Original Paper
Urologia Internationalis
Received: February 19, 2013 Accepted after revision: September 26, 2013 Published online: February 26, 2014
Urol Int 2014;93:67–73 DOI: 10.1159/000356063
Involuntary Detrusor Contraction Is a Frequent Finding in Patients with Recurrent Urinary Tract Infections Paulo Rodrigues a, b Flávio Hering a, b João Carlos Campagnari a a
Urology Clinic, Hospital Beneficência Portuguesa of São Paulo, and b Urology Department, Hospital Santa Helena of São Paulo, São Paulo, Brazil
Key Words Urinary tract infection · Urodynamics · Bladder · Voiding dysfunctions · Overactive bladder
Abstract Objective: To check whether subtle voiding dysfunction is related to recurrent urinary tract infection (rUTI). Methods: 254 consecutive patients with at least four episodes of urinary tract infection (UTI) were studied. At least three repeat urodynamic evaluations with an additional ice water test to maximize the detection of involuntary detrusor contraction (IDC) were used. Stress urinary incontinence cases were used as controls. Nonparametric univariate and multivariate analyses were used for statistics. Results: IDC was detected in 83.6% of patients in the rUTI group and in 31.7% in the control group. IDC was 50 cm H2O) IDC was observed in 6.8% in the rUTI group. Female urinary tract obstruction was diagnosed in 16.8% of patients in the rUTI group and in 7.9% in the control group. Residual volume, PdetQmax and Qmax were not predictive of UTI recurrence. Symptoms were similar in both groups. Conclusions: Patients with rUTI present with covert bladder dysfunctions represented by detrusor overactivity. © 2014 S. Karger AG, Basel
© 2014 S. Karger AG, Basel 0042–1138/14/0931–0067$39.50/0 E-Mail [email protected] www.karger.com/uin
Introduction
Doctors are frequently surprised by the recurrence of lower urinary tract symptoms (LUTS) in women who were successfully treated by antibiotics against the microorganisms identified in urine culture and their corresponding antibiotic susceptibility [1]. Even after the use of extremely effective contemporary antibiotics, the recurrence rate of urinary tract infection (UTI) can be high, and there are myths about and popular explanations for this occurrence. Among them, sex, underwear and the type of food intake are considered to be the most common causes of UTI and its high recurrence rate. This simplistic assumption fails to explain the complex and the myriad relationships between natural bladder barriers, microorganism interactions and dysfunctional voiding. Doctors may not be fully aware that a significant number of LUTS can result from bladder dysfunction and that these symptoms are not only due to the proliferation of microorganisms. An ignorance of this knowledge may promote the misuse or overuse of antibiotic regimens. Moreover, a poor correlation between urine culture, urinary sediment and LUTS surprises less attentive doctors the most because lower UTI may be asymptomatic and hence undetected [2]. As has been demonstrated previously, voiding dysfunction causes a variety of LUTS, which do not have an exact Paulo Rodrigues, MD Rua Teixeira da Silva 34 – 1° andar São Paulo 04002-030 (Brazil) E-Mail paulortrodrigues @ uol.com.br
correlation with positive urine culture, and the symptoms simply indicate intrinsic lower urinary tract dysfunction that is demonstrated by sensory urgency, detrusor instability or genuine stress incontinence [3]; this presentation is similar to that of bacterial UTI. Previously, Jeffcoate and Francis [4] noted that urinary tract symptoms resembling those of bacterial UTI lead to the anticipation of bacterial detection in 10% of women, thereby confirming the assumption that bacterial UTI is an epiphenomenon that occurs due to short-term or self-limited voiding dysfunction; in some cases, this dysfunction results in an ascending spiral of events with symptoms similar to cystitis. Surprisingly, no study in the literature has investigated the urodynamic findings in patients who regularly visit the doctor’s office with a chief complaint of recurrent UTI (rUTI). We hypothesize that since urinary tract colonisation may be asymptomatic in some patients, LUTS might result from acute and/or transient bladder dysfunction, which mimics urinary tract colonisation. As there is a lack of clarity regarding the diagnosis of dysfunctional bladder and the administration of prophylactic or reactive antibiotic treatment in these patients, in most instances there is a delay in the proper identification and management of the condition. Moreover, since this condition is not properly identified or treated by antibiotics, it recurs frequently, thereby resulting in an unrecognized and aggravating problem. Herein, we tested the hypothesis that rUTI is frequently associated with overactive bladder (OAB) and that this dysfunction is frequently overlooked during urodynamic evaluation if the examination is not repeated until the abnormalities unfold. This study was designed to determine whether detrusor overactivity was overlooked during urodynamic testing in patients with rUTI. Patients and Methods 254 consecutive female patients (median age 41.2 ± 8.2 years) with a chief complaint of rUTI were prospectively studied during a 5-year period and evaluated with full urodynamic study because of rUTI of unknown origin despite appropriate antibiotic treatment driven by identification through urine culture. Only patients without genital prolapse, malignancies or neurological diseases were included. All patients underwent ultrasound and/or intravenous pyelography evaluation to exclude the possibility of morphological alterations, dilations or urological malformation while the causes of rUTI were investigated. Most of the patients were referred by urogynaecologists or urologists in our tertiary centre for treatment of rUTI episodes. Following the treatment, it was recommended that the patients undergo a urodynamic evaluation. Patients were prospectively asked about the length of time since the first UTI episode and the number of UTI episodes per year.
