Hormonal Approach for Postmenopausal Vulvovaginal Atrophy

Menopause is a physiological and progressive phenomenon secondary to decreased ovarian follicular reserve that significantly affects the genital tract. Although postmenopausal vulvovaginal atrophy primarily affects postmenopausal women, it is also seen in premenopausal women. The hypoestrogenic condition results in hormonal and anatomical changes, with the main symptoms, are dryness, burning and genital irritation, decreased lubrication, urinary urgency, dysuria, and recurrent urinary tract infections. This review aims to update hormone therapy for urogenital atrophy, both local and systemic, and discusses the importance of understanding and the need for active treatment of this condition. The main therapeutic objective is the relief of symptoms, and hormonal therapy (HT) is still the most effective choice for treating clinical manifestations, despite the side effects of its use. HT should be used in an individualized way to the needs of the women and appropriate to the stage in which she is menopausal, perimenopausal, or after menopause.

Chronic bladder diseases: overactive bladder and interstitial cystitis/bladder pain syndrome

Background: Overactive bladder (OAB) and interstitial cystitis/bladder pain syndrome (IC/BPS) are debilitatingchronic bladder diseases that affect patients’ quality of life. Their etiologies and clinical phenotypes vary, and management strategies should be selected after excluding the possibilities of other pathological conditions with careful consideration of a multidisciplinary integrated approach to ensure optimal success.Current Concepts: OAB is a symptom complex characterized by urinary urgency and frequency and nocturia with or without urge incontinence, and its key symptom is urinary urgency. IC/BPS has symptoms similar to lower urinary tract symptoms (LUTS) associated with OAB but also has distinctly different symptoms, including the key symptom of an unpleasant sensation or pain perceived to be related to the urinary bladder associated with LUTS. Recent studies have revealed that these key symptoms of OAB or IC/BPS are also observed in some patients with other diseases. Patients showing no evidence of bacterial infection on urine culture and experiencing LUTS or pain for more than 6 weeks should be considered as having OAB or IC/BPS. Treatment strategies for OAB and IC/BPS focus on managing LUTS and bothersome pain. Noninvasive management should be considered initially, whereas surgical options should be considered only after conservative treatment failure.Discussion and Conclusion: OAB and IC/BPS symptoms overlap considerably in many patients. A more accurate differentiation of symptoms, including LUTS, would help achieve better treatment outcomes.

A Woman With Progressive Gait Difficulty and White Matter Abnormalities

A 45-year-old woman was assessed for slowly progressive gait difficulty. Eight years earlier, she first noticed dragging of her right foot and stumbling on uneven surfaces. She also described difficulty bending the right knee and intermittent spasms of the right leg. She reported bilateral, mild hand weakness when she was doing repetitive tasks such as using scissors. She reported increasing urinary urgency and frequency over the past 3 years. Magnetic resonance imaging of the spinal cord showed continuous, relatively symmetric, T2 hyperintensity of the dorsal columns and, to a lesser extent, the lateral columns, as well as medullary pyramids. Brain magnetic resonance imaging showed T2 hyperintensity in the corticospinal tracts bilaterally extending from the precentral gyrus through the corona radiata and again seen in the pons. Review of the magnetic resonance imaging pattern of white matter abnormalities led to specific clinical suspicion for leukoencephalopathy with brainstem and spinal cord involvement and lactate elevation, an autosomal recessive condition due to DARS2 gene sequence variation. Brain magnetic resonance spectroscopy did not show lactate peaks. Genetic testing findings were abnormal and showed compound heterozygous DARS2 sequence variations. The presence of DARS2 sequence variations confirmed the diagnosis of leukoencephalopathy with brainstem and spinal cord involvement and lactate elevation. The patient was counseled that gradual progression of her gait difficulties could be expected. The following year she reported increasing urinary urgency and several episodes of urge incontinence. She was referred to the urology clinic. Leukoencephalopathy with brainstem and spinal cord involvement and lactate elevation is a leukodystrophy that most commonly presents clinically with spasticity, dorsal column dysfunction, cerebellar ataxia, and sometimes mild cognitive decline. Leukoencephalopathy with brainstem and spinal cord involvement and lactate elevation classically has a childhood onset and therefore may not be included in the differential diagnosis of chronic progressive white matter disease in adults.

