Vaginal Estrogen for the Prevention of Recurrent Urinary Tract Infection in Postmenopausal Women: A Randomized Clinical Trial

Recurrent UTI in Women-Risk Factors and Management

Urinary tract infections (UTIs) are common in women; more than 50% of women will be diagnosed with a UTI in her lifetime. Many of these women will go on to develop recurrent UTI. Nevertheless, evidence-based prevention of recurrent UTI is under-utilized. Here, the authors provide detailed practical advice on UTI prevention with a thorough review of the evidence. Non-antibiotic prevention measures discussed include increased fluid intake, vaginal estrogen therapy, methenamine, and cranberry. Antibiotic prophyalxis for carefully selected patients is also discussed.

The Urinary Microbiome: Improving Diagnostics and Management of Urinary Tract Infections in Adult Females

This article discusses the urinary microbiome in relation to urinary tract infection (UTI) in women. It makes biologic sense that the microbiota of different niches (bladder, vagina, and gut) interact with each other in health, as well as during a UTI event; however, these relationships remain poorly understood. Future research should close knowledge gaps regarding the interactions between the urinary microbiota and the host, amongst the microbiota of adjacent niches, and between the microbes within the same microbiota. The new knowledge should result in improved UTI treatment in the age of antibiotic stewardship.

Menopause and High Altitude: A Scoping Review-UIAA Medical Commission Recommendations

Mateikaitė-Pipirienė, Kastė, Dominique Jean, Peter Paal, Lenka Horakova, Susi Kriemler, Alison J. Rosier, Marija Andjelkovic, Beth A. Beidleman, Mia Derstine, Jacqueline Pichler Hefti, David Hillebrandt, and Linda E. Keyes for the UIAA MedCom writing group on Women's Health in the Mountains. Menopause and high altitude: A scoping review-UIAA Medical Commission Recommendations. High Alt Med Biol. 25:1-8, 2024. Background: Older people are an important fraction of mountain travelers and climbers, many of them postmenopausal women. The aim of this work was to review health issues that older and postmenopausal women may experience at high altitude, including susceptibility to high-altitude illness. Methods: We performed a scoping review for the UIAA Medical Commission series on Women's Health in the mountains. We searched PubMed and Cochrane libraries and performed an additional manual search. The primary search focused on articles assessing lowland women sojourning at high altitude. Results: We screened 7,165 potential articles. The search revealed three relevant articles, and the manual search another seven articles and one abstract. Seven assessed menopausal low-altitude residents during a high-altitude sojourn or performing hypoxic tests. Four assessed high-altitude residents. We summarize the results of these 11 studies. Conclusions: Data are limited on the effects of high altitude on postmenopausal women. The effects of short-term, high-altitude exposure on menopause symptoms are unknown. Menopause has minimal effect on the physiological responses to hypoxia in physically fit women and does not increase the risk of acute mountain sickness. Postmenopausal women have an increased risk of urinary tract infections, which may be exacerbated during mountain travel. More research is needed on the physiology and performance of older women at high altitude.

Characteristics Associated With Recurrent Urinary Tract Infections: A Case-Control Study

IMPORTANCE

Recurrent urinary tract infections (rUTIs) affect 2-10% of adult women and are associated with a significant effect on quality of life, daily activities, and mental health.

OBJECTIVE

The aim of this study was to identify clinical characteristics associated with rUTIs among women seeking care for pelvic floor disorders at an academic tertiary urogynecology clinic.

STUDY DESIGN

A retrospective case-control study of women presenting to an academic tertiary urogynecology clinic was conducted. Cases were women with rUTIs, defined as ≥2 UTIs in 6 months or ≥3 within 1 year. Controls were women with no culture documented UTIs. Cases were matched 2:1 to controls by age and body mass index. Demographic and clinical characteristics were compared between cases and controls, and bivariate characteristics with P values ≤0.2 were assessed for an independent association with rUTIs by multivariable logistic regression.

RESULTS

A total of 285 cases with rUTIs were identified, and 150 matched controls had a mean (SD) age of 72 (11.8) years and a body mass index of 29.6 (6.7; calculated as weight in kilograms divided by height in meters squared). Multivariable analysis revealed that prolapse beyond the introitus (odds ratio [OR], 0.28; 95% confidence interval [CI], 0.13-0.60), parity (OR, 1.33; 95% CI, 1.08-1.64), Charlson Comorbidity Index (OR, 1.66; 95% CI, 1.37-2.03), and postvoid residual volume ≥100 mL (OR, 4.05; 95% CI, 2.01, 8.18) were associated with rUTIs.

CONCLUSIONS

In this ambulatory urogynecologic population, prolapse through the introitus was negatively associated with rUTIs, whereas parity, increased medical comorbidities, and elevated postvoid residual volume were positively associated with rUTI. Future research should seek an increased understanding of these factors associated with rUTI to implement effective preventive strategies.

Antiaging Strategies and Remedies: A Landscape of Research Progress and Promise

Aging is typified by a gradual loss of physiological fitness and accumulation of cellular damage, leading to deteriorated functions and enhanced vulnerability to diseases. Antiaging research has a long history throughout civilization, with many efforts put forth to understand and prevent the effects of aging. Multiple strategies aiming to promote healthy aging and extend the lifespan have been developed including lifestyle adjustments, medical treatments, and social programs. A multitude of antiaging medicines and remedies have also been explored. Here, we use data from the CAS Content Collection to analyze the publication landscape of recent research related to antiaging strategies and treatments. We review the recent advances and delineate trends in research headway of antiaging knowledge and practice across time, geography, and development pipelines. We further assess the state-of-the-art antiaging approaches and explore their correlations with age-related diseases. The landscape of antiaging drugs has been outlined and explored. Well-recognized and novel, currently evaluated antiaging agents have also been summarized. Finally, we review clinical applications of antiaging products with their development pipelines. The objective of this review is to summarize current knowledge on preventive strategies and treatment remedies in the field of aging, to outline challenges and evaluate growth opportunities, in order to further efforts to solve the problems that remain.

New avenue of diagnostic stewardship: procedural stewardship for recurrent urinary tract infections in female patients

Introduction

Societal guidelines offer a weak recommendation to perform cystoscopy for female patients with recurrent urinary tract infections (rUTI) of advanced age and/or with high-risk features. These guidelines lack the support of robust data and are instead based on expert opinion. In this retrospective cohort study, we aim to determine the utility of cystoscopy in patients with and without high-risk features for rUTI.

