Medical Education  

This case has the potential to induce a sense of desperation and a kneejerk change of antibiotic. This is not necessary. A logical approach will identify the two key issues: proven recurrent infection and the search for a causative or exacerbating factor.

Dipstick urinalysis should follow the same format as for younger women, with antibiotic use determined by the result. (see MIMS Women's Health 2008; 3(2): 46). Culture and sensitivity should be sent with information about previous antibiotic use. Prophylactic antibiotics may be considered if infection is truly recurrent.

Diagnostic clues
Listen carefully to what your patient is saying. Sheila is presenting a slightly different story to younger women and there are clues that can be picked up. For example, she says that wearing trousers is uncomfortable, so ask why. If they exacerbate soreness, is this predominantly itchy? Think about vulval dystrophy. Does she have problems with vaginal dryness? Is sex possible or is it limited by lack of lubrication or pain on penetration? How long is it since her last period? Has she used HRT and if so, when did this stop?

Asking sensitively, explaining the context of your questions, you may uncover a whole scenario of urogenital atrophic misery that Sheila has been too embarrassed to tell anybody about. Some women assume that such problems are an inevitable consequence of growing old. Some have an innate reticence about discussing matters that are very private. Some women may unintentionally be making the problem worse by much scrubbing with soap or feminine hygiene products.

A few carefully chosen questions will tell you whether this requires further discussion. The relief gained by women from being able to talk about such problems can be highly therapeutic. You will also rapidly obtain an impression of whether there is a relationship component to her difficulty. Discovering whether this is cause or effect will help to determine your future actions.

Never be surprised or judgmental about what you hear. Older women can begin new relationships and once past the possibility of pregnancy, are less likely to use condoms to avoid infection. Thin atrophic vaginal epithelium is more susceptible to STIs and this possibility should be sensitively considered and excluded. Chlamydia is not the exclusive preserve of the young.

Investigations
If vulval dystrophy, vaginal atrophy or STIs are possibilities, examination is required. If time is short or logistics constrained, it would not be unreasonable to schedule this for another occasion, when further discussion can also occur. This will enable you to provide leaflets or direct your patient to one of the internet sites that provide quality assured information. A second consultation can then be more focused.

Always inspect the vulva, but only swab for chlamydia if indicated and with consent, then look for signs of atrophy. Thin vaginal epithelium looks red, rather than pale, and visible blood vessels or petechiae can be seen at moderate levels of atrophy. At severe levels, there may be bleeding on contact and full insertion of even the smallest speculum may be limited by discomfort. Loss of elasticity in the vaginal wall renders it smooth rather than rugose. Hence, a red uncomfortable vagina that has lost its wrinkles is evidence to support intervention.

The base of the bladder and trigone derive embryologically from the same origin as the lower third of the vagina. Atrophic bladder changes cause irritability, frequency and increased susceptibility to infection. Physical trauma at intercourse has an exacerbating effect.

Treatment
Correction of vaginal atrophy should be discussed if it is clearly causing symptoms. Topical low-potency estrogens may be more effective than systemic estrogens in this respect and can be added to systemic regimens if vaginal symptoms do not resolve.

Many products are available and the choice may be a matter of patient preference. Most preparations are used daily for two weeks, then twice a week. At the cellular level, changes can be seen within two weeks and will be felt clinically in a month.

A three-month supply should be provided initially, but improvement may continue for up to a year. This is currently outside the UK licence of most preparations, but there is much variation throughout Europe and we lack clarification. The concern would be for the effect of unopposed estrogen on the endometrium. This is not an issue for hysterectomised women or those on an appropriate combined HRT regimen.

Repeating initiation courses may deliver higher systemic levels than maintenance at lowest effective dose. This creates a difficult situation that requires informed consent if prescribing outside the current marketing authorisation.

Sheila last had a period eight years ago. As a result of her cystitis and general discomfort, sex has not been possible for more than a year and this is creating some tension. She regrets this because she is fit and active and her relationship with her husband is otherwise good.

Her urine sample shows some protein and a low level of red cells, but no leukocytes or nitrite. She has moderate to severe vaginal atrophic change. After discussion, she chooses to try a topical estriol cream. She elects to await for microbiology results before embarking on more antibiotics. You agree to contact her if the laboratory reports any infection and review her in about eight weeks. You do not see her in the next two months and when she returns, she is beaming. She has had no cystitis and her marriage was restored by a relaxing holiday where intercourse, though cautious, was possible. She wants to continue her treatment. That is another discussion.

- Dr Sarah Gray is a GPSI in women's health in Truro, Cornwall.