46 Proteus mirabilis Staphylococcus saprophyticus,Klebsiella pneumonia most commonlyinvolvedpathogens are may becomeinflamed,leadingto urinarytractinfection. thebladdermucosaandurethra perineum tothebladder, thevaginaand from When fecalfloraascendviatheurethra . OBG Management Escherichia coli, | October 2012 , and t he | Vol. 24 No. 10 obgmanagement.com illustration: jOe gorMaN fOr obg MaNaGeMeNt UpdatE PELVIC FLOOR DYSFUNCTION How to prevent recurrent urinary tract infection in sexually active premenopausal women, postmenopausal patients, and women undergoing pelvic surgery ›› Autumn L. Edenfield, MD ›› Cindy L. Amundsen, MD Dr. Edenfield is a Fellow in Female Dr. Amundsen is Professor and Pelvic Medicine and Reconstructive Fellowship Director in Female Surgery and Clinical Instructor Pelvic Medicine and Reconstructive of Obstetrics and Gynecology at Surgery, Department of Obstetrics Duke University Medical Center in and Gynecology, at Duke University Durham, North Carolina. Medical Center in Durham, North Carolina. The authors report no financial relationships relevant to this article. rinary tract infections (UTIs) are preva- TABLE 1 Risk factors for urinary Ulent among women, afflicting as many tract infection in women as 60% of women during their lifetime.1 Symptoms include urgency, frequency, and Premenopausal women dysuria. Although the diagnosis can be made • History of urinary tract infection (uti) In thIs on the basis of symptoms alone in many cases, • frequent or recent sexual activity Article urinalysis and urine cultures often are help- • use of diaphragm as contraception ful in confirming it.2 The differential diagnosis • use of spermicidal agents Summary of includes infectious or atrophic vaginitis, ure- • increasing parity therapeutic strategies thritis from a sexually transmitted infection, • Diabetes mellitus for recurrent UTI urethral diverticulum, painful bladder syn- • Obesity page 48 drome, urinary tract calculi, and urinary tract • sickle cell trait neoplasms. Common risk factors for UTIs are • anatomic congenital abnormalities listed in TABLE 1.3 • urinary tract calculi Antibiotic prophylaxis Recurrent UTIs are defined as three • Neurologic disorders or medical conditions after pelvic surgery? infections in 12 months or two infections in that require an indwelling catheter or repetitive page 50 bladder catheterization 6 months. In this Update, we explore strate- gies to prevent recurrent UTIs in three groups Postmenopausal women Vaginal estrogen of women: • Vaginal atrophy prevents recurrent UTI • sexually active premenopausal women • incomplete bladder emptying in postmenopausal • postmenopausal women • Poor perineal hygiene women • women undergoing pelvic surgery. • Rectocele, cystocele, urethrocele, uterovaginal In the process, we summarize the results of prolapse page 52 five trials that explore treatment modali- • History of uti ties such as prophylactic antibiotics, vaginal • type 1 diabetes mellitus estrogen therapy, cranberry supplementa- sOurCe: adapted from aCOG3 tion, and probiotics (TABLE 2, page 48). On the Dr. Cindy Amundsen describes a novel strategy to prevent recurrent UTI Web in premenopausal women, at obgmanagement.com continued on page 48 obgmanagement.com Vol. 24 No. 10 | October 2012 | OBG Management 47 UpdatE pelvic floor dysfunction TABLE 2 Summary of therapeutic strategies for prevention of recurrent urinary tract infections Strategy Dose Advantages Disadvantages Prophylactic trimethoprim-sulfamethoxazole Highly effective Potential for future microbial antibiotics (Bactrim): 1 double-strength tablet* resistance inexpensive OR Nitrofurantoin: 50 or 100 mg Caution with nitrofurantoin, partic- ularly in older patients or women either drug can be given daily who have renal insufficiency for 6 months or as one dose postcoitally in pregnancy, nitrofurantoin is better studied Vaginal Conjugated estrogens (0.625 mg Highly effective in postmenopaus- Can be expensive estrogen** conjugated estrogens/1 g cream al women, who can be difficult to [Premarin]). Give 0.5–2.0 g cream treat Compliance may be an issue twice weekly. few true contraindications estradiol (100 µg estradiol/1 g cream [estrace]). Give 1–4 g cream Cranberry Dosing varies among products. Generally well-tolerated Can be expensive supplement unsweetened natural cranberry juice or cranberry tablets, 1–3 times few side effects or Compliance may be an issue contraindications daily. May not be as effective in post- menopausal patients Probiotics Dosing varies among products and few side effects or limited data local availability contraindications Can be expensive * Consider trimethoprim (100 mg) alone if the patient has an allergy to sulfa. ** Creams are preferred to the vaginal ring or tablets because they can be