Materials and methods

We identified 476 women who underwent cystoscopy for the evaluation of rUTI at a single tertiary academic medical center from May 1, 2015 and March 15, 2021. Patients were excluded if they had a competing indication for cystoscopy. Risk factors, demographic information, cystoscopic findings, and patient outcomes were analyzed.

Results

192 (41.1%) were classified as having complicated UTI. We identified six patients (1.3%) with findings that prompted management to significantly impact patient outcomes. All six patients had high-risk features. 14 patients (3.0%) were found to have mucosal abnormalities prompting biopsy, three of which required general anesthesia. All 14 biopsies were ultimately benign.

Conclusions

Our findings demonstrate a low diagnostic yield and increased risk exposure for women undergoing cystoscopy for the evaluation of complicated rUTI. Additionally, our observations support prior studies indicating that cystoscopy has limited utility in the evaluation of rUTI without high-risk features.

Wealth of Knowledge and Passion: Patient Perspectives on Vaginal Estrogen as Expressed on Reddit

OBJECTIVE

To qualitatively analyze the knowledge, attitudes, and beliefs of women regarding genitourinary syndrome of menopause (GSM) and vaginal estrogen therapy as expressed on Reddit, a public, anonymous internet forum for discussion and information sharing.

METHODS

"r/menopause," a Subreddit with >30,000 subscribers, was queried for "vaginal estrogen" to collect postings related to vaginal estrogen in October 2022. Posts were analyzed qualitatively by 2 independent researchers. The principles of grounded theory were applied, and preliminary themes were generated. These themes were used to derive emergent concepts.

RESULTS

Sixty-seven unique posts with 1101 responses were analyzed. Qualitative analysis revealed 5 preliminary themes: (1) questions regarding medication usage, (2) medication side effects, (3) medication alternatives, (4) frustration with the medical system, and (5) seeking validation for symptoms and experiences. Three emergent concepts were derived: (1) women experience bothersome side effects from menopause, and they desire compassionate and effective medical treatment; (2) women are engaged and active participants in their health and health care decisions; and (3) women perceive that their concerns are not taken seriously and seek validation for their medical conditions.

CONCLUSION

Peri- and post-menopausal women have many questions and concerns about the condition of GSM and vaginal estrogen as treatment. They also have a broad range of frustrations including access to health care and questions about the usage of vaginal estrogen. By better understanding patient perspectives, physicians can better meet women's needs and improve care for GSM.

Management of perimenopausal and menopausal symptoms

Most women worldwide experience menopausal symptoms during the menopause transition or postmenopause. Vasomotor symptoms are most pronounced during the first four to seven years but can persist for more than a decade, and genitourinary symptoms tend to be progressive. Although the hallmark symptoms are hot flashes, night sweats, disrupted sleep, and genitourinary discomfort, other common symptoms and conditions are mood fluctuations, cognitive changes, low sexual desire, bone loss, increase in abdominal fat, and adverse changes in metabolic health. These symptoms and signs can occur in any combination or sequence, and the link to menopause may even be elusive. Estrogen based hormonal therapies are the most effective treatments for many of the symptoms and, in the absence of contraindications to treatment, have a generally favorable benefit:risk ratio for women below age 60 and within 10 years of the onset of menopause. Non-hormonal treatment options are also available. Although a symptom driven treatment approach with individualized decision making can improve health and quality of life for midlife women, menopausal symptoms remain substantially undertreated by healthcare providers.

Efficacy of vaginal estrogen for recurrent urinary tract infection prevention in hypoestrogenic women

BACKGROUND

Vaginal estrogen is considered to be the standard of care for recurrent urinary tract infection prevention in women with hypoestrogenism. However, literature supporting its use is limited to small clinical trials with narrow generalizability.

OBJECTIVE

This study aimed to assess the association between vaginal estrogen prescription and the frequency of urinary tract infections over the following year in a diverse population of women with hypoestrogenism. Secondary objectives included evaluation of medication adherence and predictors of postprescription urinary tract infection.

STUDY DESIGN

This multicenter retrospective review included women who were prescribed vaginal estrogen for the indication of recurrent urinary tract infection from January 2009 through December 2019. Recurrent urinary tract infection was defined as having ≥3 positive urine cultures (separated by at least 14 days) in the 12 months preceding the index vaginal estrogen prescription. Patients were asked to fill their prescriptions and continue care within Kaiser Permanente Southern California system for at least 1 year. Exclusion criteria included anatomic abnormalities, malignancy, or mesh erosion of the genitourinary tract. Data on demographics, medical comorbidities, and surgical history were collected. Adherence was captured through refill data after the index prescription. Low adherence was defined as no refills; moderate adherence was defined as 1 refill; high adherence was defined as ≥2 refills. Data were abstracted from the electronic medical record system using the pharmacy database and diagnosis codes. A paired t test was used to compare pre- and postprescription urinary tract infections over the year preceding and following the vaginal estrogen prescription. A multivariate negative binomial regression was used to evaluate predictors of postprescription urinary tract infection.

RESULTS

The cohort included 5638 women with a mean (±standard deviation) age of 70.4 (±11.9) years, body mass index of 28.5 (±6.3) kg/m2, and baseline urinary tract infection frequency of 3.9 (±1.3). Most of the participants were White (59.9%) or Hispanic (29.7%) and postmenopausal (93.4%). The mean urinary tract infection frequency in the year following the index prescription decreased to 1.8 (P<.001) from 3.9 in the year preceding the prescription, which is a 51.9% reduction. During the 12 months after the index prescription, 55.3% of patients experienced ≤1 urinary tract infections, and 31.4% experienced no urinary tract infections. Significant predictors of postprescription urinary tract infection included age of 75 to 84 years (incident rate ratio, 1.24; 95% confidence interval, 1.05-1.46) and >85 years (1.41; 1.17-1.68), increased baseline urinary tract infection frequency (1.22; 1.19-1.24), urinary incontinence (1.14; 1.07-1.21), urinary retention (1.21; 1.10-1.33), diabetes mellitus (1.14; 1.07-1.21), and moderate (1.32; 1.23-1.42) or high medication adherence (1.33; 1.24-1.42). Patients with high medication adherence demonstrated more frequent postprescription urinary tract infections than patients with low adherence (2.2 vs 1.6; P<.0001).

