Recurrent urinary infection (DLI) is a fairly common disease. The occurrence, pathogenesis and treatment of DLI depend on the gender and age of the patient. Treatment of urinary tract infections (UTI) are best discussed separately, particularly highlighting the special risk group of patients – women before menopause.
WOMEN BEFORE MENOPAUSE
At least 1/3 of women suffer acute uncomplicated UTIS and most of them onset of the disease occurs at the beginning of the period of maturity after puberty. It is now known that the bacteria that cause urinary tract infection these women develop from the fecal microflora. Sexual activity is the main risk factor for clinically significant UTI, the degree of risk depends on sexual practices, and the frequency and regularity of sexual acts. The period of 48 hours after vaginal intercourse is the highest risk period. The use of oral contraceptives, urination before intercourse, frequency of wash, the direction of movement toilet paper after defecation, the use of tampons – all this does not affect the value of risk of development of UTI. Urinating after intercourse seems to reduce the risk of UTI. The use of diaphragms increases the risk of bacteriuria, but not clinically significant UTI.
Approximately 20% of women with one episode of UTI in pleasem relapses of infection.Sensitivity to DLI is mainly determined pathologically large quantity of faecal bacteria on the mucous membrane of the vagina and urethra.
In recurrent UTI indecisive, incomplete therapy of infection, persistent bacteriuria are not the main problem. The reason for the failure of drug therapy in most cases is the resistance of certain bacteria.
If bacteriuria persists continuously and UTI recurs, the reason for this is continued in the body of the patient infection or reinfection. Save infection is the recurrence of UTIS from the center within the urinary tract, In women, the preservation of infection may be due to stones, fistula, diverticulum, other relatively rare malformations of the urogenital system. Reinfection, in turn, arises from the hearth and not associated with the urinary system. Among the factors that contribute to the occurrence of RMI in women, reinfection is more common than persistence of infection. This is not surprising if we take into account the length of the urethra in women and the proximity of the external opening of the urethra to infected vaginal mucosa.
INFORMATION GATHERING AND DIAGNOSTICS
Approximately 20-40% of women with clinically significant IMP the number of bacteria in the urine is less than 105/ml In patients with dysuria a more appropriate threshold for determining significant bacteriuria is considered as 102/ml of a known pathogen in a urine sample obtained by catheter. When DLI this pathogen most often is E. coli. When screening observations the analysis of the urine almost always reveals a marked pyuria, allowing physicians to begin the initial therapy. Urine tests also help to ofdifferential DLI nevospalitelnoe from other factors that cause symptoms of dysuria in women.
Indications for urologic imaging studies and cystoscopy in women before menopause is not completely clear and depend on views on the treatment of this pathological condition adheres to the attending physician, and from information about a specific patient. Typical recurrence due to reinfection is often the result of sexual intercourse and is etiologically associated with E. Coli. Atypical circumstances are considered to be infection with pathogens, decomposing urine, obstructive symptoms associated with urination, and a sign of involvement in the upper urinary tract, such as pain on the lateral surface of the body. The suspicion of maintaining the infection and not reinfection, occurs if the UTI recurs within 2 weeks after the end of therapy. These circumstances must bring a doctor to the idea of presence in a patient with anatomical or structural changes. These patients with DLI should be referred to a urologist for detailed examination and treatment.
As already noted, some women have a biological predisposition to DLI, resulting from colonization of the vagina and periurethral tissues if fecal microflora. Understanding this process has led to clinical trials dead heat vaginal stamps coliform bacteria as a means of immunization of patients against DLI.
Prophylaxis with antibiotics is the most important practical measure for most women. Because 85% of women with DLI symptoms of the disease observed 1 day after sexual intercourse, should try prophylactic antibiotics after intercourse before it is tested “normal” course of antibiotic therapy. Randomized, double-blind, controlled trials of various drugs have proven the effectiveness of this approach.
For prevention after sexual intercourse have been tested co-trimoxazole, furadonin, quinolones, cephalosporins and sulfisoxazole. The first three of these programs have a partial effect, which implies that the decision to hold a longer course should be taken with the ineffectiveness of prevention after sexual intercourse.
