Bladder infection after hysterectomy

Recurrent Urinary Tract Infections in Postmenopausal Women

Abstract

To evaluate factors associated with recurrent urinary tract infection (UTI) in postmenopausal women, we conducted a case-control study comparing 149 postmenopausal women referred to an infectious diseases outpatient clinic who had a history of recurrent UTI (case patients) with 53 age-matched women without a history of UTI (control patients). Each woman completed a questionnaire providing demographic data, history and clinical characteristics of prior infections, and information regarding risk factors for UTI. In addition, each patient underwent a gynecologic evaluation, renal ultrasound and urine flow studies, and blood group and secretor status testing. Three urologic factors—namely, incontinence (41% of case patients vs. 9.0% of control patients; P < .001), presence of a cystocele (19% vs. 0%; P < .001), and postvoiding residual urine (28% vs. 2.0%; P = .00008)—were all strongly associated with recurrent UTI. Multivariate analysis showed that urinary incontinence (odds ratio , 5.79; 95% confidence interval , 2.05–16.42; P = .0009), a history of UTI before menopause (OR, 4.85; 95% CI, 1.7–13.84; P = .003), and nonsecretor status (OR, 2.9; 95% CI, 1.28–6.25; P = .005) were most strongly associated with recurrent UTI in postmenopausal women. Prospective studies are needed to confirm these observations and to develop approaches for prevention.

Urinary tract infection (UTI) remains one of the most common bacterial infections seen in adult women of all ages . On a global basis, an estimated 150 million UTIs occur annually, and in the United States, UTIs account for >6 billion dollars in direct health care costs . Recent prospective studies found that the incidence of symptomatic UTIs among young women initiating contraception was as high as 0.5–0.7 case per person per year . The prevalence of UTIs among women is thought to increase even further with age, with bacteriuria occurring in 10%–15% of women aged 65–70 years and 15%–20% of women aged >80 years . Despite the high prevalence of bacteriuria and the apparent high incidence of symptomatic UTIs among healthy postmenopausal women, the factors predisposing such women to UTI have been little explored as compared with those for either premenopausal women or older institutionalized women.

For younger women, sexual intercourse, diaphragm and/or spermicide exposure, a history of UTI, nonsecretor status, and recent antimicrobial exposure have been identified as important host characteristics associated with UTI . For older institutionalized women, urinary catheterization and functional status are the most important risk factors associated with UTI . Many of the risk factors associated with UTI in both of these population groups were initially identified by studying women with recurrent UTIs, whose host characteristics associated with UTI may be more easily demonstrated than those of women with sporadic UTIs. We thus undertook a case-control study to assess factors associated with recurrent UTIs in healthy postmenopausal women.

Material and Methods

Study population and subject recruitment. Women with recurrent symptomatic UTI were referred from family practitioners to the Infectious Diseases Outpatient Clinic at Haemek Medical Center, Haifa, Israel. Approximately 2000 women with recurrent urinary infections visit the clinic annually. During the period of study, consecutive postmenopausal women with recurrent UTI (defined as ≥3 microbiologically documented episodes of symptomatic UTI managed in the clinic during the last year or 2 episodes during the last 6 months) were offered enrollment in the study. All of the enrolled women (case patients) were generally healthy, and all were ambulatory and did not have indwelling catheters.

An age-matched group of women who visited the gastroenterology and metabolic units of the outpatient clinics and gave no history of UTI since the onset of menopause were invited to participate in the study as control patients. To minimize the number of control patients undergoing procedures that were of no benefit to them, 1 control patient was selected for every 3 case patients enrolled. All participants provided informed consent, and the study was approved by the National Human Subjects Review Board, Jerusalem.

Study procedures. Evaluation of both case and control patients was undertaken when the women were asymptomatic and abacteriuric. All of the case and control patients completed a nurse-administered questionnaire inquiring about their general medical history, marital status, number of pregnancies and deliveries, underlying diseases, and previous surgical procedures. They were also questioned about their history of UTIs, including age at first UTI, factors potentially related to its appearance, and urinary incontinence.

Urinary incontinence was defined as follows: urinary incontinence, involuntary loss of urine that is a social or hygienic problem and is objectively demonstrable; stress incontinence, dysfunction of the bladder outlet that leads to urinary leakage when intra-abdominal pressure is raised above urethral resistance during exertion, such as coughing, bending, or lifting heavy objects; and urge incontinence, the urge to void but an inability to inhibit leakage long enough to reach the toilet. Cystitis and pyelonephritis were defined utilizing clinical criteria, specifically dysuria; urgency and frequency (cystitis); and fever, chills, and/or loin pain (pyelonephritis).

After completion of the questionnaire, the patients underwent renal ultrasonography with a postvoiding step to evaluate the volume of residual urine (Diasonic, Santa Clara, CA). The evaluation was conducted within several minutes of voiding and was performed by a technician who had no knowledge of the case or control status of the patient. The postvoiding renal volume was calculated automatically by the ultrasound equipment. The residual urine volume was defined as follows: mild, persistence of ≤50 mL of urine after micturition; moderate, persistence of a residual urine volume of 50–100 mL; and severe, persistence of a residual urine volume >100 mL. Urinary flow was measured by use of a uroflowmeter; and women were classified as having a normal flow (0–15 mL/s) or as having mild (10–15 mL/s), moderate (5–10 mL/s), and severe (<5 mL/s) degrees of obstruction based on their peak urine flow rate.