CONCLUSION

In this retrospective review of 5600 women with hypoestrogenism who were prescribed vaginal estrogen for the prevention of recurrent urinary tract infections, the frequency of urinary tract infection decreased by more than 50% in the following year. Baseline urinary tract infection frequency, increasing age, urinary incontinence or retention, and diabetes were associated with an increased risk of postprescription urinary tract infection. The paradoxical finding that women with moderate and high medication adherence experienced the lowest-magnitude reduction in urinary tract infection frequency may represent unobserved selection or unmeasured confounding.

Using evolutionary principles to make clinical decisions: a case series of urinary tract infections

The principles of evolutionary medicine have significant potential to be useful in a wide variety of clinical situations. Despite this, few demonstrations of clinical applications exist. To address this paucity, a case series applying evolutionary medicine principles to urinary tract infections, a common medical condition is presented. This series demonstrates how applying evolutionary medicine principles can be used to augment clinical decision-making.

Fecal Incontinence and the Risk of Urinary Tract Infection in Patients Presenting for Urogynecological Consultation

IMPORTANCE

Urinary tract infection (UTI) is common in urogynecology patients. Patients with fecal incontinence (FI) often attribute their UTIs to FI, but this association has not been evaluated.

OBJECTIVES

The objectives of this study were to compare the prevalence of UTI in urogynecology patients with and without FI and to characterize factors associated with UTI and recurrent UTI.

STUDY DESIGN

This retrospective cohort study included all new adult patients who presented to an academic female pelvic medicine and reconstructive surgery practice with FI from January 2014 through December 2017. Patients were age-matched to new adult patients with stage <2 pelvic organ prolapse without FI. All urine culture results from 1 year before and 1 year after the first visit were identified. Logistic regression identified factors associated with UTI.

RESULTS

Among 399 patients, 106 (27%) had a culture-confirmed UTI in the year before or after their first urogynecology visit; the prevalence of UTI was 23% (45/198) in patients with FI and 30% (61/201) in those without FI (P = 0.09). The rate of recurrent UTI was 11.5% overall and did not differ among those with and without FI. In multivariate models, variables that were statistically significantly associated with UTI included age, diabetes mellitus, anterior vaginal wall prolapse, and sexual activity. Fecal incontinence was not associated with any or recurrent UTI.

CONCLUSIONS

The prevalence of UTI and recurrent UTI was similar in urogynecology patients with and without FI. Variables that were associated with UTI risk included older age, sexual activity, diabetes mellitus, and anterior vaginal wall prolapse.

Definitions of Urinary Tract Infection in Current Research: A Systematic Review

Defining urinary tract infection (UTI) is complex, as numerous clinical and diagnostic parameters are involved. In this systematic review, we aimed to gain insight into how UTI is defined across current studies. We included 47 studies, published between January 2019 and May 2022, investigating therapeutic or prophylactic interventions in adult patients with UTI. Signs and symptoms, pyuria, and a positive urine culture were required in 85%, 28%, and 55% of study definitions, respectively. Five studies (11%) required all 3 categories for the diagnosis of UTI. Thresholds for significant bacteriuria varied from 103 to 105 colony-forming units/mL. None of the 12 studies including acute cystitis and 2 of 12 (17%) defining acute pyelonephritis used identical definitions. Complicated UTI was defined by both host factors and systemic involvement in 9 of 14 (64%) studies. In conclusion, UTI definitions are heterogeneous across recent studies, highlighting the need for a consensus-based, research reference standard for UTI.

Etiology of recurrent cystitis in postmenopausal women based on vaginal microbiota and the role of Lactobacillus vaginal suppository

Background

The vaginal microbiota can be altered by uropathogenic bacteria associated with recurrent cystitis (RC), and the vaginal administration of Lactobacillus have suggested certain effects to prevent RC. The relationship between vaginal microbiota and the development of RC has not been elucidated. We aimed to clarify the etiology of RC from vaginal microbiota and importance of vaginal Lactobacillus.

Methods

Vaginal samples obtained from 39 postmenopausal women were classified into four groups: healthy controls; uncomplicated cystitis; RC; and prevention (prevented RC by Lactobacillus crispatus-containing vaginal suppositories). Principal coordinate analysis and beta-diversity analysis was used to assess 16S rRNA gene sequencing data from the vaginal microbiome.

Results

Cluster analysis divided the vaginal bacterial communities among 129 vaginal samples into three clusters (A, B, and C). Fourteen of 14 (100%) samples from the RC group and 51 of 53 (96%) samples from the prevention group were in clusters B and C, while 29 of 38 (76%) samples from the healthy group and 14 of 24 (58%) samples from the uncomplicated cystitis group were in cluster A. The principal coordinate analysis showed that plots in the uncomplicated cystitis group were similar to the healthy group, indicating a large separation between the RC group and the uncomplicated cystitis group. On beta-diversity analysis, there were significant differences between the healthy group and the uncomplicated cystitis group (p = 0.045), and between the RC group and the uncomplicated cystitis group or the healthy group (p = 0.001, p = 0.001, respectively). There were no significant differences between the RC group and the prevention group (p = 0.446). The top six taxa were as follows: Prevotella, Lactobacillus, Streptococcus, Enterobacteriaceae, Anaerococcus, and Bifidobacterium. Among patients with RC, Lactobacillus was undetectable before administration of suppositories, while the median relative abundance of Lactobacillus was 19% during administration of suppositories (p = 0.0211), reducing the average cystitis episodes per year (6.3 vs. 2.4, p = 0.0015).

Conclusion

The vaginal microbiota of postmenopausal women with RC is differed from healthy controls and uncomplicated cystitis in terms of lack of Lactobacillus and relatively dominant of Enterobacteriaceae. Vaginal administration of Lactobacillus-containing suppositories can prevent RC by stabilizing vaginal dysbiosis and causing a loss of pathogenic bacteria virulence.

Menopause hormone therapy and urinary symptoms: a systematic review

IMPORTANCE

Urogenital changes associated with menopause are now classified as genitourinary syndrome of menopause (GSM), which includes symptoms of urgency, frequency, dysuria, and recurrent urinary tract infections for which the recommended treatment is estrogen. However, the association between menopause and urinary symptoms and the efficacy of hormone therapy for these symptoms is uncertain.

OBJECTIVE

Our objective was to define the relationship between menopause and urinary symptoms including dysuria, urgency, frequency, recurrent urinary tract infections (UTIs), and urge and stress incontinence by conducting a systematic review of the effects of hormone therapy (HT) for urinary symptoms in perimenopausal and postmenopausal women.

