infected blood: The CDC Cooperative Needlestick Surveillance Group. Ann Intern Med 1993; 118:913.
6. Wiebe, ER, Comay, SE, McGregor, M, Ducceschi, S. Offering HIV prophylaxis to people who have been sexually assaulted: 16 months' experience in a sexual assault service. CMAJ 2000; 162:641.
7. Workowski, KA, Berman, SM. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep 2006; 55:1.
8. Smith, DK, Grohskopf, LA, Black, RJ, et al. Antiretroviral postexposure prophylaxis after sexual, injection-drug use, or other nonoccupational exposure to HIV in the United States: recommendations from the U.S. Department of Health and Human Services. MMWR Recomm Rep 2005; 54:1.
Tuesday, October 16, 2007
Blood and body fluid exposure
INTRODUCTION — Exposure to blood or other bodily fluids can cause many serious infections, including the human immunodeficiency virus (HIV, the virus that causes AIDS). While most people are not exposed to these fluids, a number of situations can arise where exposures may occur, such as finding a syringe with needle, helping an injured person, or being the victim of an assault or rape.
Experts have worked to determine the best advice for these situations. It is important to note that the guidelines are based on studies of exposures within the healthcare system, from needlestick and other exposures of healthcare workers.
Although more than 200 different diseases can be transmitted from exposure to blood, the most serious infections are hepatitis B virus (HBV), hepatitis C virus (HCV), and HIV. Fortunately, the risk of acquiring any of these infections is low. This topic review discusses the definition of exposure, the risk of infection, and treatment and follow up recommendations for non-healthcare workers.
DEFINITION OF EXPOSURE — In order to be exposed to a bloodborne pathogen, an individual must have contact with blood, a visibly bloody fluid (eg, phlegm or urine containing blood), or another bodily fluid (eg, semen or vaginal secretions) that contain a virus. The blood or fluid must come in direct contact with some part of the person's body. A virus can enter the body through the bloodstream or mucous membranes, which include the eye, mouth, or genitals. Contact with skin that is intact (without new cuts, scraps, or rashes) poses little to no risk of infection.
Thus, exposure to a bloodborne pathogen is possible after: A percutaneous (through the skin) injury such as a needlestick or cut with a sharp object Contact with a mucous membrane (including exposure through sexual intercourse, especially if an ulcer is present or trauma to vaginal tissues occurs) or non-intact skin
INFECTION AFTER EXPOSURE
Needlestick — Of the viruses that may be transmitted through the blood or bodily fluids, hepatitis B virus (HBV) is the most infectious. A healthcare worker who sustains a needlestick with blood from a known HBV-infected patient has between a 6 and 30 percent chance of developing HBV. The risk of HCV and HIV in the same situation is 1.8 and 0.3, respectively. Other factors influence the risk of becoming infected, including the amount of blood or bodily fluid involved, the depth of penetration, and the amount of virus in the source's blood or body fluid.
Mucous membrane — The risk of becoming infected from a mucous membrane exposure is more difficult to define. When healthcare workers were followed after mucous membrane exposure to HIV, no cases of HIV were identified among those who had been exposed. However, no other explanation for HIV has been found in a few cases where mucous membrane exposure occurred in a work setting. This has led most experts to believe that the risk of acquiring HIV following a mucous membrane exposure is far less than 0.3 percent, but the risk is not zero.
One versus multiple exposures — There is also a difference in terms of risk if the individual has a one-time exposure or has multiple exposures. Thus, the risk of infection for the victim of a single sexual assault is far less than that of a regular sexual partner of an infected person.
POST-EXPOSURE RECOMMENDATIONS — The first and most important measure to take following exposure to blood or bodily fluids is to wash the area well with soap and water. Crime victims are exceptions to this rule since washing may destroy important evidence for criminal prosecution. Recommendations to prevent infection after exposure depend upon the risk of a specific virus being present:
Hepatitis B — The risk of becoming infected with hepatitis B is greater than the risk of other infections. Fortunately, there is an effective vaccine that can help to prevent infection.
Hepatitis B vaccine — The vaccine may be administered to individuals who are exposed to blood, even if the blood is not known to carry HBV. The vaccine should be given at the time of exposure, and repeated one month and six months later to achieve full protection. (See "Patient information: Hepatitis B").
Many people have previously been given the series of three HBV vaccines. In this case, some experts recommend a single booster dose of the vaccine.
Hepatitis B immune globulin — If the source of the blood is known to be positive for HBV, treatment with hepatitis B immune globulin (HBIG) is recommended. HBIG contains antibodies that provide temporary protection against the infection. HBIG is an injection, which should be given as soon as possible after exposure, preferably within 24 hours. The first dose of hepatitis B vaccine should be given at the same time. HBIG is not needed if a person was previously vaccinated with HBV vaccine.
Hepatitis C — HCV can cause a form of hepatitis that leads to chronic liver disease. There is no known way to prevent this infection following exposure. Blood tests should be done immediately after exposure to measure liver function and test for the presence of hepatitis C; the tests should be repeated after four to six weeks and again after four to six months, or sooner if symptoms of hepatitis develop. Symptoms of hepatitis C include loss of appetite, nausea, abdominal pain, darkening of urine, light stools, or jaundice (yellowing of the skin or whites of the eye). (See "Patient information: Hepatitis C").
Human immunodeficiency virus (HIV) — Treatments are available to reduce the risk of becoming infected with HIV after exposure. One retrospective study suggested that the use of an anti-HIV medication, zidovudine (ZDV), reduced the already low risk of healthcare workers becoming infected with HIV by about 81 percent. The risk of becoming infected with HIV as a result of other types of exposure (eg, trauma, rape) is probably even lower than that of a healthcare worker.
However, unlike in healthcare settings, it is often difficult after a rape or trauma if the blood or bodily fluid contains HIV. If the source of the exposure is known, an attempt can be made to test the person for HIV. However, treatment is available even if the source's HIV status cannot be determined.
The benefits of post-exposure treatment (eg, reduced risk of infection) must be weighed against the risks (eg, side effects of treatment, interactions with other medications, cost of treatment). All women of childbearing age should be tested for pregnancy before beginning treatment. Anyone who was exposed to potentially infected blood or bodily fluids should be tested for HIV at the time of exposure (baseline) and at six weeks, three months, and six months postexposure (show table 1).
Recommendations — Experts from the United States Center for Disease Control recommend use of medications to reduce the risk of HIV infection if all of the following criteria are met: Exposure occurred less than 72 hours previously One or more of the following areas were exposed: the vagina, rectum, eye, mouth, or other mucous membrane, open skin, through the skin (eg, from a sharp or needle) One or more of the following bodily fluids was involved in the exposure: blood, semen, vaginal secretions, rectal secretions, breast milk, or any body fluid that is visibly contaminated with blood
However, the CDC also recommends that each situation be considered on an individual basis; preventive treatment may be recommended to people who do not meet these criteria in some situations. In all situations, regardless of whether treatment is used, it is important to follow strategies to prevent further spread of the potential infection (see "Protecting others after exposure" below).
The CDC recommends NOT using preventive treatment when: the exposure occurred more than 72 hours prior; when the exposure is to intact skin; or when the exposure fluid is urine, nasal secretions, saliva, sweat, or tears, and is not visibly contaminated with blood.
Anyone who is exposed to blood or bodily fluids should consult with a healthcare provider if symptoms of fever, swollen lymph nodes (glands), sore throat, skin lesions, muscle or joint pain, diarrhea, headache, nausea/vomiting, or weight loss develop. The usual time from HIV exposure to the first symptoms of HIV is two to four weeks. (See "Patient information: Symptoms of HIV infection").
Treatment regimen — Postexposure prevention treatment should be started as soon as possible after exposure, within a few hours rather than days. Animal studies suggest that the longer treatment is delayed, the less effective it is. Preventive treatment should not be given if more than 72 hours have elapsed since exposure.
The Centers for Disease Control and Prevention (CDC) recommends a combination of two or three medications to prevent developing HIV after exposure; the best regimen should be determined by a healthcare provider who is experienced with HIV prevention and treatment regimens (show table 2). The optimal length of preventive treatment is unknown, although four weeks is generally recommended.
It is important to be aware of the potential side effects of these drugs, possible interactions with other medications, and the proper timing of doses. Because there are a variety of medications and combinations, it is best to discuss these issues with the person who prescribes them. In all cases, it is crucial to take all of the medication exactly as directed.
FOLLOW-UP
Testing — Follow-up testing for HBV, HCV, and HIV should be performed after possible exposure (see above for specific recommendations on frequency of testing). For people receiving HBV vaccine, return appointments to complete the vaccine series are crucial.
People exposed to a bloodborne pathogen via sexual intercourse are often tested for other sexually transmitted diseases (STDs). In particular, blood tests for syphilis and cultures for gonorrhea and chlamydia are usually performed immediately after exposure and four to six weeks later (show table 1).
Anxiety — It is common to feel anxious or scared after being exposed to blood or bodily fluids.
These fears are normal but may interfere with a person's ability to concentrate on normal day to day responsibilities.
However, the risk of becoming infected with hepatitis B, C, and HIV is small in most cases. Following the steps outlined here and the advice provided by healthcare personnel can further decrease this risk. Counseling may be helpful for people who have difficulty coping, especially during the first few weeks and months after exposure.
PROTECTING OTHERS AFTER EXPOSURE — Anyone exposed to a bloodborne pathogen should understand how to prevent spreading their potential infection to others (for example, family, sexual partner or breastfeeding child) during the follow-up period, especially during the first six months after exposure; this is when most people who are infected with HIV become antibody positive.
Precautions should include abstaining from sexual intercourse or using condoms every time. Condoms reduce, but do not completely eliminate, the chances of transmitting HBV, HCV, or HIV infection to others. Women who have been exposed to blood or body fluids from a person known to be infected should avoid becoming pregnant during this time. In addition, individuals who have been exposed to HIV-infected fluids should not donate blood, plasma, organs, tissue, or semen during the follow-up period. Women who are breastfeeding may consider stopping temporarily. To maintain a supply of breastmilk, it is acceptable to pump milk and then dump it.
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)
Toll-free: (800) 311-3435
(www.cdc.gov)
[1-8]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Bamberger, JD, Waldo, CR, Gerberding, JL, Katz, MH. Postexposure prophylaxis for human immunodeficiency virus (HIV) infection following sexual assault. Am J Med 1999; 106:323.
2. Beck-Sague, CM, Solomon, F. Sexually transmitted diseases in abused children and adolescent and adult victims of rape: review of selected literature. Clin Infect Dis 1999; 28 Suppl 1:S74.
3. Fong, C. Post-exposure prophylaxis for HIV infection after sexual assault: when is it indicated?. Emerg Med J 2001; 18:242.
4. Lurie, P, Miller, S, Hecht, F, Chesney, M. Postexposure prophylaxis after nonoccupational HIV exposure: clinical, ethical, and policy considerations. JAMA 1998; 280:1769.
5. Tokars, JI, Marcus, R, Culver, DH, et al. Surveillance of HIV infection and zidovudine use among health care workers after occupational exposure to HIV-infected blood: The CDC Cooperative Needlestick Surveillance Group. Ann Intern Med 1993; 118:913.
6. Wiebe, ER, Comay, SE, McGregor, M, Ducceschi, S. Offering HIV prophylaxis to people who have been sexually assaulted: 16 months' experience in a sexual assault service. CMAJ 2000; 162:641.
7. Workowski, KA, Berman, SM. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep 2006; 55:1.
8. Smith, DK, Grohskopf, LA, Black, RJ, et al. Antiretroviral postexposure prophylaxis after sexual, injection-drug use, or other nonoccupational exposure to HIV in the United States: recommendations from the U.S. Department of Health and Human Services. MMWR Recomm Rep 2005; 54:1.
Experts have worked to determine the best advice for these situations. It is important to note that the guidelines are based on studies of exposures within the healthcare system, from needlestick and other exposures of healthcare workers.
Although more than 200 different diseases can be transmitted from exposure to blood, the most serious infections are hepatitis B virus (HBV), hepatitis C virus (HCV), and HIV. Fortunately, the risk of acquiring any of these infections is low. This topic review discusses the definition of exposure, the risk of infection, and treatment and follow up recommendations for non-healthcare workers.
DEFINITION OF EXPOSURE — In order to be exposed to a bloodborne pathogen, an individual must have contact with blood, a visibly bloody fluid (eg, phlegm or urine containing blood), or another bodily fluid (eg, semen or vaginal secretions) that contain a virus. The blood or fluid must come in direct contact with some part of the person's body. A virus can enter the body through the bloodstream or mucous membranes, which include the eye, mouth, or genitals. Contact with skin that is intact (without new cuts, scraps, or rashes) poses little to no risk of infection.
Thus, exposure to a bloodborne pathogen is possible after: A percutaneous (through the skin) injury such as a needlestick or cut with a sharp object Contact with a mucous membrane (including exposure through sexual intercourse, especially if an ulcer is present or trauma to vaginal tissues occurs) or non-intact skin
INFECTION AFTER EXPOSURE
Needlestick — Of the viruses that may be transmitted through the blood or bodily fluids, hepatitis B virus (HBV) is the most infectious. A healthcare worker who sustains a needlestick with blood from a known HBV-infected patient has between a 6 and 30 percent chance of developing HBV. The risk of HCV and HIV in the same situation is 1.8 and 0.3, respectively. Other factors influence the risk of becoming infected, including the amount of blood or bodily fluid involved, the depth of penetration, and the amount of virus in the source's blood or body fluid.
