The natural history of symptomatic recurrent bacteriuria in women

In 23 adult women having uncomplicated recurrent urinary tract infections treated with 10 days of appropriate antibiotic for each infection, the following findings were noted. 1. The attack rate was 0.17 infections per month. 2. 94% of infections has associated symptoms. 3. 73% of symptomatic episodes had an associated infection. 4. 21% of infections had less than 10(5) bacteria per ml. 5. 34% of all infections were followed by an infection-free interval of at least six months and averaged 12.8 months. All but one patient had at least one infection-free interval. 6. Long infection-free intervals were followed by further infections; a remission is not a cure. 7. Between infection-free intervals the infections tended to occur in clusters with an attack rate of 0.47 infections per month. 8. Prophylaxis is less costly if begun at the second infection within a six-month period.

Use of hemiacidrin in management of infection stones

Unless all fragments are removed at the time of surgery for struvite stones a high incidence of recurrent infection and stone formation is likely. To reduce the recurrence rate of such stones the renal pelvis is irrigated postoperatively with 10 per cent hemiacidrin solution for at least 48 hours or until all fragments have been dissolved. We have managed successfully 35 patients (36 kidneys) without enxountering any complications. Included in our most recent series are 2 patients with solitary kidneys who had successful dissolution of stone fragments. Absolute contraindications to the use of hemiacidrin are infected urine, fever or flank discomfort. Although we have found hemiacidrin dissolution of renal stones to be safe and effective it is essential that the clinician be aware of the proper technique and its possible complications.

Resistance to nalidixic acid. A misconception due to underdosage

The clinical impression of inordinate selection of resistant mutants to nalidixic acid cannot be substantiated on close scrutiny when sensitive infections are treated at a full dosage of 4 gm/day. When 27 consecutive patients were treated with 4 gm of nalidixic acid per day, resistance developed in the bacteriuric population in only 7%. Moreover, resistance in the fecal reservoir was surprisingly minimal and much less than that reported for sulfonamides, tetracyclines, and ampicillin. The observation is important because multiply-resistant Enterobacteriaceae maintain their sensitivity to nalidixic acid since extrachromosomal R-factor resistance to nalidixic acid has never been demonstrated and cannot be transferred from one organism to another. In vitro data on 100 sensitive strains of Enterobacteriaceae show that the developmental of resistance to nalidixic acid is inversely proportional to the concentration of nalidixic acid regardless of whether the inoculum size is 10(5) or 10(8) bacteria per milliliter. Underdosage (less than 4 gm/day) with nalidixic acid is the probable cause of excessive resistance.

Unilateral medullary sponge kidney: cause of persistent bacteriuria

A patient with twenty years of persistent bacteriuria secondary to unilateral medullary sponge kidney, and in whom no antibiotic would sterilize the urine, was cured of her infection by nephrectomy in the presence of contralateral hydronephrosis. A review of the literature shows 23 cases of unilateral medullary sponge kidney in which nephrectomy or partial nephrectomy was apparently equally successful, although no bacteriologic follow-up data are given.

The effect of hysterectomy on colonization of the vaginal vestibule with Escherichia coli

Using an experimental model in the rabbit, we have demonstrated for the first time that hysterectomy significantly prolongs introital carriage of Escherichia coli. Normal and oophorectomized rabbits rapidly clear E. coli from the mucosa of the vaginal vestibule. The altered vaginal biology induced by hysterectomy lends credence to the clinical observation that some hysterectomized women are unusually susceptible to urinary infections. These data may be the first to indicate that the 700,000 hysterectomies performed each year in the United States may adversely affect vaginal biology. Reexposure of the vaginal mucosa of hysterectomized rabbits to E. coli produced rapid clearing of the organism characteristic of a secondary immunologic response. The presence of secretory antibodies in cervical and vaginal secretions and the occurrence of systemic antibodies after vaginal inoculation supports an immunologic role in determining vaginal carriage of Gram negative organisms.

Studies of introital colonization in women with recurrent urinary infection. VI. Analysis of segmented leukocytes on the vaginal vestibule in relation to enterobacterial colonization

Segmented leukocytes on the vaginal vestibule were quantitated in 93 specimens from 27 women with recurrent bacteriuria (1.03 times 10(5) plus or minus 4.9 times 10(5) cells per ml.) and compared to 251 specimens from 26 control women who had never had bacteriuria (8.0 times 10(4) plus or minus 1.7 times 10(5)). There was no significant difference (p more than 0.6). Leukocyte counts accompanying colonization with more than 100 Enterobacteriaceae per ml. (6.4 times 10(4) plus or minus 1.0 times 10(5) cells per ml). were no different from those unaccompanied by Enterobacteriaceae (8.7 times 10(4) plus or minus 3.3 times 10(5) cells per ml., p more than 0.9). No distinctive pattern was observed in excretion of vaginal leukocytes during the menstrual cycles of 21 premenopausal, control volunteers.

Studies of introital colonization in women with recurrent urinary infections. V. The inhibitory activity of normal vaginal fluid on Proteus mirabilis and Pseudomonas aeruginosa

Normal vaginal fluid from premenopausal volunteers was inoculated with 10 strains of Proteus mirabilis and 14 strains of Pseudomonas aeruginosa at pH's of 4.3, 4.6 and 4.9. All bacteria were killed at pH 4.3. Nine of 10 strains of Proteus mirabilis and 12 of 14 Pseudomonas aeruginosa were killed at pH 4.6. Only 4 of 14 strains of Pseudomonas aeruginosa were killed at pH 4.9, while 8 of 10 strains of Proteus mirabilis were killed at the same pH. We conclude that in comparison to the common 0 group strains of Escherichia coli, vaginal fluid is more bactericidal to Proteus mirabilis and Pseudomonas aeruginosa and that these observations may help explain the relative infrequency of bacteriuria owing to the organisms.

