Urogynecology: Evidence-Based Clinical Practice 2nd ed.

11. Recurrent Bacterial Cystitis in Women

Kate H. Moore1

(1)

Department Obstetrics & Gynaecology, St George Hospital, Kogarah, New South Wales, Australia

Abstract

Recurrent bacterial cystitis is defined as recurrent significant bacteriuria (more than 105organisms per ml of a single organism), with significant pyuria (more than ten white blood cells per ml), in the absence of upper tract pathology. “Recurrent” is usually taken to mean more than three proven UTIs in the last 5 years. (Because the abbreviation RBC usually applies to red blood cells, “UTI” is used here.) If upper urinary tract disorders are causing the UTI, then referral to a urologist is required. Also, if there is no upper tract disorder, but the patient has recurrent bouts of hematuria associated with the UTI, then urology referral is also indicated. Recurrent UTI is common in urogynecological patients. About 4 % of women aged 15–65 have significant bacteriuria at any given time (Kass et al. [2]), and the prevalence rises with age. About 25 % of women experience at least one proven recurrence within 6 months of the first attack [1].

Recurrent bacterial cystitis is defined as recurrent significant bacteriuria (more than 105 organisms per ml of a single organism), with significant pyuria (more than ten white blood cells per ml), in the absence of upper tract pathology. “Recurrent” is usually taken to mean more than three proven UTIs in the last 5 years. (Because the abbreviation RBC usually applies to red blood cells, “UTI” is used here.) If upper urinary tract disorders are causing the UTI, then referral to a urologist is required. Also, if there is no upper tract disorder, but the patient has recurrent bouts of hematuria associated with the UTI, then urology referral is also indicated. Recurrent UTI is common in urogynecological patients. About 4 % of women aged 15–65 have significant bacteriuria at any given time (Kass et al. [2]), and the prevalence rises with age. About 25 % of women experience at least one proven recurrence within 6 months of the first attack [1].

Guide to Management of Recurrent UTI

At the first visit, take history of “recurrent” carefully.

Check any previous or family history of renal calculi

Obtain old MSU results from GP if possible.

Check whether the patient has episodes of multiresistant organisms, which may explain why there are “recurrences” (the treatment may have been incorrect).

Check for unusual bacteria such as Proteus mirabilisPseudomonasStreptococcus faecalis, etc., that may suggest upper tract disease.

Ascertain whether UTI is mainly triggered by intercourse.

Check whether previous colposuspension or TVT may have caused voiding dysfunction/high residual urine volumes.

During Examination

Examine the renal angles for silent calculi.

Percuss the abdomen for an enlarged bladder/subacute retention.

Check for a large cystocele that may harbor a stagnant pool of urine.

Check for atrophic vaginitis, which increases susceptibility to UTI.

Investigations for Recurrent UTI

We find it useful to give the patient three sterile urine culture jars and ask her to give a specimen of urine at the very first symptom of any infection, to check organism type. Although dipstick testing is cost effective in general practice, in the patient with recurrent UTI and incontinence/prolapse, the organisms should be identified on culture. Ask for all organisms to be reported, even if count only 102 per ml, with pyuria. Particularly in detrusor overactivity, low-grade UTI may exacerbate the OAB symptoms [7].

Order a renal ultrasound and post-void residual to exclude:

·               Renal calculi or pyelonephritis/hydronephrosis

·               Large complex renal cysts (small simple cysts seldom warrant concern)

·               Narrow-mouthed bladder diverticulum that may collect stagnant pool of urine

·               Dilated ureters that may suggest vesicoureteric reflux (if so, order micturating cystourethrogram)

The above conditions also indicate referral to a urologist. Urine flow rate may show a picture of obstruction, suggesting urethral stenosis. Post-void ultrasound may show incomplete emptying, that is, residual greater than 50–100 ml.

Treatment

If postmenopausal, treat with topical vaginal estrogen. A large RCT showed significant reduction in the incidence of UTI after estrogen versus placebo Raz and Stamm [6].

If postcoital UTI, we advise patients to read and practice the self-help regime of Kilmartin [3], which contains many helpful points about pre- and postcoital techniques to reduce the risk of this distressing problem. If these techniques do not prevent recurrence, then postcoital antibiotic therapy with trimethoprim 300 mg stat or nitrofurantoin 100 mg is of proven value.

If associated with large prolapse and residual urine, consider using a vaginal ring pessary to elevate the prolapse. If this eradicates the UTI, then repair of the prolapse should be considered (even if otherwise asymptomatic). If associated with persistent residual urine volumes >50 ml (but no prolapse), teach the technique of double emptying (see Chap. 9, management of voiding difficulty).

In the nonincontinent woman, bacteriuria without pyuria is not usually treated because it spontaneously resolves. In the incontinent woman who has frequency and urgency, we generally treat because bacteriological studies have shown that the endotoxins produced by bacteria can reduce the contractile strength of the urethral sphincter or decrease the contractility threshold of the detrusor, thus promoting incontinence [Moore et al. 4].

At Second Visit

If further proven UTI, consider 3 months of nitrofurantoin, trimethoprim therapy, or cystoscopy. These antibiotics are preferred because they are not well absorbed into the blood stream, not broad spectrum, and not likely to cause thrush. At least three months of therapy is chosen, to completely eradicate “microbiological communities” [5] that may form within the epithelium and lamina propria of the bladder. If the patient takes 3 months of such therapy and still has “breakthrough” UTI, then cystoscopy is indicated.

What to Look for on Cystoscopy

Exclude narrow-mouthed diverticulum. One also may see small waxy-yellow raised areas of microabscesses, as part of “cystitis cystica” appearance. Diathermy will eradicate these.

References

1.

Foxman B. Recurring urinary tract infection: incidence and risk factors. Am J Public Health. 1990;80:331–3.PubMedCrossRef

2.

Kass EH, Savage W, Santamarina BAG. The significance of bacteriuria in preventive medicine. In: Kass EH, editor. Progress in pyelonephritis. Philadelphia: FA Davis; 1965. p. 3–10.

3.

Kilmartin A. The patient’s encyclopedia of urinary tract infection, sexual cystitis and interstitial cystitis. Chula Vista: New Century Press; 2002.

4.

Moore KH, Simons A, Mukerjee C, Lynch W. Relative incidence of detrusor instability and bacterial cystitis found on the urodynamic test day. Br J Urol. 2002;85:786–92.CrossRef

5.

Mulvey MA, Schilling JD, Martinez JJ, Hultgren J. Bad bugs and beleaguered bladders: interplay between uropathogenic Escherichia coli and innate host defenses. Proc Natl Acad Sci U S A. 2000;97:8829–35.PubMedCentralPubMedCrossRef

6.

Raz R, Stamm WE. A controlled trial of intravaginal estriol in post menopausal women with recurrent urinary tract infections. N Eng J Med. 1993;329:753–6.CrossRef

7.

Walsh CA, Moore KH. Overactive bladder in women: does low-count bacteriuria matter? A review. Neurourol Urodyn. 2011;30:32–7.PubMedCrossRef