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 Jackie Margolis, and I'm a urogynecologist with UCSF. 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 urogynecologist 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 anatomic 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, hematuria, or new and worsening incontinence. An uncomplicated UTI 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 UTI. In contrast, a complicated UTI is an infection seen in somebody with um complicating factors that may put her at risk for development of a UTI and potentially decrease efficacy of therapy. These factors may include an anatomic 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 UTIs, this is defined as two separate culture-proven episodes of acute bacterial cystitis with associated symptoms occurring within 6 months or 3 episodes within 1 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 the 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 2 culture proven infections in 6 months with associated symptoms or 3 in 12 months. Another term you may have heard, um, is relapsing UTI and I just wanna take a moment to compare and contrast the two. They are different. A relapsing UTI is a recurrence in acute bacterial cystitis within 2 weeks of treatment, um, and it's with the same organism. So compared to recurrent UTI, which tend to occur after 2 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 UTIs suggests that there's a bacterial reservoir that might be causing this recurrence of infections despite adequate treatment, and it warrants further workup. So lastly, um, as 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 UTIs, 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 UTIs are 2 UTIs in 6 months or 3 in 12 months. These are culture proven with symptoms, and that a relapsing UTI again is a recurrence within 2 weeks of treatment. With the same organism and warrants further workup. OK, great job. We got through that. Moving on to the epidemiology and physiology of recurrent UTIs. 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 UTI, and that 20-40% of women will have an additional episode, and that 25-50% who experience an additional episode will have multiple recurrent episodes. Um, so regardless of how this is defined, the evaluation and treatment of UTI and specifically recurrent UTI costs 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 UTIs? So these are the patients that I see very commonly. These are postmenopausal women who are sexually active, um, or premenopausal 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 maybe 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 dehydrated and with constipation. So, um, taking a little bit closer look at our elderly population, these patients tend to be in a hypoestrogenic state because they're postmenopausal. 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 I see are constipated. They may result in incomplete emptying or fecal stasis, which results in a prolonged exposure to high bacterial 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, etc. as I'm sure we've all experienced diagnosing a UTI 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 hypoestrogenic state, even though they're premenopausal if they're on oral contraceptive pills, using an IUD 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 UTIs 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 UTIs and why, recurring UTIs and why. So let's move on to the workup 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 UTIs and physical exam may be different. I'm certainly redressing patient's menopausal status, sexual history, whether or not they've had any prior genitourinary procedural or surgical intervention. Um, on physical exam, I'm looking for evidence of vulvovaginal 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 urinalysis, um, and in certain populations, STI 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 4 different images of the same um uh vagina. Looking at the epithelium, you'll see there's pallor, there's loss of architecture of the labia minora. There's some fusing over the clitoral head called the prepus. These are all very common findings for vulvovaginal atrophy here. Another thing I, uh, pick up on on patient's physical exam is evaluating the levator ani 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 levator ai muscles, evaluating the muscle tone and potentially if there's any hypertonicity or increased contraction. These 3 images here down at the bottom showed 3 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 UTIs 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 out pouching from the urethra that can capture urine and develop urinary stasis, and these patients often present with recurring infections or at minimum dysuria. 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, dysuria, dysuria is the central um uh symptom in the diagnosis of UTI. There's other symptoms like frequency, urgency, suprapubic 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 UTI and more than 90% accuracy for UTI in young women. Um, and again, caveat, that's in the absence of any, um, vaginal discharge or vag 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 UTI might be less specific. You might not get dysuria. 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 dysuria, 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, uh, there's a difference in what is considered a positive urine culture. Um, 105 CFU per milliliter was um previously thought to be a positive culture. Um, but 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 UTI and symptomatic, the definition gets a little bit, um, more lenient, and it's 10 CFU per milliliter. So now, I'd like to talk about management. Um, empiric treatment of a UTI, when can we just treat it without any urine studies? This is in somebody with an uncomplicated UTI. And if you remember back from the definition slides, that's somebody with a anatomically and functional normal urinary tract system with um presentation of acute onset dysuria. And first line therapy for an uncomplicated UTI, empiric therapy is listed here, nitrofurantoin, trimethoprim, sulmethamboxazole, phosphamycin, and if available, pivemecicilinone. 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. It's reasonable and use your sensitivities to guide you. The American Urologic 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 urinalysis 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 urinalysis 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 post-treatment 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. And now I'd 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 patient's 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 have decreased urinary frequency, 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 uh 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-Mose, cranberry, and vaginal estrogen. So we're gonna go through each of these. So methenamine or Hyprex is a salt that's converted to formaldehyde in acidified urine, and it creates an antibacterial activity or environment that bacteria cannot thrive in. Um, the dosing is 1 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, non-inferiority 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, DMs, uh, DMose is a natural sugar that mimics host uroepithelial 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 2 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 DMos to prevent or treat UTIs in all populations, but I personally Do not prescribe or recommend D-Mos. Um, I often have patients present who are already on DMos, 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 cranberry juice, there's cranberry supplement capsules, and fruit powder. And the way it's thought to work is really based on these um proanthocyanidins or PACs. It's a, a molecule in cranberry that prevents the adhesion of bacteria to the urothelium. Um, there's some data out there that, uh, really supports the use of cranberry and that it's effective at preventing UTIs. Unfortunately, many of the research studies that include cranberry had um cranberry products that were specifically developed for the study with very high concentration of PACs, concentrations that are very hard for patients to Um, uh, acquire on their own, like from a pharmacy or, um, a 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 PACs. Um, the data will say that cranberry is better than no cranberry and placebo, but again, that's a very, very high concentrations of PACs. 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 enteritis 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, etc. Um, what we also know is that this decrease in estrogen causes, uh, a decrease in 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 pH for a healthier vaginal and um perurethral 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 UTIs. So much so that the American Urologic Association has made it a strong um recommendation that in peri and postmenopausal women with recurrent UTIs, clinicians should recommend vaginal estrogen therapy to reduce the risk of future UTIs. And I did mention earlier that in our young adult population, we see hypoestrogenic states as well for patients who are on oral contraceptives or have a Mirena IUD or maybe postpartum or breastfeeding. Um, also with, um, estrogen receptor modulator medications, we can see a hypoestrogenic 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 UTIs. So I would encourage you all to use cream primarily. If there's a concern about patient's 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, um, antibiotic resistance is the concern. But following a discussion of the risks, benefits, and alternatives, and certainly clinicians can prescribe antibiotic prophylaxis to reduce the risk of future UTIs and women of all ages previously diagnosed with recurring UTIs. Antibiotic prophylaxis, um, can be, um, Prescribed either continuously, which means on a daily basis, once a day, or postcoitally for patients who noticed a correlation between intercourse and the onset of their UTI 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 3 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 to go an additional 3 months. Um, I try to, to stop all patients who are on, uh, antibiotic prophylaxis by 1 year, and hopefully, in that 12-month period of time, they've been UTI free and we've been able to fine-tune some of the behavioral, um, strategies for reducing the risk of UTI 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 3 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 Uroguid Society, AUGS has a Great website, AUGS.org, and they have, um, um, made something called Voices for PFD 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 Uogyne Association IUA and uga.org has similar handouts with really great visuals as well, and, um, 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 UTIs, as I pointed out at the beginning, and I really emphasize, that's a UTI that comes back within 2 weeks of appropriate therapy and with the same organism. That person needs further workup. 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's just not 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 workup with cystoscopy, CT 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.