Mucous membrane — The risk of becoming infected from a mucous membrane exposure is more difficult to define. When healthcare workers were followed after mucous membrane exposure to HIV, no cases of HIV were identified among those who had been exposed. However, no other explanation for HIV has been found in a few cases where mucous membrane exposure occurred in a work setting. This has led most experts to believe that the risk of acquiring HIV following a mucous membrane exposure is far less than 0.3 percent, but the risk is not zero.
One versus multiple exposures — There is also a difference in terms of risk if the individual has a one-time exposure or has multiple exposures. Thus, the risk of infection for the victim of a single sexual assault is far less than that of a regular sexual partner of an infected person.
POST-EXPOSURE RECOMMENDATIONS — The first and most important measure to take following exposure to blood or bodily fluids is to wash the area well with soap and water. Crime victims are exceptions to this rule since washing may destroy important evidence for criminal prosecution. Recommendations to prevent infection after exposure depend upon the risk of a specific virus being present:
Hepatitis B — The risk of becoming infected with hepatitis B is greater than the risk of other infections. Fortunately, there is an effective vaccine that can help to prevent infection.
Hepatitis B vaccine — The vaccine may be administered to individuals who are exposed to blood, even if the blood is not known to carry HBV. The vaccine should be given at the time of exposure, and repeated one month and six months later to achieve full protection. (See "Patient information: Hepatitis B").
Many people have previously been given the series of three HBV vaccines. In this case, some experts recommend a single booster dose of the vaccine.
Hepatitis B immune globulin — If the source of the blood is known to be positive for HBV, treatment with hepatitis B immune globulin (HBIG) is recommended. HBIG contains antibodies that provide temporary protection against the infection. HBIG is an injection, which should be given as soon as possible after exposure, preferably within 24 hours. The first dose of hepatitis B vaccine should be given at the same time. HBIG is not needed if a person was previously vaccinated with HBV vaccine.
Hepatitis C — HCV can cause a form of hepatitis that leads to chronic liver disease. There is no known way to prevent this infection following exposure. Blood tests should be done immediately after exposure to measure liver function and test for the presence of hepatitis C; the tests should be repeated after four to six weeks and again after four to six months, or sooner if symptoms of hepatitis develop. Symptoms of hepatitis C include loss of appetite, nausea, abdominal pain, darkening of urine, light stools, or jaundice (yellowing of the skin or whites of the eye). (See "Patient information: Hepatitis C").
Human immunodeficiency virus (HIV) — Treatments are available to reduce the risk of becoming infected with HIV after exposure. One retrospective study suggested that the use of an anti-HIV medication, zidovudine (ZDV), reduced the already low risk of healthcare workers becoming infected with HIV by about 81 percent. The risk of becoming infected with HIV as a result of other types of exposure (eg, trauma, rape) is probably even lower than that of a healthcare worker.
However, unlike in healthcare settings, it is often difficult after a rape or trauma if the blood or bodily fluid contains HIV. If the source of the exposure is known, an attempt can be made to test the person for HIV. However, treatment is available even if the source's HIV status cannot be determined.
The benefits of post-exposure treatment (eg, reduced risk of infection) must be weighed against the risks (eg, side effects of treatment, interactions with other medications, cost of treatment). All women of childbearing age should be tested for pregnancy before beginning treatment. Anyone who was exposed to potentially infected blood or bodily fluids should be tested for HIV at the time of exposure (baseline) and at six weeks, three months, and six months postexposure (show table 1).
Recommendations — Experts from the United States Center for Disease Control recommend use of medications to reduce the risk of HIV infection if all of the following criteria are met: Exposure occurred less than 72 hours previously One or more of the following areas were exposed: the vagina, rectum, eye, mouth, or other mucous membrane, open skin, through the skin (eg, from a sharp or needle) One or more of the following bodily fluids was involved in the exposure: blood, semen, vaginal secretions, rectal secretions, breast milk, or any body fluid that is visibly contaminated with blood
However, the CDC also recommends that each situation be considered on an individual basis; preventive treatment may be recommended to people who do not meet these criteria in some situations. In all situations, regardless of whether treatment is used, it is important to follow strategies to prevent further spread of the potential infection (see "Protecting others after exposure" below).
The CDC recommends NOT using preventive treatment when: the exposure occurred more than 72 hours prior; when the exposure is to intact skin; or when the exposure fluid is urine, nasal secretions, saliva, sweat, or tears, and is not visibly contaminated with blood.
Anyone who is exposed to blood or bodily fluids should consult with a healthcare provider if symptoms of fever, swollen lymph nodes (glands), sore throat, skin lesions, muscle or joint pain, diarrhea, headache, nausea/vomiting, or weight loss develop. The usual time from HIV exposure to the first symptoms of HIV is two to four weeks. (See "Patient information: Symptoms of HIV infection").
Treatment regimen — Postexposure prevention treatment should be started as soon as possible after exposure, within a few hours rather than days. Animal studies suggest that the longer treatment is delayed, the less effective it is. Preventive treatment should not be given if more than 72 hours have elapsed since exposure.
The Centers for Disease Control and Prevention (CDC) recommends a combination of two or three medications to prevent developing HIV after exposure; the best regimen should be determined by a healthcare provider who is experienced with HIV prevention and treatment regimens (show table 2). The optimal length of preventive treatment is unknown, although four weeks is generally recommended.
It is important to be aware of the potential side effects of these drugs, possible interactions with other medications, and the proper timing of doses. Because there are a variety of medications and combinations, it is best to discuss these issues with the person who prescribes them. In all cases, it is crucial to take all of the medication exactly as directed.
FOLLOW-UP
Testing — Follow-up testing for HBV, HCV, and HIV should be performed after possible exposure (see above for specific recommendations on frequency of testing). For people receiving HBV vaccine, return appointments to complete the vaccine series are crucial.
People exposed to a bloodborne pathogen via sexual intercourse are often tested for other sexually transmitted diseases (STDs). In particular, blood tests for syphilis and cultures for gonorrhea and chlamydia are usually performed immediately after exposure and four to six weeks later (show table 1).
Anxiety — It is common to feel anxious or scared after being exposed to blood or bodily fluids.
These fears are normal but may interfere with a person's ability to concentrate on normal day to day responsibilities.
However, the risk of becoming infected with hepatitis B, C, and HIV is small in most cases. Following the steps outlined here and the advice provided by healthcare personnel can further decrease this risk. Counseling may be helpful for people who have difficulty coping, especially during the first few weeks and months after exposure.
PROTECTING OTHERS AFTER EXPOSURE — Anyone exposed to a bloodborne pathogen should understand how to prevent spreading their potential infection to others (for example, family, sexual partner or breastfeeding child) during the follow-up period, especially during the first six months after exposure; this is when most people who are infected with HIV become antibody positive.
Precautions should include abstaining from sexual intercourse or using condoms every time. Condoms reduce, but do not completely eliminate, the chances of transmitting HBV, HCV, or HIV infection to others. Women who have been exposed to blood or body fluids from a person known to be infected should avoid becoming pregnant during this time. In addition, individuals who have been exposed to HIV-infected fluids should not donate blood, plasma, organs, tissue, or semen during the follow-up period. Women who are breastfeeding may consider stopping temporarily. To maintain a supply of breastmilk, it is acceptable to pump milk and then dump it.
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)
Toll-free: (800) 311-3435
(www.cdc.gov)
[1-8]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Bamberger, JD, Waldo, CR, Gerberding, JL, Katz, MH. Postexposure prophylaxis for human immunodeficiency virus (HIV) infection following sexual assault. Am J Med 1999; 106:323.
2. Beck-Sague, CM, Solomon, F. Sexually transmitted diseases in abused children and adolescent and adult victims of rape: review of selected literature. Clin Infect Dis 1999; 28 Suppl 1:S74.
3. Fong, C. Post-exposure prophylaxis for HIV infection after sexual assault: when is it indicated?. Emerg Med J 2001; 18:242.
4. Lurie, P, Miller, S, Hecht, F, Chesney, M. Postexposure prophylaxis after nonoccupational HIV exposure: clinical, ethical, and policy considerations. JAMA 1998; 280:1769.
5. Tokars, JI, Marcus, R, Culver, DH, et al. Surveillance of HIV infection and zidovudine use among health care workers after occupational exposure to HIV-infected blood: The CDC Cooperative Needlestick Surveillance Group. Ann Intern Med 1993; 118:913.
6. Wiebe, ER, Comay, SE, McGregor, M, Ducceschi, S. Offering HIV prophylaxis to people who have been sexually assaulted: 16 months' experience in a sexual assault service. CMAJ 2000; 162:641.
7. Workowski, KA, Berman, SM. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep 2006; 55:1.
8. Smith, DK, Grohskopf, LA, Black, RJ, et al. Antiretroviral postexposure prophylaxis after sexual, injection-drug use, or other nonoccupational exposure to HIV in the United States: recommendations from the U.S. Department of Health and Human Services. MMWR Recomm Rep 2005; 54:1.
Monday, October 15, 2007
Vaginal yeast infection
INTRODUCTION — Vaginal yeast infections are a very common problem in women. It is difficult to know the true percentage of women affected by yeast infections because they are frequently diagnosed without an examination. In addition, many women treat themselves with over-the-counter yeast treatments before seeking medical advice.
Yeast infections occur mainly in women who are menstruating (having monthly periods). They are less common in postmenopausal women who do not take estrogen and in girls who have not yet started menstruating.
Vaginal yeast infections are also called yeast vaginitis or vaginal candidiasis.
SYMPTOMS — Itching of the vulva is the most common symptom of a vaginal yeast infection (show figure 1). Women may also note pain with urination, vulvar soreness or irritation, pain with intercourse, or reddened and swollen vulvar and vaginal tissues. There is often little or no vaginal discharge. If present, discharge is typically white and clumpy (curd-like), but may be thin and watery in some cases.
Symptoms of a yeast infection are similar to a number of other conditions, including bacterial vaginosis (a bacterial infection of the vagina), trichomoniasis (a sexually transmitted infection), and contact or allergic dermatitis (a skin reaction to an irritating or allergic substance) (show table 1). It is often not possible to know, based on symptoms alone, if vulvar itching is caused by yeast or other potential causes. (See "Self-diagnosis" below).
CAUSE — Candida albicans is a fungus that normally lives on the skin and mucous membranes (mouth, nose, vagina). Normally, Candida causes no symptoms. However, when the skin or mucous membranes undergo changes due to medications, injury, or stress to the immune system, Candida may multiply and cause the characteristic symptoms, described above.
Candida albicans causes 80 to 92 percent of episodes of vulvovaginal candidiasis. Some investigators have reported an increasing frequency of other candida species, particularly C. glabrata, possibly due to widespread use of over-the-counter drugs, long-term use of suppressive yeast infection treatments, and the use of short courses of antifungal drugs.
RISK FACTORS — In most women, there is no underlying disease or event that leads to a yeast infection. There are several risk factors that may increase the chances of developing an infection, including: Antibiotics — Most antibiotics kill a wide variety of bacteria, including those that normally live in the vagina. These bacteria function to protect the vagina from the overgrowth of yeast. Some women are prone to yeast infections while taking antibiotics. Hormonal contraceptives (eg, birth control pills, patch, and vaginal ring) — The risk of yeast infections may be higher in women who use contraceptives containing estrogen. Contraceptive devices — Vaginal sponges, diaphragms, and intrauterine devices (IUDs) have been associated with a higher risk of yeast infection. Spermicides have not, although spermicides frequently cause vaginal irritation. (See "Patient information: Contraception"). Immunosuppression — Yeast infections are more common in patients who are immunosuppressed due to infection with HIV or use of immune-suppressing medications (steroids, chemotherapy, post-organ transplant medications). Pregnancy — Signs and symptoms of a yeast infection are more common during pregnancy, although there are little data to know if yeast infection is always the cause. Diabetes — Women with diabetes are at higher risk for yeast infection, especially when blood glucose levels are frequently higher than normal.
Vaginal yeast infections are not considered to be a sexually transmitted infection. They can occur in women who have never been sexually active but are more common in women who are sexually active. Yeast infections are no more frequent in women who have sex frequently, but may develop more frequently in women who receive oral sex.
DIAGNOSIS — Diagnosis of a vaginal yeast infection requires that a healthcare provider take a medical history, perform a physical examination, and perform diagnostic testing. It is important to visit the provider when symptoms are present and before any treatment is used; the diagnosis is harder to make if symptoms have resolved or if treatment was started before an examination and diagnostic testing. The combination of a medical history, physical examination, and diagnostic testing correctly diagnoses vaginal yeast infection in about 60 percent of women.
Diagnostic testing may include measurement of the vaginal pH; normally, the pH of vaginal discharge is acidic. Examination of the vaginal discharge under a microscope (called a wet mount) allows the provider to look for yeast buds and hyphae, which resemble branches of a tree (show picture 1). Other infections can be diagnosed with wet mount, including bacterial vaginosis and trichomoniasis.
