Effective postcoital prophylaxis of recurrent urinary tract infections in premenopausal women: A review

A total of 77 sexually active premenopausal women, susceptible to recurrent urinary tract infections (UTI) but otherwise healthy, were subjected to postcoital prophylaxis consisting of a single oral dose of either cotrimoxazole (80 mg trimethoprim+400 mg sulfamethoxazole), 50 mg nitrofurantoin macrocrystals, 500 mg nalidixic acid, 250 mg cinoxacin or 250 mg cephalexin. Postcoital prophylaxis reduced the incidence of recurrent UTI from 5-8 UTI per patient/year prior to prophylaxis, to a mere 0.03 UTI per patient/ year following prophylaxis. The differences in the incidence of UTI prior to and following institution of postcoital prophylaxis were statistically highly significant. A mean of 106–120 antibacterial tablets per patient were administered per year.Postcoital prophylaxis of recurrent UTI in premenopausal women is highly effective because of easy compliance, the high urinary concentration achieved and the minimal induction of resistance in the introital Gram-negative bacterial flora, irrespective of the length of time this prophylaxis is used. Furthermore, postcoital prophylaxis is significantly more effective than daily, as it achieves the same effect but requires only one third or fewer of the antibacterial tablets used in daily prophylaxis. At present, postcoital prophylaxis with cotrimoxazole, nitrofurantoin macrocrystals or cephalexin is recommended.     

Recognition of bladder instability on voiding cystourethrography in infants with urinary tract infection

PURPOSE: We evaluate voiding cystourethrography as a method for identifying bladder instability in infants. MATERIALS AND METHODS: Cystometry was combined with voiding cystourethrography in 79 male and 64 female infants with first time urinary tract infection. Bladder wall irregularity, elongation of bladder shape, and filling of the posterior urethra were transient radiological signs occurring during bladder filling and were considered to reflect bladder instability. A pediatric radiologist looked for these signs on all 480 films exposed during bladder filling. The results were correlated to simultaneous detrusor pressure recordings. The analysis was repeated independently by a urologist to evaluate the reliability of the radiological signs used. RESULTS: The sensitivity and specificity were both 90% in the evaluation of radiological signs of bladder instability. Filling of the posterior urethra was the least frequently reported radiological sign, which was seen at 53% of unstable contractions. However, when this sign was reported, instability was usually correctly detected (85%). Evaluation accuracy had improved with increasing numbers of noted signs per film. This accuracy had included 29%, 67% and 91% of unstable contractions that were correctly diagnosed when 1, 2 or 3 signs were noted, respectively. The number of noted signs was positively related to the strength of the unstable detrusor contraction. Urologist evaluations had similar results to the radiologist, although the sensitivity was somewhat lower (79% and 90%, respectively). CONCLUSIONS: Unstable detrusor contractions could be identified in infants by evaluation of radiological signs on voiding cystourethrography. Findings of bladder wall irregularity, elongation of bladder shape and filling of the posterior urethra indicated unstable detrusor contraction. The more such findings are observed, the stronger the indication.     

Cystoscopy in women with recurrent urinary tract infection

OBJECTIVE: To investigate if women with recurrent urinary tract infection (UTI) warrant cystoscopy to exclude an abnormality of the lower urinary tract. This is particularly relevant given that non-invasive imaging has often been performed to exclude abnormality. Our further aims were to correlate imaging and risk factors with cystoscopic findings to determine their predictive value in finding pathology. PATIENTS AND METHODS: A database of women undergoing cystoscopy with recurrent UTI has been maintained at our institution for 10 years. We retrospectively examined this and patient records for patient demographics, and investigative and operative data. RESULTS: A total of 118 patients (mean 55 years) having recurrent UTI (mean 4.7 infections/year) were available. There were nine patients (8%) with significant abnormalities at cystoscopy: urethral stricture (six), bladder calculus (one), bladder diverticulum (one) and colovesical fistula (one). The negative predictive value (NPV) of imaging was 99% and significant (P < 0.01). Women with no risk factors for UTI had a NPV of 93% for normal cystoscopy (P > 0.05). The positive predictive value was low for imaging and risk factors in predicting cystoscopy findings. CONCLUSIONS: In our study, 8% of women had significant abnormalities detected during cystoscopy with most over 50 years. Women without risk factors for recurrent UTI and with normal imaging could have a cystoscopy omitted. Younger women are less likely to have pathology and this must be factored into decisions to perform cystoscopy.     