A gynecologic evaluation was performed by 1 gynecologist (J.W.) to determine the presence of uterine, bladder, or rectal prolapse. Prolapse was defined as a downward or forward displacement of 1 of the pelvic organs from its normal location. These displacements have usually been graded on a scale of 0–3; the grades rise with increasing severity of the prolapse, with 0 referring to no prolapse and 3 referring to complete prolapse. All forms of female genital prolapse are described with reference to the vaginal canal. Rectal prolapse refers to protrusion of the rectum into the posterior vaginal lumen. The gynecologist was not aware of the patient’s case or control status.

For blood typing and secretor status testing, specimens of unstimulated whole saliva and blood were collected. Secretor status was determined by a hemagglutination inhibition assay . Saliva was first centrifuged at 4000 g for 15 minutes, and the supernatant was then boiled for 10 minutes and incubated at room temperature with 3 antisera (antisera to A, B, and H antigens). After 15 minutes, an equal volume of a suspension of 3% human erythrocytes in PBS (140 mM sodium chloride, 10 mM potassium phosphate, pH 7.4) was added. After 10 minutes, the presence or absence of hemagglutination was determined; saliva from secretors inhibited agglutination, whereas saliva from nonsecretors did not.

Statistical analysis. SPSS software (SPSS, Chicago) was used to determine significant differences between variables and to perform univariate and multivariate analyses for risk factors. In the univariate analysis, the χ2 test for categorical variables and the Student’s t test for numerical variables were used. Logistic regression analysis was carried out to identify variables that were independently associated with recurrent UTI. The variables in the selected model were chosen by backward elimination. Variables included in the model were a history of UTI, urogenital interventions, secretor status, urinary flow, and age.

Results

Comparability of Case and Control Patients

One hundred forty-nine postmenopausal women with recurrent UTI (case patients) and 53 postmenopausal women without UTI (control patients) completed the study and were included in the final study population (tables 1 and 2). The mean age (±SD) of the patients was 65.7 ± 7.2 years and that of the control patients was 66.6 ± 6.6 years. The mean number (±SD) of previous childbirths per patient was also similar in the 2 groups: 2.5 ± 1.2 for case patients and 2.3 ± 1.4 for control patients. Marital status and the systemic use of estrogen were proportionally similar in the 2 groups. When asked to identify factors possibly associated with their recurrent UTIs, most case patients (78%) did not relate any specific factor to the onset of recurrent UTI. However, 27 case patients (18%) believed that their UTIs started after a gynecologic surgical intervention. Only 3 case patients (2%) related their UTIs to sexual activity.

Factors Associated with Recurrent UTIs

Underlying medical and surgical conditions. A history of UTI before menopause or in childhood was more frequent in case patients than in control patients (table 1). Thus, only 6 (11%) of 53 control patients had had at least 1 episode of UTI before menopause as compared with 44 (30%) of the case patients (OR, 3.14; 95% CI, 1.32–8.36; P = .008). No differences were seen in the prevalence of other underlying diseases in the 2 groups, including diabetes mellitus (table 1). More case patients than control patients had undergone urogenital surgery (27% vs. 13%, respectively; OR, 2.41; 95% CI, 1.01–5.78; P = .04; table 2). The reasons for surgery were total hysterectomy due to myoma or uterine carcinoma in 33 case patients and 5 control patients and prolapse of the urinary bladder in 7 case patients and 2 control patients.

Residual urinary volume was considerably more common in case patients than in control patients. Thus, only 1 control patient (2%) had a measured residual urine volume as compared with 41 (28%) of the case patients (P = .0008). Most case patients had mild or moderate residual urine volumes; only 6 case patients had large residual urine volumes. Urinary flow was reduced in 67 (45%) of the case patients and only 12 (23%) of the control patients (OR, 2.79; 95% CI, 1.31–6.29; P = .004). Most of the case patients had only mild or moderate degrees of obstruction to urine flow (table 2).

Logistic regression analysis. To better define those factors independently associated with recurrent UTI in the case patients, we carried out logistic regression analysis (table 4). Even though women with either a cystocele or a residual urine volume after voiding had a very high positive predictive value for recurrent UTIs, they were excluded from the logistic regression analysis since these conditions were essentially absent in the control patients. The factors independently associated with recurrent UTIs in the multivariate analysis were urinary incontinence (OR, 5.79; 95% CI, 2.05–16.42; P = .009), a history of UTI (OR, 4.85; 95% CI, 1.7–13.84; P = .003), and nonsecretor status (OR, 2.9; 95% CI, 1.28–6.25; P = .005).

Discussion

Recurrent UTI remains an important public health problem in women of all ages. The data reported here and in other recent studies of recurrent UTI suggest that the factors underlying recurrent UTI differ by age and functional status. At least 3 groups of women with recurrent UTI should probably be distinguished: premenopausal women, healthy postmenopausal women (the group studied here), and elderly institutionalized women. Scholes et al. reported that the major risk factors for recurrent UTI in premenopausal women were sexual intercourse and spermicide exposure. In addition, a history of UTI, a history of UTIs in childhood, and a history of maternal UTIs may be associated with recurrent UTI in premenopausal women, which suggests a possible genetic predisposition to recurrent UTI in at least some women . Urologic factors (such as incontinence, postvoiding residual urine volume, abnormal urinary flow, and cystocele) were infrequent and not associated with recurrent UTI in these younger women .

We undertook this study to ascertain risk factors for recurrent UTIs in healthy postmenopausal women who were not institutionalized and did not have a catheter. Our findings indicate that most of the risk factors associated with recurrent UTIs in these women differ from those found in premenopausal women. In particular, mechanical and/or physiological factors that affect bladder emptying were strongly associated with recurrent UTIs in the women we studied but have generally not been associated with recurrent UTI in premenopausal women. A significant postvoiding residual urine volume was present in more than one-quarter of our case patients and in only 1 control patient and therefore had a very high positive predictive value for recurrent UTI. Similarly, 18% of the case patients in our study had low-grade cystoceles, whereas none of the control patients had cystoceles (positive predictive value for recurrent UTI, 100%).

