Health Promotion, Chronic and Acute Illness

Endometriosis 

Etiology, Prevalence and Significance 

Endometriosis is a benign inflammatory condition affecting women of reproductive age. The disease is characterized by estrogen-dependent extrauterine endometrial tissue and is usually present on the rectovaginal septum, the pelvic peritoneum or the ovaries. The pathogenesis of the disease has not been conclusively defined. Research points out that it might be as a result of the hematogenous dissemination of endometrial cells, retrograde menstruation, due to metaplasia of coelomic mesothelial cells or immunologic dysfunction (Vercellini et al. 2014) The most predominant symptoms of endometriosis are chronic pelvic pain, dyspereneunia, and infertility. According to Parasar et al. (2017), 6-10% of women in the United States have endometriosis, with an annual rate of hospitalization being 4 per 1000 women. Due to the estrogen-dependent nature of the disease, women in the reproductive age are most susceptible. The prevalence rate in infertile women is 20-50%, while the rate in fertile women can be as high as 71-87%. The prevalence rate increases with the increase in age. The rate is 12% for females aged 11-13 years, and approximately 45% of females aged 20-21 years. There are no variations in prevalence based on ethnic or social groups. Females below 20 years may usually experience subtle anomalies of the reproductive system; those between 25-30 years usually have pelvic endometriosis while extrapelvic disease occurs in females aged 35-40 years. The disease causes a significant economic, humanistic, and clinical burden. The main cost driver results are hospitalization which causes a huge economic burden. The patients’ quality of life, emotional well-being, intimate relationships, education and work, and fertility are also affected. 

Health Promotion and Screening of Endometriosis 

Effective identification and management of endometriosis are dependent on patient engagement. Although pelvic pain is a common symptom, pain alone is insufficient to form screening discrimination for females without and with the disease. Physicians often recommend the use of a patient-completed, symptom-based screening tool aimed at self-identification of endometriosis-related symptoms. The screening tool encourages earlier treatment as well as reducing diagnostic delay, thereby enhancing health promotion. The screening measures are often administered in an interview or questionnaire format. They, however, do not form a comprehensive conclusion and are supported by physical examination, laboratory diagnosis, or clinical interpretation. Although some measures may have good diagnostic accuracy for specific sites, the screening questionnaires are not always necessarily used to locate the endometriosis. The existing screening measures have limited clinical utility. 

Diagnostic Tests and Laboratory Workup 

The definitive diagnostic method is a gross visualization of endometrial implants. Laparoscopy and laparotomy are the preferred methods of diagnosis. The key is achieving maximum diagnosis with minimum surgical invasion. 

Laboratory studies include complete blood count, urinalysis, urine cultures, serum cancer antigen 125 (CA-125) test, and detection of autoantibodies against Thomsen-Friedenreich (T) antigen (Gal beta1-3GalNAc). The principal serum marker for late end-stage endometriosis is CA-125. CA-125 shows a marked an increase in women with endometriosis. This, however, is not a specific marker for the disease as there is an increase also in multivisceral tuberculosis and tubo-ovarian abscess. Immunological markers such as tumor necrosis factors (TNF) and interleukin-6 (IL-6) are elevated in endometriosis. 

Radiography plays an important role in diagnosis, identification, and mapping of endometriosis. The interventions used are magnetic resonance imaging (MRI), pelvic ultrasonography, and computed tomography (CT). The ultrasonographic features of endometriosis are characterized by non-vascularized cysts and solid masses. 

Biopsy and histologic features might feature hemosiderin-laden macrophages in combination with fibrosis. 

Treatment and Management 

The treatment modalities are aimed at the interruption of the normal cyclic production of reproductive hormones. Hormonal therapy that involves a gonadotropin-releasing hormone (GnRH) analogs, progestational agents, combination oral contraceptives (COCPs), and danazol are the main medical interventions used in the management of endometriosis. Multidisciplinary pain management involves the administration of analgesics, e.g. NSAIDs and aramatose inhibitors (Vercellini et al. 2014). 

COCPs act by suppressing the ovaries and is administered for 6-12 months in combination with pain relief. Progestational agents cause atrophy and decidualization of the endometrium. GnRH analogs downregulate the pituitary glands and cause pain suppression that may persist for 6-12 months after termination of treatment. Danazol inhibits the midcycle LH and FSH surges thus preventing steroidogenesis in the corpus luteum (Vercellini et al. 2014). 

