(UroToday.com) Dr. Stapleton, Professor Emeritus at the University of Washington in the Division of Infectious Disease, took the stage to introduce an expert panel that included Dr. Griebling, the John P. Wolf 33rd Masonic Distinguished Professor of Urology at the University of Kansas, and Dr. Vaughan, Division Director of Geriatrics and Gerontology at Emory University to discuss two case presentations that highlighted recurrent uncomplicated urinary tract infections in women, a common situation seen by all urologists. Urologists should not treat asymptomatic bacteriuria, but certain exceptions and symptom gray areas exist, which made these case presentations highly applicable.
The first case involved the challenging situation of an 88-year-old female that is dependent on a male caregiver with baseline dementia and presumed recurrent UTIs due to episodic behavior changes but without pyelonephritis or sepsis. For the initial workup of this patient, the panel stressed that a comprehensive history and pelvic exam is mandatory. Caregivers can usually provide valuable baseline status and changes to that status to further elucidate vague symptoms. The panel cautioned that elderly patients do not have typical UTI symptoms and commonly present with altered mental status and behavioral changes and the panel proceeded to reviewed potential urologic factors that predispose patients to behavioral changes:
- Suboptimal hydration due to blunting of thirst sensations
- Fecal incontinence or constipation
- Inability to perform basic hygiene
- Prescribed medications that affect bladder function and mental status
- Lichen sclerosis
- Bladder dysfunction or obstruction
- De-estrogenized vaginal tissue after menopause (pain at the vaginal vestibule, erythematous and patchy blanching of the labia and reabsorption of the labia minora.
This patient had signs and symptoms of de-estrogenized vaginal tissues and no infectious appearing discharge or typical UTI symptoms with a male caretaker that felt uncomfortable applying vaginal estrogen, so the provider placed an estrogen ring that was changed every three months and urinary symptoms improved. A few months later, the patient became intermittently lethargic or disruptive but with no fevers, chills, or flank pain, so a urine culture was obtained showing E. coli. The panel agreed that this was a gray area and ultimately recommended to hold antibiotic treatment at this time because there was no evidence of systemic illness but stressed to do a continued investigation into other sources of behavioral changes as previously mentioned but added that a PVR can be useful because concentrated urine can cause vague symptoms. The recommended treatment strategy was symptom prevention by continued hygiene by caregiver, continued estrogen treatment, optimizing hydration, optimizing bowel function, and timed voids.
The second case involved an 84-year-old female that was living independently and sexually active and presented with pain with initial penetration, baseline vaginal dryness, and a history of occasional dysuria, frequency, and urgency. She never had pyelonephritis. The panel recommended the same initial workup as the first case that included a complete history and pelvic exam. This patient had a past medical history notable for breast cancer, did not report current typical UTI symptoms, and had an exam with pain throughout the vaginal vestibule with signs of de-estrogenized vaginal tissue. The panel recommended no testing of the urine due to lack of symptoms at time of presentation. They stressed to evaluate for lichen sclerosis that can be treated with clobetasol and evaluate this sexually active patient for Gardnerella with subsequent treatment. With regards to estrogen supplementation and history of breast cancer, the panel mentioned that they would be very comfortable to recommend estrogen treatment based on shared decision making if the cancer has been in remission for some time with added comfort knowing if the disease was not estrogen receptor positive. For the dysuria in this patient, the panel also recommended a barrier cream such as those containing glycerin and polycarbophil. The patient noticed improvement with treatment, but her primary care doctor obtained a urinalysis and urine culture as part of a routine exam that showed 50K CFU of Klebsiella pneumonia. The panel mentioned that they would consider treatment of this infection if the sample was obtained in a truly clean way such as catheterization. Upper tract imaging would be considered if the patient had a history of Klebsiella or Proteus infections because they can cause kidney stones that might become symptomatic or act as a nidus for infection. In this case, the patient was not treated and did well but as time passed, she presented with acute dysuria, chills, and 100K ESBL E. coli without fevers, flank pain, or leukocytosis. The panel recommended that due to the patient’s age, potential unidentified comorbidities, current symptoms, and positive bacterial culture, they would admit her to the hospital for hydration and IV antibiotics and obtain upper tract imaging. The piperacillin / tazobactam given was changed to meropenem after the urine culture indicated resistance. It was recommended that upon discharge she transitions to ertapenem due to its once daily dosage and that the course be kept to seven days because the disease appears to be isolated to the bladder in her case. She should also follow up for a cystoscopy to ensure that there is no anatomic abnormality. There was a consensus that the patient should not have a test for cure but that she would benefit from a change in her care plan to include adequate hydration, a low-sugar cranberry supplement, D-mannose to prevent bacterial adhesion to the urothelium, Methenamine that requires acidification with vitamin C as a non-resistance promoting antimicrobial, optimization of bowel function, and a focused hygiene strategy.
The expert panel assessment of the cases armed the urologist with an evaluation and treatment strategy for the common yet potentially complex scenarios of the uncomplicated and recurrent UTI in the geriatric female population. The panel summarized a few general take home points for the urologist to keep in mind: ensure cultures are taken prior to beginning treatment, the decision to treat should be based on symptoms rather than the mere presence of bacteriuria, avoid surveillance and post treatment testing, and utilize the prevention strategies discussed.
Presented by:Ann Stapleton, MD, FACP, FIDSA, Professor Emeritus, Department of Medicine, Division of Allergy and Infectious Disease, University of Washington
Thomas Griebling, MD, MPH, FACS, FGSA, AGSF, John P. Wolf 33rd Masonic Distinguished Professor of Urology, Department of Urology and The Landon Center on Aging, University of Kansas
Camille P. Vaughan, MD, MS, Division Director - Geriatrics and Gerontology, Associate Professor of Medicine, Emory University School of Medicine Birmingham / Atlanta VA GRECC
Written by: Zachary E. Tano, MD, Endourology Fellow, Department of Urology, University of California Irvine, during the 2023 American Urological Association (AUA) Annual Meeting, April 28 – May 1, 2023, Chicago, Illinois during the 2023 American Urological Association (AUA) Annual Meeting, Chicago, IL, April 27 – May 1, 2023