Urinary incontinence (stress, urge, or both) was also observed more frequently in our case patients than in our control patients (41% vs. 9%, respectively) and was strongly associated with recurrent UTI in the multivariate analysis. Incontinence is very common in older women and has been estimated in population-based studies to occur in 17%–46% of community-dwelling women aged >60 years . Further studies are needed to confirm the association of incontinence with recurrent UTI and to ascertain how incontinence predisposes women to recurrent infection. Urinary incontinence increases in frequency with age and in the presence of other associated risk factors, including obesity, medical illnesses, smoking, and alcohol consumption.

A recent study by Brown et al. showed that obesity and a history of hysterectomy had a substantial impact on the prevalence of urinary incontinence; in this study, hysterectomy was performed primarily for leiomyomas (65%–70% of case patients) and infrequently for prolapse (10%) or incontinence (4%). In our study, 27% of the case patients had undergone gynecologic surgery (33 of 40 were hysterectomies) as compared with only 13% of the control patients. Most of these procedures were performed for leiomyomas and not for incontinence or prolapse. Thus, recurrent episodes of UTI in these women had their onset after urogenital surgery. Hysterectomy may cause damage to the urethral and bladder supportive structures or to the pelvic plexus, leading to subsequent incontinence later in life . In addition, other gynecologic procedures that alter the normal anatomy of the pelvis are also likely to increase the risk of recurrent UTIs. However, in our study, there was an insufficient number of such procedures, given our sample size, to adequately assess them as risk factors for recurrent UTIs.

Inherited factors may also play a role in predisposing postmenopausal women to recurrent UTIs. Thus case patients in our study reported a history of childhood and premenopausal UTIs significantly more frequently than did the control patients, which suggests a lifelong factor or factors that predispose them to urinary infection. A history of premenopausal UTIs remained strongly correlated with recurrent UTI in postmenopausal women in the multivariate analysis. Nonsecretor status was also an inherited characteristic strongly associated with recurrent UTI in the multivariate regression analysis. It is interesting that the previously reported association of nonsecretor status with recurrent UTI has been most evident in populations of women aged >35 years. The mean ages of the populations described by Sheinfeld et al. and Kinane et al. , in whom nonsecretor status was associated with recurrent UTI, were 38 and 55 years, respectively, and both populations included many postmenopausal women.

The mechanism through which nonsecretor status predisposes to recurrent UTI is probably the presence on vaginal and uroepithelial cells of 2 unique nonsecretor-associated glyco-lipids that serve as binding sites for specific Escherichia coli adhesions . It is possible that expression of these nonsecretor-associated glycolipids varies with age or hormonal status. Alternatively, nonsecretor status may become more important in older women when other risk factors such as sexual activity and spermicide exposure recede.

Finally, although not directly evaluated in this study, the reduced levels of estrogenic hormones present after menopause appear to contribute to the occurrence of recurrent UTI in postmenopausal women. In a prior double-blind, placebo- controlled intervention study, we demonstrated that topically applied intravaginal estrogen markedly reduced the incidence of recurrent UTI ; concomitantly, E. coli vaginal colonization was reduced by one-half, lactobacillus colonization was reestablished in most women, and the vaginal pH fell significantly. In contrast, the effects of oral estrogen on the risk of UTI are less clear and need further study. Prior investigators have reported both increased and decreased risks of UTI associated with the use of estrogenic hormones . In our current study, estrogen use was relatively infrequent in both case and control patients and was not related to recurrent UTI. Given the small number of estrogen users, however, the study lacked power to appropriately address this issue.

We undertook this case-control study to identify factors potentially associated with recurrent UTI, so that such factors could be subsequently further studied in more definitive prospective studies. Several limitations of our study deserve discussion. Our case patients were referred by family practitioners to a special consultation clinic for evaluation of recurrent UTI. Although this is standard practice for such practitioners, we cannot be certain whether the referred patients studied in our clinic are representative of all women with recurrent UTI. Similarly, our age-matched control patients were recruited and enrolled in other specialty clinics at the hospital and are probably not representative of all women in the community who do not have recurrent UTI. Nevertheless, the case and control patients were quite comparable in terms of demographic factors and by virtue of all being outpatients recruited from specialty clinics at the same medical center.

Finally, we were unable to carefully assess the relationship between sexual intercourse and recurrent UTI in the study because of the reticence of our patients to discuss sexual practices. However, only 2% of women with recurrent UTI thought that coitus was related to UTI, and it is thus unlikely that sexual intercourse was a major predisposing factor in women in the study. Further study of this issue, however, is warranted. Despite these limitations, our study identified strong associations between recurrent UTI and several plausible variables of interest that should now be further studied prospectively.

In conclusion, our data support the view that several factors importantly influence the incidence of recurrent UTI among postmenopausal women. These factors include a history of UTIs, nonsecretor status, and possibly other inherited predispositions, as well as urodynamic factors, especially incontinence, residual urine volume, and presence of a cystocele. These major factors predisposing to recurrent UTI in postmenopausal women differ importantly from the factors that predominate in premenopausal women with recurrent UTI. However, these factors have been identified primarily in case-control or intervention studies, and a prospective cohort study of postmenopausal women to determine more precisely the incidence of and risk factors for recurrent UTI in this group would be of great interest. Proposed interventions to reduce the incidence of recurrent UTI among postmenopausal women must take the multi-factorial nature of this condition into account.

