By Chiara Ghetti, MD
Associate Professor, Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Washington University School of Medicine, St. Louis, MO
SYNOPSIS: Only 33% of women presenting to a urogynecology practice with symptoms of recurrent urinary tract infections met diagnostic criteria for recurrent urinary tract infections. The use of preventive strategies can be improved.
SOURCE: Dieter AA, Mueller MG, Andy UU, et al. Baseline characteristics, evaluation, and management of women with complaints of recurrent urinary tract infections. Female Pelvic Med Reconstr Surg 2021;27:275-280.
The main objective of this study was to characterize women who present to tertiary urogynecology care for symptoms of recurrent urinary tract infections (rUTIs) and to describe their evaluation and treatment. This study was a retrospective cohort study performed at five academic institutions. Subjects included new patients seen over a one-year period for referral, complaint, or diagnosis of recurrent or frequent UTIs. Patients were followed for one year from their initial visit. Exclusion criteria included: age younger than 18 years, any chronic catheter use, immunosuppression as the result of prior organ transplant, prior urinary tract reconstruction, and active malignancy or treatment for malignancy within last two years.
Culture-proven rUTIs were defined as three culture-proven UTIs (> 10,000 colony forming units [CFU] for catheterized specimen and > 100,000 CFU for voided specimens) in one year or two or more in six months. Outcomes included UTI occurrence as well as medical, surgical, and urogynecologic history, including history of lower urinary tract symptoms, urinary incontinence treatment, UTI evaluation, and treatments, including prevention. Prevention therapies included daily prophylactic antibiotics, post-coital antibiotics, vaginal estrogen, cranberry products, probiotics, D-mannose, methenamine, or other. Data also were recorded on advanced testing, including cystoscopy or radiologic imaging, as well as any change in clinical care resulting from testing. Of the 600 women included in the study, 193 (33%) met criteria for rUTI at the time of their initial visit and an additional 30 women (5%) met criteria at a follow-up visit. Women who met criteria for rUTIs were older (mean age 65 years, standard deviation [SD] 17 years) compared to women who did not meet criteria (mean age 56 years, SD 18 years). Women who did not meet criteria also were more likely to have had prior hysterectomy, to be postmenopausal, and to have a history of pelvic irradiation and gynecologic cancer and they were less likely to be sexually active than women who did not meet the criteria.
Urinary incontinence symptoms, as well as urinary symptoms, were similar in the two groups of women. The most commonly reported urinary symptoms were frequency, dysuria, and urgency. Women with culture-proven rUTI were significantly more likely to have dysuria compared to women who did not meet the criteria (59% vs. 40%, P < 0.001). More than one-third of women (234, 39%) underwent advanced testing. Clinical care was altered in only 21 (9%) of these women following testing. At the time of the first visit, one-quarter of women were using a preventive strategy, with approximately an additional 10% using more than one preventive strategy. Following the initial consultation, more than 40% of women were using one strategy and an additional 25% were using two or more strategies. The use of vaginal estrogen increased from 14% to 47% following the initial consultation. Forty-four percent of the women in the study were treated for a UTI in the follow-up period. Of these, the majority of cultures (57%) were positive for Escherichia coli and 14% were positive for Klebsiella.
COMMENTARY
UTIs are very common, affecting 50% to 80% of women, and UTI symptoms are very bothersome. Studies have shown that having one infection may predispose up to 44% of women to UTI recurrence.1,2 Women ages 18 to 34 years and ages 55 to 66 years appear to have the highest rates of rUTIs.3 Guidelines for the evaluation and treatment of rUTI vary; however, UTIs are a frequent indication for referral to urogynecology subspecialists.4
Lower urinary tract symptoms associated with UTI include urinary frequency, urgency, dysuria, and suprapubic pain. However, other genitourinary symptoms can coexist and mistakenly can be attributed to a UTI and treated empirically. This study found that only 33% of women presenting with frequent UTI diagnosis or referral were, in fact, found to meet the clinical diagnosis of rUTI. Women who met clinical diagnosis were more likely to have dysuria. This finding supports prior work demonstrating that the presence of dysuria symptoms increases the likelihood of UTI diagnosis. Performing urine cultures for symptomatic patients prior to empiric treatment and avoiding routine urine testing in asymptomatic patients can decrease the treatment of asymptomatic bacteria. In addition, evaluating women for other coexisting conditions, such as urinary incontinence, genitourinary atrophy, and pelvic floor myofascial pain, which often contribute to overlapping symptoms, can help us better tease apart UTI-like symptoms from true UTIs.
Dieter et al found that a large portion of UTIs were caused by E. coli and more than half of UTIs were treated with nitrofurantoin. This is consistent with American Urogynecologic Society (AUGS) guidelines, which recommend the use of nitrofurantoin, fosfomycin, and trimethoprim-sulfamethoxazole as first-line agents when possible.4 Guidelines for nitrofurantoin have changed, and it should be avoided in women with a creatinine clearance (CrCl) < 30 mL/min. Fluroquinolones are not considered first-line agents for the treatment for acute UTI. Fluroquinolones have high rates of adverse events and should be considered second-line agents alongside beta-lactam antibiotics. Vaginal estrogen therapy (VET) has been shown to prevent UTIs in postmenopausal women and is recommended by AUGS and American Urological Association/Canadian Urological Association/Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction guidelines.4,5 This study found that only 14% of women referred for rUTI symptoms had been prescribed VET prior to consultation, increasing to 47% after consultation. VET is a safe and effective therapy and can be initiated easily by primary providers and referring physicians alike as first-line prevention of rUTI in post-menopausal women. The findings of this study also highlight various society recommendations for judicious use of advanced imaging.4,5 Although Dieter et al found that clinical care rarely was altered by advanced testing, referral for persistent UTI symptoms that do not respond to first-line measures is warranted. As OB/GYN providers, we can play an important role in the care of women with rUTIs and UTI symptoms. Although rUTIs may seem a challenging diagnosis to tackle initially, following a basic paradigm that involves a thorough assessment of symptoms to aid in careful diagnosis, thoughtful use of first-line antibiotic regimens, and implementation of initial prevention strategies, VET in particular, can improve our patients’ urinary health dramatically.
REFERENCES
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- Hooton TM, Gupta K. Recurrent simple cystitis in women. UpToDate. Updated June 4, 2021. https://www.uptodate.com/contents/recurrent-simple-cystitis-in-women
- Suskind AM, Saigal CS, Hanley JM, et al. Incidence and management of uncomplicated recurrent urinary tract infections in a national sample of women in the United States. Urology 2016;90:50-55.
- Brubaker L, Carberry C, Nardos R, et al. American Urogynecologic Society best-practice statement: Recurrent urinary tract infection in adult women. Female Pelvic Med Reconstr Surg 2018;24:321-335.
- Anger J, Lee U, Ackerman AL, et al. Recurrent uncomplicated urinary tract infections in women: AUA/CUA/SUFU guideline. J Urol 2019;202:282-289.