EVIDENCE REVIEW

Eligible studies included randomized control trials with perimenopausal and postmenopausal women with a primary or secondary outcome of the following urinary symptoms: dysuria, frequent UTI, urgency, frequency, and incontinence, included at least one treatment arm of estrogen therapy, and were in English. Animal trials, cancer studies and pharmacokinetic studies, secondary analyses, and conference abstracts were excluded. PubMed, Scopus, and the Cochrane Central Register of Controlled Trials were searched until April 2022. Two authors reviewed each article with discrepancies resolved through whole group consensus. Data extracted included the following: publication date, country, setting, subject number, follow-up, duration, age, race/ethnicity, study design, inclusion criteria, and main findings.

FINDINGS

There is insufficient evidence to confirm that menopause is associated with urinary symptoms. The effect of HT on urinary symptoms depends on type. Systemic HT may cause urinary incontinence or worsen existing urinary symptoms. Vaginal estrogen improves dysuria, frequency, urge and stress incontinence, and recurrent UTI in menopausal women.

CONCLUSIONS AND RELEVANCE

Vaginal estrogen improves urinary symptoms and decreases the risk of recurrent UTI in postmenopausal women.

Hormone therapy for sexual function in perimenopausal and postmenopausal women: a systematic review and meta-analysis update

IMPORTANCE

Distressing sexual problems are a common complaint of menopausal women. In 2013, a Cochrane review assessed the effect of hormone therapy on sexual function in menopausal women; however, new evidence has since been published, which should be considered.

OBJECTIVE

This systematic review and meta-analysis aims to update the evidence synthesis on the effect of hormone therapy, compared with control, on sexual function in perimenopausal and postmenopausal women.

EVIDENCE REVIEW

Thirteen databases and clinical trial registries (Cochrane Central Register of Controlled Trials, EMBASE, Medical Literature Analysis and Retrieval System Online, PsycINFO, Web of Science, Cumulative Index to Nursing and Allied Health Literature, Literatura Latino-Americana e do Caribe em Ciéncias da Saúde, Database of Abstracts of Reviews of Effects, ClinicalTrials.gov, International Clinical Trials Registry Platform, Iranian Registry of Clinical Trials, Chinese Clinical Trial Registry, ISRCTN) were searched from December 2012 to March 30, 2022. Backward reference searching on all retrieved full texts was also performed. Study quality was assessed using the Cochrane ROB.2 tool. Data were pooled in random-effect model meta-analyses, which included all studies identified in the present search and all studies previously included in the 2013 Cochrane review.

FINDINGS

Forty-seven randomized controlled trials (35,912 participants) were included in the systematic review, and 34 randomized controlled trials (15,079 participants) were included in the meta-analysis. The meta-analysis revealed that, in comparison to control, estrogen therapy (standardized mean difference [SMD], 0.16; 95% confidence interval [CI], 0.02 to 0.29; I2 = 59%; 2,925 participants, 16 studies), estrogen plus progestogen therapy (SMD, 0.11; 95% CI, -0.07 to 0.29; I2 = 65%; 2,432 participants, 7 studies), tibolone (SMD, 0.15; 95% CI, 0.02 to 0.28; I2 = 0%; 916 participants, 2 studies), and selective estrogen receptor modulators (SMD, 0.18; 95% CI, 0.06 to 0.30; I2 = 0%; 1,058 participants, 4 studies) may result in no effect to small benefit on sexual function composite score.

CONCLUSION AND RELEVANCE

Hormone therapy may slightly improve sexual functioning. This potential small benefit should be considered when discussing treatment options for other menopausal symptoms.

Evidence-based review of nonantibiotic urinary tract infection prevention strategies for women: a patient-centered approach

PURPOSE OF REVIEW

There is a growing interest in nonantibiotic prevention strategies for recurrent urinary tract infections (rUTIs). Our objective is to provide a focused, pragmatic review of the latest evidence.

RECENT FINDINGS

Vaginal estrogen is well tolerated and effective for preventing rUTI in postmenopausal women. Cranberry supplements at sufficient doses are effective in preventing uncomplicated rUTI. Methenamine, d -mannose, and increased hydration all have evidence to support their use, although the evidence is of somewhat variable quality.

SUMMARY

There is sufficient evidence to recommend vaginal estrogen and cranberry as first-line rUTI prevention strategies, particularly in postmenopausal women. Prevention strategies can be used in series or in tandem, based on patient preference and tolerance for side effects, to create effective nonantibiotic rUTI prevention strategies.

Supraphysiologic Vaginal Estrogen Therapy in Aged Mice Mitigates Age-Associated Bladder Inflammatory Response to Urinary Tract Infections

IMPORTANCE

Bladder diseases characterized by chronic inflammation are highly prevalent in older women, as are recurrent urinary tract infections (rUTIs). Recurrent urinary tract infections lead to chronic inflammation of the bladder mucosa and cause lower urinary tract symptoms that persist even after the infection is cleared. Vaginal estrogen therapy (VET) has long been used for the treatment of rUTIs; however, its mechanism of action remains unclear.

OBJECTIVES

The objective of this study was to examine the mechanism(s) by which VET affects bladder inflammation and response to rUTIs.

STUDY DESIGN

Here, we induced surgical menopause in aged (18 months old) mice followed by VET. Mice were then infected with uropathogenic Escherichia coli , and course of infection was investigated. Inflammatory cytokine response was assessed before and during infection using enzyme-linked immunosorbent assay. RNA sequencing analysis was used to compare the inflammatory status of the young versus aged bladder and principal changes confirmed via quantitative reverse transcriptase-polymerase chain reaction to determine the effects of VET on bladder inflammation. Impact on age-associated bladder tertiary lymphoid tissue formation was evaluated histologically.

RESULTS

In the ovariectomized aged model, VET not only mitigated uterine atrophy but was also associated with reduced rUTIs, number of bacterial reservoirs, dampened immune response, and promotion of terminal differentiation of urothelial cells. Bladder tertiary lymphoid tissue lesions were also reduced with VET, with an associated decrease in signals important for bladder tertiary lymphoid tissue formation. Finally, we determined that VET reverses age-associated upregulation of inflammatory genes and pathways.

CONCLUSIONS

Our data suggest that VET is effective by reducing age-associated hyperinflammatory conditions in bladder mucosa and in enhancing the host response to infection.

