Urogynecologist Abigail Shatkin-Margolis, MD, offers an update to help PCPs efficiently assess and treat patients prone to urinary tract infections, with a focus on both young and elderly adults. She clarifies when a workup is warranted and describes preventive strategies, noting which behavioral modifications, topical therapies and supplements are worthwhile and explaining how she proceeds when antibiotic prophylaxis is necessary.
Thank you so much. Thank you Michelle for that warm introduction. And thank you everybody who's joining today uh to um for this awesome topic of recurrent urinary tract infections in the elderly and young adult. Um like Michelle said, I'm doctor Shaq and Margolis and I'm a UO gynecologist with U CS F. And today, I'm going to define recurrent urinary tract infections. Then I'll discuss who suffers from your recurrent urinary tract infections. I'd like to review how to diagnose urinary tract recurrent urinary tract infections and then finally explore management. Um I'm just gonna take a step back. Um And if you're anything like my brothers, you might think a Euro gynecologist is a gynecologist who practices in Europe, but in fact, that's not what I am, but instead, I'm a physician with expertise in pelvic floor disorders. I've completed my residency training in obstetrics and gynecology and then an additional three year fellowship in female pelvic medicine and reconstructive surgery and I'm double board certified in both specialties. My bread and butter is pelvic floor disorders. Um This is inclusive of pelvic organ prolapse, urinary, incontinence, overactive bladder and fecal incontinence to name a few, but one of the reasons I see a lot of patients with recurrent urinary tract infections is because these anatomical and functional problems can result uh can be a result um uh can result in recurring infections. However, there's a number of non-surgical therapies that can be initiated before a referral to a urogynecologist. So what I hope to convey to you today while you're enjoying your lunch is tools for initiating the management of recurrent urinary tract infections. So I'd like to start um by going through a few definitions. This is certainly not the most exciting part of my presentation today. So bear with me here for the next few slides. But acute bacterial cystitis is a culture proven infection of a urinary tract with a bacterial pathogen associated with acute onset symptoms such as dysuria. And it may be in conjunction with other degrees of various symptoms like urgency frequency he materia or new and worsening incontinence. An uncomplicated U T I is an infection of the urinary tract that's seen in a healthy patient with an anatomically and functionally normal urinary tract with no known risk factors that would make that person susceptible for developing a U T I. In contrast, a complicated U T I is an infection seen in somebody with um complicating factors that may put her at risk for development of a U T I and potentially decrease efficacy of therapy. These factors may include an an atomic or functional abnormality of the urinary tract, more specifically like a stone or a urethral diverticulum or neurogenic bladder. It may be a patient who is immunocompromised or develops multidrug resistant bacterial infections. Now, the the real topic of today, recurrent U T I S. This is defined as two separate culture, proven episodes of acute bacterial cystitis with associated symptoms occurring within six months or three episodes within one year. And this definition really considers these episodes to be separate infections with resolution of symptoms in between episodes. And this does not include um this scenario where someone may need multiple courses of antibiotics to treat an infection. It's truly separate episodes of um often different bacteria. So just to highlight this is two culture proven infections in six months with associated symptoms or three in 12 months. Another term you may have heard um is relapsing U T I and I just wanna take a moment to compare and contrast. The two, they are different. A relapsing U T I is a recurrence in acute bacterial cystitis within two weeks of treatment. Um and it's with the same organism. So compared to recurrent U T I, which tend to occur after two weeks of completing therapy and may or may not be the same organism. Um Relapsing is one that occurs pretty quickly after completing therapy and is the same organism. And the reason this distinction is important is because relapsing U T I S suggests that there's a bacterial reservoir that might be causing this recurrence of infections despite adequate treatment and it warrants further work up. So, lastly, um asym uh asymptomatic bacteria is the um presence of bacteria in the urine that does not cause any illness or symptoms um and should not be treated. And we see this very commonly in patients with recurrent U T I S um that they get numerous urine tests even in the absence of symptoms and they often come back positive. And that's because there's an element of colonization in patients who have recurring infections. So