Download Flavoxate relieves Urinary Bladder Spasm

Flavoxate relieves Urinary Bladder Spasm
secondary to Urinary Tract Infection
Dr. Kawita Surendra Bapat
MBBS, MS
Laproscopic Surgeon, Gynaecologist
(Gold Medalist),
Obst. & Infertility Specialist,
Vice President, FOGSI Indore Branch,
Vice President, Lions Club of Indore Arpan.
CASE PRESENTATION
A 52-year-old woman was presented for urinary symptoms. She described daily
problems with urgency, frequency and dysuria. She felt the need to urinate every
2 hours during the day and has to get up 2 - 3 times every night. She also reported
nagging pain in her lower abdomen, which is somewhat relieved by voiding.
She also revealed that she has crampy abdominal pain after eating dairy products
and has occasional bouts of diarrhea when stressed. She has not been sexually
active for the last 6 months, but states that the last few times she had intercourse
it was painful. Nothing else was remarkable about her medical history except
occasional migraine headaches. The only medications she takes are over-thecounter analgesics for pain.
She has been diagnosed with diabetes six months back and was taking an
oral hypoglycemic agent which has kept her blood sugar levels under good
control. She has a strong family history of diabetes; both her parents were type 2
diabetics. She was allergic to penicillins, sulfa combinations and nitrofurantoin.
Flavoxate is
a time-tested
smooth muscle
relaxant, welltolerated
treatment and
widely used to
treat for urgency/
incontinence of
various causes
EXAMINATION AND INVESTIGATIONS
Her random blood sugar was normal. Pelvic examination revealed tenderness
in the lower abdomen and suprapubic region. There was no evidence of
hepatosplenomegaly or abdominal distension. There was no evidence of
cystocele, rectocele or enteroceles. She experienced general discomfort with
a bimanual examination, particularly during
Figure 1: E. coli microscopy
palpation of the bladder, but there were no
masses or adnexal tenderness.
No vaginal discharge was noted. Midstream
dipstick urinalysis showed pH 6.0 with trace
proteinuria and no evidence of microhematuria.
Urine specimen was sent for culture and
cytology.
01
Urine microscopy showed significant pyuria
with white blood cell (WBC) clumps and many
bacteria and culture yielded > 50,000 CFU/
mL of characteristic Gram stain morphology,
the organism was presumptively identified as
Escherichia coli (Figure 1 and Figure 2).
Figure 2: E. coli plate
MANAGEMENT
A diagnosis of lower urinary tract infection
was made. Based on susceptibility test results and documented allergies, the
patient was prescribed a 2-week course of ofloxacin therapy at 200 mg BID, with
resolution of urgency and dysuria and marked improvement in urinary frequency.
In addition, 400 - 600 mg of flavoxate hydrochloride was added to relieve urge,
dysuria and nocturia.
DISCUSSION
Flavoxate
hydrochloride
relieves
irritative urinary
symptoms,
relieves burning
sensation and
improves the
drainage capacity
of the bladder
The 2010 Infectious Disease Society of America (IDSA) consensus limits
for cystitis and pyelonephritis in women are more than 1000 colony-forming
units (CFU)/mL and more than 10,000 CFU/mL, respectively, for clean-catch
midstream urine specimens. Historically, the definition of urinary tract infection
(UTI) was based on the finding at culture of 100,000 CFU/mL of a single
organism. However, this misses up to 50% of symptomatic infections, so the
lower colony rate of greater than 1000 CFU/mL is now accepted.1
The microbial spectrum of uncomplicated cystitis and pyelonephritis consists
mainly of Escherichia coli (75 - 95%), with occasional other species of
Enterobacteriaceae, such as Proteus mirabilis and Klebsiella pneumoniae
and Staphylococcus saprophyticus. Other Gram-negative and Gram-positive
species are rarely isolated in uncomplicated UTIs. Therefore, local antimicrobial
susceptibility patterns of E. coli in particular should be considered in empirical
antimicrobial selection for uncomplicated UTIs. Given its efficacy as assessed
in numerous clinical trials, fluoroquinolones such as ofloxacin, ciprofloxacin and
levofloxacin are highly efficacious in 3-day regimens.1
Ofloxacin (200 mg) once-daily for 3 days and trimethoprim-sulfamethoxazole
(160:800 mg) twice-daily for 7 days for the treatment of acute uncomplicated
cystitis UTI in women were compared in a clinical study which concluded
that ofloxacin was more effective than trimethoprim-sulfamethoxazole in
eradicating Escherichia coli from rectal cultures during or soon after therapy.2
02
Flavoxate is a time-tested smooth muscle relaxant, well-tolerated treatment
and widely used to treat for urgency/incontinence of various causes. Patients
have been tested with 200 mg three times daily, orally, for 2 weeks and the
dose can be considered to go up to a daily dosage of 1200 mg.