68
Urol Int 2014;93:67–73 DOI: 10.1159/000356063
Patients were included if they had more than four UTI episodes/ year with a bacterial count of >105 CFU/ml during the 2 years immediately before the study. Up to 2 weeks before the urodynamic investigation, all of the patients were asked to collect sterile cleancatch midstream urine specimens. Patients were instructed to attend the clinic with a comfortably full bladder. After the urine had been released freely, the residual volume was immediately assessed through urethral catheterisation. The bladder was subsequently filled at 37 ° C at 50 ml/min in the sitting position until the patient felt the desire to void. At this time point, the patient was asked if she wished to use the bathroom. If the patient answered ‘yes’, then she was allowed to void. If the patient answered ‘no’, the filling phase was continued until the patient felt an urge to void similar to that felt in the course of daily life. At that time, the patient was allowed to void privately. Postvoid residual volume was determined by urethral aspiration immediately after each complete voiding cycle of the urodynamic examination. The urodynamic study was repeated at least three times during each session to evaluate and reproduce the parameters. If good reproduction of the parameters was achieved but there was no evidence of detrusor overactivity, the urodynamic examination was repeated for a fourth time with 4 ° C saline infusion to optimise the detection of bladder overactivity. Involuntary detrusor contraction (IDC) during the urodynamic examination was deemed relevant if the bladder contraction was >3 cm H2O and if it returned to lower levels when only traces remained after bladder filling was temporarily stopped and the patient was instructed to breathe calmly and stop talking, if there was a suspicion of detrusor overactivity or if she reported an urgent need to void. If the patient reported an urgency to void but the infused volume was 40 cm H2O and Qmax was 0.05
b Operated and nonoperated subgroups
With rUTI
Without rUTI
no operation ABS (n = 181) (n = 32) UDI-6 (0–24) 8.3±1.9 IPSS (0–35) 7.4±2.8
TVT operation TOT operation no operation ABS TVT operation TOT operation (n = 17) (n = 2) (n = 127) (n = 72) (n = 5) (n = 2)
14.7±2.1 17.7±4.7 12.3±3.3 15.6±4.3
15.5 17.6
12.7±2.1 9.8±4.2
13.8±1.9 19.7±1.1 12.9±3.4 23.4±2.8
16.8 21.2
Both groups were comparable with reference to age, parity and number of gynaecological operations (p < 0.05). ABS = Abdominal bladder suspension; TOT = transobturator tape.