Further testing with a yeast culture may be needed for a woman who has symptoms of a yeast infection but no evidence of yeast on wet mount. Culture is also useful in women with recurrent or persistent signs and symptoms who have a negative wet mount or do not respond to treatment. Yeast culture and sensitivity can determine if nonalbicans yeast is present and can guide treatment in these cases.
Self-diagnosis — Women with symptoms of vulvar itching or vaginal discharge frequently assume that their symptoms are related to a yeast infection and treat themselves with an over-the-counter treatment. In one study, only 11 percent of women accurately diagnosed their infection; women with a previous yeast infection were only slightly more accurate (35 percent correct) [1].
Incorrect self-diagnosis and treatment can delay receiving the correct diagnosis and treatment and wastes money on improper treatment, which frequently causes further irritation of the vulva and vagina.
TREATMENT — Treatment of vaginal yeast infection may include a topical cream or tablet; most are applied inside the vagina at bedtime with an applicator. Treatment durations vary according to the formulation; one, three, and seven-day treatments are equally effective.
Oral treatment is available as fluconazole (Diflucan®) 150 mg. Most patients require only one dose, although women with more complicated infections (such as those with underlying medical problems, recurrent yeast infections, or severe signs and symptoms) may require a second dose 72 hours (3 days) after the first dose. Side effects of fluconazole are mild and infrequent, but may include stomach upset, headache, and rash. Fluconazole interacts with a number of medications; a healthcare provider or pharmacist should be consulted if there are concerns about drug interactions. Fluconazole should not be taken during pregnancy.
Uncomplicated yeast infections usually resolve within a few days of treatment. Complicated infections may require more time to completely resolve; the infection generally resolves within a few days but the vulvar and vaginal irritation can persist for up to 2 weeks.
Women who do not improve after treatment with a standard oral or vaginal treatment for yeast infection should be reexamined. A different species of yeast, known as Candida glabrata, is less likely to respond to standard treatments, and can usually be diagnosed with a vaginal yeast culture.
RECURRENT YEAST INFECTIONS — Between 5 and 8 percent of women have recurrent yeast infections, defined as more than four infections per year. Risk factors for recurrent infection include the use of panty liners, pantyhose, or sexual lubricants, or the consumption of cranberry juice. Avoidance of these products may reduce the frequency of infection in some women.
There is no evidence that eating yogurt or other products containing live Lactobacillus acidophilus, or applying these products to the vagina is of any benefit in women with recurrent vaginal yeast infections.
Diagnosis — As with initial yeast infections, it is important to correctly diagnose recurrent yeast infections. A woman who has frequent signs and symptoms of vulvar or vaginal irritation or itching should be seen by a healthcare provider to ensure that her symptoms are from yeast, not as a result of other common problems (eg, other vaginal infections, allergic reaction or sensitivity to products such as detergents or soaps). As with initial infections, self-diagnosis is not accurate enough to recommend treatment.
Treatment — Women with recurrent infections should use a longer course of treatment for infections, between 10 to 14 days for a topical (cream or suppository) medication or fluconazole 150 mg by mouth with a second dose 72 hours later.
Preventive treatment can be started after the infection has resolved; this may include fluconazole (150 mg orally once per week) or clotrimazole (500 mg vaginal suppositories administered once per week).
Treatment of a sexual partner — Vaginal yeast infections are not considered to be a sexually transmitted infection, though the infection can rarely be passed from one partner to another. Most experts do not currently recommend treatment of a sexual partner.
SUMMARY Vaginal yeast infections are a very common problem in women. It is difficult to know the true percentage of women affected by yeast infections; they are frequently diagnosed without an examination and many women treat themselves with over-the-counter yeast treatments before seeking medical advice. Itching of the vulva is the most common symptom of a vaginal yeast infection. Women may also note pain with urination, vulvar soreness or irritation, pain with intercourse, or reddened and swollen vulvar and vaginal tissues. There is often little or no vaginal discharge; if present, discharge is typically white and clumpy (curd-like), but may be thin and watery in some cases. Symptoms of a yeast infection are similar to a number of other conditions, including bacterial vaginosis (a bacterial infection of the vagina), trichomoniasis (a sexually transmitted infection), and contact or allergic dermatitis (a skin reaction to an irritating or allergic substance) (show table 1). It is often not possible to know, based on symptoms alone, if vulvar itching is caused by yeast or other potential causes. Candida albicans is a fungus that normally lives on the skin and mucous membranes (mouth, nose, vagina); it causes most cases of vaginal yeast infections. Normally, candida causes no symptoms. However, when the skin or mucous membranes undergo changes due to medications, injury, or stress to the immune system, candida multiplies and causes the characteristic symptoms of a yeast infection, described above. In most women, there is no underlying disease or event that leads to a yeast infection. There are several risk factors that may increase the chances of developing an infection, including use of antibiotics, hormonal contraceptives and certain contraceptive devices, diabetes, pregnancy, and a weakened immune system (due to chemotherapy, HIV, or certain medications). Diagnosis of a vaginal yeast infection requires that a healthcare provider take a medical history, perform a physical examination, and perform diagnostic testing. It is important to visit the provider when symptoms are present and before any treatment is used. Women with symptoms of vulvar itching or vaginal discharge frequently assume that their symptoms are related to a yeast infection and treat themselves with an over-the-counter treatment. Incorrect self-diagnosis and treatment can delay receiving the correct diagnosis and treatment and wastes money on improper treatment, which frequently causes further irritation of the vulva and vagina. Treatment of vaginal yeast infection may include a topical cream or tablet; most are applied inside the vagina at bedtime with an applicator. Treatment durations vary; one, three, and seven- day treatments are equally effective. Oral treatment is available as fluconazole (Diflucan®) 150 mg. Most patients require only one dose
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)
U.S. Department of Health and Human Services
(www.4woman.gov)
[1-3]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Ferris, DG, Nyirjesy, P, Sobel, JD, et al. Over-the-counter antifungal drug misuse associated with patient-diagnosed vulvovaginal candidiasis(1). Obstet Gynecol 2002; 99:419.
2. National guideline for the management of vulvovaginal candidiasis. Clinical Effectiveness Group (Association of Genitourinary Medicine and the Medical Society for the Study of Venereal Diseases). Sex Transm Infect 1999; 75 Suppl 1:S19.
3. Rex, JH, Walsh, TJ, Sobel, JD, et al. Practice guidelines for treatment of candidiasis. Clin Infect Dis 2000; 30:662.
Yeast infections occur mainly in women who are menstruating (having monthly periods). They are less common in postmenopausal women who do not take estrogen and in girls who have not yet started menstruating.
Vaginal yeast infections are also called yeast vaginitis or vaginal candidiasis.
SYMPTOMS — Itching of the vulva is the most common symptom of a vaginal yeast infection (show figure 1). Women may also note pain with urination, vulvar soreness or irritation, pain with intercourse, or reddened and swollen vulvar and vaginal tissues. There is often little or no vaginal discharge. If present, discharge is typically white and clumpy (curd-like), but may be thin and watery in some cases.
Symptoms of a yeast infection are similar to a number of other conditions, including bacterial vaginosis (a bacterial infection of the vagina), trichomoniasis (a sexually transmitted infection), and contact or allergic dermatitis (a skin reaction to an irritating or allergic substance) (show table 1). It is often not possible to know, based on symptoms alone, if vulvar itching is caused by yeast or other potential causes. (See "Self-diagnosis" below).
CAUSE — Candida albicans is a fungus that normally lives on the skin and mucous membranes (mouth, nose, vagina). Normally, Candida causes no symptoms. However, when the skin or mucous membranes undergo changes due to medications, injury, or stress to the immune system, Candida may multiply and cause the characteristic symptoms, described above.
Candida albicans causes 80 to 92 percent of episodes of vulvovaginal candidiasis. Some investigators have reported an increasing frequency of other candida species, particularly C. glabrata, possibly due to widespread use of over-the-counter drugs, long-term use of suppressive yeast infection treatments, and the use of short courses of antifungal drugs.
RISK FACTORS — In most women, there is no underlying disease or event that leads to a yeast infection. There are several risk factors that may increase the chances of developing an infection, including: Antibiotics — Most antibiotics kill a wide variety of bacteria, including those that normally live in the vagina. These bacteria function to protect the vagina from the overgrowth of yeast. Some women are prone to yeast infections while taking antibiotics. Hormonal contraceptives (eg, birth control pills, patch, and vaginal ring) — The risk of yeast infections may be higher in women who use contraceptives containing estrogen. Contraceptive devices — Vaginal sponges, diaphragms, and intrauterine devices (IUDs) have been associated with a higher risk of yeast infection. Spermicides have not, although spermicides frequently cause vaginal irritation. (See "Patient information: Contraception"). Immunosuppression — Yeast infections are more common in patients who are immunosuppressed due to infection with HIV or use of immune-suppressing medications (steroids, chemotherapy, post-organ transplant medications). Pregnancy — Signs and symptoms of a yeast infection are more common during pregnancy, although there are little data to know if yeast infection is always the cause. Diabetes — Women with diabetes are at higher risk for yeast infection, especially when blood glucose levels are frequently higher than normal.
Vaginal yeast infections are not considered to be a sexually transmitted infection. They can occur in women who have never been sexually active but are more common in women who are sexually active. Yeast infections are no more frequent in women who have sex frequently, but may develop more frequently in women who receive oral sex.
DIAGNOSIS — Diagnosis of a vaginal yeast infection requires that a healthcare provider take a medical history, perform a physical examination, and perform diagnostic testing. It is important to visit the provider when symptoms are present and before any treatment is used; the diagnosis is harder to make if symptoms have resolved or if treatment was started before an examination and diagnostic testing. The combination of a medical history, physical examination, and diagnostic testing correctly diagnoses vaginal yeast infection in about 60 percent of women.
Diagnostic testing may include measurement of the vaginal pH; normally, the pH of vaginal discharge is acidic. Examination of the vaginal discharge under a microscope (called a wet mount) allows the provider to look for yeast buds and hyphae, which resemble branches of a tree (show picture 1). Other infections can be diagnosed with wet mount, including bacterial vaginosis and trichomoniasis.
Further testing with a yeast culture may be needed for a woman who has symptoms of a yeast infection but no evidence of yeast on wet mount. Culture is also useful in women with recurrent or persistent signs and symptoms who have a negative wet mount or do not respond to treatment. Yeast culture and sensitivity can determine if nonalbicans yeast is present and can guide treatment in these cases.
Self-diagnosis — Women with symptoms of vulvar itching or vaginal discharge frequently assume that their symptoms are related to a yeast infection and treat themselves with an over-the-counter treatment. In one study, only 11 percent of women accurately diagnosed their infection; women with a previous yeast infection were only slightly more accurate (35 percent correct) [1].
Incorrect self-diagnosis and treatment can delay receiving the correct diagnosis and treatment and wastes money on improper treatment, which frequently causes further irritation of the vulva and vagina.
TREATMENT — Treatment of vaginal yeast infection may include a topical cream or tablet; most are applied inside the vagina at bedtime with an applicator. Treatment durations vary according to the formulation; one, three, and seven-day treatments are equally effective.
Oral treatment is available as fluconazole (Diflucan®) 150 mg. Most patients require only one dose, although women with more complicated infections (such as those with underlying medical problems, recurrent yeast infections, or severe signs and symptoms) may require a second dose 72 hours (3 days) after the first dose. Side effects of fluconazole are mild and infrequent, but may include stomach upset, headache, and rash. Fluconazole interacts with a number of medications; a healthcare provider or pharmacist should be consulted if there are concerns about drug interactions. Fluconazole should not be taken during pregnancy.
Uncomplicated yeast infections usually resolve within a few days of treatment. Complicated infections may require more time to completely resolve; the infection generally resolves within a few days but the vulvar and vaginal irritation can persist for up to 2 weeks.
Women who do not improve after treatment with a standard oral or vaginal treatment for yeast infection should be reexamined. A different species of yeast, known as Candida glabrata, is less likely to respond to standard treatments, and can usually be diagnosed with a vaginal yeast culture.
RECURRENT YEAST INFECTIONS — Between 5 and 8 percent of women have recurrent yeast infections, defined as more than four infections per year. Risk factors for recurrent infection include the use of panty liners, pantyhose, or sexual lubricants, or the consumption of cranberry juice. Avoidance of these products may reduce the frequency of infection in some women.
There is no evidence that eating yogurt or other products containing live Lactobacillus acidophilus, or applying these products to the vagina is of any benefit in women with recurrent vaginal yeast infections.
Diagnosis — As with initial yeast infections, it is important to correctly diagnose recurrent yeast infections. A woman who has frequent signs and symptoms of vulvar or vaginal irritation or itching should be seen by a healthcare provider to ensure that her symptoms are from yeast, not as a result of other common problems (eg, other vaginal infections, allergic reaction or sensitivity to products such as detergents or soaps). As with initial infections, self-diagnosis is not accurate enough to recommend treatment.
Treatment — Women with recurrent infections should use a longer course of treatment for infections, between 10 to 14 days for a topical (cream or suppository) medication or fluconazole 150 mg by mouth with a second dose 72 hours later.
Preventive treatment can be started after the infection has resolved; this may include fluconazole (150 mg orally once per week) or clotrimazole (500 mg vaginal suppositories administered once per week).
Treatment of a sexual partner — Vaginal yeast infections are not considered to be a sexually transmitted infection, though the infection can rarely be passed from one partner to another. Most experts do not currently recommend treatment of a sexual partner.
