AUA 2020: Complicated UTI Management

(UroToday.com) In her presentation at AUA 2020 on the management of urinary tract infections (UTI), physician assistant Brooke Zilinskas began by providing definitions:

  • UTI is bacteriuria with symptoms
  • Asymptomatic bacteriuria may be colonization or contamination of the bladder with bacteria
  • Pyuria is WBCs in the urine with or without the presence of bacteria
  • Unresolved UTI is a UTI that has not responded to treatment.
  • Recurrent UTI is defined as reinfection or bacterial persistence following treatment.

UTI symptoms include frequency, urgency, dysuria, suprapubic pain, fever, confusion, etc. A U/A will reveal positive leukocytes and nitrites and the presence of RBCs. Ms. Zilinskas presents the differences between an uncomplicated UTI (healthy patient, normal anatomy and function of the GU tract) and complicated UTI (catheter/stent use, pregnancy, HX childhood UTIs, urinary instrumentation, immunocompromised patient).  Evaluation of complicated UTI includes medical HX (neurologic disease), bowel HX (fecal incontinence), Gyn HX (hormone status, pelvic organ prolapse, pelvic surgery/radiation), GU history (stones, incontinence, urgency, frequency unrelated to UTI), frequency of infections with culture results. Physical examination includes abdominal, pelvic exam in women (prolapse, tissue atrophy), genital exam in men (meatal stenosis, balanitis, rectal exam), post-void residual, U/A, and culture. There are several diagnostics that should be ordered depending on the type of UTI with retroperitoneal ultrasound usually indicated as it will provide information on the upper and lower urinary tract. Additional tests (e.g. CT Urogram, cystoscopy, UDS) may be indicated in complicated UTIs or those who have repeated recurrence. 

Treatment of UTIs: 

TreatmentofUTIs_AUA2020.png

Other treatment considerations include transvaginal estrogen in post-menopausal women with vaginal atrophy, Methenamine with Vitamin C for recurrent UTIs.  In patients performing intermittent-self-catheterization who have recurrent UTIs, nightly intravesical instillations with gentamicin may be indicated

Presented by: Brooke Zilinskas MMS, PA-C, University of Texas Southwestern Medical Center, Dallas, TX 

Written by: Diane Newman, DNP, ANP-BC, Adjunct Professor of Urology in Surgery, Perelman School of Medicine, University of Pennsylvania and Co-Director of the Penn Center for Continence and Pelvic Health

References:

  1. Chwa et al. Evaluation of methenamine for urinary tract infection prevention in older adults: a review of the evidence. Ther Adv Drug Saf. 2019;10:2042098619876749. 2019 Sep 23. doi:10.1177/2042098619876749
  2. Cox et al. Gentamicin bladder instillations decrease symptomatic urinary tract infections in neurogenic bladder patients on intermittent catheterization. Can Urol Assoc J. 2017;11(9):E350‐E354. doi:10.5489/cuaj.4434
  3. Smith AL, Brown J, Wyman JF, Berry A, Newman DK, Stapleton AE. Treatment and prevention of recurrent lower urinary tract infections in women: A rapid review with practice recommendations. J Urol. 2018 Dec;200(6):1174-1191. doi: 10.1016/j.juro.2018.04.088. PMID:29940246
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