The symptoms of frequency, urgency, dysuria, nocturia and incontinence are
effectively relieved.3,4
Bladder spasm is the sudden, involuntary detrusor contraction causing
an urgent need to release urine and an unwanted symptom in lower tract
urinary infection. Flavoxate hydrochloride is a urinary antispasmodic that
ameliorates the symptoms of UTI in 3 ways: relieves irritative urinary
symptoms, like dysuria and pain, relieves burning sensation by exerting a local
anaesthetic and analgesic action and improves the drainage capacity of the
bladder by relaxing its muscle so that the urine flows normally.5
Conclusion
In conclusion, it can be said that ofloxacin, given alongside flavoxate, in
combination, can have dual benefit in a patient with E. coli cystitis. The
antimicrobial efficacy of ofloxacin eradicates E. coli and flavoxate relieves
dysuria and urge, both uncomfortable symptoms in UTI.
References
1.
International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and
Pyelonephritis in Women: A 2010 Update by the Infectious Diseases Society of America and the
European Society for Microbiology and Infectious Diseases Clinical Infectious Diseases. 2011; 52:e103
-e120.
2.
T M Hooton, C Johnson, C Winter, et al. Single-dose and three-day regimens of ofloxacin versus
trimethoprim-sulfamethoxazole for acute cystitis in women. Antimicrob Agents Chemother July 1991;
35(7):1479-1483.
3.
Gu FL, et al. Treatment of urgency and urge incontinence with flavoxate in the People’s Republic of
China. J Int Med Res Sep-Oct 1987; 15(5):312-8.,
4.
Fehrmann-Zumpe P, Karbe K, Blessman G. Using flavoxate as primary medication for patients suffering
from urge symptomatology. Int Urogynecol J Pelvic Floor Dysfunct 1999; 10(2):91-5.
5.
Wadhwa SN Overcoming Catheter-Associated UTI. openmed.nic.in/2346/01/Wadhwa.pdf.
EXPERT COMMENTS
Antimicrobial
efficacy of
ofloxacin
eradicates E. coli
and flavoxate
relieves dysuria
and urge
Urinary tract infection is the second most common clinical indication for empirical
antimicrobial treatment in primary and secondary care and urine samples
constitute the largest single category of specimens examined in most medical
microbiology laboratories.
In women, significant bacteriuria is confirmed among women with symptomatic
UTI ≥ 102 cfu/mL. If dysuria and frequency are both present, then the probability of
UTI is increased to > 90% and empirical treatment with antibiotic is indicated.1
The algorithm provides a management approach to lower urinary tract infections
in women who are not pregnant (Figure 3).2
Among the etiological factors, being sexually active seems to be the most
important, both before and after menopause.3 Diabetes is a well-known risk
factor.4
Conventional treatment has principally focussed on eradicating bacterial
causes, symptoms of infection (especially frequency and dysuria). Antibiotics
are the mainstay of treatment to negate the bacteriuria; however, bladder
antispasmodics such as flavoxate that act on the bladder muscle can relieve
the urge and dysuria in symptomatic women with lower urinary tract infection.
03
Figure 3: Management approach to lower urinary tract
infections in women
Vaginal itch or
discharge?
NO
Signs and symptoms
of UTI?
• Dysuria
• Urgency
• Frequency
• Polyuria
• Suprapubic tenderness
• Fever
• Flank or back pain
Limited (no more than two)
symptoms
YES
C
In women with symptoms of
vaginal itch or discharge explore
alternative diagnosis and
consider pelvic examination.
C
Dipstick tests should only be
used to diagnose bacteriuria
in women with limited signs
and symptoms
Multiple symptoms
Fever & back pain?
Bladder
antispasmodics
such as flavoxate
that act on the
bladder muscle
can relieve
the urge and
dysuria in
symptomatic
women with
lower urinary
tract infection
YES
Consider the possibility
of UUTI
Dipstick
positive
Dipstick negative
or equivocal
No, LUTI probable
B
B
• Non-pregnant
women of any age
with symptoms or
signs of acute LUTI
should be treated
with trimethoprim
or nitrofurantoin for
three days.
• Patients who do
not respond to
trimethoprim should
have urine taken
for culture to guide
change of antibiotic.
• Offer empirical
antibiotic treatment.
• The risks and
benefits of empirical
treatment should be
discussed with the
patient and managed
accordingly.
• If a woman remains
symptomatic after
a single course of
treatment investigate
other potential
causes.
Women with renal impairment should not be treated
with nitrofurantoin.
D
Women prescribed nitrofurantoin should not take
alkanalising agents (potassium citrate),
UUTI = Upper urinary tract infection; LUTI = Lower in urinary tract infection.
References
1.
04
International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis
and Pyelonephritis in Women: A 2010 Update by the Infectious Diseases Society of America and
the European Society for Microbiology and Infectious Diseases Clinical Infectious Diseases 2011;
52:e103-e120.
2.
SIGN 88. Clinical guideline. 2008.
3.
Moore EE, Hawes SE, Scholes D, Boyko EJ, Hughes JP, Fihn SD. Sexual intercourse and risk of
symptomatic urinary tract infection in postmenopausal women. J Gen Intern Med 2008, 23:595-599.
4.
Jackson SL, Boyko EJ, Scholes D, Abraham L, Gupta K, Fihn SD. Predictors of urinary tract infection
after menopause a prospective study. Am J Med 2004; 117:903-911.
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