SUMMARY Vaginal yeast infections are a very common problem in women. It is difficult to know the true percentage of women affected by yeast infections; they are frequently diagnosed without an examination and many women treat themselves with over-the-counter yeast treatments before seeking medical advice. Itching of the vulva is the most common symptom of a vaginal yeast infection. Women may also note pain with urination, vulvar soreness or irritation, pain with intercourse, or reddened and swollen vulvar and vaginal tissues. There is often little or no vaginal discharge; if present, discharge is typically white and clumpy (curd-like), but may be thin and watery in some cases. Symptoms of a yeast infection are similar to a number of other conditions, including bacterial vaginosis (a bacterial infection of the vagina), trichomoniasis (a sexually transmitted infection), and contact or allergic dermatitis (a skin reaction to an irritating or allergic substance) (show table 1). It is often not possible to know, based on symptoms alone, if vulvar itching is caused by yeast or other potential causes. Candida albicans is a fungus that normally lives on the skin and mucous membranes (mouth, nose, vagina); it causes most cases of vaginal yeast infections. Normally, candida causes no symptoms. However, when the skin or mucous membranes undergo changes due to medications, injury, or stress to the immune system, candida multiplies and causes the characteristic symptoms of a yeast infection, described above. In most women, there is no underlying disease or event that leads to a yeast infection. There are several risk factors that may increase the chances of developing an infection, including use of antibiotics, hormonal contraceptives and certain contraceptive devices, diabetes, pregnancy, and a weakened immune system (due to chemotherapy, HIV, or certain medications). Diagnosis of a vaginal yeast infection requires that a healthcare provider take a medical history, perform a physical examination, and perform diagnostic testing. It is important to visit the provider when symptoms are present and before any treatment is used. Women with symptoms of vulvar itching or vaginal discharge frequently assume that their symptoms are related to a yeast infection and treat themselves with an over-the-counter treatment. Incorrect self-diagnosis and treatment can delay receiving the correct diagnosis and treatment and wastes money on improper treatment, which frequently causes further irritation of the vulva and vagina. Treatment of vaginal yeast infection may include a topical cream or tablet; most are applied inside the vagina at bedtime with an applicator. Treatment durations vary; one, three, and seven- day treatments are equally effective. Oral treatment is available as fluconazole (Diflucan®) 150 mg. Most patients require only one dose
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)
U.S. Department of Health and Human Services
(www.4woman.gov)
[1-3]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Ferris, DG, Nyirjesy, P, Sobel, JD, et al. Over-the-counter antifungal drug misuse associated with patient-diagnosed vulvovaginal candidiasis(1). Obstet Gynecol 2002; 99:419.
2. National guideline for the management of vulvovaginal candidiasis. Clinical Effectiveness Group (Association of Genitourinary Medicine and the Medical Society for the Study of Venereal Diseases). Sex Transm Infect 1999; 75 Suppl 1:S19.
3. Rex, JH, Walsh, TJ, Sobel, JD, et al. Practice guidelines for treatment of candidiasis. Clin Infect Dis 2000; 30:662.
Vaginal yeast infection
INTRODUCTION — Vaginal yeast infections are a very common problem in women. It is difficult to know the true percentage of women affected by yeast infections because they are frequently diagnosed without an examination. In addition, many women treat themselves with over-the-counter yeast treatments before seeking medical advice.
Yeast infections occur mainly in women who are menstruating (having monthly periods). They are less common in postmenopausal women who do not take estrogen and in girls who have not yet started menstruating.
Vaginal yeast infections are also called yeast vaginitis or vaginal candidiasis.
SYMPTOMS — Itching of the vulva is the most common symptom of a vaginal yeast infection (show figure 1). Women may also note pain with urination, vulvar soreness or irritation, pain with intercourse, or reddened and swollen vulvar and vaginal tissues. There is often little or no vaginal discharge. If present, discharge is typically white and clumpy (curd-like), but may be thin and watery in some cases.
Symptoms of a yeast infection are similar to a number of other conditions, including bacterial vaginosis (a bacterial infection of the vagina), trichomoniasis (a sexually transmitted infection), and contact or allergic dermatitis (a skin reaction to an irritating or allergic substance) (show table 1). It is often not possible to know, based on symptoms alone, if vulvar itching is caused by yeast or other potential causes. (See "Self-diagnosis" below).
CAUSE — Candida albicans is a fungus that normally lives on the skin and mucous membranes (mouth, nose, vagina). Normally, Candida causes no symptoms. However, when the skin or mucous membranes undergo changes due to medications, injury, or stress to the immune system, Candida may multiply and cause the characteristic symptoms, described above.
Candida albicans causes 80 to 92 percent of episodes of vulvovaginal candidiasis. Some investigators have reported an increasing frequency of other candida species, particularly C. glabrata, possibly due to widespread use of over-the-counter drugs, long-term use of suppressive yeast infection treatments, and the use of short courses of antifungal drugs.
RISK FACTORS — In most women, there is no underlying disease or event that leads to a yeast infection. There are several risk factors that may increase the chances of developing an infection, including: Antibiotics — Most antibiotics kill a wide variety of bacteria, including those that normally live in the vagina. These bacteria function to protect the vagina from the overgrowth of yeast. Some women are prone to yeast infections while taking antibiotics. Hormonal contraceptives (eg, birth control pills, patch, and vaginal ring) — The risk of yeast infections may be higher in women who use contraceptives containing estrogen. Contraceptive devices — Vaginal sponges, diaphragms, and intrauterine devices (IUDs) have been associated with a higher risk of yeast infection. Spermicides have not, although spermicides frequently cause vaginal irritation. (See "Patient information: Contraception"). Immunosuppression — Yeast infections are more common in patients who are immunosuppressed due to infection with HIV or use of immune-suppressing medications (steroids, chemotherapy, post-organ transplant medications). Pregnancy — Signs and symptoms of a yeast infection are more common during pregnancy, although there are little data to know if yeast infection is always the cause. Diabetes — Women with diabetes are at higher risk for yeast infection, especially when blood glucose levels are frequently higher than normal.
Vaginal yeast infections are not considered to be a sexually transmitted infection. They can occur in women who have never been sexually active but are more common in women who are sexually active. Yeast infections are no more frequent in women who have sex frequently, but may develop more frequently in women who receive oral sex.
DIAGNOSIS — Diagnosis of a vaginal yeast infection requires that a healthcare provider take a medical history, perform a physical examination, and perform diagnostic testing. It is important to visit the provider when symptoms are present and before any treatment is used; the diagnosis is harder to make if symptoms have resolved or if treatment was started before an examination and diagnostic testing. The combination of a medical history, physical examination, and diagnostic testing correctly diagnoses vaginal yeast infection in about 60 percent of women.
Diagnostic testing may include measurement of the vaginal pH; normally, the pH of vaginal discharge is acidic. Examination of the vaginal discharge under a microscope (called a wet mount) allows the provider to look for yeast buds and hyphae, which resemble branches of a tree (show picture 1). Other infections can be diagnosed with wet mount, including bacterial vaginosis and trichomoniasis.
Further testing with a yeast culture may be needed for a woman who has symptoms of a yeast infection but no evidence of yeast on wet mount. Culture is also useful in women with recurrent or persistent signs and symptoms who have a negative wet mount or do not respond to treatment. Yeast culture and sensitivity can determine if nonalbicans yeast is present and can guide treatment in these cases.
Self-diagnosis — Women with symptoms of vulvar itching or vaginal discharge frequently assume that their symptoms are related to a yeast infection and treat themselves with an over-the-counter treatment. In one study, only 11 percent of women accurately diagnosed their infection; women with a previous yeast infection were only slightly more accurate (35 percent correct) [1].
Incorrect self-diagnosis and treatment can delay receiving the correct diagnosis and treatment and wastes money on improper treatment, which frequently causes further irritation of the vulva and vagina.
TREATMENT — Treatment of vaginal yeast infection may include a topical cream or tablet; most are applied inside the vagina at bedtime with an applicator. Treatment durations vary according to the formulation; one, three, and seven-day treatments are equally effective.
Oral treatment is available as fluconazole (Diflucan®) 150 mg. Most patients require only one dose, although women with more complicated infections (such as those with underlying medical problems, recurrent yeast infections, or severe signs and symptoms) may require a second dose 72 hours (3 days) after the first dose. Side effects of fluconazole are mild and infrequent, but may include stomach upset, headache, and rash. Fluconazole interacts with a number of medications; a healthcare provider or pharmacist should be consulted if there are concerns about drug interactions. Fluconazole should not be taken during pregnancy.
Uncomplicated yeast infections usually resolve within a few days of treatment. Complicated infections may require more time to completely resolve; the infection generally resolves within a few days but the vulvar and vaginal irritation can persist for up to 2 weeks.
Women who do not improve after treatment with a standard oral or vaginal treatment for yeast infection should be reexamined. A different species of yeast, known as Candida glabrata, is less likely to respond to standard treatments, and can usually be diagnosed with a vaginal yeast culture.
RECURRENT YEAST INFECTIONS — Between 5 and 8 percent of women have recurrent yeast infections, defined as more than four infections per year. Risk factors for recurrent infection include the use of panty liners, pantyhose, or sexual lubricants, or the consumption of cranberry juice. Avoidance of these products may reduce the frequency of infection in some women.
There is no evidence that eating yogurt or other products containing live Lactobacillus acidophilus, or applying these products to the vagina is of any benefit in women with recurrent vaginal yeast infections.
Diagnosis — As with initial yeast infections, it is important to correctly diagnose recurrent yeast infections. A woman who has frequent signs and symptoms of vulvar or vaginal irritation or itching should be seen by a healthcare provider to ensure that her symptoms are from yeast, not as a result of other common problems (eg, other vaginal infections, allergic reaction or sensitivity to products such as detergents or soaps). As with initial infections, self-diagnosis is not accurate enough to recommend treatment.
Treatment — Women with recurrent infections should use a longer course of treatment for infections, between 10 to 14 days for a topical (cream or suppository) medication or fluconazole 150 mg by mouth with a second dose 72 hours later.
Preventive treatment can be started after the infection has resolved; this may include fluconazole (150 mg orally once per week) or clotrimazole (500 mg vaginal suppositories administered once per week).
Treatment of a sexual partner — Vaginal yeast infections are not considered to be a sexually transmitted infection, though the infection can rarely be passed from one partner to another. Most experts do not currently recommend treatment of a sexual partner.
SUMMARY Vaginal yeast infections are a very common problem in women. It is difficult to know the true percentage of women affected by yeast infections; they are frequently diagnosed without an examination and many women treat themselves with over-the-counter yeast treatments before seeking medical advice. Itching of the vulva is the most common symptom of a vaginal yeast infection. Women may also note pain with urination, vulvar soreness or irritation, pain with intercourse, or reddened and swollen vulvar and vaginal tissues. There is often little or no vaginal discharge; if present, discharge is typically white and clumpy (curd-like), but may be thin and watery in some cases. Symptoms of a yeast infection are similar to a number of other conditions, including bacterial vaginosis (a bacterial infection of the vagina), trichomoniasis (a sexually transmitted infection), and contact or allergic dermatitis (a skin reaction to an irritating or allergic substance) (show table 1). It is often not possible to know, based on symptoms alone, if vulvar itching is caused by yeast or other potential causes. Candida albicans is a fungus that normally lives on the skin and mucous membranes (mouth, nose, vagina); it causes most cases of vaginal yeast infections. Normally, candida causes no symptoms. However, when the skin or mucous membranes undergo changes due to medications, injury, or stress to the immune system, candida multiplies and causes the characteristic symptoms of a yeast infection, described above. In most women, there is no underlying disease or event that leads to a yeast infection. There are several risk factors that may increase the chances of developing an infection, including use of antibiotics, hormonal contraceptives and certain contraceptive devices, diabetes, pregnancy, and a weakened immune system (due to chemotherapy, HIV, or certain medications). Diagnosis of a vaginal yeast infection requires that a healthcare provider take a medical history, perform a physical examination, and perform diagnostic testing. It is important to visit the provider when symptoms are present and before any treatment is used. Women with symptoms of vulvar itching or vaginal discharge frequently assume that their symptoms are related to a yeast infection and treat themselves with an over-the-counter treatment. Incorrect self-diagnosis and treatment can delay receiving the correct diagnosis and treatment and wastes money on improper treatment, which frequently causes further irritation of the vulva and vagina. Treatment of vaginal yeast infection may include a topical cream or tablet; most are applied inside the vagina at bedtime with an applicator. Treatment durations vary; one, three, and seven- day treatments are equally effective. Oral treatment is available as fluconazole (Diflucan®) 150 mg. Most patients require only one dose
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)
U.S. Department of Health and Human Services
(www.4woman.gov)
[1-3]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Ferris, DG, Nyirjesy, P, Sobel, JD, et al. Over-the-counter antifungal drug misuse associated with patient-diagnosed vulvovaginal candidiasis(1). Obstet Gynecol 2002; 99:419.
2. National guideline for the management of vulvovaginal candidiasis. Clinical Effectiveness Group (Association of Genitourinary Medicine and the Medical Society for the Study of Venereal Diseases). Sex Transm Infect 1999; 75 Suppl 1:S19.