I've just created a summary slide here. Um But I think what's important is the box. I've highlighted that recurrent U T I S are two U T I S in six months or three in 12 months. These are culture proven with symptoms and that a relapsing U T I again is a recurrence within two weeks of treatment with the same organism and warrants further work up. Ok, great job we got through that. Moving on to the epidemiology and physiology of recurrent U T I S. These are highly prevalent and costly and burdensome to um the health care system. They affect a great deal of women. Um Obviously, like all prevalence measures. It really depends on how you define the disease of interest. But our best estimates show that 60% of women will experience a symptomatic acute bacterial cystitis in their lifetime or U T I. And that 20 to 40% of women will have an additional episode and that 25 to 50% who experience an additional episode will have multiple recurrent episodes. Um So, regardless of how this is defined, the evaluation and treatment of U T I and specifically recurrent U T I cost several billion dollars globally each year. Um Last year in the US alone, this uh evaluation and treatment cost upwards of $2 billion. So this is um a serious condition who suffers from recurrent U T I S. So, these are the patients that I see very commonly. These are post menopausal women who are sexually active, um or pre menopausal women who are sexually active, the presence of a foreign body or stone that could be a bladder stone or kidney stone. Um And the foreign body is may be related to a previous prolapse or incontinence surgery that involved mesh patients who have incomplete emptying, which may be due to obstruction, um or advanced stage prolapse or even neurogenic bladder where their detrusor muscle is not contracting adequately. And then I also commonly see patients who are de dehydrated and with constipation. So, um taking a little bit closer look at our elderly population, these patients tend to be in a hypo estrogenic state because they're post menopausal. They often have reduced bladder sensation which reduces how much or how often they're urinating, which leads to urinary stasis and increases the risk of recurring infections. Often our elderly patients that they see are constipated. They may result in incomplete emptying or fecal stasis which results in a prolonged exposure to high bacteria loads and increases the risk of an urinary tract infection diagnosis can be challenging in the elderly population. Um because it often presents with atypical symptoms such as mental status changes, falls, et cetera. As I'm sure we've all experienced diagnosing A U T I in the elderly before moving on to young adults. Um young adults are um at risk for recurring infections often because uh they're sexually active. They may also have a hypo estrogenic state even though they're pre menopausal if they're on oral contraceptive pills using an I U D or potentially postpartum or breastfeeding. Um Also young adults can suffer from constipation with the same mechanism as previously mentioned. And the diagnosis and management of recurrent U T I S in the young adult population can be challenging as well. But for different reasons, often this is the population that's receiving empiric treatment without urine studies. So we have less information and limited data to help guide therapy. So again, here, I've created a summary of um kind of who gets U T I S and why recurring U T I s and why? So let's move on to the work up and diagnosis. A lot of this is primary care providers. This is your um routine history, physical and labs. I'm gonna just spend a little bit of time talking about how my history that when I see patients with recurrent U T I S and physical exam may be different. I'm certainly redressing patients, menopausal status, sexual history, whether or not they've had any prior genital urinary procedural or surgical intervention. Um on physical exam, I'm looking for evidence of vocal vaginal atrophy, pelvic organ prolapse, any prior or um any notable vaginal cyst or mass or potentially a mesh exposure from a prior surgery and on labs uh clean catch your analysis um And in certain populations S T I testing. So I'll take a moment here just to point out a few things that I consider on pelvic exam. So I'm gonna start with the images at the top. Here. These are four different images of the same um uh vagina looking at the epithelium. You'll see there's poor, there's loss of architecture of the labia menorah. There's some fusing over the clitoral head called the prep. These are all very common findings for vocal vaginal atrophy. Here. Another thing I I pick up on, on patients physical exam is evaluating the elder A I or the pelvic floor muscles. So here this image, there's a finger inside the vagina, um deflected posteriorly, feeling in the um posterior vagina through the wall and against the elevator, an I muscles evaluating the muscle tone and potentially if there's any hypertonicity or in increased contraction. These three images here down at the bottom show three different uh varieties of