What is the evidence for the role of oestrogen in the prevention of recurrent urinary tract infections in postmenopausal women? An evidence-based review

Urinary Tract Infection Prevention and Treatment

Urinary tract infections are the most common bacterial infections encountered by health care professionals. In women, the lifetime incidence of urinary tract infections may be up to 40% to 50%, of whom a further 40% may have recurrent infections. Urinary tract infections are associated with significant morbidity and potential mortality-they may be complicated by frequent recurrences, kidney damage, sepsis, and preterm birth, as well as collateral damage of antimicrobial use, which includes Clostridium difficile colitis and selection of drug-resistant organisms. There are personal costs such as reduced quality of life in patients affected by recurrent urinary tract infections, and societal impacts resulting from absenteeism and health care costs. In this review, we discuss the definitions and classifications, pathogenesis, and current principles of management and prevention of urinary tract infections. Semin Nephrol 43:x-xx © 2023 Elsevier Inc. All rights reserved.

Emerging Non-Antibiotic Options Targeting Uropathogenic Mechanisms for Recurrent Uncomplicated Urinary Tract Infection

Urinary tract infections (UTIs) are the most frequent bacterial infections in the clinical setting. Even without underlying anatomic or functional abnormalities, more than 40% of women experience at least one UTI in their lifetime, of which 30% develop recurrent UTIs (rUTIs) within 6 months. Conventional management with antibiotics for rUTIs may eventually lead to the development of multidrug-resistant uropathogens. Targeting of the pathogenicity of rUTIs, the evolution of uropathogenic Escherichia coli (UPEC), and inadequate host defenses by immune responses should be explored to provide non-antibiotic solutions for the management of rUTIs. The adaptive evolution of UPEC has been observed in several aspects, including colonization, attachment, invasion, and intracellular replication to invade the urothelium and survive intracellularly. Focusing on the antivirulence of UPEC and modulating the immunity of susceptible persons, researchers have provided potential alternative solutions in four categories: antiadhesive treatments (i.e., cranberries and D-mannose), immunomodulation therapies, vaccines, and prophylaxis with topical estrogen therapy and probiotics (e.g., Lactobacillus species). Combination therapies targeting multiple pathogenic mechanisms are expected to be a future trend in UTI management, although some of these treatment options have not been well established in terms of their long-term efficacy. Additional clinical trials are warranted to validate the therapeutic efficacy and durability of these techniques.

Topical and Oral Oestrogen for Recurrent Urinary Tract Infection-Evidence-based Review of Literature, Treatment Recommendations, and Correlation with the European Association of Urology Guidelines on Urological Infections

CONTEXT

Urinary tract infection (UTI) represents a significant disease for women, with 20-40% suffering from recurrent UTIs (rUTIs) across their lifetime.

OBJECTIVE

This review aims to provide evidence for current European Association of Urology (EAU) guidance that topical, but not oral, oestrogen is a worthwhile preventative therapy for rUTIs in postmenopausal women. We also aim to establish whether a relationship exists between oestrogen dosage and treatment efficacy.

EVIDENCE ACQUISITION

A literature search was performed across databases for this review. All studies that included oral or topical oestrogen in females with urinary tract infections were selected. Studies were inspected to establish treatment and follow-up duration, average weekly oestrogen dosage, efficacy of treatment, and reasons for dropout.

EVIDENCE SYNTHESIS

Clinical resolution and reduction of UTIs were evaluated. Six studies (seven treatment groups) using topical oestrogen as a treatment arm (258 patients total) and four studies using oral oestrogen as the treatment arm were included (1376 patients total). Topical oestrogen was administered as creams, pessaries, or per-vaginal tablets with follow-up spanning 2-12 mo. Of the patients, 51-100% remained UTI free throughout the duration of follow-up with minimal dropouts. Patients enrolled and treated with oral oestrogen were generally given higher weekly doses and had follow-up between 3 mo and 4.1 yr. All included studies agreed that topical oestrogen is an effective prophylaxis for rUTIs in women, with higher efficacy associated with weekly doses of ≥850 µg. Conversely, only one study arrived at the same conclusion for oral oestrogen.

