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oxybutynin chl oride (D itropan X L) have l argely
replaced genericox ybutyninasa first-line treatment
optionforoveracti vebl adderbecauseof favorable
sideeffectprofi les.
3. ERT i s al so an effective treatm ent for w omen w ith
overactivebl adder.E veni npati entstak ingsy stemic
estrogen, localizedE RT(i e, estradiol-impregnated
vaginal ri ng) m ay i ncrease inadequate estrogen
levels and decreasethesy mptomsassoci ated with
overactivebl adder.
4. Pelvicfl oorel ectrical stimulationi sal soeffecti vei n
treatingw omenw ithoveracti vebl adder.P elvic floor
electrical stimulation resul ts i n a 50 percent cure
rateo fd etrusorin stability.
5. Neuromodulation of thesacral nerverootsthrough
electrodes i mplanted i n the sacral foram ina i s a
promising n ew su rgical t reatment t hat h as been
foundtobeeffecti vei nthetreatm entofurgei ncon
tinence.
6. The FD A has recentl y approved ex tracorporeal
magnetic innervation,anoni nvasiveprocedurefor
thetreatm entofi ncontinencecausedby pelvicfl oor
weakness. E xtracorporeal m agnetic i nnervation
mayhave a place i n the treatm ent of w omen w ith
bothstressandurgei ncontinence.
References:S eepage166.
UrinaryT ractInfection
Urinarytracti nfections(U TIs)areal eading cause of morbid
ity i n persons of al l ages. S exually active y oung w omen,
elderly persons and th ose undergoi ng geni tourinary i nstru
mentationorcatheteri zationareatri sk.
I. Acuteu ncomplicatedcy stitisin y oungwo men
A. Sexuallyacti vey oung women are most atri skforU TIs.
B. Approximately 90 percent of uncom plicated cy stitis
episodes are caused by E scherichia c oli, 10 to 20
percent are caused by coagulase-negative S taphylo
coccussaprophy ticusand5percentorl essarecaused
byother Enterobacteriaceaeorgani smsorenterococci .
Up to one-thi rd of uropathogens are resi stant to
ampicillin and, but the m ajority are suscepti ble to
trimethoprim-sulfamethoxazole (85 to95percent)and
fluoroquinolones(95percent).
C. Patients shoul d be eval uated fo r pyuria by uri nalysis
(wetm ountex aminationof spun urine) or adi psticktest
forl eukocyteesterase.
UrinaryT ractIn fectionsin A dults
Cate Diag First-lin Comments
gory nostic ether
criteria apy
Acute Urinaly TMP-SM Three-daycoursei s
uncom sisfor XD S best
plicate pyuria (Bactrim Quinolonesm aybe
dcy sti and ,S eptra) usedi nareasof
tis hema Trimetho TMP-SMXr esistance
turia prim ori npati entsw ho
(culture (Prolopri cannottol erate
notre m) TMP-SMX
quired) Ciproflox
acin
(Cipro)
Ofloxaci
n
(Floxin)
Recur Symp Ifthe Repeattherapy for
rent toms patient sevento10day s
cystitis anda has basedoncul turere
in urine more sultsandthenuse
young culture than prophylactictherapy
women witha three
bacterial cystitis
countof episodes
more pery ear,
than100 treat
CFUp er prophy
mLo f lactically
urine with
postcoita
l,pa
tient
directed
orcon
tinuous
daily
therapy
Acute Urine Samea s Treatforsevento10
cystitis culture foracute days
in witha uncom
young bacterial plicated
men countof cystitis
1,000to
10,000
CFUp er
mLo f
urine
Cate Diag First-lin Comments
gory nostic ether
criteria apy
Acute Urine If Switchfrom I Vtooral
uncom culture gram-ne administrationw hen
plicate witha gative thepati enti sabl eto
d bacterial organ takem edicationby
pyelo countof ism,oral mouth;com pletea
neph 100,000 fluoroqui 14-daycourse
ritis CFUp er nolone
mLo f If
urine gram-po
sitive
organ
ism,
amoxi
cillin
If
parenter
alad
ministra
tioni s
required,
ceftri
axone
(Rocephi
n)ora
fluoroqui
nolone
If
Enteroco
ccus
species,
addoral
orI V
amoxicill
in
Com Urine If Treatfor10to14
plicate culture gram-ne days
duri witha gative
nary bacterial organ
tract countof ism,oral
infec more fluoroqui
tion than nolone
10,000 If
CFUp er Enteroco
mLo f ccus
urine species,
ampi
cillino r
amoxi
cillinw ith
orw ith
outgent
amicin
(Gara
mycin)
Cathe Symp If Removecatheteri f
ter-ass toms gram-ne possible,andtreatfor
ociated anda gative sevento10day s