Urinary Glycosaminoglycans Are Associated with Recurrent UTI and Urobiome Ecology in Postmenopausal Women

Glycosaminoglycans (GAGs) are linear, negatively charged polysaccharides composed of repeating disaccharide units of uronic acid and amino sugars. The luminal surface of the bladder epithelium is coated with a GAG layer. These urothelial GAGs are thought to provide a protective barrier and serve as a potential interaction site with the urinary microbiome (urobiome). Previous studies have profiled urinary GAG composition in mixed cohorts, but the urinary GAG composition in postmenopausal women remains undefined. To investigate the relationship between GAGs and recurrent urinary tract infection (rUTI), we profiled urinary GAGs in a controlled cohort of postmenopausal women. We found that chondroitin sulfate (CS) is the major urinary GAG in postmenopausal women and that urinary CS was elevated in women with active rUTI. We also associated urinary GAGs with urobiome composition and identified bacterial species that significantly associated with urinary GAG concentration. Corynebacterium amycolatum, Porphyromonas somerae, and Staphylococcus pasteuri were positively associated with heparin sulfate or hyaluronic acid, and bacterial species associated with vaginal dysbiosis were negatively correlated with urinary CS. Altogether, this work defines changes in urinary GAG composition associated with rUTI and identifies new associations between urinary GAGs and the urobiome that may play a role in rUTI pathobiology.

Vaginal Hormone Therapy for Conditions of the Lower Urinary Tract

PURPOSE OF REVIEW

Up to half of postmenopausal women experience genitourinary symptoms secondary to hormone deficiency, and there is little consensus on the use of vaginal hormone therapy (VHT) for lower urinary tract symptoms (LUTS) in these patients. This is a review of the scientific literature in the last decade evaluating the use of VHT for disorders of the lower urinary tract including overactive bladder (OAB), stress urinary incontinence (SUI), recurrent urinary tract infections (UTI), and interstitial cystitis/bladder pain syndrome (ICS/BPS).

RECENT FINDINGS

Vaginal estrogen therapy improves OAB symptoms in postmenopausal women, but results are mixed when VHT is used in combination with other treatments. There is inconclusive or limited data for the use of VHT to treat SUI and IC/BPS. Vaginal estrogen and prasterone (DHEA) therapies have demonstrated efficacy as treatment modalities for patients who experience recurrent UTIs. VHT preparations show efficacy for the treatment of certain LUTS and can be considered in carefully selected patients when clinically indicated.

Urinary Glycosaminoglycans are Associated with Recurrent UTI and Urobiome Ecology in Postmenopausal Women

Glycosaminoglycans (GAGs) are linear, negatively charged polysaccharides composed of repeating disaccharide units of uronic acid and amino sugars. The luminal surface of the bladder epithelium is coated with a GAG layer. These urothelial GAGs are thought to provide a protective barrier and serve as a potential interaction site with the urinary microbiome (urobiome). Previous studies have profiled urinary GAG composition in mixed cohorts, but the urinary GAG composition in postmenopausal women remains undefined. To investigate the relationship between GAGs and recurrent UTI (rUTI), we profiled urinary GAGs in a controlled cohort of postmenopausal women. We found that chondroitin sulfate (CS) is the major urinary GAG in postmenopausal women and that urinary CS was elevated in women with active rUTI. We also associated urinary GAGs with urobiome composition and identified bacterial species that significantly associated with urinary GAG concentration. Corynebacterium amycolatum, Porphyromonas somerae , and Staphylococcus pasteuri were positively associated with heparin sulfate or hyaluronic acid and bacterial species associated with vaginal dysbiosis were negatively correlated to urinary CS. Altogether, this work defines changes in urinary GAG composition associated with rUTI and identifies new associations between urinary GAGs and the urobiome that may play a role in rUTI pathobiology.

Analysis of Characteristics, Pathogens and Drug Resistance of Urinary Tract Infection Associated with Long-Term Indwelling Double-J Stent

Objective

To investigate the characteristics, pathogens and drug resistance of urinary tract infection (UTI) associated with long-term indwelling double-J stent.

Methods

The clinical data of 102 patients with urinary tract infection associated with long-term indwelling double-J stent in University-Town Hospital of Chongqing Medical University and Chongqing Traditional Chinese Medicine Hospital from September 2010 to July 2022 were collected retrospectively, and the difference between etiological characteristics were analyzed. Urine and double-J stent samples of patients were collected for pathogen identification and drug sensitivity test.

Results

A total of 102 patients, 39 (38.23%) males and 63 (61.77%) females, aged 24-72 years, with a median age of 48 years, were included in this study. Urinary calculi (40.20%) and ureteral stricture (24.50%) were the main causes of urinary tract infection associated with long-term indwelling double-J stent. Among the patients with urinary tract infection caused by double-J stent, female patients were higher than male patients (61.77% vs 38.23%). In terms of positive rate of pathogenic bacteria culture, the rate of double-J stent was higher than that of urine (67.65% vs 35.29%). The main pathogenic bacteria in urine were Escherichia coli (30.55%) of Gram negative bacteria, while the main pathogenic bacteria in double-J stent were enterococcus faecalis (27.53%) of Gram positive bacteria. The resistance rate of Gram positive bacteria in double-J stent to vancomycin, ciprofloxacin, meropenem and piperacillin/tazobactam was significantly higher than that in urine (P<0.05). The resistance rate of Gram negative bacteria in double-J stent to imipenem, cefepime, piperacillin/tazobactam, meropenem and cefoperazone/sulbactam was significantly higher than that in urine (P<0.05).

Conclusion

Double-J stent associated urinary tract infection is more common in women than in men. Escherichia coli and Enterococcus faecalis are the main pathogens, and the pathogens show strong drug resistance.

Microhematuria in Women Presenting for Overactive Bladder

PURPOSE OF REVIEW

Microscopic hematuria and overactive bladder are two common urologic conditions. The objective of this review is to provide an overview of current literature as well as highlight important guidelines that will aid physicians in the diagnostic workup of microscopic hematuria in patients experiencing symptoms of overactive bladder.

RECENT FINDINGS

Updated microscopic hematuria guidelines provide a structured and appropriate workup for women based on risk factors, which stratifies patients to prevent unnecessary procedures and imaging. Women presenting with microscopic hematuria in the setting of overactive bladder should undergo microscopic hematuria workup according to their risk stratification while receiving appropriate treatment for their overactive bladder. The physician should consider the presence of irritative voiding symptoms during the investigation and management of microscopic hematuria in patients with overactive bladder and should not delay overactive bladder treatment due to the presence of microscopic hematuria.