3. Rex, JH, Walsh, TJ, Sobel, JD, et al. Practice guidelines for treatment of candidiasis. Clin Infect Dis 2000; 30:662.
Yeast infections occur mainly in women who are menstruating (having monthly periods). They are less common in postmenopausal women who do not take estrogen and in girls who have not yet started menstruating.
Vaginal yeast infections are also called yeast vaginitis or vaginal candidiasis.
SYMPTOMS — Itching of the vulva is the most common symptom of a vaginal yeast infection (show figure 1). Women may also note pain with urination, vulvar soreness or irritation, pain with intercourse, or reddened and swollen vulvar and vaginal tissues. There is often little or no vaginal discharge. If present, discharge is typically white and clumpy (curd-like), but may be thin and watery in some cases.
Symptoms of a yeast infection are similar to a number of other conditions, including bacterial vaginosis (a bacterial infection of the vagina), trichomoniasis (a sexually transmitted infection), and contact or allergic dermatitis (a skin reaction to an irritating or allergic substance) (show table 1). It is often not possible to know, based on symptoms alone, if vulvar itching is caused by yeast or other potential causes. (See "Self-diagnosis" below).
CAUSE — Candida albicans is a fungus that normally lives on the skin and mucous membranes (mouth, nose, vagina). Normally, Candida causes no symptoms. However, when the skin or mucous membranes undergo changes due to medications, injury, or stress to the immune system, Candida may multiply and cause the characteristic symptoms, described above.
Candida albicans causes 80 to 92 percent of episodes of vulvovaginal candidiasis. Some investigators have reported an increasing frequency of other candida species, particularly C. glabrata, possibly due to widespread use of over-the-counter drugs, long-term use of suppressive yeast infection treatments, and the use of short courses of antifungal drugs.
RISK FACTORS — In most women, there is no underlying disease or event that leads to a yeast infection. There are several risk factors that may increase the chances of developing an infection, including: Antibiotics — Most antibiotics kill a wide variety of bacteria, including those that normally live in the vagina. These bacteria function to protect the vagina from the overgrowth of yeast. Some women are prone to yeast infections while taking antibiotics. Hormonal contraceptives (eg, birth control pills, patch, and vaginal ring) — The risk of yeast infections may be higher in women who use contraceptives containing estrogen. Contraceptive devices — Vaginal sponges, diaphragms, and intrauterine devices (IUDs) have been associated with a higher risk of yeast infection. Spermicides have not, although spermicides frequently cause vaginal irritation. (See "Patient information: Contraception"). Immunosuppression — Yeast infections are more common in patients who are immunosuppressed due to infection with HIV or use of immune-suppressing medications (steroids, chemotherapy, post-organ transplant medications). Pregnancy — Signs and symptoms of a yeast infection are more common during pregnancy, although there are little data to know if yeast infection is always the cause. Diabetes — Women with diabetes are at higher risk for yeast infection, especially when blood glucose levels are frequently higher than normal.
Vaginal yeast infections are not considered to be a sexually transmitted infection. They can occur in women who have never been sexually active but are more common in women who are sexually active. Yeast infections are no more frequent in women who have sex frequently, but may develop more frequently in women who receive oral sex.
DIAGNOSIS — Diagnosis of a vaginal yeast infection requires that a healthcare provider take a medical history, perform a physical examination, and perform diagnostic testing. It is important to visit the provider when symptoms are present and before any treatment is used; the diagnosis is harder to make if symptoms have resolved or if treatment was started before an examination and diagnostic testing. The combination of a medical history, physical examination, and diagnostic testing correctly diagnoses vaginal yeast infection in about 60 percent of women.
Diagnostic testing may include measurement of the vaginal pH; normally, the pH of vaginal discharge is acidic. Examination of the vaginal discharge under a microscope (called a wet mount) allows the provider to look for yeast buds and hyphae, which resemble branches of a tree (show picture 1). Other infections can be diagnosed with wet mount, including bacterial vaginosis and trichomoniasis.
Further testing with a yeast culture may be needed for a woman who has symptoms of a yeast infection but no evidence of yeast on wet mount. Culture is also useful in women with recurrent or persistent signs and symptoms who have a negative wet mount or do not respond to treatment. Yeast culture and sensitivity can determine if nonalbicans yeast is present and can guide treatment in these cases.
Self-diagnosis — Women with symptoms of vulvar itching or vaginal discharge frequently assume that their symptoms are related to a yeast infection and treat themselves with an over-the-counter treatment. In one study, only 11 percent of women accurately diagnosed their infection; women with a previous yeast infection were only slightly more accurate (35 percent correct) [1].
Incorrect self-diagnosis and treatment can delay receiving the correct diagnosis and treatment and wastes money on improper treatment, which frequently causes further irritation of the vulva and vagina.
TREATMENT — Treatment of vaginal yeast infection may include a topical cream or tablet; most are applied inside the vagina at bedtime with an applicator. Treatment durations vary according to the formulation; one, three, and seven-day treatments are equally effective.
Oral treatment is available as fluconazole (Diflucan®) 150 mg. Most patients require only one dose, although women with more complicated infections (such as those with underlying medical problems, recurrent yeast infections, or severe signs and symptoms) may require a second dose 72 hours (3 days) after the first dose. Side effects of fluconazole are mild and infrequent, but may include stomach upset, headache, and rash. Fluconazole interacts with a number of medications; a healthcare provider or pharmacist should be consulted if there are concerns about drug interactions. Fluconazole should not be taken during pregnancy.
Uncomplicated yeast infections usually resolve within a few days of treatment. Complicated infections may require more time to completely resolve; the infection generally resolves within a few days but the vulvar and vaginal irritation can persist for up to 2 weeks.
Women who do not improve after treatment with a standard oral or vaginal treatment for yeast infection should be reexamined. A different species of yeast, known as Candida glabrata, is less likely to respond to standard treatments, and can usually be diagnosed with a vaginal yeast culture.
RECURRENT YEAST INFECTIONS — Between 5 and 8 percent of women have recurrent yeast infections, defined as more than four infections per year. Risk factors for recurrent infection include the use of panty liners, pantyhose, or sexual lubricants, or the consumption of cranberry juice. Avoidance of these products may reduce the frequency of infection in some women.
There is no evidence that eating yogurt or other products containing live Lactobacillus acidophilus, or applying these products to the vagina is of any benefit in women with recurrent vaginal yeast infections.
Diagnosis — As with initial yeast infections, it is important to correctly diagnose recurrent yeast infections. A woman who has frequent signs and symptoms of vulvar or vaginal irritation or itching should be seen by a healthcare provider to ensure that her symptoms are from yeast, not as a result of other common problems (eg, other vaginal infections, allergic reaction or sensitivity to products such as detergents or soaps). As with initial infections, self-diagnosis is not accurate enough to recommend treatment.
Treatment — Women with recurrent infections should use a longer course of treatment for infections, between 10 to 14 days for a topical (cream or suppository) medication or fluconazole 150 mg by mouth with a second dose 72 hours later.
Preventive treatment can be started after the infection has resolved; this may include fluconazole (150 mg orally once per week) or clotrimazole (500 mg vaginal suppositories administered once per week).
Treatment of a sexual partner — Vaginal yeast infections are not considered to be a sexually transmitted infection, though the infection can rarely be passed from one partner to another. Most experts do not currently recommend treatment of a sexual partner.
SUMMARY Vaginal yeast infections are a very common problem in women. It is difficult to know the true percentage of women affected by yeast infections; they are frequently diagnosed without an examination and many women treat themselves with over-the-counter yeast treatments before seeking medical advice. Itching of the vulva is the most common symptom of a vaginal yeast infection. Women may also note pain with urination, vulvar soreness or irritation, pain with intercourse, or reddened and swollen vulvar and vaginal tissues. There is often little or no vaginal discharge; if present, discharge is typically white and clumpy (curd-like), but may be thin and watery in some cases. Symptoms of a yeast infection are similar to a number of other conditions, including bacterial vaginosis (a bacterial infection of the vagina), trichomoniasis (a sexually transmitted infection), and contact or allergic dermatitis (a skin reaction to an irritating or allergic substance) (show table 1). It is often not possible to know, based on symptoms alone, if vulvar itching is caused by yeast or other potential causes. Candida albicans is a fungus that normally lives on the skin and mucous membranes (mouth, nose, vagina); it causes most cases of vaginal yeast infections. Normally, candida causes no symptoms. However, when the skin or mucous membranes undergo changes due to medications, injury, or stress to the immune system, candida multiplies and causes the characteristic symptoms of a yeast infection, described above. In most women, there is no underlying disease or event that leads to a yeast infection. There are several risk factors that may increase the chances of developing an infection, including use of antibiotics, hormonal contraceptives and certain contraceptive devices, diabetes, pregnancy, and a weakened immune system (due to chemotherapy, HIV, or certain medications). Diagnosis of a vaginal yeast infection requires that a healthcare provider take a medical history, perform a physical examination, and perform diagnostic testing. It is important to visit the provider when symptoms are present and before any treatment is used. Women with symptoms of vulvar itching or vaginal discharge frequently assume that their symptoms are related to a yeast infection and treat themselves with an over-the-counter treatment. Incorrect self-diagnosis and treatment can delay receiving the correct diagnosis and treatment and wastes money on improper treatment, which frequently causes further irritation of the vulva and vagina. Treatment of vaginal yeast infection may include a topical cream or tablet; most are applied inside the vagina at bedtime with an applicator. Treatment durations vary; one, three, and seven- day treatments are equally effective. Oral treatment is available as fluconazole (Diflucan®) 150 mg. Most patients require only one dose
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)
U.S. Department of Health and Human Services
(www.4woman.gov)
[1-3]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Ferris, DG, Nyirjesy, P, Sobel, JD, et al. Over-the-counter antifungal drug misuse associated with patient-diagnosed vulvovaginal candidiasis(1). Obstet Gynecol 2002; 99:419.
2. National guideline for the management of vulvovaginal candidiasis. Clinical Effectiveness Group (Association of Genitourinary Medicine and the Medical Society for the Study of Venereal Diseases). Sex Transm Infect 1999; 75 Suppl 1:S19.
3. Rex, JH, Walsh, TJ, Sobel, JD, et al. Practice guidelines for treatment of candidiasis. Clin Infect Dis 2000; 30:662.
Urinary tract infection in adult
INTRODUCTION — Urinary tract infection (UTI) is one of the most common infections. Approximately 50 percent of adult women report that they have had a UTI at some time during their life.
A UTI can be an infection of the bladder (cystitis) or a more serious infection of the kidney (pyelonephritis); most patients with UTI have an uncomplicated bladder infection that is easily treated with a short course of antibiotics.
This discussion will focus on bladder infections in a healthy adult.
DEFINITION — The urinary tract includes the kidneys (which filter urine), bladder (which stores urine), and urethra (the tube that carries urine out of the bladder) (show figure 1). Bacteria do not normally live in these areas. When bacteria enter the urinary tract and begin to multiply, they can cause a UTI. The majority of UTIs occur in the bladder.
UTI occurs more frequently in women since women have a short urethra and a small distance between the urethral opening and the anus (where bacteria commonly live, show figure 2). Both factors make it easy for bacteria to enter the bladder.
Most UTIs are caused by the bacterium Escherichia coli (E. coli), which is commonly found in feces. The bacteria can move from the anus to the urethra and into the bladder (and less commonly into the kidney), causing infection. E. coli have certain properties that enable this movement, including the ability to adhere to the lining of the urethra and bladder.
A patient who does not have symptoms but has bacteria in the urine is said to have asymptomatic bacteriuria. This is especially common in elderly men and women. Treatment is not always needed for persons with asymptomatic bacteriuria, except in selected circumstances, such as during pregnancy.
RISK FACTORS — The risk of developing cystitis or pyelonephritis may be increased by a number of factors, especially sexual intercourse. The use of spermicides, particularly in combination with a diaphragm, also increases the risk of UTI in women.
Some women are prone to recurring episodes of cystitis. Factors that may predispose a young woman to repeated episodes of cystitis include: Sexual activity Use of spermicides Genetic factors A new sex partner A history of previous UTIs is a very strong risk factor for having subsequent UTIs.
A small number of otherwise healthy young men can also develop UTI. Men who engage in insertive anal intercourse are more likely to become infected, as are men who are uncircumcised.
Men, women, and children with underlying health problems may also be at higher risk for developing a UTI, including use of a bladder catheter, a recent procedure or surgery involving the urinary tract, an anatomic abnormality or blockage of the urinary tract, the inability to empty the bladder completely, pregnancy, diabetes, or age 65 years.
SYMPTOMS — The typical symptoms of acute cystitis are: Pain or burning when urinating Frequent need to urinate Urgent need to urinate Blood in the urine Discomfort in the middle of the lower abdomen (suprapubic pain)
Burning with urination can also occur in patients with vaginitis (eg, yeast infection) or urethritis (inflammation of the urethra). The presence of blood in the urine is common in cystitis, but not in vaginitis or urethritis. Vaginal discharge, odor, itching, or pain with sexual intercourse are typical features of vaginitis. Urethritis is possible if the patient has a new sexual partner, has a partner with urethritis, or gradually develops symptoms over several weeks. (See "Patient information: Vaginal yeast infection" and see "Patient information: Blood in the urine (hematuria)").
