Efficacy and safety of self-start therapy in women with recurrent urinary tract infections

PURPOSE: We evaluated the efficacy of self-start therapy in women with recurrent urinary tract infections. MATERIALS AND METHODS: Women with recurrent urinary tract infections received a dip slide urine culture kit and 6 tablets of norfloxacin (400 mg.). At each symptomatic urinary tract infection episode the patient performed a culture and initiated therapy. The culture was returned and the patient was resupplied with another kit and norfloxacin. Patients were seen 5 to 9 days and 4 to 6 weeks after therapy to assess treatment outcome. RESULTS: A total of 34 women were enrolled in the study and were evaluable for treatment outcomes. Six women followed for 74 months were asymptomatic and 9 followed for 103 months had no infections. A total of 28 women followed for 355 months had 84 symptomatic episodes and 25 had 67 urinary tract infections. Patients had symptomatic episodes at a rate of 2.8 per patient-year (range 0 to 9) and infections at a rate of 2.3 per patient-year (range 0 to 9). The greatest risk of symptoms of infection or infection occurred in the first 3 months and among patients with a higher rate of infection before entering the study. Of the 84 symptomatic episodes 78 (92%) responded clinically. Of 78 cultured episodes 11 (14%) were negative. The remaining 67 cultured documented infections were cured microbiologically 5 to 7 days after therapy. No adverse effects occurred. The annual cost unaccompanied by a symptomatic episode was $86 and $259 if symptomatic episodes occurred. CONCLUSIONS: Intermittent self-start therapy is effective, safe and economical in women with recurrent urinary tract infections.     

Symptomatic recurrent urinary tract infections in patients with renal scarring in relation to fecal colonization with P-fimbriated Escherichia coli

We evaluated prospectively 49 women with renal scarring and a history of febrile urinary tract infections in regard to the incidence of recurrent symptomatic urinary tract infection and fecal colonization with P-fimbriated Escherichia coli. During a 3-year followup 26 patients (53 per cent) had symptomatic urinary tract infection (0.036 infections per patient-month), including 8 (16 per cent) who had 9 new episodes of febrile urinary tract infection, while 33 (67 per cent) had Escherichia coli bacteriuria (10(5) bacteria per ml. urine in pure culture). Thus, patients with previous febrile urinary tract infections and renal scarring have a high risk for recurrent infections. For comparison, the incidence of symptomatic urinary tract infection also was determined in 35 women with a recent episode of acute nonobstructive pyelonephritis and with normal kidneys on excretory urography. These patients had 0.031 symptomatic infections per patient-month. The fecal flora were examined twice a year for P-fimbriated Escherichia coli in 48 patients with renal scarring. Of these patients 21 (44 per cent) had at least 1 fecal colonization with a P-fimbriated Escherichia coli strain. However, in only 1 instance was a relationship detected between the presence of P-fimbriated Escherichia coli in the fecal flora and the development of subsequent febrile urinary tract infection. The findings indicate that fecal sampling twice a year is not of value to predict future urinary tract infections in adults with renal scarring.     

Comparative results of urological evaluation of children with initial and recurrent urinary tract infection.

Complete urologic evaluation was done on male and female children having initial or recurrent urinary tract infection. Of 200 girls having recurrent urinary tract infection 43 per cent showed ureterovesical reflux on the cystogram. Of 39 boys with recurrent urinary tract infection 41 per cent had reflux. Thus, the incidence of reflux is comparable in male versus female patients. Of 47 girls studied after only 1 episode of urinary tract infection 36 per cent had reflux and of 20 boys studied after initial infection 45 per cent had reflux. The data indicate that initial or recurrent urinary tract infection in boys or girls is of equal significance. All other factors being equal, failure to evaluate a patient urologically after 1 or more episodes of urinary tract infection solely because of the sex of the child could mean that a potentially severe urinary tract abnormality can be undetected and untreated.     