Effects of aging on urinary tract epithelial homeostasis and immunity

A global increase in older individuals creates an increasing demand to understand numerous healthcare challenges related to aging. This population is subject to changes in tissue physiology and the immune response network. Older individuals are particularly susceptible to infectious diseases, with one of the most common being urinary tract infections (UTIs). Postmenopausal and older women have the highest risk of recurrent UTIs (rUTIs); however, why rUTIs become more frequent after menopause and during old age is incompletely understood. This increased susceptibility and severity among older individuals may involve functional changes to the immune system with age. Aging also has substantial effects on the epithelium and the immune system that led to impaired protection against pathogens, yet heightened and prolonged inflammation. How the immune system and its responses to infection changes within the bladder mucosa during aging has largely remained poorly understood. In this review, we highlight our understanding of bladder innate and adaptive immunity and the impact of aging and hormones and hormone therapy on bladder epithelial homeostasis and immunity. In particular, we elaborate on how the cellular and molecular immune landscape within the bladder can be altered during aging as aged mice develop bladder tertiary lymphoid tissues (bTLT), which are absent in young mice leading to profound age-associated change to the immune landscape in bladders that might drive the significant increase in UTI susceptibility. Knowledge of host factors that prevent or promote infection can lead to targeted treatment and prevention regimens. This review also identifies unique host factors to consider in the older, female host for improving rUTI treatment and prevention by dissecting the age-associated alteration of the bladder mucosal immune system.

Comparison of Urinary Tract Infection Incidence Following Intradetrusor OnabotulinumtoxinA in Office Versus Operating Room Settings

IMPORTANCE

Urinary tract infection (UTI) is a known complication of intradetrusor onabotulinumtoxinA (BTX) injection. However, whether administering intradetrusor BTX in different clinical settings affects the risk of postprocedural UTI has not been investigated.

OBJECTIVES

The objective of this study was to assess differences in the incidence of postprocedural UTI in women who received intradetrusor BTX in an outpatient office versus an operating room (OR).

STUDY DESIGN

We performed a retrospective chart review of intradetrusor BTX procedures at a single institution between 2013 and 2020. Demographic data, comorbidities, and perioperative data were abstracted. The primary outcome was UTI defined as initiation of antibiotics within 30 days following BTX administration based on clinician assessment of symptoms and/or urine culture results. Univariate analysis of patients with and without UTI was performed.

RESULTS

A total of 446 intradetrusor BTX procedures performed on female patients either in an outpatient office (n = 160 [35.9%]) or in an OR (n = 286 [64.1%]) were included in the analysis. Within 30 days of BTX administration, UTI was diagnosed after 14 BTX procedures (8.8%) in the office group and 29 BTX procedures (10.1%) in the OR group ( P = 0.633). De novo postprocedural urinary retention occurred in more women who were treated in the office than in the OR (13 [9.6%] vs 3 [1.3%], P < 0.001).

CONCLUSIONS

Selecting the appropriate setting for BTX administration is dependent on multiple factors. However, the clinical setting in which intradetrusor BTX is administered may not be an important factor in the development of postprocedural UTI, and further research is warranted.

Recurrent urinary tract infection and estrogen shape the taxonomic ecology and function of the postmenopausal urogenital microbiome

Postmenopausal women are severely affected by recurrent urinary tract infection (rUTI). The urogenital microbiome is a key component of the urinary environment. However, changes in the urogenital microbiome underlying rUTI susceptibility are unknown. Here, we perform shotgun metagenomics and advanced culture on urine from a controlled cohort of postmenopausal women to identify urogenital microbiome compositional and function changes linked to rUTI susceptibility. We identify candidate taxonomic biomarkers of rUTI susceptibility in postmenopausal women and an enrichment of lactobacilli in postmenopausal women taking estrogen hormone therapy. We find robust correlations between Bifidobacterium and Lactobacillus and urinary estrogens in women without urinary tract infection (UTI) history. Functional analyses reveal distinct metabolic and antimicrobial resistance gene (ARG) signatures associated with rUTI. Importantly, we find that ARGs are enriched in the urogenital microbiomes of women with rUTI history independent of current UTI status. Our data suggest that rUTI and estrogen shape the urogenital microbiome in postmenopausal women.

Case Report: Urinary Tract Infection in a Diabetic Postmenopausal Woman With Multiple Episodes of Recurrence: An Antimicrobial Susceptibility dispute

Urinary tract infection (UTI) is caused by bacteria growing in urine and affect kidneys, bladder, ureters, and urethra. Women with diabetes are at high risk of developing UTI. This is a case of a 60-year-old postmenopausal woman with uncontrolled type-I diabetes mellitus and hypertension, who presented with an acute onset of dysuria, burning micturition, and increased frequency. This case highlights the shortfall in the preliminary management plan of performing imperative clinical laboratory investigations including urine detailed report (DR), urine culture and sensitivity(C/S), and plasma glucose testing to initiate antimicrobial treatment. UTI requires to be treated precisely in diabetic patients with the help of a comprehensive diagnosis for signs of dysuria, frequent urination, and pelvic pain. The treatment of UTIs should always begin with culture and sensitivity analysis while the patient is symptomatic, to initiate antimicrobial treatment. Comorbidities should be managed appropriately during treatment to achieve desired therapeutic outcomes.

Feasibility and Research Insights From a Randomized Controlled Trial for Recurrent Urinary Tract Infection Prevention in Postmenopausal Women Using Vaginal Estrogen Therapy

OBJECTIVE

The aim of the study was to inform feasibility parameters (eligibility, enrollment, and retention) for a recurrent urinary tract infection (rUTI) prevention randomized controlled trial (RCT).

METHODS

We assessed feasibility parameters of an RCT of postmenopausal women with uncomplicated rUTIs using vaginal estrogen. Participants were randomized to either d-mannose or a control arm. All participants were required to be using vaginal estrogen and to have a negative urine culture before 90-day trial participation. An RCT exit survey and separate survey for UTI patients (N = 196) were added to inform feasibility parameters and patient preferences for rUTI prevention and study participation after slower enrollment than anticipated.