Pyelonephritis — Symptoms of pyelonephritis (an infection of the kidney) almost always include fever, which is defined in adults as a temperature greater than 100.4º F (38º C). Pyelonephritis can also cause pain in the flank (side of lower back) on the involved side, nausea, and vomiting. Burning or pain on urination, frequent urination, urgency, and suprapubic pain may also occur in people with pyelonephritis.
DIAGNOSIS — Simple cystitis is usually diagnosed based upon symptoms alone. This is especially true if a woman has frequent UTIs and can recognize the symptoms easily. However, most patients, especially those with a first episode, should see a healthcare provider for testing.
The provider will examine the patient and look for fever or flank tenderness, which could indicate pyelonephritis. If vaginitis or urethritis are possible, a pelvic examination and appropriate cultures will be performed.
One way to distinguish between UTI and vaginitis is by performing a urinalysis to determine if there are white blood cells present. The urine will contain white blood cells in a person with a UTI, but these cells are not usually present in persons with vaginitis (although white blood cells in vaginal fluid can sometimes contaminate the urine specimen).
Urine culture — A urine culture is a test that uses a sample of urine to try and grow bacteria in a laboratory. A sensitivity test can be done with any bacteria that grow on the culture to determine the best antibiotic treatment. It usually requires about 48 hours for results to return.
Urine culture is done by obtaining a "clean catch" urine sample. The patient is asked to clean the external genitalia and collect a sample of urine after voiding for a few seconds. This avoids collecting the first drops of urine, which may be contaminated with bacteria from the skin.
However, a urine culture is not always required to diagnose a UTI. As noted above, it is often possible to accurately diagnose a UTI based on symptoms alone. Urine culture is helpful in patients who have symptoms that are not typical for UTI. Culture is also useful in patients who are at greater risk for having a bacteria that is resistant to antibiotics, such as a person who has recently taken antibiotics. In such cases, the information from the laboratory can be helpful in choosing the optimal antibiotic for the UTI.
TREATMENT — In young, healthy women with simple cystitis, the usual treatment includes several days of antibiotics. The typical drugs chosen are: trimethoprim-sulfamethoxazole (Bactrim®), nitrofurantoin (Macrobid®), ciprofloxacin (Cipro®) or levofloxacin (Levaquin®). Ciprofloxacin and levofloxacin should not be used by women who are pregnant or nursing. Symptoms generally resolve one to three days after starting treatment. It is important to take the full course of antibiotics to completely eliminate the infection.
If needed, medicine that numbs the bladder and urethra can be given for symptoms of painful urination (phenazopyridine [Pyridium®]). A nonprescription medication that is similar to Pyridium is also available (eg, Uristat). Both medications cause the urine to appear discolored (usually blue or orange) and can interfere with laboratory testing; for this reason, it is important to seek testing and treatment first.
Some providers recommend increasing fluid intake to help flush bacteria from the bladder. Others believe that increasing fluid in the body dilutes the antibiotic in the bladder and makes the medication less effective. No studies have been performed to address this issue. There are also no definitive studies on the effectiveness of cranberry juice for the treatment of a UTI.
Treatment in pregnancy — Pregnant women with a UTI or asymptomatic bacteriuria (a UTI without symptoms) need to be treated. Pregnant women are more likely to develop pyelonephritis following a UTI or asymptomatic bacteriuria, and UTIs can cause complications with the pregnancy. In pregnant women, the urine is sent for culture to identify the specific bacteria causing the problem, and the treatment is given for three to seven days.
Follow-up care — Follow-up testing is not needed in healthy, young women with simple cystitis if symptoms resolve. Pregnant women are usually asked to have a repeat urine culture two weeks after treatment has ended.
PREVENTING RECURRENT INFECTIONS — Young women with recurring urinary tract infections may be advised to take steps to prevent UTIs, including one or more of the following:
Changes in contraception — Women who use spermicides, particularly those who also use a contraceptive diaphragm, may be encouraged to use an alternate means of contraception UTIs frequently. (See "Patient information: Contraception").
Cranberry products — Several small studies have suggested that there may be some benefit to consuming cranberry products to prevent recurrent UTIs, but their effectiveness has not been proven. In the laboratory, cranberry extracts appear to decrease the ability of E. coli to stick to the cells lining the urinary tract. More definitive studies are needed before cranberry juice or supplements are recommended for this purpose.
Increasing fluid intake and urinating after intercourse — Although clinical studies have not proven that increasing fluid intake (for a total of 32 to 64 ounces of fluid per day from food or fluids) or urinating soon after intercourse can prevent infection, healthcare providers frequently recommend these measures since they are not harmful.
Postmenopausal women — Postmenopausal women who develop recurrent UTIs may benefit from use of a vaginal estrogen. Estrogen is thought to promote the growth of normal bacteria in the vagina while preventing the growth of harmful bacteria. Vaginal estrogen is available in a flexible ring that is worn in the vagina for three months (eg, Estring®), a small tablet (Vagifem®), or a cream (eg, Premarin® or Estrace®).
Antibiotics — A preventive antibiotic treatment should be considered for people who continue to develop UTIs despite use of other preventive measures. Antibiotics are highly effective in preventing recurrent UTIs and can be given in several different ways.
Continuous use of antibiotics — A low dose of an antibiotic may be taken daily or three times per week for six months to several years.
Antibiotics following intercourse — In women who develop urinary tract infections after sexual intercourse, a single low dose antibiotic after intercourse is often effective in preventing infection.
Self-treatment — A plan to begin antibiotics at the first sign of a UTI may be recommended for some. Before this is started, it is important that prior infections have been confirmed with a urine culture; some women have symptoms of a UTI but do not actually have an infection. (See "Patient information: Chronic pelvic pain in women", section on Painful bladder syndrome and interstitial cystitis).
Need for further testing — Young healthy women with UTI who respond to antibiotic therapy, even those with pyelonephritis or frequent bladder infections, rarely need to undergo further testing. However, further testing may be recommended for some people with recurrent urinary tract infections, especially if there is any possibility of an anatomic abnormality in the kidneys, ureter, bladder, or urethra, or if there is concern about other factors that increase the risk of a urinary tract infection (eg, kidney stone). In addition, anyone who continues to have blood in the urine after the infection has cleared should be evaluated. (See "Patient information: Kidney stones" and see "Patient information: Blood in the urine (hematuria)").
Further evaluation of the urinary tract may include a computed tomography (CT) scan, ultrasound, or cystoscopy (looking inside the bladder with a thin, lighted telescope-like instrument).
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)
Toll-free: (800) 311-3435
(www.cdc.gov)
Infectious Diseases Society of America
(www.idsociety.org)
National Kidney and Urologic Disease Information Clearinghouse
(http://kidney.niddk.nih.gov/kudiseases/pubs/utiadult/)
[1-7]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Gupta, K, Hooton, TM, Roberts, PL, Stamm, WE. Patient-initiated treatment of uncomplicated recurrent urinary tract infections in young women. Ann Intern Med 2001; 135:9.
2. Hooton, TM, Besser, R, Foxman, B, et al. Acute uncomplicated cystitis in an era of increasing antibiotic resistance: a proposed approach to empirical therapy. Clin Infect Dis 2004; 39:75.
3. Hooton, TM, Stamm, WE. Diagnosis and treatment of uncomplicated urinary tract infection. Infect Dis Clin North Am 1997; 11:551.
4. Scholes, D, Hooton, TM, Roberts, PL, et al. Risk factors associated with acute pyelonephritis in healthy women. Ann Intern Med 2005; 142:20.
5. Hooton, TM. The current management strategies for community-acquired urinary tract infection. Infect Dis Clin North Am 2003; 17:303.
6. Raz, R, Chazan, B, Dan, M. Cranberry juice and urinary tract infection. Clin Infect Dis 2004; 38:1413.
7. Stamm, WE. Estrogens and urinary-tract infection. J Infect Dis 2007; 195:623.
A UTI can be an infection of the bladder (cystitis) or a more serious infection of the kidney (pyelonephritis); most patients with UTI have an uncomplicated bladder infection that is easily treated with a short course of antibiotics.
This discussion will focus on bladder infections in a healthy adult.
DEFINITION — The urinary tract includes the kidneys (which filter urine), bladder (which stores urine), and urethra (the tube that carries urine out of the bladder) (show figure 1). Bacteria do not normally live in these areas. When bacteria enter the urinary tract and begin to multiply, they can cause a UTI. The majority of UTIs occur in the bladder.
UTI occurs more frequently in women since women have a short urethra and a small distance between the urethral opening and the anus (where bacteria commonly live, show figure 2). Both factors make it easy for bacteria to enter the bladder.
Most UTIs are caused by the bacterium Escherichia coli (E. coli), which is commonly found in feces. The bacteria can move from the anus to the urethra and into the bladder (and less commonly into the kidney), causing infection. E. coli have certain properties that enable this movement, including the ability to adhere to the lining of the urethra and bladder.
A patient who does not have symptoms but has bacteria in the urine is said to have asymptomatic bacteriuria. This is especially common in elderly men and women. Treatment is not always needed for persons with asymptomatic bacteriuria, except in selected circumstances, such as during pregnancy.
RISK FACTORS — The risk of developing cystitis or pyelonephritis may be increased by a number of factors, especially sexual intercourse. The use of spermicides, particularly in combination with a diaphragm, also increases the risk of UTI in women.
Some women are prone to recurring episodes of cystitis. Factors that may predispose a young woman to repeated episodes of cystitis include: Sexual activity Use of spermicides Genetic factors A new sex partner A history of previous UTIs is a very strong risk factor for having subsequent UTIs.
A small number of otherwise healthy young men can also develop UTI. Men who engage in insertive anal intercourse are more likely to become infected, as are men who are uncircumcised.
Men, women, and children with underlying health problems may also be at higher risk for developing a UTI, including use of a bladder catheter, a recent procedure or surgery involving the urinary tract, an anatomic abnormality or blockage of the urinary tract, the inability to empty the bladder completely, pregnancy, diabetes, or age 65 years.
SYMPTOMS — The typical symptoms of acute cystitis are: Pain or burning when urinating Frequent need to urinate Urgent need to urinate Blood in the urine Discomfort in the middle of the lower abdomen (suprapubic pain)
Burning with urination can also occur in patients with vaginitis (eg, yeast infection) or urethritis (inflammation of the urethra). The presence of blood in the urine is common in cystitis, but not in vaginitis or urethritis. Vaginal discharge, odor, itching, or pain with sexual intercourse are typical features of vaginitis. Urethritis is possible if the patient has a new sexual partner, has a partner with urethritis, or gradually develops symptoms over several weeks. (See "Patient information: Vaginal yeast infection" and see "Patient information: Blood in the urine (hematuria)").
Pyelonephritis — Symptoms of pyelonephritis (an infection of the kidney) almost always include fever, which is defined in adults as a temperature greater than 100.4º F (38º C). Pyelonephritis can also cause pain in the flank (side of lower back) on the involved side, nausea, and vomiting. Burning or pain on urination, frequent urination, urgency, and suprapubic pain may also occur in people with pyelonephritis.
DIAGNOSIS — Simple cystitis is usually diagnosed based upon symptoms alone. This is especially true if a woman has frequent UTIs and can recognize the symptoms easily. However, most patients, especially those with a first episode, should see a healthcare provider for testing.
The provider will examine the patient and look for fever or flank tenderness, which could indicate pyelonephritis. If vaginitis or urethritis are possible, a pelvic examination and appropriate cultures will be performed.
One way to distinguish between UTI and vaginitis is by performing a urinalysis to determine if there are white blood cells present. The urine will contain white blood cells in a person with a UTI, but these cells are not usually present in persons with vaginitis (although white blood cells in vaginal fluid can sometimes contaminate the urine specimen).
Urine culture — A urine culture is a test that uses a sample of urine to try and grow bacteria in a laboratory. A sensitivity test can be done with any bacteria that grow on the culture to determine the best antibiotic treatment. It usually requires about 48 hours for results to return.
Urine culture is done by obtaining a "clean catch" urine sample. The patient is asked to clean the external genitalia and collect a sample of urine after voiding for a few seconds. This avoids collecting the first drops of urine, which may be contaminated with bacteria from the skin.
However, a urine culture is not always required to diagnose a UTI. As noted above, it is often possible to accurately diagnose a UTI based on symptoms alone. Urine culture is helpful in patients who have symptoms that are not typical for UTI. Culture is also useful in patients who are at greater risk for having a bacteria that is resistant to antibiotics, such as a person who has recently taken antibiotics. In such cases, the information from the laboratory can be helpful in choosing the optimal antibiotic for the UTI.
TREATMENT — In young, healthy women with simple cystitis, the usual treatment includes several days of antibiotics. The typical drugs chosen are: trimethoprim-sulfamethoxazole (Bactrim®), nitrofurantoin (Macrobid®), ciprofloxacin (Cipro®) or levofloxacin (Levaquin®). Ciprofloxacin and levofloxacin should not be used by women who are pregnant or nursing. Symptoms generally resolve one to three days after starting treatment. It is important to take the full course of antibiotics to completely eliminate the infection.
If needed, medicine that numbs the bladder and urethra can be given for symptoms of painful urination (phenazopyridine [Pyridium®]). A nonprescription medication that is similar to Pyridium is also available (eg, Uristat). Both medications cause the urine to appear discolored (usually blue or orange) and can interfere with laboratory testing; for this reason, it is important to seek testing and treatment first.
