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.     

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.     

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.     

Evaluation of and antimicrobial therapy for recurrent urinary tract infections in women

The problem with recurrent urinary tract infections in women is enormous and contributes significantly to national health care costs. As the role of office urology and the external "cost-effective" pressures placed on the practicing urologist have heightened, a consistent, logical approach towards diagnosis and management of urinary tract infection becomes essential. This article briefly discusses the cause and pathophysiology behind recurrent urinary tract infections in women. A practical discussion of proper evaluation and treatment options will also be provided in hopes of offering the clinician a simple, stepwise approach to this sometimes difficult condition.     

d-mannose powder for prophylaxis of recurrent urinary tract infections in women: a randomized clinical trial

Purpose

To test whether d-mannose powder is effective for recurrent urinary tract infection (UTI) prevention.

Materials and methods

After initial antibiotic treatment of acute cystitis, 308 women with history of recurrent UTI and no other significant comorbidities were randomly allocated to three groups. The first group (n = 103) received prophylaxis with 2 g of d-mannose powder in 200 ml of water daily for 6 months, the second (n = 103) received 50 mg Nitrofurantoin daily, and the third (n = 102) did not receive prophylaxis.

Results

Overall 98 patients (31.8 %) had recurrent UTI: 15 (14.6) in the d-mannose group, 21 (20.4) in Nitrofurantoin group, and 62 (60.8) in no prophylaxis group, with the rate significantly higher in no prophylaxis group compared to active groups (P < 0.001). Patients in d-mannose group and Nitrofurantoin group had a significantly lower risk of recurrent UTI episode during prophylactic therapy compared to patients in no prophylaxis group (RR 0.239 and 0.335, P < 0.0001). In active groups, 17.9 % of patients reported side effects but they were mild and did not require stopping the prophylaxis. Patients in d-mannose group had a significantly lower risk of side effects compared to patients in Nitrofurantoin group (RR 0.276, P < 0.0001), but the clinical importance of this finding is low because Nitrofurantoin was well tolerated.

Conclusions

In our study, d-mannose powder had significantly reduced the risk of recurrent UTI which was no different than in Nitrofurantoin group. More studies will be needed to validate the results of this study, but initial findings show that d-mannose may be useful for UTI prevention.     

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.

     

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.     

Prevention and alternative methods for prophylaxis of recurrent urinary tract infections in women

General recommendations to prevent recurrent urinary tract infections (rUTI) result in about one-third of patients remaining free of recurrences. Oral and parenteral immunotherapy were effective in several controlled studies for prevention of rUTI. These therapies can be combined with acute antibiotic therapy. Vaginal prophylaxis with oestriol has proven its positive effect without serious gynaecological side effects. Also there is increasing evidence that cranberries prevent rUTI. The exact mode (juice, tablets or preserved berries), dosage and duration of this therapy remain to be defined. There are also promising therapy modalities such as changing bacterial gut flora, general immune response (acupuncture, inpatient rehabilitation) and urine acidity.     

Value of urologic investigation in a targeted group of women with recurrent urinary tract infections.

According to the conclusions of clinical studies, excretory urography and cystoscopy are of no value in managing the majority of women who have a history of recurrent urinary tract infection (UTI). Of 475 women with recurrent UTIs, 186 were prospectively targeted for evaluation by cystoscopy and ultrasonography or excretory urography from selection criteria based on the degree of complicating factors, to determine the value of urologic investigation. Thirty-nine patients had significant detectable abnormalities, and 20 of them required surgical intervention. Definite indications for urologic evaluation include hematuria (gross hematuria and persistent microscopic hematuria between infections), pyelonephritis and a presentation that is not typical for simple uncomplicated UTIs (obstructive symptoms, infection with urea-splitting bacteria, clinical impression of persistent infection or urinary calculi). Diabetes itself does not warrant urologic evaluation. The findings from this study suggest that cystoscopy and upper urinary tract evaluation do play a role in the management of a selected group of women with UTIs.     

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.     

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.     

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.     

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.     

Lower urinary tract infections in women

The combination of increased ability of the bacteria to adhere plus susceptible epithelial cells appears to predispose certain women to infection. The author presents a practical approach to the selection and employment of common urinary tract agents for pre- and postmenopausal women. Discussed are therapeutic goals, initial and chronic therapy, and complications of treatment (in postmenopausal women, pregnancy, and renal failure).     

Uncomplicated urinary tract infections in women

Uncomplicated urinary tract infections, such as acute uncomplicated cystitis and pyelonephritis, are common infections in otherwise healthy women. Although severe complications are rare, the high prevalence of these infections contributes to significant costs to health care systems. The present review addresses recent publications that concern the epidemiology, pathogenesis, aetiology, diagnosis, treatment and prevention of uncomplicated urinary tract infections and recurrent urinary tract infections in women.     

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.