pelvic organ prolapse. You can see the cervix protruding through the um genital hiatus. Here, this person here in the middle has already had a hysterectomy. So they have what's called the vaginal cuff protruding. And then finally here another cervix and anterior vaginal wall protruding. These patients can be at increased risk of recurrent U T I S potentially um due to incomplete emptying. And then lastly here on the far right, this is a picture of a urethral diverticulum, which is an outpouching from the urethra that can capture urine and develop urinary stasis. And these patients often present with recurring infections or at minimum Dyer. So that is a nice segue to talk about the signs and symptoms of um urinary tract infections, which we're all quite familiar with. But I use this to take a moment to really point out the importance of dysuria. Dysuria. Dyer Dyer is the central um uh symptom in the diagnosis of U T I. There's other symptoms like frequency urgency, superpubic pain, hematuria. These are all very much um likely as well um but they're variably present. So, um the acute onset of dysuria is highly specific um for the diagnosis of U T I and more than 90% accuracy for U T I and young women. Um and again, caveat that's in the absence of any um vaginal discharge or vagi vaginal irritation that could make you think more of a sexually transmitted infection. Um However, like I did mention previously in older adults, um the symptoms of U T I might be less specific. You might not get dyer, they may present more with hematuria or a worsening of their baseline urgency frequency or incontinence. Um But I would say uh if you have dyer, that is a very, very, very likely uh urinary tract infection. So, moving on to lab results, um the point I want to make here is that um there's a difference in what is considered a positive urine culture. Um 10 to the fifth C F U per milliliter was um previously thought to be a positive culture. Um But that that definition is based on literature from over 60 years ago. So certainly it's still true in somebody who you have a low suspicion and who is asymptomatic. But I would argue why even test that person. Um When you have somebody who is highly suspicious for a U T I and symptomatic, the definition gets a little bit uh more lenient and it's 10 to the second C F U per milli milliliter. So now I'd like to talk about management um empiric treatment of a U T I. When can we just treat it without any urine studies? This is in somebody with an uncomplicated U T I. And if you remember back from the definition slides, that's somebody with a anatomically and functional normal urinary tract sys system with um presentation of acute onset Dyer and first line therapy for an uncomplicated U T I empiric therapy is listed here. Nitro trime cell metox phospho and if available targeted therapy, meaning you've obtained cultures and now you're gonna use your um sensitivities to help guide treatment. The generally speaking, um just use the shortest duration of antibiotics as reasonable and use your sensitivities to guide you the American Neurologic Association. Best practices for patients who are having recurrent urinary tract infections is always to document a history and physical exam, um document the positive urine cultures from prior episodes because that can help guide future uh treatments and therapy. Consider repeating urine studies when there's concern of contamination such as squamous cells, possibly from the vaginal epithelium. And that a ur analysis and urine culture and sensitivity with each symptomatic episode is important prior to initiating treatment. It is certainly reasonable to um do patient initiated or self start treatment after a ur analysis or urine sample is given uh while you're awaiting the results and then following up what is necessary for asymptomatic patients, meaning you've adequately treated their infection, there is no posttreatment test of cure needed. Even for patients with recurring infections. If they get an infection, you treat it with appropriately targeted antibiotics and their symptoms resolve. You do not need to do any test of cure for symptomatic patients, meaning they continue to feel like um a urinary tract infection is present even after the full course of antibiotics. It is recommended to repeat the urine culture. I now like to move on to prevention strategies. And I think this is the most important takeaways from our discussion today. I wanna give you strategies that you can initiate with your patients who are presenting with recurring infections. So, first line treatment or prevention is behavioral modification. Um This involves increasing patients. Uh water intake, I typically recommend 30 to 40 ounces daily. Um constipation management, which may include a fiber supplement or an osmotic laxative depending on the frequency of their stooling habits and the consistency of their stool for patients who are have decreased urinary frequency, but um often seen in our elderly population because they have decreased bladder sensation. I recommend timed voiding where I instruct them