Among the 254 consecutive women with rUTI (>4 episodes/year), 232 (median age 39.2 ± 7.3 years) presented normal anatomy of the upper and lower urinary tracts. 22 women were excluded due to abnormal urological findings (pyeloureteral duplication: 4 cases; pelvi-ureteric junction stenosis: 3 cases; ureterocoele: 1 case; unilateral coraliform stone: 2 cases). As expected, the groups differed in the number of UTI episodes per year (p < 0.007). The operated patient subgroups in each arm (rUTI or SUI control arms) showed a statistically significant difference in the number of UTI episodes per year (p < 0.04); however, this result was obtained only when the tension-free vaginal tape (TVT)-operated patients were analysed, and this particular subgroup showed a higher rate of UTI compared to the other operated patient subgroups in the same arm (p < 0.047) and the operated patient subgroups in the SUI control arm (p < 0.002). The low number of TVTs performed in the operated patient subgroup of the SUI control arm did not allow for a statistical comparison between the TVT-operated patient subgroups or between the subgroups of the SUI control arm (table 1). The questionnaire (UDI-6 and IPSS) result neither differed between the two groups of patients nor among the different subgroups inside the same group or compared
to their peer pair; however, when the operated patient subgroups in both arms were analysed, they presented higher total scores for both of the questionnaires when compared to the nonoperated patient subgroups in both the rUTI and SUI control groups. IDC was detected in 83.6% of cases in the rUTI group and in 31.7% of cases in the SUI control group (p < 0.05). The number of cases with clinical manifestations of OAB also differed between the groups. There were 19 cases with clinical manifestations of OAB in the rUTI group (8.2%) versus 43 cases with clinical manifestations of OAB in the SUI control group (21.3%) (p < 0.05). Table 2 shows the amplitude of the detected IDC during the filling phase. It can be observed that in 54.7% of cases in the rUTI group, the IDC was 50 cm H2O, whereas only 0.9% (2 cases) in the SUI control group showed a similar detrusor contraction amplitude. Similarly, the rate of female urinary tract obstruction was higher in the rUTI group compared to the SUI control group (16.8 vs. 7.9%). PdetQmax, residual volume and Qmax values from the univariate and multivariate analyses were different between the two groups and between the operated patient subgroups (data not shown).
Overactive Bladder is Frequent in Urinary Tract Infection
Urol Int 2014;93:67–73 DOI: 10.1159/000356063
Results
69
Table 2. Comparison between urodynamic findings of patients in the rUTI group and the SUI control group
Free flow (Qmax) Voided, ml Bladder capacity, ml Normal Clinical OAB Female obstruction Detrusor OAB Amplitude of contraction 3–5 cm H2O 6–10 cm H2O 11–15 cm H2O 16–20 cm H2O 21–30 cm H2O 31–50 cm H2O 51–100 cm H2O 101–150 cm H2O >151 cm H2O Intubated flow rate (Qmax) PdetQmax, cm H2O Residual volume, ml Female obstruction
rUTI (n = 232)
SUI control p value (n = 202)
14.7±11.3 197±127 347±141 3.4% (8) 8.2% (19) 4.8% (11) 83.6% (194)
15.2±6.2 165±117 289±153 30.6% (62) 36.1% (73) 1.5% (3) 31.7% (64)
n.s.
Urologia Internationalis
Received: February 19, 2013 Accepted after revision: September 26, 2013 Published online: February 26, 2014
Urol Int 2014;93:67–73 DOI: 10.1159/000356063
Involuntary Detrusor Contraction Is a Frequent Finding in Patients with Recurrent Urinary Tract Infections Paulo Rodrigues a, b Flávio Hering a, b João Carlos Campagnari a a
Urology Clinic, Hospital Beneficência Portuguesa of São Paulo, and b Urology Department, Hospital Santa Helena of São Paulo, São Paulo, Brazil
Key Words Urinary tract infection · Urodynamics · Bladder · Voiding dysfunctions · Overactive bladder
Abstract Objective: To check whether subtle voiding dysfunction is related to recurrent urinary tract infection (rUTI). Methods: 254 consecutive patients with at least four episodes of urinary tract infection (UTI) were studied. At least three repeat urodynamic evaluations with an additional ice water test to maximize the detection of involuntary detrusor contraction (IDC) were used. Stress urinary incontinence cases were used as controls. Nonparametric univariate and multivariate analyses were used for statistics. Results: IDC was detected in 83.6% of patients in the rUTI group and in 31.7% in the control group. IDC was 50 cm H2O) IDC was observed in 6.8% in the rUTI group. Female urinary tract obstruction was diagnosed in 16.8% of patients in the rUTI group and in 7.9% in the control group. Residual volume, PdetQmax and Qmax were not predictive of UTI recurrence. Symptoms were similar in both groups. Conclusions: Patients with rUTI present with covert bladder dysfunctions represented by detrusor overactivity. © 2014 S. Karger AG, Basel
