Outpatient: rUTIs

Question 1

A 45F has been referred by the GP with a hx of rUTIs. How would approach this case?

Answer 1

Ideally I would review this patient in a routine urology clinic. Patient should provide a urinalysis and if of child bearing age should be tested for pregnancy.

Focussed Urol history:

• duration, frequency, responsive to antibiotics
• associated LUTs, incomplete bladder emptying, LUTs outwith UTI episodes, flank pain, PV discharge/bleeding, childhood history
• triggers- post coitus, hygiene, menopause, STI, undiagnosed diabetes
• red flags: weight loss, bony pain, night sweats, new neurological symptoms
• fluid hx
• PMHx: Pelvic surg for prolapse, radiation
• Dhx: tried medications, triggers [anticholinergic- retention, SSRIs], anticoagulants, allergies

Exam with chaperone:
Abdo exam- scars, palpable bladder
PV exam- atrophic vaginitis, evidence of FGM, prolapse [cough test]
Neurological exam if hx suggests so

Initial tests:
Urinalysis and bHCG: check for undiagnosed diabetes, current infection, NVH and VH
USS urinary tract with PVS

Question 2

What is the definition of a rUTI?

Answer 2

According to EAU rUTI is an episode of UTI that is confirmed on urine culture and treated, but then occurring at a frequency of 2 times in 6 months or 3 times in a year

Question 3

What is the definition of a complicated UTI?

Answer 3

UTI in the presence of a structural or functional abnormal urinary tract, or UTI in the presence of underlying disease which is known to increase the risk of infection.
According to NICE factors suggesting complicated UTI include:
-being male, elderly, pregnant women
-catheterised patients
-immunosuppression, diabetes

Question 4

What are you looking at in the urinalysis?

Answer 4

Blood- NVH or VH would warrant cystoscopy and imaging
leucocytes- WBCs in urine. if sterile pyuria, then could be TB, CIS, interstitial cystitis , schisto, bladder stones
Nitrates- could be sign of infection
Ketones/glucose- raises suspicion of poor controlled or undiagnosed diabetes
pH- average is 5.5-6.5. if alkaline >7.5 then could be stones

Question 5

You found no cause for infections. What is your management plan?

Answer 5

Explain that given that there is no obvious cause the main treatment is prevention. General advice:

• Pre and post coital voiding
• Educate on hygiene
• fluid intake
• Avoid detergents in bath
• keep urine acidic
• topical oestrogen
• daily cranberry juice or tablets

Offer other means of non-antimicrobial intervention before consideration of antimicrobial therapy.
Non-antimicrobial intervention:
-Intravesical Cystistat- replenishes GAG layer
-D-Mannose- sugar monomer that helps prevent bacteria [specifically E.coli] from adhering to urothelial wall.
-Hiprex- hydrolyses into formaldehyde preventing bacterial growth, also keeps urine acid.

Due to Antimicrobial stewardship I would offer this last and counsel the patient appropriately [side effects, resistance].
Antimicrobial therapy:
-self-start antibiotics or post-coitus Abx
- Low dose prophylaxis abx
- Intravesical gentamicin

If none work, consideration Uromune trial