RESULTS

At the time of interim and subsequent futility analyses, 545 patients had been evaluated for frequent/recurrent UTIs from March 1, 2018, to January 18, 2020. Of these, 213 (39.1%) had culture-proven rUTIs and 71 (33.3% of those with culture-proven rUTIs) were eligible for the RCT. Reasons for ineligibility included complicated UTIs, premenopausal/perimenopausal status, or existing UTI prevention regimen. Of the 71 eligible participants, 57 (80.3%) enrolled, and 44 began their planned 90-day study period (77.2%; 80.0% after excluding 2 participants awaiting negative urine cultures at the time of analysis). The study was halted before conclusion. Study retention (76.0%-83.7%) was slightly lower than expected. Urinary tract infection survey patients demonstrated significant interest in rUTI research participation.

CONCLUSIONS

We learned several important lessons that can benefit future research. Many patients with frequent/recurrent UTIs are interested in research, but rigorous eligibility criteria and referral urine culture documentation made recruitment challenging.

Individual Benefits and Risks of Intravaginal Estrogen and Systemic Testosterone in the Management of Women in the Menopause, With a Discussion of Any Associated Risks for Cancer Development

ABSTRACT

Several formulations of intravaginal oestrogen are available for the treatment of genitourinary syndrome of menopause (GSM). These are safe and effective treatments for the symptoms of GSM. Licensed doses of intravaginal oestrogen do not elevate systemic estradiol levels above the normal postmenopausal range with long term use and there is no evidence of an increased risk of coronary heart disease, stroke, thromboembolism, colorectal cancer, endometrial cancer, breast cancer or breast cancer recurrence with their use. This should reassure both women and their healthcare professionals and should lead to more women receiving these localised, vaginally administered hormonal treatments. Available evidence also suggests a positive safety profile for transdermal testosterone treatment when delivered at physiological concentrations.

Vitamin D and the Immune System in Menopause: A Review

Menopause is a normal phenomenon in a woman’s life cycle involving multiple health-related issues that contribute to physical instability. Changes in the immune system in postmenopausal women are caused by estrogen deprivation along with age. Increased proinflammatory serum marker levels, cytokine responses in body cells, decreased CD4 T and B lymphocyte levels, and natural killer cell cytotoxic activity are also observed during postmenopause. Moreover, vitamin D, in addition to its classical effects on calcium homeostasis and bone density, plays an important role. Current evidence indicates that vitamin D regulates innate and adaptive immune responses; however, vitamin D deficiency is linked to increased autoimmune activity and infection susceptibility. This review provides an overview of the consequences of immune alterations as an outcome of aging in postmenopausal women and the benefit of vitamin D supplementation.

The impact of biological sex on diseases of the urinary tract

Biological sex, being female or male, broadly influences diverse immune phenotypes, including immune responses to diseases at mucosal surfaces. Sex hormones, sex chromosomes, sexual dimorphism, and gender differences all contribute to how an organism will respond to diseases of the urinary tract, such as bladder infection or cancer. Although the incidence of urinary tract infection is strongly sex biased, rates of infection change over a lifetime in women and men, suggesting that accompanying changes in the levels of sex hormones may play a role in the response to infection. Bladder cancer is also sex biased in that 75% of newly diagnosed patients are men. Bladder cancer development is shaped by contributions from both sex hormones and sex chromosomes, demonstrating that the influence of sex on disease can be complex. With a better understanding of how sex influences disease and immunity, we can envision sex-specific therapies to better treat diseases of the urinary tract and potentially diseases of other mucosal tissues.

THE MOST COMMON UROLOGICAL CONDITIONS IN POSTMENOPAUSAL WOMEN

OBJECTIVE

The aim: To analyze the available literature on the most common daily urological problems in menopausal women and to evaluate the use of hormone replacement therapy for troublesome urological symptoms.

PATIENTS AND METHODS

Materials and methods: Analysis of publications from PubMed databases on the most common disorders during menopause was performed and the most common urog¬ynaecological problems in postmenopausal women were selected according to literature data. Different available methods of treatment of these disorders were compared. Conclusions: During menopause, women struggle with many unpleasant symptoms from the genitourinary system. For most women, this is a very embarrassing topic and, although bothersome, underestimated. The urinary tract infections, urinary incontinence or kidney stones can lead to serious complications, if left untreated. We should strive to make women more aware of possible methods of prevention and treatment of the menopausal symptoms in the context of urological disorders.

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.

Induction of bacterial cystitis in female rabbits by uropathogenic Escherichia coli and the differences between the bladder dome and trigone

This study is designed to evaluate the histological effects of uropathogenic Escherichia coli (UPEC) infection in the urinary bladder of female rabbits and compare the differences between the dome and trigone. Bacterial cystitis was induced in 13 female rabbits by transurethral inoculation of UPEC into the urinary bladder. Eight animals served as controls. Urine samples were collected by catheterization and cultured for bacterial growth after 12 and 24 hours then every 48 hours. Infection was defined as ≥(1X10⁵) colony-forming unit/ml of UPEC in the first two urine samples. Bladder dome and trigonal specimens were examined by light and scanning electron microscopy eight days after infection. There was a sustained increase in bacterial count, with urethral bleeding and rabbit weakness suggesting bladder colonization in the 10/13 study group (77%). Infection was not demonstrated in two animals and was spontaneously cleared in the third after 48 hours. No control animals developed an infection. In infected rabbits (n = 10), the dome showed inflammatory changes including the epithelial loss or thinning, inflammatory cell infiltration, and congested blood vessels compared to controls. The trigone showed a more pronounced inflammatory response than the dome. The presence of urinary bacterial growth, infection manifestations, and inflammatory changes that were more severe in the trigone than in the dome indicate successful bacterial inoculation and induction of cystitis. This animal model can be used for clinical trials on female cystitis. Our histological findings support a possible role of trigone in the pathogenesis of urinary tract infection.

Impact of Vaginal Estrogen on the Urobiome in Postmenopausal Women With Recurrent Urinary Tract Infection

OBJECTIVE

The aim of this study was to describe effects of vaginal estrogen (VE) on the urogenital microbiome in postmenopausal women with recurrent urinary tract infections (rUTIs).

METHODS

This is a secondary analysis of 17 participants enrolled in a randomized controlled trial of VE versus placebo on urinary tract infection recurrence in postmenopausal women with rUTIs. Paired clean-catch urine samples were collected at baseline and after 6 months of VE and sequenced using 16S rRNA gene sequencing. Sequence reads were analyzed using Quantitative Insights Into Microbial Ecology 2. Changes in α diversity, β diversity, and differentially abundant genera were measured between paired baseline and 6-month samples and between those with a urinary tract infection at 6 months (failures) and those without (successes).