© 2014 S. Karger AG, Basel 0042–1138/14/0931–0067$39.50/0 E-Mail [email protected] www.karger.com/uin
Introduction
Doctors are frequently surprised by the recurrence of lower urinary tract symptoms (LUTS) in women who were successfully treated by antibiotics against the microorganisms identified in urine culture and their corresponding antibiotic susceptibility [1]. Even after the use of extremely effective contemporary antibiotics, the recurrence rate of urinary tract infection (UTI) can be high, and there are myths about and popular explanations for this occurrence. Among them, sex, underwear and the type of food intake are considered to be the most common causes of UTI and its high recurrence rate. This simplistic assumption fails to explain the complex and the myriad relationships between natural bladder barriers, microorganism interactions and dysfunctional voiding. Doctors may not be fully aware that a significant number of LUTS can result from bladder dysfunction and that these symptoms are not only due to the proliferation of microorganisms. An ignorance of this knowledge may promote the misuse or overuse of antibiotic regimens. Moreover, a poor correlation between urine culture, urinary sediment and LUTS surprises less attentive doctors the most because lower UTI may be asymptomatic and hence undetected [2]. As has been demonstrated previously, voiding dysfunction causes a variety of LUTS, which do not have an exact Paulo Rodrigues, MD Rua Teixeira da Silva 34 – 1° andar São Paulo 04002-030 (Brazil) E-Mail paulortrodrigues @ uol.com.br
correlation with positive urine culture, and the symptoms simply indicate intrinsic lower urinary tract dysfunction that is demonstrated by sensory urgency, detrusor instability or genuine stress incontinence [3]; this presentation is similar to that of bacterial UTI. Previously, Jeffcoate and Francis [4] noted that urinary tract symptoms resembling those of bacterial UTI lead to the anticipation of bacterial detection in 10% of women, thereby confirming the assumption that bacterial UTI is an epiphenomenon that occurs due to short-term or self-limited voiding dysfunction; in some cases, this dysfunction results in an ascending spiral of events with symptoms similar to cystitis. Surprisingly, no study in the literature has investigated the urodynamic findings in patients who regularly visit the doctor’s office with a chief complaint of recurrent UTI (rUTI). We hypothesize that since urinary tract colonisation may be asymptomatic in some patients, LUTS might result from acute and/or transient bladder dysfunction, which mimics urinary tract colonisation. As there is a lack of clarity regarding the diagnosis of dysfunctional bladder and the administration of prophylactic or reactive antibiotic treatment in these patients, in most instances there is a delay in the proper identification and management of the condition. Moreover, since this condition is not properly identified or treated by antibiotics, it recurs frequently, thereby resulting in an unrecognized and aggravating problem. Herein, we tested the hypothesis that rUTI is frequently associated with overactive bladder (OAB) and that this dysfunction is frequently overlooked during urodynamic evaluation if the examination is not repeated until the abnormalities unfold. This study was designed to determine whether detrusor overactivity was overlooked during urodynamic testing in patients with rUTI. Patients and Methods 254 consecutive female patients (median age 41.2 ± 8.2 years) with a chief complaint of rUTI were prospectively studied during a 5-year period and evaluated with full urodynamic study because of rUTI of unknown origin despite appropriate antibiotic treatment driven by identification through urine culture. Only patients without genital prolapse, malignancies or neurological diseases were included. All patients underwent ultrasound and/or intravenous pyelography evaluation to exclude the possibility of morphological alterations, dilations or urological malformation while the causes of rUTI were investigated. Most of the patients were referred by urogynaecologists or urologists in our tertiary centre for treatment of rUTI episodes. Following the treatment, it was recommended that the patients undergo a urodynamic evaluation. Patients were prospectively asked about the length of time since the first UTI episode and the number of UTI episodes per year.