Studies of introital colonization in women with recurrent urinary infections. IV. The role of local vaginal antibodies

Immunoglobulins IgG and IgA were determined in 94 collections of vaginal fluid from 10 patients before, during and after 17 episodes of bacteriuria. The results were compared to 49 collections from 6 volunteer controls who had never had bacteriuria. The mean IgG concentration in patients (48 plus or minus 54 mg. per cent) was no different from controls (50 plus or minus 33 mg. per cent). IgA concentrations were 2.6 plus or minus 2.1 and 2.6 plus or minus 2.4 mg. per cent, respectively. Bacterial agglutination titers in vaginal fluid to Escherichia coli colonizing the vaginal vestibule of the patients were no different (7.7 plus or minus 9.8, reciprocal tube titer) than the titers to be predominant Escherichia coli cultured from the rectum of the controls (9.7 plus or minus 5.0). Longitudinal studies in patients failed to show any relationship between vaginal colonization with changing serotypes of Escherichia coli and agglutination titers in vaginal fluid.

Studies of introital colonization in women with recurrent urinary infections. II. A comparison of growth in normal vaginal fluid of common versus uncommon serogroups of Escherichia coli

Vaginal fluid collected from volunteers who denied a history of urinary infections was bactericidal to Escherichia coli at pH 4.0. When the pH was increased to 6.5 with sodium hydroxide, the same vaginal fluids supported bacterial growth. If vaginal fluid was adjusted at pH increments between 4.0 and 5.0, and inoculated with common and uncommon serogroups of Escherichia coli, the uncommon O-groups that never cause urinary infections were significantly (p less than 0.005) more inhibited by the lower vaginal pH than were the common O-groups of Escherichia coli.

Studies of introital colonization in women with recurrent urinary infections. I. The role of vaginal pH

The pH of the vaginal introitus was compared to quantitative cultures of the introital mucosa (Escherichia coli, Proteus mirabilis and Streptococcus faecalis) in 800 samples. Introital carriage of more than 100 bacteria per ml. was significantly greater at pH of more than 4.4 (p less than 0.005) when compared to mucosal pH of less than or equal to 4.4.

Studies of introital colonization in women with recurrent urinary infections. III. Vaginal glycogen concentrations

The concentration of glycogen in vaginal fluid was measured in 37 samples from 6 volunteers without urinary infections and in 96 samples from 12 patients with recurrent urinary infections. The mean glycogen concentrations, 440 mug. per ml. from the controls and 564 mug. per ml. from the patients, were not statistically different (p more than 0.05). Although an introital pH more than or equal to 4.4 was associated with low concentrations of glycogen in vaginal fluid, a pH less than 4.4 was found with high and low glycogen concentration. Sodium concentration was statistically higher in vaginal fluid from patients compared to controls (p less than 0.01) while potassium concentration was the same in both groups.

The diffusion and concentration of trimethoprim in human vaginal fluid

Colonization of the vaginal introitus with Enterobacteriaceae was cleared dramatically in women receiving trimethoprim-sulfamethoxazole for recurrent urinary tract infections. Vaginal fluid was collected from seven women; five of the seven had two vaginal fluid collections each while on full-dose therapy (total, 10 samples), and five had two or more collections each while on prophylactic, low-dose therapy (total, 14 samples). Bactericidal concentrations of trimethoprim were found in all samples of vaginal fluid, often exceeding the serum level by severalfold. Sulfamethoxazole was either undetectable or present only in fractional concentrations.

Clinical and roentgenographic evaluation of endoscopic suspension of the vesical neck for urinary incontinence

Forty-four consecutive patients, without residual urine or infecttion, were operated upon for urinary stress incontinence by endoscopie suspension of the vesical neck. All patients had preoperative and post-operative lateral view cystograms which showed after operation substantial upward and forward elevation of the urethrovesical junction as measured by the posterior urethrovesical angle, the angle of urethral inclination, and elevation of the base of bladder. Despite a significant history of an urgency component to their incontinence in many patients, as well as 44 previous operations in 22 of the patients, a carefully performed cystometrogram and cholinergic sensitivity test were not helpful in detecting abnormalities of the detrusor muscle. Fourty-one patients were cured, and in three others, the condition was not cured, the failure group. The lateral view cystogram was the most diagnostic test in that two in the failure group did not show preoperatively the roentgenographic hallmark of stress urinary incontinence.

The role of vaginal colonization with enterobacteriaceae in recurrent urinary infections

Quantitative cultures of the vaginal introitus for Enterobacteriaceae, S. faecalis and P. aeruginosa were compared in 20 premenopausal normal women (200 cultures) to 198 consecutive cultures from 9 premenopausal women in between episodes of bacteriuria. Introital colonization in patients susceptible to urinary infections was significantly higher for E. coli (p equals 0.001), S. faecalis (p equals 0.001) and for the presence of any gram-negative pathogens (p equals less than 0.001). In addition, introital colonization with these bacteria occurred in larger numbers and persisted through consecutive cultures for longer periods in women with recurrent infections.