Radiographic studies for women with recurrent urinary tract infections

The etiology and management of recurrent urinary tract infections in postmenopausal women

Urinary tract infections (UTIs) are one of the most common infections and affect up to 50% of women in their lifetime, with almost half of these women experiencing a recurrence in 6-12 months. Menopause predisposes women to recurrent UTI (rUTI), as normally lower levels of estrogen lead to changes in the urogenital epithelium and subsequently urogenital microbiome. The recently discovered urobiome is now known to have different compositions in both healthy and unhealthy bladders, including a role in the pathophysiology of rUTI, and may be a therapeutic target for prevention and treatment options for rUTI. In postmenopausal women with frequent UTI, the diagnosis of acute UTI should be made using a combination of the symptom assessment and urine diagnostic studies. The choice of UTI antibiotic should include consideration of efficacy, collateral effects, and side-effects. Some women may be candidates for self-start therapy, in which the patient accurately recognizes her UTI symptoms and then starts previously prescribed antibiotics. A large component of the management of women with rUTI is prevention. Urobiome research for bladder health and disease is a young field of investigation with significant potential to improve care for postmenopausal women affected by rUTI through novel, evidence-based prevention and treatment strategies.

The Use of Ultrasonography in Evaluating Adults with Febrile Urinary Tract Infection

BACKGROUND

Urinary tract infection (UTI) is a common disease. Controversy exists about the role of radiological evaluation in the patient with urinary tract infection.

MATERIALS AND METHODS

From April 2001 to December 2001, patients with febrile UTI admitted to Chang Gung Memorial Hospital, Chiayi were prospectively evaluated by ultrasonography. The inclusion criteria of febrile UTI was a body temperature of more than 38 degrees C with a bacterial count of 10(3) or more per mL in a freshly voided midstream or catheterized urine.

RESULTS

A total of 94 patients were evaluated and all patients recovered. Major abnormal sonograms were present in 17 (18%) of the patients. A history of urolithiasis and a duration of fever > or = 3 days after admission were statistically significant clinical parameters in predicting major abnormal sonogram. Although diabetes mellitus was not statistically significant in predicting major abnormal sonogram, diabetic patients had 2.5 times the likelihood of major structural abnormalities than nondiabetic patients.

CONCLUSION

Ultrasonographic study of patients with febrile UTI should be limited only to those with a duration of fever > or = 3 days and a history of urolithiasis. Ultrasonographic study should also be considered in febrile UTI patients with diabetes mellitus.

Ultrasonography and abdominal radiography versus intravenous urography in investigation of urinary tract infection in men: prospective incident cohort study

OBJECTIVES

To compare ultrasonography and abdominal radiography with intravenous urography in the investigation of urinary tract infection in men.

DESIGN

Prospective study in two hospital departments. Radiological procedures and urological assessments performed on different days by different clinicians

SETTING

District general hospital.

PARTICIPANTS

Consecutive series of men (n=114) referred to the department of urology for investigation of proved urinary tract infection.

INTERVENTIONS

Ultrasonography and intravenous urography of renal tract and assessment of urinary flow rate. Clinical assessment, cystoscopy, urodynamic studies, and transrectal ultrasonography with biopsy.

MAIN OUTCOME MEASURES

Sensitivity and specificity of ultrasonography and abdominal radiography compared with intravenous urography.

RESULTS

Important abnormalities were seen in 53 of 100 fully evaluated patients, the most common being a poorly emptying bladder (34). The combination of plain radiographs of kidneys, ureter, and bladder and ultrasonography detected more abnormalities than intravenous urography alone. No important abnormality was missed by this combination (sensitivity 100% and specificity 93%).

CONCLUSIONS

Ultrasonography with abdominal radiography is as accurate as intravenous urography in detecting important urological abnormalities in men presenting with urinary tract infection. This combination is safer than intravenous urography and should be the initial investigation for such patients. Additional determination of urinary flow rate is useful for the assessment of an incompletely emptying bladder.

Recurrent urinary tract infection in women

Recurrent urinary tract infections (UTI) are common among young healthy women even though they generally have anatomically and physiologically normal urinary tracts. Women with recurrent UTI have an increased susceptibility to vaginal colonization with uropathogens, which is due to a greater propensity for uropathogenic coliforms to adhere to uroepithelial cells. Risk factors for recurrent UTI include sexual intercourse, use of spermicidal products, having a first UTI at an early age, and having a maternal history of UTIs. Inherited factors may be important in some women with recurrent UTI. Many factors thought to predispose to recurrent UTI in women, such as pre- and post-coital voiding patterns, frequency of urination, wiping patterns, and douching have not been proven to be risk factors for UTI. In contrast to the predominantly behavioral risk factors for young women, mechanical and/or physiological factors that affect bladder emptying are most strongly associated with recurrent UTI in healthy postmenopausal women. The management of recurrent UTI is the same as that for sporadic UTI except that the likelihood of infection with an antibiotic resistant uropathogen is higher in women who have received recent antimicrobials. Strategies to prevent recurrent UTI in young women should include education about the association of recurrent UTI with frequency of sexual intercourse and the usage of spermicide-containing products. Continuous or post-coital prophylaxis with low-dose antimicrobials or intermittent self-treatment with antimicrobials have all been demonstrated to be effective in managing recurrent uncomplicated UTIs in women. Estrogen use is very effective in preventing recurrent UTI in post-menopausal women. Exciting new approaches to prevent recurrent UTI include the use of probiotics and vaccines. Further understanding of the pathogenesis of UTI will lead to more effective and safer methods to prevent these frequent infections.