Recurrent pyelonephritis without vesicoureteral reflux: is there a role for an antireflux procedure?

PURPOSE: To evaluate the results of an endoscopic antireflux procedure in women with recurrent acute pyelonephritis and no evidence of vesicoureteral reflux (VUR) on voiding cystograms. PATIENTS AND METHODS: From 1989 to 1999, 603 female patients were hospitalized for acute pyelonephritis with unilateral loin pain, chills, fever, and a positive urine culture. Of these patients, 48 (8%) had recurrent episodes of acute pyelonephritis and underwent a thorough diagnostic work-up including intravenous urography or renal CT scan, cystoscopy, and voiding cystourethrography (VCUG). Vesicoureteral reflux was demonstrated in 21 patients, who were then offered an antireflux procedure, either surgical or endoscopic. Another 27 patients had no reflux on VCUG; in 15 cases, the upper urinary tract was normal, and the ureteral orifices did not show any abnormality on cystoscopy. The other 12 patients in this group with a normal VCUG had one or more abnormal findings normally associated with VUR: renal scarring in five and ureteral duplication in two. Golf-hole ureteral orifices were noted in two patients. The intravesical ureter was short (< 5 mm) in five patients. In spite of the normal VCU, we offered these patients endoscopic treatment of VUR by submeatal injection of Teflon or microparticulate silicone (Macroplastic). The median follow-up before treatment was 4 years (range 1-15.3 years); 0.3 episodes of acute pyelonephritis per patient-month of follow-up were noted. The frequence of preoperative and postoperative episodes of acute pyelonephritis was compared with Wilcoxon's paired analysis. The median postoperative follow-up was 3.9 years (range 1.1 months-10.2 years). RESULTS: There were no significant postoperative complications. One patient had two episodes of acute pyelonephritis during pregnancy. On the whole, 11 patients (91%) were free of recurrent pyelonephritis after treatment. Overall, 0.003 episodes of acute pyelonephritis per patient-month of postoperative follow-up were observed. The result was statistically significant (P < 0.01). CONCLUSION: Recurrent acute pyelonephritis is frequently related to VUR. Intermittent reflux can be difficult to demonstrate on voiding conventional or nuclear cystograms but can be suspected in the presence of ureteral duplication, renal scarring, or abnormal ureteral orifices. Adult patients with recurrent episodes of upper urinary tract infection and normal cystograms should be considered for an endoscopic antireflux procedure in the presence of anatomic abnormalities commonly associated with reflux.     

Endoscopic Treatment for Vesicoureteral Reflux in Recurrent Urinary Tract Infections in Kidney Transplant: Experience of One Center

Vesicoureteral reflux (VUR) after renal transplantation in adult patients has been reported. In renal transplant recipients, symptomatic urinary tract infection can cause high morbidity despite improved immunosuppressive and antibiotic treatment. In our country there have been few reported cases about use of copolymer of dextranomer and hyaluronic acid (DX-HA) injection in a renal transplant. We present 3 cases of recurrent or complicated infections with evidence of high-grade VUR, which were treated with DX-HA. Only 1 case had a partial remission; however, there were no episodes of urinary tract infection in 12 months of follow-up. Suburethral injection is an endoscopic treatment modality with low morbidity in our country.     

Congenital bladder diverticula in children

BACKGROUND/PURPOSE: The authors report their experience with the management of congenital bladder diverticula in children. METHODS: The authors reviewed the histories of six boys (mean age, 4.4 years) in whom congenital bladder diverticula was treated from 1980 to 1996. Diverticula were unilateral in four patients and bilateral in two patients. All patients presented recurrent urinary tract infection, and two boys had several episodes of urinary retention. Secondary kidney damage was present in two patients with ureteral obstruction and one with vesicoureteral reflux. Surgical treatment was undertaken in all patients. RESULTS: After surgical treatment, none of the patients has had recurrence of the diverticula, and all remain asymptomatic. CONCLUSIONS: Congenital bladder diverticula have a wide clinical spectrum and could lead to severe kidney damage. Urinary tract infection and urinary retention are the most frequent presentation forms. Surgical treatment should be indicated in all symptomatic cases according to each anatomic and functional situation.     