Surgical intervention may result in conservation or elimination of the reproductive function. The aim of surgery is the removal of the endometrial implants and rectifies possible anatomic changes caused by the implants. Laser energy or use of electrosurgical techniques might be applied to achieve ablation of the implants (Vercellini et al. 2014). 

Patient Education and Follow Up 

Patients should be made aware of the possible symptoms of endometriosis, and be encouraged to take medical action in case the disease is suspected. This, especially, is if the persistent chronic pelvic pain is present. It is important to emphasize to the patients the significance of following through the medical therapy to completion. This therapy is often taken for six months. The patients should also be made aware of the adverse effects the medical therapy may cause. Before the surgical intervention, the patient is told the possible outcomes, which include the complete elimination of reproductive function. 

The physician has a duty of ensuring that the patient complies with the therapy and discharge instructions (if applicable). For surgical patients, follow up with adjuvant medical treatment is imperative. 

Traditional versus Non-traditional Treatment Options 

The traditional treatment options for endometriosis involve the use of herbal medicine, homoeopathy, nutrition therapy, the traditional Chinese medicine, yoga, and massage. The traditional therapies believe in the body’s capacity to heal itself and support the maintenance of the body’s vital energy and hormonal balance. These therapies tend to take a holistic approach by taking into consideration the patient’s social, spiritual, and emotional wellbeing. This is achieved by the little to no harm afflicted to the patient. 

The non-traditional treatment options include the synthetic hormonal therapies and the surgical interventions. Like the traditional modalities, the non-traditional hormonal therapies target the hormonal cycles. However, the non-traditional modalities are more centered on the restoration of the patient’s health and the elimination of the endometrial implants at the expense of the patient’s future reproductive ability. This impacts on the patient’s social and psychological well-being (Vercellini et al. 2014). 

Collaboration with Other Healthcare Practitioners 

A multidisciplinary approach in the management of endometriosis in patients results in the best patient outcomes. 

Urinary Tract Infections 

Etiology, Prevalence and Significance 

Urinary tract infections (UTIs) are a group of acute infections that are caused by colonization of the urinary tract by bacteria. Escherichia coli ( E. coli ), Proteus mirabilis, Enterococcus faecalis , and Klebsiella pneumonia are the main bacterial causative agents of UTIs. The condition affects the bladder (cystitis), urethra (urethritis) and kidneys (pyelonephritis) (Flores-Mireles et al. 2015). Frequent sexual intercourse, diabetes, poor personal hygiene, incomplete urination and prolonged urinary retention, pregnancy, use of spermicides and tampons, and urinary catheters are the predisposing factors for the condition. The symptoms are dependent on the age, and the part affected. The common symptoms include pain during voiding, abdominal pains, frequent urge to urinate, cloudy, bloody, or foul-smelling urine, fever, fatigue, and chills. There are no serious complications associated with UTIs. According to Flores-Mireles et al. (2015), approximately 25-40% of women in the productive age in the United States have Urinary tract infections, which translates to more than 6 million patient consultations with physicians annually. Approximately 4% of the UTI patient visits are due to genitourinary tract infections. The economic significance in the US is estimated at the cost of $1 billion annually. In Europe, 20% of the female population is affected by UTIs. Susceptibility to infections tends to increase with an increase in age, with occurrence at as low as 5% in school-aged girls. 

Health Promotion and Screening of UTIs 

UTIs may be asymptomatic in some patients. A regular screening and pre-clinical evaluation are recommended to determine the early onset of the disease. Late detection or untreated infections could result in other health complications to the patient. The easiest way of screening and detection of UTI is the use of a home-test rapid detection kit, e.g. AZO Test Strips. The detection kits are available locally and can be purchased over the counter. They often offer a combination of UTI tests in one, e.g., leucocyte and nitrite tests. Positive results require an immediate medical consultation for further diagnosis and treatment. 

Asymptomatic females are not obliged to take the regular screening measures. Detection of bacteria in urine is not indicative of infection. The concentration of  ≥ 10 5 cfu/mL in urine is the threshold for infection in patients. Bacteriuria above the threshold is asymptomatic is no clinical symptoms are manifested. Screening is important for pregnant or menopausal women even in asymptomatic cases. 

Diagnostic Tests and Laboratory Work Up 

Urinalysis is the most accurate method of determining the presence and concentration of leucocytes, proteins, blood, and other urine parameters. Leukocyte concentrations >10 WBC/mL is considered abnormal and indicative of infection. Low-grade proteinuria is also observed in UTIs. White cell masts are also observed in urine. Urinalysis can be done using hemocytometer chamber or dipsticks. Nitrate test detects the presence of substrates of nitrate reductase and is usually positive in UTIs. Urine cultures are the gold standard in urinary bacterial identification. 