Some providers recommend increasing fluid intake to help flush bacteria from the bladder. Others believe that increasing fluid in the body dilutes the antibiotic in the bladder and makes the medication less effective. No studies have been performed to address this issue. There are also no definitive studies on the effectiveness of cranberry juice for the treatment of a UTI.
Treatment in pregnancy — Pregnant women with a UTI or asymptomatic bacteriuria (a UTI without symptoms) need to be treated. Pregnant women are more likely to develop pyelonephritis following a UTI or asymptomatic bacteriuria, and UTIs can cause complications with the pregnancy. In pregnant women, the urine is sent for culture to identify the specific bacteria causing the problem, and the treatment is given for three to seven days.
Follow-up care — Follow-up testing is not needed in healthy, young women with simple cystitis if symptoms resolve. Pregnant women are usually asked to have a repeat urine culture two weeks after treatment has ended.
PREVENTING RECURRENT INFECTIONS — Young women with recurring urinary tract infections may be advised to take steps to prevent UTIs, including one or more of the following:
Changes in contraception — Women who use spermicides, particularly those who also use a contraceptive diaphragm, may be encouraged to use an alternate means of contraception UTIs frequently. (See "Patient information: Contraception").
Cranberry products — Several small studies have suggested that there may be some benefit to consuming cranberry products to prevent recurrent UTIs, but their effectiveness has not been proven. In the laboratory, cranberry extracts appear to decrease the ability of E. coli to stick to the cells lining the urinary tract. More definitive studies are needed before cranberry juice or supplements are recommended for this purpose.
Increasing fluid intake and urinating after intercourse — Although clinical studies have not proven that increasing fluid intake (for a total of 32 to 64 ounces of fluid per day from food or fluids) or urinating soon after intercourse can prevent infection, healthcare providers frequently recommend these measures since they are not harmful.
Postmenopausal women — Postmenopausal women who develop recurrent UTIs may benefit from use of a vaginal estrogen. Estrogen is thought to promote the growth of normal bacteria in the vagina while preventing the growth of harmful bacteria. Vaginal estrogen is available in a flexible ring that is worn in the vagina for three months (eg, Estring®), a small tablet (Vagifem®), or a cream (eg, Premarin® or Estrace®).
Antibiotics — A preventive antibiotic treatment should be considered for people who continue to develop UTIs despite use of other preventive measures. Antibiotics are highly effective in preventing recurrent UTIs and can be given in several different ways.
Continuous use of antibiotics — A low dose of an antibiotic may be taken daily or three times per week for six months to several years.
Antibiotics following intercourse — In women who develop urinary tract infections after sexual intercourse, a single low dose antibiotic after intercourse is often effective in preventing infection.
Self-treatment — A plan to begin antibiotics at the first sign of a UTI may be recommended for some. Before this is started, it is important that prior infections have been confirmed with a urine culture; some women have symptoms of a UTI but do not actually have an infection. (See "Patient information: Chronic pelvic pain in women", section on Painful bladder syndrome and interstitial cystitis).
Need for further testing — Young healthy women with UTI who respond to antibiotic therapy, even those with pyelonephritis or frequent bladder infections, rarely need to undergo further testing. However, further testing may be recommended for some people with recurrent urinary tract infections, especially if there is any possibility of an anatomic abnormality in the kidneys, ureter, bladder, or urethra, or if there is concern about other factors that increase the risk of a urinary tract infection (eg, kidney stone). In addition, anyone who continues to have blood in the urine after the infection has cleared should be evaluated. (See "Patient information: Kidney stones" and see "Patient information: Blood in the urine (hematuria)").
Further evaluation of the urinary tract may include a computed tomography (CT) scan, ultrasound, or cystoscopy (looking inside the bladder with a thin, lighted telescope-like instrument).
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)
Toll-free: (800) 311-3435
(www.cdc.gov)
Infectious Diseases Society of America
(www.idsociety.org)
National Kidney and Urologic Disease Information Clearinghouse
(http://kidney.niddk.nih.gov/kudiseases/pubs/utiadult/)
[1-7]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Gupta, K, Hooton, TM, Roberts, PL, Stamm, WE. Patient-initiated treatment of uncomplicated recurrent urinary tract infections in young women. Ann Intern Med 2001; 135:9.
2. Hooton, TM, Besser, R, Foxman, B, et al. Acute uncomplicated cystitis in an era of increasing antibiotic resistance: a proposed approach to empirical therapy. Clin Infect Dis 2004; 39:75.
3. Hooton, TM, Stamm, WE. Diagnosis and treatment of uncomplicated urinary tract infection. Infect Dis Clin North Am 1997; 11:551.
4. Scholes, D, Hooton, TM, Roberts, PL, et al. Risk factors associated with acute pyelonephritis in healthy women. Ann Intern Med 2005; 142:20.
5. Hooton, TM. The current management strategies for community-acquired urinary tract infection. Infect Dis Clin North Am 2003; 17:303.
6. Raz, R, Chazan, B, Dan, M. Cranberry juice and urinary tract infection. Clin Infect Dis 2004; 38:1413.
7. Stamm, WE. Estrogens and urinary-tract infection. J Infect Dis 2007; 195:623.
Urinary tract infection in adult
INTRODUCTION — Urinary tract infection (UTI) is one of the most common infections. Approximately 50 percent of adult women report that they have had a UTI at some time during their life.
A UTI can be an infection of the bladder (cystitis) or a more serious infection of the kidney (pyelonephritis); most patients with UTI have an uncomplicated bladder infection that is easily treated with a short course of antibiotics.
This discussion will focus on bladder infections in a healthy adult.
DEFINITION — The urinary tract includes the kidneys (which filter urine), bladder (which stores urine), and urethra (the tube that carries urine out of the bladder) (show figure 1). Bacteria do not normally live in these areas. When bacteria enter the urinary tract and begin to multiply, they can cause a UTI. The majority of UTIs occur in the bladder.
UTI occurs more frequently in women since women have a short urethra and a small distance between the urethral opening and the anus (where bacteria commonly live, show figure 2). Both factors make it easy for bacteria to enter the bladder.
Most UTIs are caused by the bacterium Escherichia coli (E. coli), which is commonly found in feces. The bacteria can move from the anus to the urethra and into the bladder (and less commonly into the kidney), causing infection. E. coli have certain properties that enable this movement, including the ability to adhere to the lining of the urethra and bladder.
A patient who does not have symptoms but has bacteria in the urine is said to have asymptomatic bacteriuria. This is especially common in elderly men and women. Treatment is not always needed for persons with asymptomatic bacteriuria, except in selected circumstances, such as during pregnancy.
RISK FACTORS — The risk of developing cystitis or pyelonephritis may be increased by a number of factors, especially sexual intercourse. The use of spermicides, particularly in combination with a diaphragm, also increases the risk of UTI in women.
Some women are prone to recurring episodes of cystitis. Factors that may predispose a young woman to repeated episodes of cystitis include: Sexual activity Use of spermicides Genetic factors A new sex partner A history of previous UTIs is a very strong risk factor for having subsequent UTIs.
A small number of otherwise healthy young men can also develop UTI. Men who engage in insertive anal intercourse are more likely to become infected, as are men who are uncircumcised.
Men, women, and children with underlying health problems may also be at higher risk for developing a UTI, including use of a bladder catheter, a recent procedure or surgery involving the urinary tract, an anatomic abnormality or blockage of the urinary tract, the inability to empty the bladder completely, pregnancy, diabetes, or age 65 years.
SYMPTOMS — The typical symptoms of acute cystitis are: Pain or burning when urinating Frequent need to urinate Urgent need to urinate Blood in the urine Discomfort in the middle of the lower abdomen (suprapubic pain)
Burning with urination can also occur in patients with vaginitis (eg, yeast infection) or urethritis (inflammation of the urethra). The presence of blood in the urine is common in cystitis, but not in vaginitis or urethritis. Vaginal discharge, odor, itching, or pain with sexual intercourse are typical features of vaginitis. Urethritis is possible if the patient has a new sexual partner, has a partner with urethritis, or gradually develops symptoms over several weeks. (See "Patient information: Vaginal yeast infection" and see "Patient information: Blood in the urine (hematuria)").
Pyelonephritis — Symptoms of pyelonephritis (an infection of the kidney) almost always include fever, which is defined in adults as a temperature greater than 100.4º F (38º C). Pyelonephritis can also cause pain in the flank (side of lower back) on the involved side, nausea, and vomiting. Burning or pain on urination, frequent urination, urgency, and suprapubic pain may also occur in people with pyelonephritis.
DIAGNOSIS — Simple cystitis is usually diagnosed based upon symptoms alone. This is especially true if a woman has frequent UTIs and can recognize the symptoms easily. However, most patients, especially those with a first episode, should see a healthcare provider for testing.
The provider will examine the patient and look for fever or flank tenderness, which could indicate pyelonephritis. If vaginitis or urethritis are possible, a pelvic examination and appropriate cultures will be performed.
One way to distinguish between UTI and vaginitis is by performing a urinalysis to determine if there are white blood cells present. The urine will contain white blood cells in a person with a UTI, but these cells are not usually present in persons with vaginitis (although white blood cells in vaginal fluid can sometimes contaminate the urine specimen).
Urine culture — A urine culture is a test that uses a sample of urine to try and grow bacteria in a laboratory. A sensitivity test can be done with any bacteria that grow on the culture to determine the best antibiotic treatment. It usually requires about 48 hours for results to return.
Urine culture is done by obtaining a "clean catch" urine sample. The patient is asked to clean the external genitalia and collect a sample of urine after voiding for a few seconds. This avoids collecting the first drops of urine, which may be contaminated with bacteria from the skin.
However, a urine culture is not always required to diagnose a UTI. As noted above, it is often possible to accurately diagnose a UTI based on symptoms alone. Urine culture is helpful in patients who have symptoms that are not typical for UTI. Culture is also useful in patients who are at greater risk for having a bacteria that is resistant to antibiotics, such as a person who has recently taken antibiotics. In such cases, the information from the laboratory can be helpful in choosing the optimal antibiotic for the UTI.
TREATMENT — In young, healthy women with simple cystitis, the usual treatment includes several days of antibiotics. The typical drugs chosen are: trimethoprim-sulfamethoxazole (Bactrim®), nitrofurantoin (Macrobid®), ciprofloxacin (Cipro®) or levofloxacin (Levaquin®). Ciprofloxacin and levofloxacin should not be used by women who are pregnant or nursing. Symptoms generally resolve one to three days after starting treatment. It is important to take the full course of antibiotics to completely eliminate the infection.
If needed, medicine that numbs the bladder and urethra can be given for symptoms of painful urination (phenazopyridine [Pyridium®]). A nonprescription medication that is similar to Pyridium is also available (eg, Uristat). Both medications cause the urine to appear discolored (usually blue or orange) and can interfere with laboratory testing; for this reason, it is important to seek testing and treatment first.
Some providers recommend increasing fluid intake to help flush bacteria from the bladder. Others believe that increasing fluid in the body dilutes the antibiotic in the bladder and makes the medication less effective. No studies have been performed to address this issue. There are also no definitive studies on the effectiveness of cranberry juice for the treatment of a UTI.
Treatment in pregnancy — Pregnant women with a UTI or asymptomatic bacteriuria (a UTI without symptoms) need to be treated. Pregnant women are more likely to develop pyelonephritis following a UTI or asymptomatic bacteriuria, and UTIs can cause complications with the pregnancy. In pregnant women, the urine is sent for culture to identify the specific bacteria causing the problem, and the treatment is given for three to seven days.
Follow-up care — Follow-up testing is not needed in healthy, young women with simple cystitis if symptoms resolve. Pregnant women are usually asked to have a repeat urine culture two weeks after treatment has ended.
PREVENTING RECURRENT INFECTIONS — Young women with recurring urinary tract infections may be advised to take steps to prevent UTIs, including one or more of the following:
Changes in contraception — Women who use spermicides, particularly those who also use a contraceptive diaphragm, may be encouraged to use an alternate means of contraception UTIs frequently. (See "Patient information: Contraception").
Cranberry products — Several small studies have suggested that there may be some benefit to consuming cranberry products to prevent recurrent UTIs, but their effectiveness has not been proven. In the laboratory, cranberry extracts appear to decrease the ability of E. coli to stick to the cells lining the urinary tract. More definitive studies are needed before cranberry juice or supplements are recommended for this purpose.
Increasing fluid intake and urinating after intercourse — Although clinical studies have not proven that increasing fluid intake (for a total of 32 to 64 ounces of fluid per day from food or fluids) or urinating soon after intercourse can prevent infection, healthcare providers frequently recommend these measures since they are not harmful.
Postmenopausal women — Postmenopausal women who develop recurrent UTIs may benefit from use of a vaginal estrogen. Estrogen is thought to promote the growth of normal bacteria in the vagina while preventing the growth of harmful bacteria. Vaginal estrogen is available in a flexible ring that is worn in the vagina for three months (eg, Estring®), a small tablet (Vagifem®), or a cream (eg, Premarin® or Estrace®).
Antibiotics — A preventive antibiotic treatment should be considered for people who continue to develop UTIs despite use of other preventive measures. Antibiotics are highly effective in preventing recurrent UTIs and can be given in several different ways.
Continuous use of antibiotics — A low dose of an antibiotic may be taken daily or three times per week for six months to several years.