Control of recurrent lower urinary tract infection in the postmenopausal woman

There were 5 postmenopausal women with severe recurrent cystitis who were placed on a protocol of intravaginal estrogen in an effort to control infection. Before therapy all patients had colonization of the vagina by 1 or more species of Enterobacteriaceae and an associated elevation of vaginal pH greater than 5.2 (normal range 4.0 to 4.5). After acute antibiotic treatment and continuous low dose intravaginal estrogen all 5 patients showed a return of vaginal pH to the normal range and disappearance of vaginal bacterial pathogens. Of the 5 women 4 have had no further urinary tract infection off antibiotics and on low dose intravaginal estrogen. One patient had a urinary tract infection in association with a flare in colitis, which was controlled with reinstitution of antibiotics and high dose intravaginal estrogen therapy.     

Do intravenous urography and cystoscopy provide important information in otherwise healthy women with recurrent urinary tract infection?

An investigation of the influence on therapy of intravenous urography (IVU) and cystoscopy in a prospective study of 93 women with recurrent urinary tract infections is presented. The patients fulfilled the following criteria: a history of recurrent urinary tract infection (at least three episodes a year), a physical and gynaecological examination, determination of plasma creatinine, urine culture, microscopy, and uroflowmetry. It is concluded that IVU seldom reveals abnormalities that influence treatment in otherwise healthy women. On the other hand, uroflowmetry and cystoscopy occasionally yield helpful information.     

Complications of chronic indwelling urinary catheters among male nursing home patients: a prospective study

We studied prospectively the incidence of symptomatic infections of presumed urinary tract origin requiring antimicrobial therapy among 54 male nursing home patients with chronic indwelling bladder catheters. During 514 patient-months at risk there were 106 episodes of symptomatic infection, for an incidence of 0.21 per patient-month at risk. Of the patients 80 per cent had at least 1 episode and 48 per cent had 2 or more. None of the clinical factors we examined, including age, nutritional status, stool incontinence, diabetes mellitus, episodes of catheter blockage and the use of chronic suppressant antimicrobial therapy, was associated with the development of symptomatic infection. Further research on host and pathogen-related factors that increase the risk for symptomatic infection, and improvements in infection control and catheter care protocols are necessary to decrease catheter-associated morbidity among male nursing home patients who must be managed by chronic indwelling catheterization.     

URODYNAMIC FACTORS INFLUENCE THE DURATION OF ESCHERICHIA COLI BACTERIURIA IN DELIBERATELY COLONIZED CASES

Purpose

We evaluated the influence of urodynamic factors on the establishment of bacteriuria, after deliberate intravesical inoculation with Escherichia coli.

Materials and Methods

Nine women and 7 men with recurrent symptomatic urinary tract infections underwent intravesical injection of E. coli 83972. This strain had documented ability to persist in the urinary tract and it lacks expressed virulence factors associated with urinary tract infection.

Results

Successful long-term colonization (5 months to 3 years) was achieved in 6 of 12 patients with neurogenic bladder disorder, including normal or high bladder capacity, normal or low detrusor pressure and residual urine. Short-term bacteriuria (13 days) occurred in 1 but long-term bacteriuria was not established in the 4 patients with normal lower urinary tract function. Occasionally urine samples from the colonized patients contained other bacterial strains, which cleared spontaneously except for a Klebsiella strain that became established in 2 and subsequently eliminated E. coli 83972.

Conclusions

E. coli 83972 bacteriuria could only be established in a subset of patients with defective bladder voiding, suggesting that urodynamic defects permit a nonvirulent strain to establish in the urinary tract, but that additional host factors determine if bacteriuria will persist.     