urinary urine organ Forpati entsw ith
tract culture ism,a long-termcatheters
infec witha fluoro andsy mptoms,treat
tion bacterial quinolon forfivetosevenday s
countof e
more If
than100 gram-po
CFUp er sitive
mLo f organ
urine ism,
ampi
cillino r
amoxi
cillin
plus
genta
micin
AntibioticTher apyfor U rinaryTr actInfections
Diagnostic Dura Empiricopti ons
group tionof
ther
apy
Acuteun Three
complicated days Trimethoprim-sulfamethoxa
urinarytract zole( BactrimDS) ,o ne
infectionsin double-strengthtabl etP O
women twiced aily
Trimethoprim(P roloprim),
100m gP Otw icedai ly
Norfloxacin(N oroxin),400
mgtw iced aily
Ciprofloxacin( Cipro),2 50
mgtw iced aily
Lomefloxacin(M axaquin),
400m gperday
Ofloxacin(Fl oxin),200m g
twiced aily
Enoxacin(P enetrex),200m g
twiced aily
Sparfloxacin(Zagam ),400
mgasi nitialdose,then200
mgperday
Levofloxacin(Levaqui n),250
mgperday
Nitrofurantoin(M acrodantin),
100m gfourti mesdai ly
Cefpodoxime(V antin),100
mgtw iced aily
Cefixime(S uprax),400m g
perday
Amoxicillin-clavulanate(Au
gmentin),500m gtw ice
daily
Acuteun 14
complicated days Trimethoprim-sulfamethoxa
pyelonephrit zoleD S,onedou
is ble-strengthtabl etP O
twiced aily
Ciprofloxacin( Cipro),5 00
mgtw iced aily
Levofloxacin(M axiquin),250
mgperday
Enoxacin(P enetrex),400m g
twiced aily
Sparfloxacin(Zagam )400
mgi nitialdose,then200
mgperday 104.50
Ofloxacin(Fl oxin),400m g
twiced aily
Cefpodoxime(V antin),200
mgtw iced aily
Cefixime(S uprax),400m g
perday
Upto3
days Trimethoprim-sulfamethoxa
zole(B actrim)160/800I V
twiced aily
Ceftriaxone(R ocephin),1g
IVperday
Ciprofloxacin( Cipro),4 00
mgtw iced aily
Ofloxacin(Fl oxin),400m g
twiced aily
Levofloxacin(P enetrex),250
mgperday
Aztreonam(A zactam),1g
threeti mesdai ly
Gentamicin(Garam ycin),3
mgperk gperday i n3di
videddosesevery 8hours
Compli 14 FluoroquinolonesP O
cateduri days
narytract
infections
Upto3 Ampicillin,1 g I Ve verysix
days hours,andgentam icin,3
mgperk gperday
Urinarytract Seven
infectionsin days Trimethoprim-sulfamethoxa
youngm en zole,onedoubl e-strength
tabletP Otw icedai ly
Fluoroquinolones
D. Treatmentofacuteuncom plicatedcy stitisiny oung
women
1. Three-day regimens appear to offer the opti mal
combination of conveni ence, l ow cost and an
efficacyc omparable to that of seven-day or l onger
regimens.
2. Trimethoprim-sulfamethoxazole is the m ost
cost-effective treatm ent. T hree-day regimens of
ciprofloxacin (C ipro), 250 m g twice dai ly, and
ofloxacin (Floxin), 200 m g tw ice dai ly, produce
bettercureratesw ithlesstox icity.
3. Quinolones that are useful i n treati ng com plicated
and uncom plicated cy stitis i nclude ci profloxacin,
norfloxacin, ofloxacin, enox acin (P enetrex),
lomefloxacin (Maxaquin),sparfl oxacin(Zagam )and
levofloxacin(Levaqui n).
4. Trimethoprim-sulfamethoxazolerem ainstheanti bi
otic of choi ce i n the treatm ent of uncom plicated
UTIsi n young women.Fl uoroquinolonesarerecom
mended for pati ents w ho cannot tol erate sul fona
mides ortri methoprimorw hohave a high frequency
of anti biotic resi stance. T hree day s i s the op timal
duration of treatm ent for uncom plicated cy stitis. A
seven-daycourseshoul dbeconsi deredi npregnant
women,di abeticw omenandw omen whohavehad
symptomsform orethanonew eek.
II. Recurrentcy stitisin y oungwo men
A. Up to 20 percent of y oung w omen w ith acute cy stitis
develop recurrent U TIs. T he causa tive organi sm
shouldbei dentifiedby uri necul ture.
B. Women w ho have m ore than three U TI recurr ences
within one y ear ca n be m anaged usi ng one of three
preventivestrategi es.
1. Acute sel f-treatment w ith a three-day course of
standardtherapy .
2. Postcoital prophy laxis with one-hal f of a
trimethoprim-sulfamethoxazole double-strength
tablet(40/200m g).
3. Continuous dai ly prophy laxis for si x m onths w ith
trimethoprim-sulfamethoxazole,one-hal ftabl etper
day (40/200 m g); ni trofurantoin, 50 to 100 m g per
day; norfl oxacin (Noroxin), 200 m g per day ;
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