applied to periurethral tissues. Postcoital antibiotic prophylaxis prevents some cases of recurrent UTI Melekos MD, Asbach HW, Gerharz E, Zarakovitis IE, recurrent UTIs in premenopausal women are Weingaertner K, Naber KG. Post-intercourse versus often postcoital in temporal pattern. daily ciprofloxacin prophylaxis for recurrent urinary Daily antibiotic prophylaxis for 6 to tract infections in premenopausal women. J Urol. 12 months has proved to be effective in the 1997;157(3):935–939. prevention of recurrent UTIs, reducing the risk of recurrence by 95%, compared with placebo.4 In this trial by Melekos and colleagues, TIs typically involve fecal flora that col- sexually active premenopausal women who U onize the vagina and perineum, most had a history of three or more documented commonly Escherichia coli, Staphylococcus UTIs in the preceding 12 months were ran- saprophyticus, Klebsiella pneumonia, and domly assigned to: Proteus mirabilis. These pathogens ascend • oral ciprofloxacin, one dose daily, or to the bladder via the urethra. Sexual inter- • oral ciprofloxacin, one dose immediately course is thought to facilitate this process, and after intercourse. continued on page 50 48 OBG Management | October 2012 | Vol. 24 No. 10 obgmanagement.com UpdatE pelvic floor dysfunction A total of 135 patients (65 in the daily group What ThIS EVIDENCE MEANS and 70 in the postcoital group) were followed FOR PRACTICE for 12 months. The regimens were equally effective at preventing UTIs. The mean num- postcoital antibiotic prophylaxis is an ber of UTIs in 12 months decreased signifi- effective strategy for the prevention of cantly in both groups—from 3.74 to 0.031 in utis associated with sexual intercourse the daily group and from 3.67 to 0.043 in the in premenopausal women. although the postcoital group. optimal duration of such a regimen was not addressed in this study, it would be The best antibiotic? Nitrofurantoin or appropriate to revisit the need for prophy- trimethoprim-sulfamethoxazole laxis after 1 year. This randomized, controlled trial was rigor- ous and well-executed and included only and the Infectious Disease Society of healthy premenopausal women. However, America recommend that fluoroquinolones given the emergence of antibiotic resistance be avoided, if possible, in the treatment of since this trial was conducted, ciprofloxacin uncomplicated UTIs.5 A better therapeutic is not an ideal antibiotic for prophylaxis. choice would be nitrofurantoin or trime- Both the American Urological Association thoprim-sulfamethoxazole. Is there a role for antibiotic prophylaxis among patients who are catheterized Catheterization remained an following pelvic surgery? independent risk factor for UTI after adjusting for other Dieter AA, Amundsen CL, Visco AG, Siddiqui NY. Catheterization increased Treatment for urinary tract infection after midurethral the risk of UTI confounding factors sling: a retrospective study comparing patients who Fifty-eight percent of women required place- receive short-term postoperative catheterization and ment of a catheter postoperatively—either patients who pass a void trial on the day of surgery. an indwelling Foley or intermittent self- Female Pelvic Med Reconstr Surg. 2012;18(3):175–178. catheterization. The duration of catheteriza- tion ranged from 1 to 14 days, with a mean of 4 days. The incidence of UTI was significantly rinary tract catheterization and urogy- higher in the group that was catheterized Unecologic surgery are associated with postoperatively, compared with the group an increased risk for UTI. The risk of UTI that was not (30.0% vs 5.2%), and catheter- following a midurethral sling procedure, in ization remained an independent risk factor particular, ranges from 4.1% to 33.6% in the for UTI after adjusting for other confounding literature.6,7 To further explore the risk of factors. UTI after placement of a midurethral sling, Dieter and colleagues followed 138 women Data may not be applicable to other who had undergone the procedure with and types of surgery without concomitant pelvic surgery. The pri- This large retrospective cohort study of a mary outcome was treatment of UTI within well-characterized population was based the first 3 weeks postoperatively. on consistent postoperative data related to 50 OBG Management | October 2012 | Vol. 24 No. 10 obgmanagement.com UpdatE pelvic floor dysfunction catheterization and UTI treatment. Because What ThIS EVIDENCE MEANS the study focused on patients who had FOR PRACTICE undergone placement of a midurethral sling, its findings may not be applicable to women the risk of uti is increased with short- undergoing other types of pelvic surgery, term catheterization following placement including general gynecologic procedures. of a midurethral