Acknowledgments

We thank Frances Nachmani for her assistance in typing the manuscript, Dr. H. Ben-Arie for performing the secretor status studies, and Dr. Kvitko for determining the blood groups.

1 Schappert SM . National ambulatory medical care survey: 1992 summary, Advanced data from vital and health statistics, no 253, 1994 Hyattsville, MD National Center for Health Statistics(pg. 94-1250) DHHS publication 2 Ronald AR . Editorial comment: sexually transmitted diseases and urinary tract infections, Curr Opin Infect Dis, 1995, vol. 8 (pg. 1-3) 3 Hooton TM , Scholes D , Hughes JP , et al. A prospective study of risk factors for symptomatic urinary tract infection in young women, N Engl J Med, 1996, vol. 335 (pg. 468-74) 4 Nygaard IE , Johnson JM . Urinary tract infection in elderly women, Am Fam Physician, 1996, vol. 53 (pg. 175-82) 5 Nicolle LE . Urinary tract infection in the elderly, J Antimicrob Chemother, 1994, vol. 33 Suppl A(pg. 99-109) 6 Boscia JA , Kobasa WD , Knight RA , et al. Epidemiology of bacteriuria in an elderly ambulatory population, Am J Med, 1986, vol. 80 (pg. 208-14) 7 Strom BL , Collins M , West SL , Kreisberg J , Weller S . Sexual activity, contraceptive use and other risk factors for symptomatic and asymptomatic bacteriuria: a case-control study, Ann Intern Med, 1987, vol. 107 (pg. 816-23) 8 Foxman B , Fredrichs RR . Epidemiology of urinary tract infection. I. Diaphragm use and sexual intercourse, Am J Public Health, 1985, vol. 75 (pg. 1308-13) 9 Sheinfeld J , Schaeffer AJ , Cordon-Cardo C , Rogatko A , Fair WR . Association of the Lewis blood-group phenotype with recurrent urinary tract infections in women, N Engl J Med, 1989, vol. 320 (pg. 773-7) 10 Kinane DF , Blackwell CC , Brettle RP , Weir DM , Winstanley FP , Elton RA . ABO blood group, secretor status and susceptibility to recurrent urinary tract infection in women, BMJ, 1982, vol. 285 (pg. 7-9) 11 Smith HS , Hughes JP , Hooton TM , et al. Antecedent antimicrobial use increases the risk of uncomplicated cystitis in young women, Clin Infect Dis, 1997, vol. 25 (pg. 63-8) 12 Raz R , Stamm WE . A controlled trial of intravaginal estriol in postmenopausal women with recurrent urinary tract infections, N Engl J Med, 1993, vol. 329 (pg. 753-6) 13 Eriksson W , Partanen K , Frank RD , et al. ABH secretion polymorphism in Icelanders, Aland Icelanders, Finns, Finnish Lapps, Komi and Greenland Eskimos: a review and new data, Ann Hum Biol, 1986, vol. 3 (pg. 273-85) 14 Scholes D , Hooton TM , Roberts PL , et al. Risk factors for recurrent UTI in young women, Clin Infect Dis, 1997, vol. 25 pg. 440 15 Hooton TM , Stapleton AE , Roberts PL , et al. Perineal anatomy and urine voiding characteristics in young women with and without recurrent urinary tract infections, Clin Infect Dis, 2000 in press 16 Versi E . Incontinence in the climacteric, Clin Obstet Gynecol, 1990, vol. 33 (pg. 392-8) 17 Brown JS , Seeley DG , Fong J , et al. Urinary incontinence in older women: who is at risk?, Obstet Gynecol, 1996, vol. 87 (pg. 715-21) 18 Taylor T , Smith A , Fulton M . Effects of hysterectomy on bowel and bladder function, Int J Colorectal Dis, 1990, vol. 5 (pg. 228-31) 19 Lomberg HB , Cedergren H , Leffler B , Nilson AS , Svanberg-Eden C . Influence of blood group on the availability of receptors for attachment of uropathogenic E. coli , Infect Immun, 1986, vol. 51 (pg. 919-26) 20 Stapleton A , Hooton TM , Fennell C , Roberts DL , Stamm W . Effect of secretor status on vaginal and rectal colonization with fimbriated Escherichia coli in women with and without recurrent urinary tract infection, J Infect Dis, 1995, vol. 171 (pg. 717-20) 21 Orlander JD , Jick SS , Dean AD , Jick H . Urinary tract infections and estrogen use in older women, J Am Geriatr Soc, 1992, vol. 40 (pg. 817-20) 22 Kirkengen AL , Andersen P , Gjersoe E , Johannessen GR , Johnson N , Bodd E . Oestriol in the prophylactic treatment of recurrent urinary tract infections in postmenopausal women, Scand J Prim Health Care, 1992, vol. 10 (pg. 139-42)

Figures and Tables

Table 1

Univariate analysis of demographic and historical factors associated with recurrent UTI in postmenopausal women.

Table 1

Univariate analysis of demographic and historical factors associated with recurrent UTI in postmenopausal women.

Table 2

Univariate analysis of urologic factors associated with recurrent UTI in postmenopausal women.

Table 2

Univariate analysis of urologic factors associated with recurrent UTI in postmenopausal women.

Table 3

Univariate analysis of blood group and secretor status in postmenopausal women with recurrent UTI and in control patients.

Table 3

Univariate analysis of blood group and secretor status in postmenopausal women with recurrent UTI and in control patients.

Table 4

Multivariate analysis of factors predisposing postmenopausal women to UTI.

Table 4

Multivariate analysis of factors predisposing postmenopausal women to UTI.