Treatment and Management of UTIs 

Hooton (2017) points out that the most effective treatment modality for UTIs is the use of antibiotics. The severity of the symptoms and the patient’s previous medical history affects the length of the treatment. A three-day treatment plan is recommended for uncomplicated UTI. First line antibiotic therapy involves the administration of sulfamethoxazole 800 mg and trimethoprim 160 mg (TMP-SMX double strength). This regimen is administered twice daily for three days. Second-line antibacterial therapy involves the administration of ciprofloxacin 250 mg two times a day for three days. Fluoroquinolones may also be administered. Third line therapy involves the administration of Cephalexin twice daily for seven days. Increased antibiotic resistance makes the effectiveness of β-lactams. Adjunctive therapy may be administered to relieve intense dysuria-induced pain. 

Patient Education and Follow Up 

Patients need to be educated on the importance of adherence to the prescribed medication. Patient non-compliance is one of the causes of bacterial resistance. Intensive patient education on the predisposing factors of UTIs also needs to be conducted, with emphasis on the lifestyle and behavioral causes to instill the need for lifestyle and behavior modifications. These modifications include encouraging patients to increase oral fluid intake and frequent voiding. Increase in oral fluid intake increase diuresis. Frequent voiding empties the bladder and urinary tubules, reducing the chances of bacterial colonization. Patients should also be educated on the prevention strategies, e.g. voiding before and after intercourse to prevent disease dissemination to the genitalia, wearing loose clothing for sufficient circulation and keeping good hygiene. The patient is also counseled about re-infection risk factors and educated on self-evaluation therapy (Tamimi & Mikhail, 2015). 

Following completion of the treatment therapy, the physician should schedule a follow up with the patient to determine prognosis and if there is a recurrent infection. Laboratory tests and urine cultures are conducted to determine the bacterial colony concentrations 

Traditional Versus Non-traditional Treatment Options 

Traditional treatment modalities include home remedies such as oral fluid intake, cranberry extracts, blueberries, nutrition, and exercise. These remedies are effective for non-complicated UTI and do not evaluate the severity of infections. Non-traditional treatment options include the use of antibiotic therapies and probiotics. These treatment options are effective both in uncomplicated and complicated infections. The effectiveness of the treatment can be quantitatively determined by determining the number of antibiotics administered. Unlike the traditional treatment options, the non-traditional treatment options have a risk of pathogen-resistance. 

Collaboration with Other Health Care Practitioners 

It is the collective responsibility of all health care practitioners to ensure effective management of UTIs in patients. Teamwork is involved in the drafting of the patient education strategies. 

References 

Vercellini, P., Viganò, P., Somigliana, E., & Fedele, L. (2014). Endometriosis: pathogenesis and treatment.  Nature Reviews Endocrinology ,  10 (5), 261. 

Parasar, P., Ozcan, P., & Terry, K. L. (2017). Endometriosis: Epidemiology, diagnosis and clinical management.  Current obstetrics and gynecology reports ,  6 (1), 34-41. 

Flores-Mireles, A. L., Walker, J. N., Caparon, M., & Hultgren, S. J. (2015). Urinary tract infections: epidemiology, mechanisms of infection and treatment options.  Nature reviews microbiology ,  13 (5), 269. 

Tamimi, N. A., & Mikhail, A. I. (2016). Management of urinary tract infections in adults: An overview.  African Journal of Nephrology ,  2 (1), 7-11. 

Hooton, T. M., & UpToDate, M. D. (2015). Patient education: Urinary tract infections in adolescents and adults (Beyond the Basics).  Up to date. Updated May . 

Eldredge, L. K. B., Markham, C. M., Ruiter, R. A., Kok, G., & Parcel, G. S. (2016).  Planning health promotion programs: an intervention mapping approach . John Wiley & Sons. 

Riazi, H., Tehranian, N., Ziaei, S., Mohammadi, E., Hajizadeh, E., & Montazeri, A. (2015). Clinical diagnosis of pelvic endometriosis: a scoping review.  BMC Women’s Health ,  15 , 39. http://doi.org/10.1186/s12905-015-0196-z 

Ugwumadu, L., Chakrabarti, R., Williams-Brown, E., Rendle, J., Swift, I., John, B., ... & Ofuasia, E. (2017). The role of the multidisciplinary team in the management of deep infiltrating endometriosis.  Gynecological surgery ,  14 (1), 15.