Urinary urgency acts as a source of divided attention leading to changes in gait in older adults with overactive bladder

Aims There is a well-recognised but unexplained association between lower urinary tract symptoms including urgency and urgency incontinence and falls in older people. It has been hypothesised that urinary urgency acts as a source of divided attention, leading to gait changes which increase falls risk. This study aimed to assess whether urinary urgency acts as a source of divided attention in older adults with overactive bladder (OAB). Methods 27 community-dwelling adults aged 65 years and over with a clinical diagnosis of OAB underwent 3-Dimensional Instrumented Gait Analysis under three conditions; bladder empty, when experiencing urgency, and when being distracted by the n-back test. Temporal-spatial gait and kinematic gait data were compared between each condition using repeated measures ANOVA. Results Gait velocity decreased from 1.1ms-1 in the bladder empty condition to 1.0ms-1 with urgency and 0.9ms-1 with distraction (p = 0.008 and p<0.001 respectively). Stride length also decreased, from 1.2m to 1.1m with urgency and 1.0m with distraction (p<0.001 for both). The presence of detrusor overactivity did not influence these results (p = 0.77). Conclusions In older adults with OAB, urinary urgency induced similar changes in gait to those caused by a distracting task. These gait changes are associated with increased fall risk. This may be part of the explanation for the association between falls and lower urinary tract symptoms in older people. Future research should examine the effect of pharmacological treatment of OAB on gait and on the effect of dual-task training on gait when experiencing urgency.

Staghorn Calculus: A Stone out of Proportion to Pain

Case Presentation: A 25-year-old woman presented to the emergency department with two weeks of crampy right-flank pain, and urinary urgency and frequency. She was found to have a staghorn calculus filling her entire right renal pelvis on computed tomography imaging. Discussion: In contrast to ureteral calculi, staghorn calculi are more commonly observed in female patients and typically present with an indolent clinical course. A low threshold for imaging should be maintained, as prompt referral to urology for stone removal or treatment is necessary. Staghorn calculi have a high likelihood of leading to renal failure or urosepsis without treatment.

Benign masses of the female paraurethral region

Introduction. Benign female paraurethral masses (BFPM) are not often found during practice. This is due to the small size of the BMP and the low specificity and effectiveness of imaging techniques (urethrocystography, ultrasound, computed tomography).Purpose of the study. To determine the frequency and structure of female BMP.Materials and methods. We conducted a retrospective analysis of the female medical records (n = 5,112) who went to the urologist in 2018 with complaints of a frequent and painful urination. In this population, 92 (1.79%) patients were diagnosed with BFPM.Results. In the structure of BFPM, the most common is urethral diverticulum -57 (61.9%) and paraurethral cyst - 24 (26%). In other cases, we identified a urethral polyp and leiomyoma in 7 (7,6%) и 4 (4,5%) of cases, respectively. The average womens' age who were diagnosed with was 29.2 ± 7.3 years. BFPM were detected most often in women aged 26 to 35 years (48.9%). All patients complained of frequent urination. We have recorded the following complaints as well: feeling of a foreign body in the perineum - 77.1%, imperative urinary urgency - 64.1%, perineal pain - 28.2%, dyspareunia - 26%, difficulty urinating - 14.1%. The above-mentioned complaints were noted within 1 year by more than half of women (72.8%).Conclusions. BFPM were diagnosed in 1.79% of women. Of these, 2/3 of cases were urethral diverticula, and % of cases were paraurethral cyst. The diagnosis of BFPM should be comprehensive and combine examination, palpation and instrumental (ultrasound, urethrocystoscopy, MRI) diagnosis of the urethral region.