Diagnosis and treatment of uncomplicated urinary tract infection

Acute uncomplicated urinary tract infection is one of the most common problems for which young women seek medical attention and accounts for considerable morbidity and health care costs. Acute cystitis or pyelonephritis in the adult patient should be considered uncomplicated if the patient is not pregnant or elderly, if there has been no recent instrumentation or antimicrobial treatment, and if there are no known functional or anatomic abnormalities of the genitourinary tract. Most of these infections are caused by E. coli, which are susceptible to many oral antimicrobials, although resistance is increasing to some of the commonly used agents. Review of the published data suggests that a 3-day regimen is more effective than a single-dose regimen for all antimicrobials tested. Regimens with trimethoprim-sulfamethoxazole seem to be more effective than those with beta lactams, regardless of the duration. Because of increasing resistance to trimethoprim-sulfamethoxazole, an alternative regimen such as nitrofurantoin (in a 7-day regimen), a fluoroquinolone, or an oral third-generation cephalosporin may be a better empiric choice in some areas. Acute pyelonephritis caused by highly virulent uropathogens in an otherwise healthy woman may be considered an uncomplicated infection. The optimal treatment duration for acute uncomplicated pyelonephritis has not been established, but 10- to 14-day regimens are recommended. We prefer to use antimicrobials that attain high renal tissue levels, such as a fluoroquinolone, trimethoprim-sulfamethoxazole, or an aminoglycoside, for pyelonephritis. Acute uncomplicated cystitis or pyelonephritis in healthy adult men is uncommon but is generally caused by the same spectrum of uropathogens with the same antimicrobial susceptibility profile as that seen in women.

Ultrasonography in medical imaging. Influence on diagnostic routines

It has been assumed that the introduction of ultrasonography in diagnostic imaging has led to dramatic changes in imaging routines by replacing other modalities like angiography, intravenous urography, and computerized tomography in several diagnostic procedures. The present retrospective study from five Norwegian hospitals during the period from 1978 to 1991 confirm this assumption, showing how ultrasonographic examinations have influenced diagnostic routines.

Radiological examinations of the urinary tract. Changes during the last 24 years

Procedures for imaging the urinary tract have been recorded in six Norwegian hospitals for the last 24 years. For three of the hospitals, data were collected from 1965 to 1989, and for the other three from 1966, 1971 and 1975, respectively. There was a significant reduction in the number of intravenous pyelograms, voiding cystograms, and renal angiograms, but the number of retrograde pyelograms and plain radiographs of the urinary tract remained constant. Computed tomography of the urinary tract increased during the first years, but after the introduction of ultrasonography, the number of computed tomograms decreased. Ultrasonographic examinations of the urinary tract are still rapidly increasing, and seem to have replaced some of the other imaging techniques. The present results should be taken into consideration when planning the health care for the future.

Ultrasound of the pelvis and renal tract combined with a plain film of abdomen in young women with urinary tract infection: can it replace intravenous urography? A prospective study

Urinary tract infection (UTI) is common in women and intravenous urography (IVU) is a frequently requested radiological investigation for recurrent UTI. The aim of this study was to assess whether pelvic and renal ultrasound combined with a plain film of the abdomen (KUB) could replace IVU as the initial radiological investigation in young women with recurrent UTI. Ninety-four young women with recurrent UTI who were referred for IVU were studied. Ultrasound of the pelvis and renal tract was performed, and information obtained from ultrasound and KUB was compared with that obtained from the IVU examination. Patient management was altered as a result of radiological investigation in eight cases. A case of staghorn calculus and a case of pelviureteric junction obstruction were diagnosed by both IVU and ultrasound with KUB. An intrarenal abscess was diagnosed by ultrasound in a patient with a normal IVU. In addition ultrasound demonstrated significant findings in the pelvis, including ovarian and uterine abnormalities and an ectopic and an intrauterine pregnancy. In all cases the patient had symptoms referable to the urinary tract and a history of documented UTI. The KUB did not yield any unsuspected finding not diagnosed by ultrasound, but did serve to delineate more clearly the extent of calculus disease in two patients. We suggest that ultrasound of the pelvis and renal tract combined with a KUB should be the radiological investigation of choice in young women with UTI.

Selective use of excretory urography in women with acute pyelonephritis

The outcome of excretory urography was analyzed in 103 nonpregnant women followed prospectively after community acquired acute pyelonephritis. Radiological abnormality was found in 40 per cent of the patients (17 per cent had major abnormalities, including renal scarring, calculi and obstruction). All 5 women with surgically correctable lesions had rapid bacteriological relapse or recurrent acute pyelonephritis. Neither a history of urinary tract infection, the acute inflammatory response nor infection due to Escherichia coli with or without adhesins specific for Gal alpha 1----4Gal beta-containing receptors was efficient in predicting major radiographic lesions or the outcome of treatment. Bacteremia was detected in 27 per cent of the patients but in the absence of obstruction. These results suggest that excretory urography is dispensable in most women with acute pyelonephritis, and that those needing such investigation may be identified by failure to respond to antibiotic treatment or by the recurrence pattern.

Unnecessary intravenous urography in young women with recurrent urinary tract infections

Intravenous urography was evaluated in 201 young women with recurrent urinary tract infections. In 118 of 121 patients with uncomplicated recurrent infections the intravenous urogram (IVU) was normal. Insignificant abnormalities were found in only three cases. It is concluded that, in order to avoid unnecessary investigation, an additional risk indication should be present to warrant an IVU. The additional risk indications have been identified.