Although the results of the application of antibiotics has been successful, from the choice as a therapeutic agent in this case is not unambiguous. Comparative trials of co-trimoxazole and furadonin gave approximately the same results, despite the claim that co-trimoxazole are able to induce a sustainable breeding dies of intestinal and vaginal microflora. Furadonin, although it does not affect the intestinal microflora during long-term treatment can cause irreversible pulmonary fibrosis in some patients, and some doctors use it is not recommended. Quinolones seem to possess somewhat more efficient, although more expensive. These drugs not only sterilize the urine, but also contribute to the elimination of urinary microflora that inhabit the urethra and zones in the natural openings of the body.
If there is no effect from prophylaxis of infection after sexual intercourse women exchange treatment is carried out with a duration of 6-12 months.
WOMEN AFTER MENOPAUSE
Circulating blood estrogen stimulates colonization of the vagina by lactobacilli. These bacteria produce lactic acid from glycogen, which maintains a low pH in the vagina, and this factor inhibits the growth of many bacteria. In the absence of sexual activity this mechanism is effective to maintain the sterility of urine.
According to some estimates, 10-15% of women over the age of 60 years is often marked by IMP. After menopause, the changes in vaginal microflora due to the lack of circulating blood estrogen play, as is commonly believed, a key role in the emergence of this significant addiction. Because of the disappearance of lactobacilli the vagina is colonized Enterobacteriaceae, especially E. Coli.
THE TREATMENT OF WOMEN IN THE PERIOD AFTER MENOPAUSE
The DLI treatment in women of this age group should be directed on carrying out of replacement estrogen therapy. The results of several studies using estriol per os confirmed the effectiveness of this prophylactic DLI. However, one large-scale control study, however, showed that the use of estrogen per os corresponded to a twofold increase in the risk of first episode of UTI.
Other findings concerning the effectiveness of systemic administration of estrogen to female patients age group, also proved inconclusive. Therefore recently carried out a randomized, double-blind control study on local application of cream containing estriol. This technique will significantly reduce the pH in the vagina, to increase its colonization by lactobacilli and to reduce the number of colonizing Enterobacteriaceae without showing systemic effects of estrogens. It is particularly important that the number of UTIS in these patients was significantly decreased compared with group, which used placedo.
Local application of estrogen (in the vagina) seems to be a method of choice of initial therapy for many patients after menopause, although the exchange nebolshimi prevention doses of antibiotics are still necessary for many patients. Research conducted over several years, showed a long period the effectiveness of therapy many drugs with little data obtained about the increase in bacterial resistance or increased toxicity of therapy.
The dominance of RMI among pregnant women is similar to the pattern observed among non-pregnant sexually active and women under the age of menopause. DLI during pregnancy, however, can develop to the degree of acute pyelonephritis that occurs about 1/3 of the cases. This frequency, possibly associated with dilatation of the upper urinary tract and, ultimately, stasis, often occurring in late pregnancy.
The apparent increase in the number of UTI in the upper urinary tract with fever, occurring during pregnancy, convinced of the need for more vigorous prevention of an infection of the lower urinary tract of pregnant women. Comparative data on the frequency of UTIS in pregnant and nonpregnant women show that 43% of women (in whom a UTI developed during pregnancy) was observed UTIS before pregnancy and it seems to indicate a common mechanism of infection in all women before the cessation of menstruation, regardless of the factor of pregnancy.
TREATMENT OF PREGNANT WOMEN
It was suggested many schemes of antibacterial therapy DLI during pregnancy. Without a doubt, when asymptomatic bacteriuria in patients at high risk therapy is indicated. Many people believe that prevention should be carried out after treatment of the first UTI during pregnancy, especially if the patient is in the history already was IMP. The optimal course of therapy, including choice of drugs and duration of treatment, are still being debated. However, the majority of obstetricians recommend the use of furadonin or benzylpenicillin.
As to menopause, when the UTIS occur after sexual intercourse, pregnant women have investigated the effectiveness of postcoital antibiotic prophylaxis as a “start-up” therapy. This technique was, ultimately, just as effective as daily, one-time therapy. A recent study of 39 women during previous pregnancies noted a total of 130 PULSES, the period of observation only one pregnant woman was observed PULSES after the start of therapy. Using a single small dose of cefalexin or furadonin. Dignity postcoital prophylaxis compared with daily is to use minimum number of drugs. It seems that the use in this case of co-trimoxazole or furadonin can be effective, but it should be emphasized that only penicillin and cephalosporins is known as a means, safe to apply on all stages of pregnancy.