to set an alarm clock and use the restroom every 2 to 3 hours when they're awake and then toilet posturing and diaphragmatic breathing. There's an image here on the right of the slide of what I call good toilet posturing. Um You'll see the patient's feet are slightly elevated on a step stool. Um The brand name that everybody knows about is the squatty potty. It does in fact help with a complete emptying of the bladder and rectum because it allows the pelvic floor muscles to relax. Um And all of these strategies have been shown to be beneficial in the prevention of urinary tract infections when behavioral strategies fail. Then we talk about non antibiotic, prophylaxis. And these are the four most commonly evaluated and discussed methenamine d mannose cranberry and vaginal estrogen. So, we're gonna go through each of these. So, methenamine or Hiprex is a salt that's converted to formaldehyde and acidified urine and it creates an antibacterial activity or environment that bacteria cannot thrive in. Um The dosing is one g by mouth, uh twice a day. These are large pills. I do sometimes find this is challenging for patients to swallow when they're older or have any difficulties with swallowing and the efficacy is good. Um I like methenamine and I would encourage and empower you to feel free to try it in the correct patient. Um uh historically, it was thought to be not as good as um preventative or prophylactic antibiotics. But more recently, we've had newer data, uh noninferiority randomized trials that show methenamine is non inferior to antibiotic, prophylaxis and it's not an antibiotic. And you all know what the limitation is to antibiotic, prophylaxis being antibiotic resistant. So this is really nice in a patient where we don't need to be concerned about um developing resistances. Um Moving on de mannose uh de manos is a natural sugar that mimics host uo epithelial receptors and it competitively binds bacteria. So um decreases the number of bacteria that can potentially attach to the mucosa. The dosing is really uncertain um literature and patients use anywhere from 500 mg to two g by mouth daily and the efficacy is poor. Uh The Cochrane review from last year. Really boldly said there's no, there's currently little to no evidence to support or refute the use of Dam De Manos to prevent or treat U T I S in all populations. But I personally do not prescribe or recommend de mannose. Um I often have patients present who are already on de Manos. And by that point, they've already been shown that it's not having an effect because they're continuing to have infections and I will typically encourage them to stop taking it. Next is cranberry. So um cranberry can come in a lot of different forms. There's cranberries juice, there's cranberries, supplement capsules and fruit powder. And the way it's thought to work is really based on these um pro anthocyanins or PAC S. It's a a molecule in Cranberry that prevents the adhesion of bacteria to the euro thelium. Um There's some data out there that uh really supports the use of cranberry and that it's effective at preventing U T I S. Unfortunately, the many of the research studies that include cranberry had um cranberry products that were specifically developed for the study with very high concentration of PAC S concentrations that are very hard for patients to um uh acquire on their own like from a pharmacy or um uh supplement store. So my opinion is I don't prescribe cranberry. Um I don't think over the counter cranberry capsules, cranberry juice, they just don't work. There's not a high enough level of pac S um the data will say that cranberry is better than no cranberry and placebo. But again, that's a very, very high concentrations of PAC S. And then last but certainly not least. Um to me, the most important preventative strategy for a lot of the patients, I see is vaginal estrogen. Um We all know that the lower urinary tract in women and the vagina and the introitus have very rich uh levels of estrogen receptors. And when our bodies, as women go through menopause and the ovaries stop making estrogen, there can be a significant effect to uh lower urinary tract symptoms also including vaginal dryness, irritation, et cetera. Um What we also know is that this decrease in estrogen causes uh a decrease and a change in the vaginal microbiome resulting in lower levels of lactobacillus. And it creates an environment in the vagina. That's much more um uh uh allowable or favorable for bacteria to latch on and create a urinary tract infection. So, the mechanism of action for vaginal estrogen is that it increases the lactobacillus and creates more elasticity and changes the P H for a healthier vaginal and um periurethral environment, reducing the risk of a urinary tract infection. The dosing depends, vaginal estrogen can come as a ring, a cream or a vaginal insert or suppository. Um And the efficacy is great. I cannot hit this home uh hard enough, but vaginal estrogen is certainly a very good method for um treatment of recurrent U T I S so much so that the American Neurologic Association has made it a