RESULTS

Of the 17 women, 11 were successes and 6 were failures after 6 months of VE treatment. There was a significant change in α diversity from baseline to month 6 in samples overall (Kruskal-Wallis χ2 = 3.47, P = 0.037) and in the treatment success group (Yuen T = -2.53, P = 0.035). The increase in relative abundance of Lactobacillus crispatus, Lactobacillus gasseri, and Lactobacillus iners AB-1 was correlated with month 6. A relative bloom of L. crispatus compared with L. gasseri was associated with treatment success (Kruskal-Wallis χ2 = 4.9, P = 0.0014).

CONCLUSIONS

Lactobacillus increases in the urogenital microbiome of postmenopausal women with rUTI after 6 months of VE. However, only the relative increase in L. crispatus specifically may be associated with treatment success.

Evaluation of systemic estrogen for preventing urinary tract infections in postmenopausal women

IMPORTANCE

Current guidelines for postmenopausal recurrent urinary tract infection (rUTI) prevention recommend the use of vaginal topical estrogen products but not systemic estrogens. Studies show that vaginal estrogen decreases the risk of rUTI, but evidence against use of systemic estrogen is less convincing.

OBJECTIVE

We performed a comprehensive literature review to evaluate the effect of systemic estrogen on UTI occurrence among postmenopausal women.

EVIDENCE REVIEW

MEDLINE (PubMed), EMBASE, and CINAHL were searched for manuscripts published in English between January 1990 and July 2020. The search terms were "urinary tract infection" and "estrogen." Inclusion criteria were studies of postmenopausal women who received systemic estrogen therapy (any regimen) that reported UTI frequency during any follow-up period. Case studies, commentaries, and reviews were excluded. A priori specifications of seven study criteria were set representing the ideal study for assessing efficacy of systemic estrogen for rUTI prevention and were used to evaluate each included study.

FINDINGS

Searches identified 281 results, and after deduplication and review, 8 studies met inclusion criteria: 4 randomized controlled trials, 1 secondary analysis of a randomized controlled trial, 1 prospective cohort study, 1 case-control study, and 1 cross-sectional study. Of the eight included studies, only two enrolled postmenopausal women with a rUTI diagnosis, four had sufficient sample size to detect a clinically meaningful difference between systemic estrogen versus placebo, two used dosage regimens anticipated to achieve a therapeutic effect, and three assessed UTI rates for an adequate duration of 6 months or more (the standard minimum duration of time needed to make a diagnosis of rUTI). Overall, none of the studies met all predefined criteria for the ideal study to assess the efficacy of systemic estrogen for rUTI prevention.

CONCLUSIONS AND RELEVANCE

UTIs will continue to be a significant cause of morbidity and hospitalizations in postmenopausal women unless more research is done to better understand the role of estrogen on UTI rates. The evidence arguing use (or abandonment) of systemic estrogen for the prevention of rUTI is based on few studies with substantial methodologic limitations; there is significant room for improvement.

Topical estrogens and non-hormonal preparations for postmenopausal vulvovaginal atrophy: An EMAS clinical guide

INTRODUCTION

Vulvovaginal atrophy (VVA) is a chronic condition caused by estrogen deficiency. It affects around 50% of postmenopausal women, reducing their general and sexual quality of life as well as the quality of their personal relationships.

AIM

The aim of this clinical guide is to set out an individualized approach to the management of VVA with topical estrogens and non-hormonal preparations.

MATERIALS AND METHODS

Literature review and consensus of expert opinion.

SUMMARY RECOMMENDATIONS

An individualized approach is required for the management of VVA. Topical low-dose estrogens are effective and also alleviate urinary incontinence and prevent recurrent urinary tract infections. Women should not be denied long-term use of topical estrogens as long as they feel that this treatment is of benefit to them, because the safety data are reassuring. Non-hormonal preparations (lubricants and moisturizers) should be the first-line treatment for VVA in women taking adjuvant endocrine therapies for cancers considered to be hormone-dependent. They can be used over the long term.

Sex effects in pyelonephritis

Urinary tract infections (UTIs) are generally considered a disease of women. However, UTIs affect females throughout the lifespan, and certain male populations (including infants and elderly men) are also susceptible. Epidemiologically, pyelonephritis is more common in women but carries increased morbidity when it does occur in men. Among children, high-grade vesicoureteral reflux is a primary risk factor for upper-tract UTI in both sexes. However, among young infants with UTI, girls are outnumbered by boys; risk factors include posterior urethral valves and lack of circumcision. Recent advances in mouse models of UTI reveal sex differences in innate responses to UTI, which vary somewhat depending on the system used. Moreover, male mice and androgenized female mice suffer worse outcomes in experimental pyelonephritis; evidence suggests that androgen exposure may suppress innate control of infection in the urinary tract, but additional androgen effects, as well as non-hormonal sex effects, may yet be specified. Among other intriguing directions, recent experiments raise the hypothesis that the postnatal testosterone surge that occurs in male infants may represent an additional factor driving the higher incidence of UTI in males under 6 months of age. Ongoing work in contemporary models will further illuminate sex- and sex-hormone-specific effects on UTI pathogenesis and immune responses.

Pharmacotherapeutic advances for recurrent urinary tract infections in women

INTRODUCTION

Treatment of recurrent Urinary tract infections (UTIs) has become challenging because of the dramatic increase in the rates of recurrent infection andof multidrug-resistant (MDR) infections.

AREAS COVERED

The authors review recurrent UTIs(rUTI) management in women.

EXPERT OPINION

Continuous or post-coital prophylaxis with low-dose antimicrobials or intermittent self-treatment has all been demonstrated to be effective in managing rUTIs in women. Intravaginal estrogen therapy , shows potential toward preventing rUTI. Oral vaccine Uro-Vaxom seems to reduce the number of UTIs. There is evidence that other therapies (e.g. cranberry, Methenamine hippurate, oral D-mannose) may decrease the number of symptomatic UTIs. The treatment of CRE-UTIs is focused on a colistin backbone. Carbapenems are considered first-line agents for UTIs caused by ESBL, but their use is associated with increased MDR. The usage of non-carbapenem for the treatment of ESBL UTIs is necessary. Cefepime, Piperacillin-Tazobactam, Ceftolozane-Tazobactam, and Ceftazidime-Avibactam are justified options. Oral therapy with Pivmecillinam, Fosfomycin, and Nitrofurantoin can be used against uncomplicated UTIs due to ESBL infection.