Welcome to NP Certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question so you can better understand how to arrive at the correct test answer. So, if you're ready, let's jump right in.
A 68-year-old woman presents for follow-up to her primary care provider with the chief complaint of, “Another urine infection,” stating she was seen four days ago at urgent care with new onset of dysuria and urinary frequency. Review of her clinical record reveals that she's had three symptomatic culture-confirmed UTIs in the past eight months. She's currently on day four of five of the antimicrobial prescribed and is without symptoms. Her concomitant health issues include hypertension and dyslipidemia, both at treatment goals with lifestyle modification and medication. When discussing patient efforts to help avoid future UTIs, the NP considers which of the following will be appropriate?
And the correct answer is: D. Regular use of a vaginal estrogen.
Where should you start with this question? First, determine what kind of a question it is. Given that we're asked to choose a treatment for a person with a stated health problem, we're told that she's having issues with recurrent UTIs, this is, of course, a plan question.
First, let's take a look at some background information. Prior to menopause, due to the presence of naturally occurring estrogen, the relatively acid peri-urethral and vaginal pH along with the sturdier vaginal, bladder, and peri-urethral tissue help protect against UTI. Postmenopausal, of course, estrogen levels drop dramatically. As a result, in the absence of estrogen, there's thinning of the vaginal, bladder, and urethral tissue, as well as an increase in peri-urethral and vaginal pH.
The end result is that UTI protective factors are minimized in post-menopause. Now you might say, well, the question doesn't say anything about her being post-menopausal. But you know what? What we have to do is use our clinical common sense with things. This is a woman in her late sixties, the average age for menopause defined as one year post LMP is at age 51 in North America.
Given that this woman is likely 15 years into menopause and is suffering with a significant health issue, recurrent UTIs. What we need to do is have a discussion with her about preventing these recurrent infections. She also is voicing her great frustration with this. And, you know, a lot of times UTIs in older adults, we hear that it can cause confusion, delirium, a number of other issues. Even in patients who don't suffer with those severe manifestations of UTI, such as change in cognition, having a UTI simply wears the person out. It's uncomfortable. It's debilitating. So, let's see what we can do to help her out. And the other part, what is the definition of a recurrent UTI in a postmenopausal woman? It's defined as three or more culture-proven symptomatic UTIs in one year or two of the same in six months. And as we could see, she has three in eight months. So, she does meet that diagnostic criteria for recurrent UTI.
With that in mind, let's take a look at the questions and answers. And please keep in mind that pathophysiology that I just covered on what the major risk is for UTI in women who are post-menopausal.
A 68-year-old woman presents for follow-up to her primary care provider with the chief complaint of, “Another urine infection,” stating she was seen four days ago in urgent care with new onset dysuria and urinary frequency. Review of her clinical record reveals that she's had three symptomatic culture-confirmed UTIs in the past eight months. She's currently on day four of five of the antimicrobial prescribed and is without symptoms. Her concomitant health problems include hypertension and dyslipidemia, both at treatment goals with lifestyle modification and medication. With the patient, efforts to prevent future UTIs the NP considers that which of the following will be appropriate?
A. Adding cranberry juice supplements to her diet daily. This is incorrect. The question here really asks about most appropriate. So, for lack of a better way of putting it, you're really looking for the most bang for the therapeutic buck, if you will, and you're looking for the choice that will yield the most therapeutic action for this particular patient.
The evidence is quite variable on whether cranberry juice in any dose is helpful for the prevention of UTI. I could right now produce half a dozen studies that say aye, and then I could have another stack of a dozen studies that say nay, that it's not helpful. And in the few studies where cranberry juice supplements are helpful, it is generally in a very, very high dose, like 12 ounces of high concentration cranberry juice per day with greater than 40% of cranberry juice in the beverage. And so that's not a particularly good answer.
B. Avoiding tub baths. As with cranberry juice supplement response, this is incorrect. The evidence is simply not there to support a correlation with tub baths and UTIs.
C. Initiating long-term antimicrobial prophylaxis. Well, now we're getting into things that we actually know work and antimicrobial prophylaxis is effective to treat recurrent UTIs, particularly in a patient with known risk factors. At the same time, what do we need to do? We need to consider benefit versus risk. Long-term antimicrobial prophylaxis significantly increased risk for carriage in future infection with resistant pathogens. This practice is considered to be an option, but only when safer therapy has not been effective. Great example of something that is correct but just might not be the best answer.
Option D: Regular use of a vaginal estrogen. This is the best answer. So, option D is our correct answer. Adding estrogen back to the peri-urethral and peri-vaginal area helps reverse the menopause-related changes. Evidence supports this practice in relieving GU syndrome of menopause, i.e. the vaginitis, urethritis that can go along with the low estrogen state, and reducing UTIs.
And if you're thinking yes, but estrogen, blood clot risk, endometrial hyperplasia, the use of vaginal estrogen is supported by numerous organizations and evidence-based practice guidelines because with vaginal estrogen, the amount of estrogen systemically absorbed is minuscule, does not increase clot risk, breast cancer risk or cause endometrial hyperplasia.
Key takeaway: Once again on the NP boards, you will often encounter two correct answers, in fact, sometimes more than two correct answers. But there will only be one best answer.
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