strong um recommendation that in perry and post menopausal women with recurrent U T I S clinicians should recommend vaginal estrogen therapy to reduce the risk of future U T I S. And they did mention earlier that in our young adult population, we see hypo estrogenic states as well for patients who are on oral contraceptives or have a marina I U D or may be postpartum or breastfeeding. Um Also with um estrogen receptor modulator medications, we can see a hypo estrogenic vaginal environment and they will benefit from vaginal estrogen therapy as well. There's several FDA approved vaginal estrogen products. I will really emphasize that the cream is best for the prevention of recurrent U T I S. So I would encourage you all to use cream primarily if there's a concern about patients preference or medication adherence. Certainly, um you could try a ring or insert instead. Um You don't need to remember any of this. There's dosing and available formulations all easily accessible and up to date. So again, no need to remember. This is just a really quick reference so that you can get your patients started on vaginal estrogen and then lastly, antibiotic, prophylaxis. So, antibiotic, prophylaxis is typically what we try to use last in the prevention of urinary tract infections. Because as you all know, as I I'm well aware and um antibiotic resistance is the concern. But following a discussion of the risks benefits and alternatives, I am certainly clinicians can prescribe antibiotic, prophylaxis to reduce the risk of future U T I S. And women of all ages previously diagnosed with recurring U T I S antibiotic, prophylaxis um can be um prescribed either continuously which means on a daily basis, once a day or post quarterly for patients who noticed a correlation between intercourse and the onset of their U T I symptoms. The question is duration. How long should we keep somebody on this? And also which antibiotic to choose? I can tell you my general practice is I will start somebody on um antibiotic prophylaxis and I will recommend for three months and then we check in follow up if they're having benefit and if I had no infections during that time, I will allow people to go an additional three months. Um I try to cut to stop all patients who are on uh antibiotic prophylaxis by one year. And hopefully in that 12 month period of time, they've been U T I free and we've been able to fine tune some of the behavioral um strategies for reducing the risk of U T I in that time frame. Again, up to date saves the day. There is dosing available for all antibiotic prophylaxis. It's a quick reference. Super easy. I'll tell you that my typical go to is trimethoprim 100 mg daily. And again, I do that for three months. Um And then have a follow up visit after that. So, um the last few things I would like to point out is there are some really great resources for patients. I print these out commonly for my patients or I'll put them in their after visit, summaries. But our, um, American Guide Society A U G S has a great website. A U G S dot org. And they have um uh made something called voices for P F D or voices for pelvic floor disorders um which have really nice patient facing handouts on all things. I've really just covered. I also really appreciate our International Euro Association AUA and AUA dot org has similar handouts with really great visuals as well and, and patients have really appreciated these resources. So finally, and also I think a really important takeaway from today's talk is when do you refer, um this is a, a short list of when you can feel really confident and comfortable referring to a urogynecologist if they've had prior incontinence or prolapse surgery, relapsing U T I S as I pointed out at the beginning. And I really emphasize that's a U T I that comes back within two weeks of appropriate therapy and with the same organism that person needs further work up. Or if you have a patient with incomplete emptying or notable findings on pelvic exam like prolapse, a vaginal cyst, maybe you see a diverticulum or significant atrophy. Um Those are all reasons that you can feel free to refer or if somebody is just not per responding to prevention, you've tried the prevention strategies that you feel comfortable with and a patient continues to have recurring infections. That's certainly someone worth referring. They may warrant further work up with cystoscopy, C T urogram or potentially a renal ultrasound. And if you do um feel the need to refer, I also wanted to point out other things that I can offer, that we can offer your patients from our urogynecology division. We treat overactive bladder urinary, incontinence, pelvic organ prolapse and fecal incontinence with a slew of different therapy options listed here and with that, um here is some information on how to place a referral. You can call, you can fax, you can order a referral in apex. I've listed my email and cell phone number. If you feel like you would like to reach out and discuss a patient or have further questions. I'm also happy to answer questions now and thank you so much for your attention.