Antibiotics following intercourse — In women who develop urinary tract infections after sexual intercourse, a single low dose antibiotic after intercourse is often effective in preventing infection.
Self-treatment — A plan to begin antibiotics at the first sign of a UTI may be recommended for some. Before this is started, it is important that prior infections have been confirmed with a urine culture; some women have symptoms of a UTI but do not actually have an infection. (See "Patient information: Chronic pelvic pain in women", section on Painful bladder syndrome and interstitial cystitis).
Need for further testing — Young healthy women with UTI who respond to antibiotic therapy, even those with pyelonephritis or frequent bladder infections, rarely need to undergo further testing. However, further testing may be recommended for some people with recurrent urinary tract infections, especially if there is any possibility of an anatomic abnormality in the kidneys, ureter, bladder, or urethra, or if there is concern about other factors that increase the risk of a urinary tract infection (eg, kidney stone). In addition, anyone who continues to have blood in the urine after the infection has cleared should be evaluated. (See "Patient information: Kidney stones" and see "Patient information: Blood in the urine (hematuria)").
Further evaluation of the urinary tract may include a computed tomography (CT) scan, ultrasound, or cystoscopy (looking inside the bladder with a thin, lighted telescope-like instrument).
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)
Toll-free: (800) 311-3435
(www.cdc.gov)
Infectious Diseases Society of America
(www.idsociety.org)
National Kidney and Urologic Disease Information Clearinghouse
(http://kidney.niddk.nih.gov/kudiseases/pubs/utiadult/)
[1-7]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Gupta, K, Hooton, TM, Roberts, PL, Stamm, WE. Patient-initiated treatment of uncomplicated recurrent urinary tract infections in young women. Ann Intern Med 2001; 135:9.
2. Hooton, TM, Besser, R, Foxman, B, et al. Acute uncomplicated cystitis in an era of increasing antibiotic resistance: a proposed approach to empirical therapy. Clin Infect Dis 2004; 39:75.
3. Hooton, TM, Stamm, WE. Diagnosis and treatment of uncomplicated urinary tract infection. Infect Dis Clin North Am 1997; 11:551.
4. Scholes, D, Hooton, TM, Roberts, PL, et al. Risk factors associated with acute pyelonephritis in healthy women. Ann Intern Med 2005; 142:20.
5. Hooton, TM. The current management strategies for community-acquired urinary tract infection. Infect Dis Clin North Am 2003; 17:303.
6. Raz, R, Chazan, B, Dan, M. Cranberry juice and urinary tract infection. Clin Infect Dis 2004; 38:1413.
7. Stamm, WE. Estrogens and urinary-tract infection. J Infect Dis 2007; 195:623.
A UTI can be an infection of the bladder (cystitis) or a more serious infection of the kidney (pyelonephritis); most patients with UTI have an uncomplicated bladder infection that is easily treated with a short course of antibiotics.
This discussion will focus on bladder infections in a healthy adult.
DEFINITION — The urinary tract includes the kidneys (which filter urine), bladder (which stores urine), and urethra (the tube that carries urine out of the bladder) (show figure 1). Bacteria do not normally live in these areas. When bacteria enter the urinary tract and begin to multiply, they can cause a UTI. The majority of UTIs occur in the bladder.
UTI occurs more frequently in women since women have a short urethra and a small distance between the urethral opening and the anus (where bacteria commonly live, show figure 2). Both factors make it easy for bacteria to enter the bladder.
Most UTIs are caused by the bacterium Escherichia coli (E. coli), which is commonly found in feces. The bacteria can move from the anus to the urethra and into the bladder (and less commonly into the kidney), causing infection. E. coli have certain properties that enable this movement, including the ability to adhere to the lining of the urethra and bladder.
A patient who does not have symptoms but has bacteria in the urine is said to have asymptomatic bacteriuria. This is especially common in elderly men and women. Treatment is not always needed for persons with asymptomatic bacteriuria, except in selected circumstances, such as during pregnancy.
RISK FACTORS — The risk of developing cystitis or pyelonephritis may be increased by a number of factors, especially sexual intercourse. The use of spermicides, particularly in combination with a diaphragm, also increases the risk of UTI in women.
Some women are prone to recurring episodes of cystitis. Factors that may predispose a young woman to repeated episodes of cystitis include: Sexual activity Use of spermicides Genetic factors A new sex partner A history of previous UTIs is a very strong risk factor for having subsequent UTIs.
A small number of otherwise healthy young men can also develop UTI. Men who engage in insertive anal intercourse are more likely to become infected, as are men who are uncircumcised.
Men, women, and children with underlying health problems may also be at higher risk for developing a UTI, including use of a bladder catheter, a recent procedure or surgery involving the urinary tract, an anatomic abnormality or blockage of the urinary tract, the inability to empty the bladder completely, pregnancy, diabetes, or age 65 years.
SYMPTOMS — The typical symptoms of acute cystitis are: Pain or burning when urinating Frequent need to urinate Urgent need to urinate Blood in the urine Discomfort in the middle of the lower abdomen (suprapubic pain)
Burning with urination can also occur in patients with vaginitis (eg, yeast infection) or urethritis (inflammation of the urethra). The presence of blood in the urine is common in cystitis, but not in vaginitis or urethritis. Vaginal discharge, odor, itching, or pain with sexual intercourse are typical features of vaginitis. Urethritis is possible if the patient has a new sexual partner, has a partner with urethritis, or gradually develops symptoms over several weeks. (See "Patient information: Vaginal yeast infection" and see "Patient information: Blood in the urine (hematuria)").
Pyelonephritis — Symptoms of pyelonephritis (an infection of the kidney) almost always include fever, which is defined in adults as a temperature greater than 100.4º F (38º C). Pyelonephritis can also cause pain in the flank (side of lower back) on the involved side, nausea, and vomiting. Burning or pain on urination, frequent urination, urgency, and suprapubic pain may also occur in people with pyelonephritis.
DIAGNOSIS — Simple cystitis is usually diagnosed based upon symptoms alone. This is especially true if a woman has frequent UTIs and can recognize the symptoms easily. However, most patients, especially those with a first episode, should see a healthcare provider for testing.
The provider will examine the patient and look for fever or flank tenderness, which could indicate pyelonephritis. If vaginitis or urethritis are possible, a pelvic examination and appropriate cultures will be performed.
One way to distinguish between UTI and vaginitis is by performing a urinalysis to determine if there are white blood cells present. The urine will contain white blood cells in a person with a UTI, but these cells are not usually present in persons with vaginitis (although white blood cells in vaginal fluid can sometimes contaminate the urine specimen).
Urine culture — A urine culture is a test that uses a sample of urine to try and grow bacteria in a laboratory. A sensitivity test can be done with any bacteria that grow on the culture to determine the best antibiotic treatment. It usually requires about 48 hours for results to return.
Urine culture is done by obtaining a "clean catch" urine sample. The patient is asked to clean the external genitalia and collect a sample of urine after voiding for a few seconds. This avoids collecting the first drops of urine, which may be contaminated with bacteria from the skin.
However, a urine culture is not always required to diagnose a UTI. As noted above, it is often possible to accurately diagnose a UTI based on symptoms alone. Urine culture is helpful in patients who have symptoms that are not typical for UTI. Culture is also useful in patients who are at greater risk for having a bacteria that is resistant to antibiotics, such as a person who has recently taken antibiotics. In such cases, the information from the laboratory can be helpful in choosing the optimal antibiotic for the UTI.
TREATMENT — In young, healthy women with simple cystitis, the usual treatment includes several days of antibiotics. The typical drugs chosen are: trimethoprim-sulfamethoxazole (Bactrim®), nitrofurantoin (Macrobid®), ciprofloxacin (Cipro®) or levofloxacin (Levaquin®). Ciprofloxacin and levofloxacin should not be used by women who are pregnant or nursing. Symptoms generally resolve one to three days after starting treatment. It is important to take the full course of antibiotics to completely eliminate the infection.
If needed, medicine that numbs the bladder and urethra can be given for symptoms of painful urination (phenazopyridine [Pyridium®]). A nonprescription medication that is similar to Pyridium is also available (eg, Uristat). Both medications cause the urine to appear discolored (usually blue or orange) and can interfere with laboratory testing; for this reason, it is important to seek testing and treatment first.
Some providers recommend increasing fluid intake to help flush bacteria from the bladder. Others believe that increasing fluid in the body dilutes the antibiotic in the bladder and makes the medication less effective. No studies have been performed to address this issue. There are also no definitive studies on the effectiveness of cranberry juice for the treatment of a UTI.
Treatment in pregnancy — Pregnant women with a UTI or asymptomatic bacteriuria (a UTI without symptoms) need to be treated. Pregnant women are more likely to develop pyelonephritis following a UTI or asymptomatic bacteriuria, and UTIs can cause complications with the pregnancy. In pregnant women, the urine is sent for culture to identify the specific bacteria causing the problem, and the treatment is given for three to seven days.
Follow-up care — Follow-up testing is not needed in healthy, young women with simple cystitis if symptoms resolve. Pregnant women are usually asked to have a repeat urine culture two weeks after treatment has ended.
PREVENTING RECURRENT INFECTIONS — Young women with recurring urinary tract infections may be advised to take steps to prevent UTIs, including one or more of the following:
Changes in contraception — Women who use spermicides, particularly those who also use a contraceptive diaphragm, may be encouraged to use an alternate means of contraception UTIs frequently. (See "Patient information: Contraception").
Cranberry products — Several small studies have suggested that there may be some benefit to consuming cranberry products to prevent recurrent UTIs, but their effectiveness has not been proven. In the laboratory, cranberry extracts appear to decrease the ability of E. coli to stick to the cells lining the urinary tract. More definitive studies are needed before cranberry juice or supplements are recommended for this purpose.
Increasing fluid intake and urinating after intercourse — Although clinical studies have not proven that increasing fluid intake (for a total of 32 to 64 ounces of fluid per day from food or fluids) or urinating soon after intercourse can prevent infection, healthcare providers frequently recommend these measures since they are not harmful.
Postmenopausal women — Postmenopausal women who develop recurrent UTIs may benefit from use of a vaginal estrogen. Estrogen is thought to promote the growth of normal bacteria in the vagina while preventing the growth of harmful bacteria. Vaginal estrogen is available in a flexible ring that is worn in the vagina for three months (eg, Estring®), a small tablet (Vagifem®), or a cream (eg, Premarin® or Estrace®).
Antibiotics — A preventive antibiotic treatment should be considered for people who continue to develop UTIs despite use of other preventive measures. Antibiotics are highly effective in preventing recurrent UTIs and can be given in several different ways.
Continuous use of antibiotics — A low dose of an antibiotic may be taken daily or three times per week for six months to several years.
Antibiotics following intercourse — In women who develop urinary tract infections after sexual intercourse, a single low dose antibiotic after intercourse is often effective in preventing infection.
Self-treatment — A plan to begin antibiotics at the first sign of a UTI may be recommended for some. Before this is started, it is important that prior infections have been confirmed with a urine culture; some women have symptoms of a UTI but do not actually have an infection. (See "Patient information: Chronic pelvic pain in women", section on Painful bladder syndrome and interstitial cystitis).
Need for further testing — Young healthy women with UTI who respond to antibiotic therapy, even those with pyelonephritis or frequent bladder infections, rarely need to undergo further testing. However, further testing may be recommended for some people with recurrent urinary tract infections, especially if there is any possibility of an anatomic abnormality in the kidneys, ureter, bladder, or urethra, or if there is concern about other factors that increase the risk of a urinary tract infection (eg, kidney stone). In addition, anyone who continues to have blood in the urine after the infection has cleared should be evaluated. (See "Patient information: Kidney stones" and see "Patient information: Blood in the urine (hematuria)").
Further evaluation of the urinary tract may include a computed tomography (CT) scan, ultrasound, or cystoscopy (looking inside the bladder with a thin, lighted telescope-like instrument).
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)
Toll-free: (800) 311-3435
(www.cdc.gov)
Infectious Diseases Society of America
(www.idsociety.org)
National Kidney and Urologic Disease Information Clearinghouse
(http://kidney.niddk.nih.gov/kudiseases/pubs/utiadult/)
[1-7]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Gupta, K, Hooton, TM, Roberts, PL, Stamm, WE. Patient-initiated treatment of uncomplicated recurrent urinary tract infections in young women. Ann Intern Med 2001; 135:9.
2. Hooton, TM, Besser, R, Foxman, B, et al. Acute uncomplicated cystitis in an era of increasing antibiotic resistance: a proposed approach to empirical therapy. Clin Infect Dis 2004; 39:75.
3. Hooton, TM, Stamm, WE. Diagnosis and treatment of uncomplicated urinary tract infection. Infect Dis Clin North Am 1997; 11:551.
4. Scholes, D, Hooton, TM, Roberts, PL, et al. Risk factors associated with acute pyelonephritis in healthy women. Ann Intern Med 2005; 142:20.
5. Hooton, TM. The current management strategies for community-acquired urinary tract infection. Infect Dis Clin North Am 2003; 17:303.
6. Raz, R, Chazan, B, Dan, M. Cranberry juice and urinary tract infection. Clin Infect Dis 2004; 38:1413.
7. Stamm, WE. Estrogens and urinary-tract infection. J Infect Dis 2007; 195:623.
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)
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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.
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