Adherence of Lactobacillus crispatus to vaginal epithelial cells from women with or without a history of recurrent urinary tract infection

PURPOSE: Lactobacillus crispatus strain CTV-05 is a vaginal probiotic proposed for use in women with recurrent urinary tract infection to reduce vaginal colonization with Escherichia coli and the risk of urinary tract infection. However, the ability of this probiotic strain to adhere to the target mucosa, vaginal epithelial cells, has not been assessed in women with recurrent urinary tract infection. We measured the adherence of L. crispatus strain CTV-05 to vaginal epithelial cells collected from more than 100 premenopausal women with (cases) and without (controls) a history of recurrent urinary tract infection. We also examined the effects of relevant host factors on bacterial adherence. MATERIALS AND METHODS: Bacterial adherence assays were performed by combining L. crispatus CTV-05 with exfoliated vaginal epithelial cells collected from 51 case women and 51 controls. RESULTS: L. crispatus CTV-05 adhered in high numbers to vaginal epithelial cells from women with recurrent urinary tract infection (mean adherence of 50.5 lactobacilli per vaginal epithelial cell) and controls (mean adherence of 39.4 lactobacilli per vaginal epithelial cell). Adherence was significantly higher using vaginal epithelial cells from women with a maternal history of urinary tract infection (p = 0.036) and a nonsecretor phenotype (p < 0.001), but was not significantly affected by recent spermicide use, oral contraceptive use, menstrual cycle phase or sexual activity. CONCLUSIONS: L. crispatus strain CTV-05 is highly adherent to vaginal epithelial cells collected from a large sample of premenopausal women with or without a history of recent recurrent urinary tract infection. These data strongly support further evaluation of this probiotic in clinical trials of women with recurrent urinary tract infection.     

Acute and recurrent symptomatic urinary tract infections in women

Urinary tract infections remain a common problem affecting a wide population, especially adult females. The purpose of this paper is to provide an understanding of the pathogenesis, and to recommend practical approaches to therapy. Due to the size of the field, comments have been limited to acute and recurrent urinary tract infection in women.     

Long-term efficacy of fulguration of trigonitis for recurrent urinary tract infections in women

ObjectiveWomen with a longstanding history of recurrent urinary tract infections (RUTIs) represent a challenging population because of gradual development of antibiotic resistance and frequent antibiotic allergies. We report on the long-term results of women with RUTIs and trigonitis who were treated using endoscopic fulguration and were prospectively followed.Materials and methodsFollowing institutional review board approval, charts of non-neurogenic women with RUTIs (defined as ≥3 UTIs/y), no voiding dysfunction or incontinence, and normal upper tracts by imaging, who underwent cystoscopy with fulguration of trigonitis (CFT) under anesthesia with 1 year minimum follow up after CFT, were reviewed. Trigonitis was defined as a condition of inflammation of the trigone region of the bladder. The primary outcome was complete resolution of trigonitis based on follow-up office cystoscopy 6 months after CFT. The secondary outcome was the total number of antibiotic courses (AC) prescribed for UTI-related symptoms and/or positive urine cultures (PUC) following CFT. We hypothesized that patients with complete trigonitis resolution after CFT fared best.ResultsFrom 2004 to 2008, 33 women met the inclusion criteria with a mean follow up of 48 ± 19 months (range, 14–82 months). Resolution of trigonitis at 6 months was noted in 25 (76%) patients. This group averaged 0.51 ± 0.5 total AC and/or PUC/y compared with 2.03 ± 1.1 total AC and/or PUC/y for women with persistent trigonitis following CFT (p = 0.006).ConclusionPatients with resolved trigonitis at 6 months after CFT did best; however, both groups benefited from the procedure over time.     