CONCLUSIONS

Our review concurs with current EAU guidance that topical but not oral oestrogen therapy can be a valid treatment for women suffering from rUTIs. Administration weekly topical doses of ≥850 µg is associated with the best outcomes.

PATIENT SUMMARY

In this study, we look at the role of oral and topical oestrogens for the treatment of urinary tract infections and their adherence to European Association of Urology guidelines. We found that administration of weekly topical doses of ≥850 µg is associated with the best outcomes.

Vaginal Microbiota: Age Dynamic and Ethnic Particularities of Algerian Women

The composition of the vaginal microbiota is a key element for maintaining gynecological and reproductive health. With the aim of obtaining an accurate overview of the vaginal microbiota of Algerian women, in terms of their age and ethnic group, we conducted a 16S rRNA gene targeted metagenomic analysis of 100 vaginal samples taken from healthy childbearing and menopausal women. These data were used to establish the pattern of the vaginal microbiota during reproductive and postreproductive phases. Hormone levels were correlated to changes in microbial composition for menopausal women. The ethnic comparison revealed a particular microbiota profile for Algerian women, with a dominance of CST III and CST I. A rapid qPCR method developed by the authors was successfully used to identify the vaginal bacterial pattern for a customized gynecological management.

Clinical manifestations and evaluation of postmenopausal vulvovaginal atrophy

INTRODUCTION

It is estimated that 50% of women will suffer a severe form of vulvovaginal atrophy (VVA) related to menopause. Equally, young women may temporarily present this clinical problem while receiving various pharmacological or endocrine treatments or radiotherapy.

AIM

To determine clinical and diagnostic exams required to confirm the presence of VVA (also referred to as atrophic vaginitis, urogenital atrophy, or genitourinary syndrome of menopause) and rule out other genital or pelvic clinical conditions.

MATERIALS AND METHODS

Literature review searches were carried out on the main scientific article search engines (PubMed, SciELO, Cochrane) using different clinical terms, treatments or interventions and comorbidity related to VVA.

RESULTS

The development and severity of VVA depend mainly on the duration of hypoestrogenism. Hypoestrogenism causes changes in the urogenital tissue, generating signs and symptoms, such as dryness, burning, soreness, itching, and irritation of the genital skin. The diagnosis can be made through anamnesis (patient history), questionnaires, physical exam, and, sometimes, complementary exams. Objective vaginal assessment is essential and can be completed with the Vaginal Health Index, the Vaginal Maturation Index, or vaginal pH in the absence of infection or semen. The exclusion of other vulvovaginal organic pathology is essential to reach an accurate diagnosis and provide adequate treatment.

CONCLUSIONS

The specialist should be able to identify VVA, rule out other pathologies that make a differential diagnosis and conduct proper management.

The management of lower urogenital changes in the menopause

Currently, 25% of women seek the advice of a medical professional for symptoms related to the menopause. However, with an increasingly ageing and medically aware population, it is likely this proportion will grow. The main symptoms related to the menopause are systemic vasomotor and localized urogenital symptoms. Numerous forms of estrogen have been used to alleviate these symptoms. Further problems that increase during the menopause include incontinence, pelvic organ prolapse and recurrent urinary tract infections. This article reviews the process by which estrogen affects the tissues of the urogenital tract, what symptoms occur during this period and what modalities of treatments are available.

Prevention of recurrent urinary tract infections in women

Around 40-50% of women experience at least one urinary tract infection (UTI) during their lifetime and 20-30% of these have a recurrence within 3-4 months of the initial infection.¹ Recurrent UTI (usually defined as three episodes in the last 12 months or two episodes in the last 6 months) can have a considerable impact on a woman's quality of life. Each episode of acute UTI in young women is typically associated with about 6 days of symptoms, 2.4 days of restricted activities and 0.4 days of bed rest.¹ Antibacterial prophylaxis is effective in preventing recurrent episodes, but at the expense of unwanted effects and a risk of promoting bacterial resistance. Here we assess the efficacy of different antibacterial regimens and non-antibacterial alternatives (cranberry, probiotics, oestrogens, immunostimulation, hyaluronic acid and chondroitin, acupuncture and herbs) in the prevention of recurrent uncomplicated UTIs in women.