The Prevalence of Urinary Tract Infections in Patients with Gestational Diabetes Mellitus

Microbiologic evidence of urinary tract infection was studied in 447 pregnant women with (n= 149) or without (control group, n= 298) gestational diabetes mellitus after mid-pregnancy. Laboratory investigations included chemical analysis, microscopic examination and culture of a clean midstream voided urine specimen. Nineteen women (4.2%) had asymptomatic bacteriuria (7 study, 12 contorl, P = 0.7). Of these, 7 (38%) developed symptomatic infection despite treatment with antibiotics (2 study, 5 control, P = 0.7) and 6 (31%) had recurrent bacteriuria later in pregnancy (3 study, 3 control, P = 0.3). Twelve more women (2.6%) had symptomatic infection (5 study, 7 control, P = 0.5), 7 had acute cystitis (3 study, 4 control, P = 0.5) and 5 had acute pyelonephritis (2 study, 3 control, P = 0.7). Escherichia coli was the commonest pathogen, accounting for 22 (71%) infection episodes. Gestational diabetes mellitus was not associated with increased risk of urinary tract infections nor of maternal and perinatal morbidity as a result of infection.     

Incidence and significance of positive urine cultures in patients with an orthotopic neobladder

PURPOSE: With an intact normal bladder bacterial colonization is uncommon unless intermittent catheterization is instituted. Because intestine, which is normally colonized with bacteria, is used to form an orthotopic neobladder, we determined whether patients with orthotopic urinary diversion are at increased risk for urinary tract infection and urosepsis. MATERIALS AND METHODS: A total of 66 patients who received an orthotopic neobladder after radical cystectomy were prospectively evaluated with urinalysis and culture 2 months to 4 years postoperatively. No patient was on suppressive antibiotics unless they had recurrent urinary tract infections. RESULTS: A total of 55 voided normally and 11 performed intermittent catheterization at least once daily due to high post-void residual urine. Of the patients who voided normally 78% had at least 1 positive urinalysis. If a patient had a positive urinalysis, bacteria was identified on culture in 50%. Overall 26 (39%) and 8 (12%) patients had a urinary tract infection and urosepsis, respectively. The estimated 5-year probability of urinary tract infection and urosepsis for patients who voided independently were 58% and 18%, respectively. Urine culture with greater than 100,000 cfu bacteria and female gender were the only factors predictive of urinary tract infection on multivariate analysis. Recurrent urinary tract infection was the only predictor for urosepsis. Intermittent catheterization or hydronephrosis was not related to urinary tract infection or urosepsis. CONCLUSIONS: The presence of small bowel intestine appears to promote asymptomatic bacterial colonization but urosepsis rarely occurs unless the patient has recurrent urinary tract infections. Prophylactic antibiotics are recommended only for patients with recurring urinary tract infections but treating a positive urinary culture in the absence of specific voiding symptoms is not advocated in this patient population.     

Symptomatic urinary tract infections in patients on maintenance hemodialysis

15 episodes of symptomatic urinary tract infection are described in 11 patients on maintenance hemodialysis. The diagnosis was confirmed by clean-catch or simple voided urine samples where possible, urethral catheterization and bladder washout being used only in anuric patients. Treatment with oral antibiotics proved successful in 13 episodes but 2 patients with polycystic kidneys were admitted to hospital for intravenous therapy. Urinary tract infections are common in dialysis patients including those who are anuric, and patients with polycystic kidneys have an increased risk of serious complications.     