This work was presented in part at the 37th Interscience Conference on Antimicrobial Agents and Chemotherapy held on 28 September to 1 October 1997 in Toronto, Canada Grant support: This work was supported by the National Institutes of Health (grants DK 40045 and DK 53369). © 2000 by the Infectious Diseases Society of America

Postoperative Urinary Retention and Urinary Track Infection (UTI) After Laparoscopic Assisted Vaginal Hysterectomy (LAVH) for Benign Disease

Hysterectomy is the most common major gynecological operation performed; in previous study, 20% of women will have undergone a hysterectomy by the age of 50 years, mostly for nonmalignant conditions such as uterine fibroids, endometriosis, abnormal bleeding, uterine prolapse and intra-epithelial neoplasia of the cervix grade 3. (1) Fever is the most common perioperative complication of hysterectomy, arising in about 25%. (2) The other early complications associated with hysterectomy including hemorrhage, infection, and injury to adjacent organs, femoral neuropathy, and thromboembolic disease. (3) However, whether hysterectomy is linked to the development of urinary symptoms remains controversial. Some groups observed no effect or improved urinary dysfunction after hysterectomy, (4-7) others reported that hysterectomy is the cause of a variety of urinary symptoms including the urethral syndrome, stress incontinence, detrusor overactivity and voiding difficulty. (8, 9) Voiding difficulty in the female is a condition in which the bladder fails to empty completely and easily after micturition. Failure to detect voiding difficulties after surgery may lead to bladder overdistention and irreversible damage of the detrusor muscle. (10) Postoperative urinary retention (PUR) is defined as the inability to void with a full bladder during the postoperative period. The etiology of PUR involves a combination of many factors, including sedation, type of anesthesia, increased sympathetic stimulation, overdistension of bladder by large quantities of fluids given intravenously, pain and anxiety. (11) In the literature, incidence of postoperative urinary retention (PUR) has ranged from 3.8% to 80%, depending on the definition used and the type of surgery performed. (12-15) There is no consensus on how to diagnose PUR and various criteria, such as clinical symptoms, bladder palpation and a fixed time interval or drainage by catheterization of more than 500 ml of urine, have been used. (16) Traditionally gynecologists have used an indwelling catheter for abdominal surgical procedures for several reasons, including the beliefs that women would be unable to void satisfactorily in the immediate postoperative period, that the indwelling catheter provided the only reliable method of assuring adequate exposure, and that a catheter would be necessary in the recording of intake-output. In fact, prompted by women’s dislike of the catheter as well as an increased incidence of postoperative urinary tract infection (UTI). (17) The potential sequelae of UTI include gram-negative bacteremia, antimicrobial toxicity, chronic bacteriuria and chronic renal disease. (18) In most cases the infection is mild and easily treated, but UTI is the commonest nosocomial infection and leads to increased morbidity and treatment costs. (18-20) Some North American studies addressing postoperative UTI have been confounded by the use of perioperative antibiotics, (17, 21) suggesting UTI rates of 3-10%, whereas British work has suggested a rate of 35% in control patients receiving no antibiotics. (22) It has been estimated that the risk of UTI associated with indwelling catheterization is 5-10% per day of catheterization (18) and that the commonest cause of UTI in hospital is urinary catheterization (23). Short-term catheterization has been associated with subsequent bacterial colony counts of > 105/ml of urine in 21% of women undergoing minor surgery, (24) and the incidence of positive urine cultures rises with the length of time catheterization is continued. (17, 18) In a randomized trial study for the effect of prophylactic antibiotics on the postoperative UTI in patients undergoing abdominal hysterectomy, Ireland et al found single dose cotrimoxazole is effective in reducing the incidence of postoperative UTI from 35% in the control group to 4% in the treated group. (25) Hakvoort et al studied whether prolonged urinary bladder catheterization after vaginal prolapse surgery is advantageous. (26) They found that residual volumes > 200 ml and need for recatheterization occurred in 9% in the 4 days catheterization group versus 40% of patients in the one day catheterization group (OR 0.15, 95% CI 0.045-0.47). Positive urine cultures were found in 40% of cases in the 4 days catheterization group versus 4% of patients in the one day catheterization group (OR 15, 95% CI 3.2-68.6). By contrast, in a prospective study of postoperative infection after abdominal and vaginal gynecological surgery, Kingdom et al reported 40% of 115 patients receiving no prophylactic antibiotics developed a UTI in the postoperative period and this was not clearly related to the need for postoperative catheterization. (25) Since prolonged indwelling urinary catheterization may be associated with an increased risk of UTI, increasing patient morbidity and potentially prolonging the hospital stay (18), prophylactic antibiotics and a reduction in catheter time or no catheter after surgery might be expected to reduce this risk.

