A 58-year-old woman, gravida 2 para 2, comes to the office for evaluation of increased urinary frequency and painful urination. The patient developed these symptoms 2 days ago, and they did not improve despite increasing fluid intake and voiding regularly. She has had 2 other episodes of acute simple cystitis in the past 8 months, which resolved with antibiotics. The patient underwent menopause at age 53 and has had no episodes of postmenopausal bleeding. BMI is 28 kg/m². Vital signs are normal. Physical examination shows mild suprapubic tenderness and no costovertebral tenderness. Pelvic examination shows thin vulvar tissue but no excoriations or lesions. Urinalysis is positive for leukocyte esterase and nitrites. The patient is prescribed a course of antibiotics and is asymptomatic a week later. Which of the following is the best next step in management of this patient's symptoms?

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Quizplus · Accepted Answer

Explanation: 11ec25c8_d97e_42e2_bc81_7b6308b24785_MD0003_00 This patient has recurrent urinary tract infections (UTI), defined as ≥3 episodes in a year (or ≥2 episodes in 6 months) of simple cystitis (eg, leukocyte esterase and nitrites on urinalysis with no costovertebral tenderness). Women are at increased risk for cystitis due to the proximity of the urethra to the vagina and rectum. In postmenopausal women, the risk increases further due to estrogen deficiency, which causes: vulvovaginal atrophy (eg, thin vulvar tissue). decreased bulk and elasticity of the bladder trigone and urethra, resulting in an increased risk for ascending infection. decreased vaginal lactobacilli levels and an elevated vaginal pH, leading to an increased rate of vaginal Escherichia coli colonization. Therefore, in addition to behavioral changes (eg, increased fluid intake), treatment of postmenopausal women with recurrent UTI is with topical vaginal estrogen. Topical estrogen can improve genitourinary atrophy and prevent future UTI episodes. In addition to vaginal estrogen, antibiotic prophylaxis (daily or postcoital) can be considered. (Choices A and E) Cystoscopy and urine cytology can evaluate for bladder cancer, which may present with recurrent UTIs; however, bladder cancer is typically associated with gross hematuria or red blood cells on urinalysis, which are not seen in this patient. In addition, she has no significant risk factors (eg, tobacco use, prior pelvic radiation). (Choice B) Daily probiotic consumption has not been shown to increase vaginal Lactobacillus colonization or decrease the risk of recurrent cystitis. (Choice C) Pelvic ultrasonography may be indicated in patients with abnormal uterine bleeding (eg, postmenopausal bleeding) or a pelvic mass; it is not used to evaluate recurrent cystitis. (Choice D) Topical corticosteroids can treat vulvar lichen planus and lichen sclerosus, which may present in postmenopausal patients with dyspareunia and atrophic vulvar tissue. However, patients typically have visible lesions (ie, plaques) or excoriations due to vulvar pruritus, which are not seen in this patient. lichen planus Educational objective: Recurrent urinary tract infections (≥3 episodes in a year or ≥2 episodes in 6 months) commonly occur in postmenopausal patients due to estrogen deficiency, which causes vulvovaginal atrophy, decreased bulk and elasticity of the bladder trigone and urethra, and increased vaginal pH. Treatment is with vaginal estrogen. References: Genitourinary syndrome of menopause: an overview of clinical manifestations, pathophysiology, etiology, evaluation, and management. (http://www.ncbi.nlm.nih.gov/pubmed/27472999)

A 58-Year-Old Woman, Gravida 2 Para 2, Comes to the Office