Incidence and risk factors for medical complications after carotid artery stenting

OBJECTIVE: Carotid angioplasty and stenting (CAS) is being evaluated as an alternative to carotid endarterectomy for the treatment of carotid artery stenosis; however, to date little is known about the incidence of medical complications after CAS. The goal of this study was to determine the frequency of, and to identify potential clinical risk factors for, the development of medical complications after CAS. METHODS: Medical complications that occurred < or = 30 days after CAS in 327 consecutive patients (241 men, 86 women; mean age, 69 +/- 9 years; range, 45 to 90 years) treated for symptomatic (n = 182, 56%) or asymptomatic (n = 145, 44%) carotid artery stenosis were recorded. The effect of clinical characteristics on the subsequent development of medical complications was analyzed by logistic regression. RESULTS: Fifty-one patients (15%) had 62 medical complications: 3 (0.9%) myocardial infarctions, 3 (0.9%) cardiac arrhythmias, 4 (1.2%) episodes of angina pectoris, 3 (0.9%) episodes of symptomatic hypertension, 16 (4.9%) episodes of symptomatic hypotension, 10 (3.1%) chest infections, 9 (2.7%) had periods of confusion, 5 (1.5%) had urinary retention, and 9 (2.7%) urinary tract infections. One chest infection was fatal and 16 complications prolonged the intensive care unit monitoring period > 24 hours. Advanced age (odds ratio [OR], 1.1; 95% confidence interval [CI], 1.05 to 1.14) and a symptomatic carotid stenosis (OR, 2.1; 95% CI, 1.07 to 4.1) independently predicted the occurrence of medical complications. CONCLUSION: Although life-threatening or fatal non-neurologic events were uncommon in this series, the overall incidence of medical complications after CAS might be higher than currently anticipated. Older and symptomatic patients are at the highest risk, and these subgroups should be monitored closely.     

Double balloon positive pressure urethrography is a more sensitive test than voiding cystourethrography for diagnosing urethral diverticulum in women

PURPOSE: We determined the relative sensitivity of double balloon positive pressure urethrography and voiding cystourethrography for diagnosing urethral diverticula in women, and for evaluating which presenting symptoms should be considered clinically suspicious for even smaller diverticula. MATERIALS AND METHODS: The series comprised 32 women, including those with new onset urinary tract infections not related to intercourse, menopause or catheters, those with urethral symptoms, such as point urethral tenderness or a mass, urethral pain, dysuria, dyspareunia or post-void dribbling, and those with new onset urgency and frequency. All patients underwent a history and physical examination by the same physician. Each patient underwent double balloon urethrography and voiding cystourethrography on the same day at a single radiology department. RESULTS: Of the 32 women 30 (94%) were diagnosed with at least 1 diverticulum by double balloon urethrography. In 22 of these cases voiding cystourethrography failed to show the diverticulum. Only 11 of these patients (37%) had a palpable mass on clinical examination. The most common presenting symptoms in patients diagnosed with a diverticulum were recurrent urinary tract infection (52%), dysuria (52%), urgency (41%), frequency (38%), stress incontinence (38%) and urge incontinence (34%). Only 3 patients (9%) presented with 1 symptom. Diverticulectomy was performed in 16 patients. Double balloon urethrography had greater sensitivity (100%) than voiding cystourethrography (44%) relative to a confirmed surgical diagnosis (z test p = 0.002). Of 9 diverticula missed by voiding cystourethrography in the surgery group the maximum diameter was less than 15 mm. in 5. Average followup in the surgery cases is 34 months (median 35, range 17 to 50). None of these patients has had new symptoms suggestive of recurrent diverticulum, failure, new urethritis or new stress urinary incontinence. Conservative therapy consisted of long-term antibiotics in 6 patients and symptomatic treatment with short-term antibiotics in the remaining 8. Conservative therapy offered symptomatic relief in most cases but did not prevent recurrent symptoms. CONCLUSIONS: A diverticulum should be suspected in patients with new onset urinary tract infection, urgency and frequency as well as dyspareunia, post-void dribbling and dysuria. Double balloon urethrography is a more sensitive diagnostic test than voiding cystourethrography for diagnosing urethral diverticula. Patients with mild symptoms may be treated with conservative therapy, although we believe that satisfactory long-term treatment of diverticula is best achieved by surgical excision.     

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.     