Family history and behavioral abnormalities in girls with recurrent urinary tract infections: a controlled study

PURPOSE: We evaluated the role of family history, infrequent voiding, poor fluid intake, functional stool retention and inadequate anogenital hygiene or toilet habits in girls with recurrent urinary tract infections. MATERIALS AND METHODS: The possible occurrence of these risk factors was assessed in 90 Swiss girls with recurrent urinary tract infections and in a control group of 45 girls. RESULTS: Family history was positive in 42% of patients and in 11% of controls (p <0.001). Behavioral abnormalities were also more frequently noted in girls with recurrent urinary tract infections than in the control group (81% vs 56%, p <0.01). There were 137 abnormalities in 73 girls with recurrent urinary tract infections and 30 abnormalities in 25 controls. Two or more abnormalities each, that is 2 in 32 girls and 3 in 16, were noted in 48 girls with recurrent urinary tract infections and in 5 control girls. No controls presented with more than 2 abnormalities. Infrequent voiding (54% vs 24%, p <0.001), poor fluid intake (53% vs 16%, p <0.001) and functional stool retention (30% vs 13%, p <0.05) were more frequently disclosed in girls with recurrent urinary tract infections than in control girls. In contrast, the frequency of inadequate stool hygiene or toilet habits was similar in patients and controls (14% and 13%, respectively). CONCLUSIONS: The evaluation of girls with recurrent urinary tract infections should focus on identifying behavioral aspects, including infrequent voiding, poor fluid intake and functional stool retention.     

Vaginal mucosal vaccine for recurrent urinary tract infections in women: results of a phase 2 clinical trial

PURPOSE: We assessed the clinical efficacy of vaginal mucosal immunization with a multivalent bacterial vaccine in women with recurrent urinary tract infections. MATERIALS AND METHODS: A total of 75 patients in a double-blind study were randomly assigned to receive placebo only, primary immunization without boosters, or primary immunization plus boosters using vaginal suppositories containing placebo or vaccine. Vaccine suppositories contained 10 strains of heat-killed uropathogenic bacteria and placebo suppositories had no vaccine organisms. All women were monitored for 6 months to record the number of infections and adverse events. RESULTS: Analysis of data on urinary tract infections caused by any bacteria showed the greatest difference in infection rates between patients in the vaccine plus boosters protocol compared to those receiving placebo only (p = 0.100). When only E. coli urinary tract infections were considered in the analysis, urinary tract infection recurrence rates were significantly less in women given booster immunizations compared to placebo (p = 0.0015). Furthermore, women who received vaccine with boosters and who were sexually active, less than 52 years old, or had not undergone hysterectomy had E. coli urinary tract infections at a much lower rate than women given placebo only (p = 0.0002, 0.002 and 0.003, respectively). No significant adverse events were associated with vaccine treatment. CONCLUSIONS: This study demonstrated the efficacy of vaginal mucosal immunization with a multivalent vaccine in reducing recurrence of E. coli urinary tract infections. The results suggest that the vaccine may provide the most benefit to sexually active women in the 20 to 50-year-old age group.     

Excretion of urinary Tamm-Horsfall glycoprotein in girls with recurrent urinary tract infections

Summary Tamm-Horsfall glycoprotein (THG) might constitute a bacteria-fixing mucus which contributes to the nonimmunological anti-infectious mechanisms of the lower urinary tract. To evaluate the role of THG in girls with idiopathic recurrent lower urinary tract infections, the THG excretion and concentration in 24-h urine were measured by a radial immunodiffusion method in 16 patients with a median age of 9 years and in 14 healthy age-matched girls. The results showed no significant differences in the THG excretion of concentration between the patients and the controls. Transiently decreased THG excretion rates as well as functional changes in the ability and/or capacity to trap bacteria, however, may leave girls periodically prone to colonization of the bladder. Thus, further studies are warranted to evaluate the importance of THG in the bladder defence mechanism.     

