probe produces a contraction of the levator ani muscle. Cure or improvement in 48 percent of treated patients, compared with 13 percent of control subjects.

D.Occlusive devices, such as pessaries, can mimic the effects of a retropubic urethropexy. A properly fitted pessary prevents urine loss during vigorous coughing in the standing position with a full bladder.

E.Medications such as estrogens and alpha-adrenergic drugs may also be effective in treating women with stress incontinence. Stress incontinence may be treated with localized estrogen replacement therapy (ERT). Localized ERT can be given in the form of estrogen cream or an estradiol-impregnated vaginal ring (Estring).

Medications Used to Treat Urinary Incontinence

F.Alpha-adrenergic drugs such as pseudoephedrine improve stress incontinence by increase resting urethral tone. These drugs cause subjective improvement in 20 to 60 percent of patients.

G.Surgery to correct genuine stress incontinence is a viable option for most patients. Retropubic urethropexies (ie, Burch laparoscopic and Marshall-Marchetti-Krantz [MMK] procedures) and suburethral slings have long-term success rates consistently reported in the 80 to 96 percent range.

H.Another minimally invasive procedure for the treatment of stress incontinence caused by intrinsic sphincter deficiency is periurethral injection.

I.Overactive bladder

1.Behavioral therapy, in the form of bladder retraining and biofeedback, seeks to reestablish cortical control of the bladder by having the patient ignore urgency and void only in response to cortical signals during waking hours.

2.Pharmacologic agents may be given empirically to women with symptoms of overactive bladder. Tolterodine (Detrol) and extended-release oxybutynin chloride (Ditropan XL) have largely replaced generic oxybutynin as a first-line treatment option for overactive bladder because of favorable side effect profiles. Oxybutynin transdermal may cause less dry mouth than the oral formulation.

3.ERT is also an effective treatment for women with overactive bladder. Even in patients taking systemic estrogen, localized ERT (ie, estradiol-impregnated vaginal ring) may increase inadequate estrogen levels and decrease the symptoms associated with overactive bladder.

4.Pelvic floor electrical stimulation is also effective in treating women with overactive bladder. Pelvic floor electrical stimulation results in a 50 percent cure rate of detrusor instability.

5.Neuromodulation of the sacral nerve roots through electrodes implanted in the sacral foramina is a promising new surgical treatment that has been found to be effective in the treatment of urge incontinence.

6.The FDA has recently approved extracorporeal magnetic innervation, a noninvasive procedure for the treatment of incontinence caused by pelvic floor weakness.

Extracorporeal magnetic innervation may have a place in

the treatment of women with both stress and urge incontinence.

References: See page 155.

Urinary Tract Infection

Urinary tract infections (UTIs) are a leading cause of morbidity in persons of all ages. Sexually active young women, elderly persons and those undergoing genitourinary instrumentation or catheterization are at risk.

I.Acute uncomplicated cystitis in young women

A.Sexually active young women are most at risk for UTIs.

B.Approximately 90 percent of uncomplicated cystitis episodes are caused by Escherichia coli, 10 to 20 percent are caused by coagulase-negative Staphylococcus saprophyticus and 5 percent or less are caused by other Enterobacteriaceae

organisms or enterococci. Up to one-third of uropathogens are resistant to ampicillin and, but the majority are susceptible to trimethoprim-sulfamethoxazole (85 to 95 percent) and fluoroquinolones (95 percent).

C.Patients should be evaluated for pyuria by urinalysis (wet mount examination of spun urine) or a dipstick test for leukocyte esterase.

Urinary Tract Infections in Adults

Antibiotic Therapy for Urinary Tract Infections

Pubic Infections

I.Molluscum contagiosum

A.This disease is produced by a virus of the pox virus family and is spread by sexual or close personal contact. Lesions are usually asymptomatic and multiple, with a central umbilication. Lesions can be spread by autoinoculation and last from 6 months to many years.

B.Diagnosis. The characteristic appearance is adequate for diagnosis, but biopsy may be used to confirm the diagnosis.

C.Treatment. Lesions are removed by sharp dermal curette,

liquid nitrogen cryosurgery, or electrodesiccation.

II.Pediculosis pubis (crabs)

A.Phthirus pubis is a blood sucking louse that is unable to survive more than 24 hours off the body. It is often transmitted sexually and is principally found on the pubic hairs. Diagnosis is confirmed by locating nits or adult lice on the hair shafts.

B.Treatment

1.Permethrin cream (Elimite), 5% is the most effective treatment; it is applied for 10 minutes and washed off.

2.Kwell shampoo, lathered for at least 4 minutes, can also be used, but it is contraindicated in pregnancy or lactation.

3.All contaminated clothing and linen should be laundered.

III.Pubic scabies

A.This highly contagious infestation is caused by the Sarcoptes scabiei (0.2-0.4 mm in length). The infestation is transmitted by intimate contact or by contact with infested clothing. The female mite burrows into the skin, and after 1 month, severe pruritus develops. A multiform eruption may develop, characterized by papules, vesicles, pustules, urticarial wheals, and secondary infections on the hands, wrists, elbows, belt line, buttocks, genitalia, and outer feet.

B.Diagnosis is confirmed by visualization of burrows and observation of parasites, eggs, larvae, or red fecal compactions under microscopy.

C.Treatment. Permethrin 5% cream (Elimite) is massaged in

from the neck down and remove by washing after 8 hours.

References: See page 155.

Sexually Transmissible Infections

Approximately 12 million patients are diagnosed with a sexually transmissible infection (STI) annually in the United States. Sequella of STIs include infertility, chronic pelvic pain, ectopic pregnancy, and other adverse pregnancy outcomes.

Diagnosis and Treatment of Bacterial Sexually Transmissible Infections