Baseline Characteristics, Evaluation, and Management of Women With Complaints of Recurrent Urinary Tract Infections

Abstract

Objective The aims of this study were to determine the proportion of women presenting for recurrent urinary tract infections (UTIs) who met the diagnostic criteria (culture-proven UTI ≥3 in 1 year or ≥2 in 6 months) and to assess advanced testing utilization, preventive therapy use, and risk factors. Methods This is a retrospective chart review of women seen as new urogynecology consults for recurrent UTI (rUTI) between April 1, 2017, and April 1, 2018, followed through April 1, 2019. Exclusion criteria included catheter use, cancer treatment within 2 years, and prior organ transplant, urinary diversion, conduit, or bladder augmentation. Results Of 600 women, 71% had follow-up with a median of 179 days. Urinary tract infection symptoms included frequency (50%), dysuria (46%), urgency (43%), and malodorous urine (7%). One third met the rUTI diagnostic criteria. Two hundred thirty-four (39%) underwent advanced testing, and 9% (21/234) of women who underwent advanced testing had a change in clinical care. Preventive therapy use increased after consultation (P < 0.001), with vaginal estrogen (47%) being most common. Compared with women not meeting the rUTI criteria, women meeting the rUTI criteria were more likely to be older (adjusted odds ratio [aOR], 1.03/year; 95% confidence interval [CI], 1.02–1.04), have a prior history of gynecologic cancer (aOR, 4.07; 95% CI, 1.02–16.25), or report UTI symptoms of dysuria (aOR, 2.27; 95% CI, 1.57–3.27), or malodorous urine (aOR, 2.96; 95% CI, 1.47–5.94) and, while equally likely to be receiving preventive treatment prior to consultation, were more likely after consultation (OR, 3.06; 95% CI, 2.05–4.55). Discussion Thirty-seven percent of women seen for rUTI met the diagnostic criteria. Advanced imaging rarely changed care. Education about diagnostic criteria and preventive therapy is warranted.

Clinical characteristics, factors associated with urinary tract infection and outcome in acutely admitted patients with infection; an exploratory cross-sectional cohort study

“…In line with other studies, we established that classic UTI symptoms are strongly associated with a UTI diagnosis [ 28 , 29 ]. Dysuria is the symptom with the highest risk of a UTI diagnosis in our study, which is in line with other reports and is part of the UTISA (UTI Symptoms Assessment questionnaire) score for UTIs [ 10 , 21 , 28 , 30 ]. Urinary retention is a well-known risk factor for UTI, which our data confirm even in the case of the symptom being present for less than fourteen days [ 31 ].…”

New avenue of diagnostic stewardship: procedural stewardship for recurrent urinary tract infections in female patients

“…The diagnostic yield of cystoscopy in female patients with rUTI in the literature varies from 0 to 7.6%, with cohort sizes ranging from 15 to 379. [20][21][22][23][24][25] Only 1.3% (6/467) of cystoscopies in this cohort demonstrated significant findings that altered management. It is important to point out that significant findings among all patients were exclusively in the cohort of patients with high-risk features/complicated rUTI.…”

“… 17 – 19 Recent studies examining women with rUTI undergoing cystoscopy by Pat et al ( n = 379), Dokubo et al ( n = 236), and Dieter et al ( n = 173) demonstrated diagnostic yields of 0.26%, 3.4%, and 2%, respectively, including findings such as calculi, diverticuli, fistulae, and bladder tumors. 20 – 22 Urologic societies consistently recommend reserving cystoscopy for patients with high-risk features and/or of advanced age, although these recommendations are based upon expert opinion and lack robust supporting evidence. 10 – 12 The EAU offers a “weak” recommendation to avoid cystoscopy in women without risk factors that are less than 40 years of age.…”

“…While there exists an increasing body of evidence to suggest that cystoscopy offers little to no clinical benefit in the evaluation and subsequent management of female patients with uncomplicated rUTI, there still remains a significant lack of evidence evaluating the utility of cystoscopy in complicated rUTI patients or those of advanced age. [10][11][12][20][21][22][23][24][25] A recent "Guideline of Guidelines" on rUTI found most recommendations aimed at otherwise healthy non-pregnant women with uncomplicated cystitis and suggested further recommendations to assist management of complex patient groups, such as patients with complicated rUTI. 26 This retrospective cohort study seeks to build an evidentiary basis for the utility of cystoscopy in the evaluation of patients with rUTI by analyzing a larger cohort with a more robust classification of high-risk features than previous studies.…”

Antibiotic-Sparing Prevention of Urinary Tract Infections—New Evidence Regarding d-Mannose

“…To some extent, the ambiguity in the trial’s primary outcome is merely a reflection of the uncertainty about the optimal approach to diagnosing and initiating treatment for recurrent UTIs in the broader medical community. In routine practice, clinicians vary widely in their reliance on clinical tests to confirm episodes of recurrent UTIs, many patients are presumptively treated for recurrent UTIs when they do not meet conventional diagnostic criteria, and antibiotic overtreatment for both nonspecific symptoms and for asymptomatic bacteriuria is common. In contrast with routine care, women with preexisting chronic bladder syndromes were excluded from the trial by Hayward et al, decreasing the likelihood that participants were inappropriately suspected of having a recurrent UTI due to a mild or temporary flare in their chronic bladder symptoms.…”