Regarding the relationship of bladder catheterization with PUR, in published data of prospective or retrospective studies on PUR after abdominal or vaginal hysterectomy, we found that several factors of postoperative care affect the result of PUR including type of surgery, use of catheter, duration of catheterization, and postoperative analgesia. (16, 17, 25, 27-30) During 4-year period, Summitt et al have not used postoperative bladder catheter drainage after routine vaginal hysterectomy. (28) To assess the potential differences in postoperative outcome, they prospectively compared the use of indwelling bladder catheter drainage with no catheter use after standard vaginal hysterectomy. Their data showed 2 patients in the catheterized group required recatheterization after the catheters were removed; none in the no-catheter group required a catheter. The results inferred that indwelling catheterization appears unnecessary after routine vaginal hysterectomy. In a prospective randomized trial study, Dobbs et al compared the infection rate and postoperative morbidity between indwelling catheterization and in-out catheterization at the time of abdominal hysterectomy. (27) Of the 95 patients in their study, 36% of that undergoing in-out catheterization had PUR, requiring bladder emptying, compared with 4% of those receiving an indwelling catheter. In addition, 29% of the catheterized group had urinary tract bacteriuria compared with 13% of the uncatheterized group. They concluded that in-out urinary catheterization at the time of routine abdominal hysterectomy was associated with a significantly higher incidence of PUR compared with indwelling catheterization, and may have implications for long-term bladder function. (27) Dobbs et al also pointed out that abdominal muscular pain when the intra-abdominal pressure is increased during voiding coupled with the decreased sensation for voiding due to analgesia, suggests that an indwelling catheter in the immediate postoperative period will help to prevent long-term morbidity from bladder atony. Bodker and Lose presented the prevalence of PUR was 9.2% in their patients receiving gynecological surgery. (16) Of 124 patients undergoing abdominal hysterectomy, 13.7% had PUR. Of 24 patients undergoing laparoscopic assisted vaginal hysterectomy (LAVH), 8.7% had PUR. They concluded patients at risk of PUR are difficult to predict. The risk is higher after laparotomy than after laparoscopy. A retention rate of 13.7% after abdominal hysterectomy is fairly similar to that of 11.8% after gynecologic laparotomies reported by Schiotz, (29) Who used an indwelling Foley catheter routinely for 20-24 hours to ascertain the risks of UTI and aymptomatic bacteriuria. Based on 949 gynecologic laparotomies without the use of catheters but with bladder needling at the end of surgery, Bartzen and Halferty found that 26% needed catheterization. (17) They suggested that abstaining from the use of an indwelling catheter was also associated with lower cost and greater patient satisfaction.

With the advent of minimally invasive surgery, LAVH is currently advocated as an alternative to abdominal hysterectomy. Reported benefits of LAVH in short-term study, when compared with the abdominal hysterectomy, include shorter hospital stays and convalescence, less postoperative pain, lower morbidity, and, in some series, greater cost-effectiveness. (31-35) Whereas benefits of LAVH in long-term follow-up, only few studies have appeared in the literature. A report from Taiwan, Shen et al compared 1-month and 8-year follow-up of LAVH and abdominal hysterectomy. In their 8-year follow-up showed no statistically significant differences in vaginal vault prolapse, cystocele, rectocele, enterocele, postcoital bleeding, and cuff granulation between LAVH and abdominal hysterectomy procedures. (36) However, with regard to the consequences of PUR and UTI after LAVH, to our best knowledge, no study has been conducted to examine bladder catheterization is associated with this problem. Furthermore, no study has been performed to evaluate the long-term sequelae of PUR after LAVH.

Almost all women experience the side effect of having an infection after they have had a hysterectomy, and the most common infections after a hysterectomy are:

• Urinary tract infection
• Infection of any abdominal wounds.

Abdominal hysterectomy wound infections

According to Professor Patrick Duff, infections of the wound occur in approximately 3% of abdominal hysterectomies. Research suggests that the risk is increased by obesity, diabetes, immunodeficiency disorder, use of systemic corticosteroids, smoking, wound hematoma, and pre-existing infection such as pelvic inflammatory disease. Most wound infections take the form of what’s called an incisional abscess or cellulitis.

Typical signs of infection in the wound include:

• Increased pain, swelling, warmth, or redness around the site of any abdominal wound
• Red streaks or lines leading from the wound
• Pus and discharge draining from the wound
• Foul smells around the site of the wound
• Swollen lymph nodes in your neck, armpits, or groin
• High fever and raised temperature of 38ºC (100.4ºF) plus

Urinary tract infections

There are two types of urinary tract infection, also known as acute cystitis or bladder infection. An upper urinary tract infection involves the kidneys and ureters. A lower urinary tract infection usually involves the bladder and urethra and it is easy for one infection to spread to the other area. They are most commonly caused by the use of catheters following surgery.

Typical signs of a urinary tract infection include:

• A burning or itchy feeling when you urinate
• An increased need to urinate, even though little comes out when you do
• Pain or pressure in your back or lower abdomen
• Cloudy, dark, bloody, or strange-smelling urine
• An unusual or foul smell
• Feeling tired or shaky
• Low, dull backache around the kidney area
• High temperature of 38ºC (100.4ºF) plus
• Shivering
• Nausea (feeling sick) and/ or vomiting.

Treatment and self help

If you are suffering from any of these symptoms then it would be advisable to consult your GP. Treatment for both types of infection is usually with a course of antibiotics. Infections in an abdominal wound are often treated by draining the wound, covering it with a dressing which is bathed and changed at regular intervals until the infection subsides. You can help prevent infections in the wound by following the advice the hospital gives you about wound care.

Taking over the counter painkillers can help to reduce any aches and pains associated with urinary tract infections. Drinking plenty of water will help to reduce the effect of a urinary tract infection. Wearing cotton knickers and washing regularly with mild soap and water can also help to reduce discomfort. Some women may benefit from drinking cranberry juice or taking tablets with extract of cranberry as these have been shown to help prevent recurring infections. However, women taking anticoagulants such as Warfarin should avoid taking cranberrry juice or tablets as it may increase the risk of bleeeding.

(Image: Dried cranberries2 by Tiia Monto – Own work. Wikimedia Commons)

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Can I Prevent Frequent UTIs?

Q1. I am a 48 year old woman who had a hysterectomy a year and a half ago. I seem to get a lot of bladder infections now. I take antibiotics and it clears up. It seems that after having sex the infection starts again. What can I do to prevent this?