Micturition syncope: an atypical case

A forty-nine-year-old man had episodes of micturition syncope associated with an asymptomatic urinary tract infection. Treatment of the infection resolved the syncopal episodes. Micturition syncope occurs in the standing position; physical, electrocardiographic, and electroencephalographic studies usually have normal results. The case reported here is atypical in that micturition syncope was the only apparent symptom of urinary tract infection.     

Value of the echography of the maternal kidney during pregnancy

Routine ultrasonographic detection of renal tract dilatations in pregnant women is used to define a high risk population for urinary tract infections. In a first group of 96 patients with symptomatic urinary tract infection, 34% of the cases of uncomplicated infection were accompanied by ultrasonographic abnormalities, while 73% of cases of pyelonephritis presented such signs. Antibody coated bacteria were only found in 12% of uncomplicated urinary tract infections and in 30% of cases of pyelonephritis. In a second group of 273 patients, routine ultrasonography revealed abnormalities in 11.5% of cases. 7.5% of patients had dilatations of the upper renal tract, 2% had renal stones and 2% had occult renal malformations. Dilatations of the upper renal tract were associated with asymptomatic urinary tract infections in 30% of cases. Screening for upper renal tract dilatations is recommended between the 17th and 20th weeks of pregnancy. The presence of such lesions constitutes a risk factor for urinary tract infection and appropriate prophylactic treatment should be prescribed.     

Urinary oxalate excretion in female calcium oxalate stone formers with and without a history of recurrent urinary tract infections

Therapy with antibiotics in recurrent urinary tract infections may destroy colonies of Oxalobacter formigenes in the intestinal tract. A lack of oxalate degradation caused by the absence of this bacterium is suggested to contribute to the hyperabsorption of dietary oxalate and to the increase in urinary oxalate excretion. The present study was performed to evaluate the effect of recurrent urinary tract infections and subsequent changes induced in the urinary excretion profile in female calcium oxalate stone formers. Serum biochemical profiles, 24-h urinary parameters, and the personal characteristics of 57 female calcium oxalate stone patients with recurrent urinary tract infections (RUTI) were compared with 78 female calcium oxalate stone patients without a history of urinary tract infection. All subjects were recruited during the same period. In female patients with RUTI, urinary oxalate excretion was significantly higher (0.374 mmol/day) than in females without urinary tract infection (0.308 mmol/day) (P < 0.05). Moreover, the mean 24-h pH value and urinary sodium excretion were significantly higher in women with RUTI than in women without a history of urinary tract infection. The significantly higher urinary oxalate excretion in female calcium oxalate stone formers with recurrent urinary tract infections may be associated with the application of antibiotics and a subsequent temporary or permanent decolonization of Oxalobacter formigenes.     

Urinary excretion of Tamm-Horsfall protein in women with recurrent urinary tract infections

Since MS-fimbriated bacteria adhere to Tamm-Horsfall protein, it has been suggested that Tamm-Horsfall protein may trap urinary pathogens and prevent them from colonizing the mucosal surfaces of the urinary tract. To test the hypothesis that low urinary Tamm-Horsfall protein excretion rates predispose to urinary tract infection we obtained serial urine samples from 17 women with and 18 without a history of recurrent urinary tract infection. None of the women had known structural abnormalities of the urinary tract. Concentrations of Tamm-Horsfall protein in urine were measured with a sensitive enzyme-linked immunosorbent assay method. On the average, 3 urine samples per person collected within 3 to 6 months were analyzed. The mean Tamm-Horsfall protein excretion of women with recurrent urinary tract infection was 57.0 mg./l. and that of controls was 66.3 mg./l.; this difference was not statistically significant. The mean coefficient of variation was 44.2 and 62.1%, respectively. We conclude that urinary Tamm-Horsfall protein concentration is not significantly decreased in women with recurrent urinary tract infection compared with controls, and that excretion varies widely in repeat samples obtained from the same individual.