Premenopausal women with recurrent urinary tract infections have lower quality of life

Objectives

To examine the impact on quality of life of recurrent acute uncomplicated urinary tract infection among premenopausal Singaporean women, and to determine the risk factors for lower quality of life among these patients.

Methods

A total of 85 patients with recurrent acute uncomplicated urinary tract infection who were referred to the Urology Department at the National University Hospital, Singapore, were prospectively recruited over a 3‐year period to complete the validated Short Form 36 Health Survey version 1. In addition, demographic and clinical details including symptomology and medical history were analyzed for factors impacting quality of life. Short Form 36 Health Survey version 1 results were compared with published population norms.

Results

After adjusting for age, gender and race, recurrent acute uncomplicated urinary tract infection patients had significantly lower quality of life on seven out of eight Short Form 36 Health Survey version 1 domains when compared with age‐, gender‐ and race‐adjusted population norms for Singapore. Among those with recurrent acute uncomplicated urinary tract infection, those who also reported caffeine consumption had significantly lower Short Form 36 Health Survey version 1 scores than those who did not. Those who reported chronic constipation also had consistently lower Short Form 36 Health Survey version 1 scores across all domains.

Conclusions

Recurrent acute uncomplicated urinary tract infection has a negative impact on the quality of life of premenopausal, otherwise healthy women. Recurrent acute uncomplicated urinary tract infection patients who also have chronic constipation or consume caffeine have lower quality of life than those who do not. More studies are required to understand the relationships between these common problems and risk factors.

     

The sensory bladder (1): an update on the different sensations described in the lower urinary tract and the physiological mechanisms behind them

AIMS: To give an update of the actual information on sensory function in the lower urinary tract (LUT). METHODS: We give an up-to-date review of the most modern and reasonable approach to the topic of physiological mechanisms involved in LUT sensory function and different sensations described in the LUT. RESULTS: Although the sensory function of the LUT is a main player in the function of continence and micturition, it has been dealt with rather superficially for many decades. More recently the interest in this function grows and does so rapidly, both in basic as in clinical research. Sensation depends on neurophysiologic mechanisms in several different nerves, receptors, and transmitters. This knowledge creates a better understanding of sensory symptoms. Different stimuli can elicit sensations in the LUT such as bladder filling, micturition, noxious stimuli, external stimuli. CONCLUSION: Sensation is the prerequisite of conscious bladder control and deserves full attention in the management of LUT dysfunction.     

Hygiene and urinary tract infections after cystectomy in 452 Swedish survivors of bladder cancer

Study Type – Symptom prevalence (retrospective cohort)
Level of Evidence 2b

OBJECTIVES

To determine whether or not an improved hygiene can lessen the incidence of symptomatic urinary tract infections (UTIs) in patients treated by cystectomy for urinary bladder cancer.

PATIENTS AND METHODS

We attempted to contact during their follow‐up all men and women aged 30–80 years who had undergone cystectomy and urinary diversion at seven Swedish hospitals. During a qualitative phase we identified hygienic measures and included them in a study‐specific questionnaire. The patients completed the questionnaire at home. Outcome variables were dichotomized and the results presented as relative risks (RR) with 95% confidence interval.

RESULTS

We received the questionnaire from 452 (92%) of 491 identified patients. The proportion of patients who had a symptomatic UTI in the previous year was 22% for orthotopic neobladder and cutaneous continent reservoir, and 23% for non‐continent urostomy diversion. The RR for a UTI was 1.1 (0.5–2.5) for ‘never washing hands’ before handling with catheters or ostomy material. Patients with diabetes mellitus had a RR of 2.1 (1.4–3.2) for having a symptomatic UTI.

CONCLUSIONS

We could not confirm lack of hygiene measures as a cause of UTI for men and women who had a cystectomy with urinary diversion. Patients with diabetes mellitus have a greater risk of contracting a UTI.