Frequent urinary tract infections are a common problem for women in the United States. An important area of consideration for recurrent urinary tract infection is whether there are anatomical abnormalities that could predispose you to infection. Any abnormality of bladder emptying that prevents complete expulsion of urine leaves residual urine, which increases the risk of developing a urinary tract infection. Some forms of hysterectomy, especially the radical techniques, can lead to incomplete bladder emptying, providing a setup for infection. Sometimes hysterectomy is accompanied by other procedures to lift up or correct bladder prolapse. These can also sometimes cause urine retention and can increase the risk for infection. The fact that you associate the onset of infection with sexual activity is not uncommon. The short length of the urethra in women makes it more likely that normal bacteria from the vagina will ascend up the urethra after sexual activity. As a precaution, it’s a good idea to empty your bladder after sexual activity to help flush out any bacteria that may have been introduced during sexual intercourse. Another strategy to prevent infection is the administration of a single dose of oral antibiotic immediately after sex. This needs to be done under the supervision of a physician. Interestingly, frequent bladder infections wax and wane so that over a year a woman may have many infections, but the following year have few. Finally, there are other causes of frequent infections, including kidney stones, foreign body material in the bladder, or other anatomical abnormalities of the urinary tract unrelated to hysterectomy. If you haven’t already, you might want to seek out an opinion from a urologist who focuses on female incontinence.

Q2. I am postmenopausal and am about to have a full hysterectomy. What do you suggest as an appropriate amount of time to be out of work? How long does it take to heal? I have a very stressful job that sucks the life out of me when I’m in good health, so I can’t imagine going back if I don’t feel 100 percent.

— Doreen, Massachusetts

Post-hysterectomy recovery depends on the type of hysterectomy that is being performed. If you are having a laparoscopic procedure, in which the uterus alone is being removed through tiny incisions in the abdomen, you should plan on staying several days in the hospital and at least four weeks at home before returning to work. If you are having a transabdominal surgery, with an incision of several inches below your navel (usually a bikini-line shape), and in which both your uterus and ovaries are being removed, you will be in the hospital for four to six days. You’ll probably require four to six weeks at home before you return to work.

Q3. Is a yearly pelvic exam still necessary after a hysterectomy? I had a complete hysterectomy in 1999. When I go for my yearly physical, should I be having a pelvic exam? One doctor I see says yes, but a physician’s assistant said I didn’t need one. What is your opinion?

Pelvic exams do serve a purpose even in post-hysterectomy women. Most important, if your cervix was not removed, you still need a yearly Pap smear to check for possible cervical cancer cells. But even if the cervix was removed with the rest of the uterus, the pelvic exam is a good way for your doctor to examine the pelvis internally for masses. There are (rarely) forms of gynecologic cancers that can arise even after the uterus and ovaries are removed. So while the most important part of the pelvic exam is the Pap smear, the internal examination is also useful, although not quite as necessary.

Q4. I have gained weight since I had a hysterectomy, and I cannot seem to lose it. I exercise every day; I try to eat right; and I have had my thyroid checked. What could be the cause of my inability to lose weight or budge from this plateau? What else can I do?

— Apryl, Missouri

Post-hysterectomy weight gain may be the result of hormonal changes that are associated with menopause. Often women will gain four to seven pounds at this time.

Although your diet and exercise regimen may be consistent, it seems that your metabolic rate has shifted. If you have had a complete medical exam and are sure there is no other explanation, here is my best advice:

  1. Increase your daily protein intake, and minimize your carbohydrate intake.
  2. Minimize or eliminate simple carbs with a high glycemic index — model your diet after a South Beach-type diet.
  3. Emphasize weight lifting to build your muscle mass.
  4. Be sure your cardio exercise is sufficient — it should get your heart rate into the target zone for at least 40 minutes three to four times a week.

These changes should help with the weight loss. If they don’t, you might try consulting a weight-loss expert and a nutritionist.

Q5. I have horrific period pains, and I have tried everything. What are the side effects or consequences if I decide to remove my uterus? Is there anything I should be concerned about? What can I expect afterward?

Hysterectomy is an option for period-related pain if other options fail. However, often taking the pill, nonsteroidal anti-inflammatory agents (such as Advil, Aleve, or a product made especially for periods like Midol), or other medications can lessen period-related pain. It is also important for your doctor to do tests and make sure that this pain is not related to fibroids or endometriosis, both of which have their own treatment options.

If you do choose to have a hysterectomy, keep in mind that the side effects include those related to the surgery, namely recovery from laparoscopy. These side effects can include postoperative pain, difficulty in the first days with bowel function, and longer recovery time in general. When you’re getting your uterus removed, you can also choose to have your ovaries removed at the same time. Depending on your age, the decision to remove or keep your ovaries is an important one because it will determine whether you will go through menopause as a result of your hysterectomy. Be sure to discuss this with your doctor.

Learn more in the Everyday Health Women’s Health Center.

Hysterectomy

Hysterectomy is a surgical method in which the uterus of a woman is removed. Sometimes, the ovaries and fallopian tubes are also removed.

The uterus, also referred to as the womb, is where a baby grows inside their mother.

Once a woman has had a hysterectomy, she will no longer menstruate and cannot become pregnant.

Indications

Your doctor may suggest you undergo a hysterectomy if you have the following conditions

  • Uterine fibroids
  • Endometriosis not cured by medicine or surgery
  • Uterine prolapse – when the uterus descends into the vagina
  • Cancer of the uterus, cervix, or ovaries
  • Vaginal bleeding that continues despite treatment
  • Chronic pelvic pain

Types of Hysterectomies include Partial, Total or Radical Hysterectomy.

  • Partial or supra-cervical hysterectomy is where the upper part of the uterus is removed, but the cervix is left in place.
  • Total hysterectomy involves removal of both the uterus and cervix. Radical hysterectomy is usually done in cases of cancer and involves removal of the uterus, tissue on the sides of the uterus, upper part of the vagina, and the cervix.

Salpingo-oophorectomy may be performed along with hysterectomy in cases of cancer or infection. It is a procedure in which the fallopian tube and ovary on one side of the uterus are removed.

Bilateral oophorectomy is where the fallopian tubes and ovaries on both sides of the uterus are removed. This results in menopause right away from the sudden drop in hormone levels.

There are various ways to perform hysterectomy:

  • Abdominal hysterectomy is where the incision is made through the skin and tissue in the lower abdomen to reach the uterus.
  • Laparoscopic hysterectomy uses a laparoscope to guide the surgery. Laparoscope is a thin, lighted tube that is inserted into the abdomen through a tiny incision in or around the umbilicus (belly button) which allows the surgeon to view the internal pelvic organs on a monitor.
  • Total laparoscopic hysterectomy is a method where the uterus is separated from inside the body and then removed in small pieces either through tiny incisions or through the vagina.
  • Laparoscopic assisted vaginal hysterectomy uses a laparoscope to guide the surgery and the uterus is removed through the vagina.
  • Robot-assisted laparoscopic hysterectomy uses a robot attached to instruments to help perform the surgery through tiny incisions with a laparoscope.
  • Vaginal hysterectomy is a method where the uterus is removed through the vagina. As the incision is made inside the vagina, healing time may be less than with abdominal surgery.

Post-operative care:

Your recovery depends on the type of surgery performed and the progress of your healing. You will be prescribed pain medications to keep you comfortable and antibiotics to prevent infection.

You will be instructed to get adequate rest and avoid heavy lifting after your surgery. You can continue normal activities once the pain, bleeding, and abdominal pressure have resolved. Sexual activity can be resumed after about six weeks following surgery. Exercises should be avoided until 3 weeks after surgery.

Recovery and return to activities of daily living is earlier in cases of women who have undergone vaginal hysterectomy when compared to women who have undergone abdominal hysterectomy. Generally it takes around 4-6 weeks for complete healing from an abdominal hysterectomy and about 3-4 weeks recovery from vaginal hysterectomy.

Most women recover without any complications from the surgery. However, Risks and Complications associated with Hysterectomy surgery can include the following:

  • Infection
  • Bleeding
  • Blood clots
  • Urinary incontinence: loss of bladder control
  • Vaginal prolapse: a condition in which the vagina protrudes from the vaginal opening.
  • Chronic pain
  • Bladder or ureter injury
  • Painful intercourse
  • Early menopause if ovaries were removed

Call your doctor if you experience any of the following signs:

  • heavy vaginal bleeding
  • pain, redness, swelling, or discharge around the incisions
  • fever over 101° F
  • nausea and vomiting
  • Shortness of breath

Hysterectomy is a common gynecological procedure involving the removal of the uterus. Once a hysterectomy has been performed, the woman will no longer menstruate or be able to become pregnant. If the ovaries are also removed, menopause will occur. Discuss any concerns you may have with your doctor.

This week, a patient came in reporting two awful urinary tract infections that she had this summer while traveling on vacation. She is in her 50s, postmenopausal, and fit and healthy. After having sex with her partner, she woke up with burning and pain with urination. She was treated for a urinary tract infection with antibiotics and felt better in a few days. She did fine for two weeks until they had sex again, when the same symptoms returned. Although antibiotics worked again, and quickly, at this point she felt consumed by the whole thing. She was unable to enjoy her vacation, and she was afraid to have sex. It took several weeks before she felt normal “down there.”

If this sounds familiar, then you may be suffering from recurrent urinary tract infection (UTI). Recurrent UTIs are defined as either three episodes of infection in the previous 12 months or two episodes in the previous 6 months.

Recurrent UTIs are common among both young healthy women and healthy women at midlife. Here’s why. There are many types of bacteria that normally live in the vagina and happily coexist. And they keep each other in check, like a mini-ecosystem. The hormone estrogen allows the “good” bacteria called Lactobacillus to thrive. These bacteria produce acid, which lowers the pH in the vagina, which helps keep the “bad” bacteria in check.

For younger women, frequent sex is one of the biggest risk factors for a UTI. Sexual intercourse can cause the bacteria in the vagina and rectum to get into the urinary tract, since they are close neighbors. But at midlife, the main culprits behind recurrent UTIs are physical changes, including thinning of vaginal tissue, pelvic organ prolapse, incontinence, and trouble completely emptying the bladder. The lower levels of estrogen after menopause are also a factor.

There are effective prevention strategies for healthy women at midlife who are struggling with recurrent UTIs. A good place to start is with urination habits. When sitting on the toilet, make yourself as comfortable as possible in a relaxed seated position (not squatting). Start the stream of urine by relaxing the pelvic floor muscles, rather than straining to urinate. Allow enough time for your bladder to completely empty. Also empty your bladder after intercourse. This can help wash away any bacteria that might have been introduced into the urinary tract during sex. Some studies suggest that cranberry extracts can help prevent UTIs by decreasing the “stickiness” of the bacteria. I prefer cranberry supplements to cranberry juice, which tends to be very high in sugar and calories.

Vaginal estrogen creams or rings can help restore the normal bacterial balance of the vagina. Ask your doctor about taking antibiotics preventively, either after sex, or regularly at a low dose. Your doctor can also check to see if you have pelvic organ prolapse, which can be associated with an inability to fully empty your bladder.

Take charge of your bladder health, and don’t let recurrent UTIs get in the way of your active lifestyle. If you are struggling with recurrent UTIs, see your doctor for a thorough check-up — and know that this condition is both entirely preventable and easily treatable.

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