68
Urol Int 2014;93:67–73 DOI: 10.1159/000356063
Patients were included if they had more than four UTI episodes/ year with a bacterial count of >105 CFU/ml during the 2 years immediately before the study. Up to 2 weeks before the urodynamic investigation, all of the patients were asked to collect sterile cleancatch midstream urine specimens. Patients were instructed to attend the clinic with a comfortably full bladder. After the urine had been released freely, the residual volume was immediately assessed through urethral catheterisation. The bladder was subsequently filled at 37 ° C at 50 ml/min in the sitting position until the patient felt the desire to void. At this time point, the patient was asked if she wished to use the bathroom. If the patient answered ‘yes’, then she was allowed to void. If the patient answered ‘no’, the filling phase was continued until the patient felt an urge to void similar to that felt in the course of daily life. At that time, the patient was allowed to void privately. Postvoid residual volume was determined by urethral aspiration immediately after each complete voiding cycle of the urodynamic examination. The urodynamic study was repeated at least three times during each session to evaluate and reproduce the parameters. If good reproduction of the parameters was achieved but there was no evidence of detrusor overactivity, the urodynamic examination was repeated for a fourth time with 4 ° C saline infusion to optimise the detection of bladder overactivity. Involuntary detrusor contraction (IDC) during the urodynamic examination was deemed relevant if the bladder contraction was >3 cm H2O and if it returned to lower levels when only traces remained after bladder filling was temporarily stopped and the patient was instructed to breathe calmly and stop talking, if there was a suspicion of detrusor overactivity or if she reported an urgent need to void. If the patient reported an urgency to void but the infused volume was 40 cm H2O and Qmax was 0.05
b Operated and nonoperated subgroups
With rUTI
Without rUTI
no operation ABS (n = 181) (n = 32) UDI-6 (0–24) 8.3±1.9 IPSS (0–35) 7.4±2.8
TVT operation TOT operation no operation ABS TVT operation TOT operation (n = 17) (n = 2) (n = 127) (n = 72) (n = 5) (n = 2)
14.7±2.1 17.7±4.7 12.3±3.3 15.6±4.3
15.5 17.6
12.7±2.1 9.8±4.2
13.8±1.9 19.7±1.1 12.9±3.4 23.4±2.8
16.8 21.2
Both groups were comparable with reference to age, parity and number of gynaecological operations (p < 0.05). ABS = Abdominal bladder suspension; TOT = transobturator tape.
Among the 254 consecutive women with rUTI (>4 episodes/year), 232 (median age 39.2 ± 7.3 years) presented normal anatomy of the upper and lower urinary tracts. 22 women were excluded due to abnormal urological findings (pyeloureteral duplication: 4 cases; pelvi-ureteric junction stenosis: 3 cases; ureterocoele: 1 case; unilateral coraliform stone: 2 cases). As expected, the groups differed in the number of UTI episodes per year (p < 0.007). The operated patient subgroups in each arm (rUTI or SUI control arms) showed a statistically significant difference in the number of UTI episodes per year (p < 0.04); however, this result was obtained only when the tension-free vaginal tape (TVT)-operated patients were analysed, and this particular subgroup showed a higher rate of UTI compared to the other operated patient subgroups in the same arm (p < 0.047) and the operated patient subgroups in the SUI control arm (p < 0.002). The low number of TVTs performed in the operated patient subgroup of the SUI control arm did not allow for a statistical comparison between the TVT-operated patient subgroups or between the subgroups of the SUI control arm (table 1). The questionnaire (UDI-6 and IPSS) result neither differed between the two groups of patients nor among the different subgroups inside the same group or compared
to their peer pair; however, when the operated patient subgroups in both arms were analysed, they presented higher total scores for both of the questionnaires when compared to the nonoperated patient subgroups in both the rUTI and SUI control groups. IDC was detected in 83.6% of cases in the rUTI group and in 31.7% of cases in the SUI control group (p < 0.05). The number of cases with clinical manifestations of OAB also differed between the groups. There were 19 cases with clinical manifestations of OAB in the rUTI group (8.2%) versus 43 cases with clinical manifestations of OAB in the SUI control group (21.3%) (p < 0.05). Table 2 shows the amplitude of the detected IDC during the filling phase. It can be observed that in 54.7% of cases in the rUTI group, the IDC was 50 cm H2O, whereas only 0.9% (2 cases) in the SUI control group showed a similar detrusor contraction amplitude. Similarly, the rate of female urinary tract obstruction was higher in the rUTI group compared to the SUI control group (16.8 vs. 7.9%). PdetQmax, residual volume and Qmax values from the univariate and multivariate analyses were different between the two groups and between the operated patient subgroups (data not shown).
Overactive Bladder is Frequent in Urinary Tract Infection
Urol Int 2014;93:67–73 DOI: 10.1159/000356063
Results
69
Table 2. Comparison between urodynamic findings of patients in the rUTI group and the SUI control group
Free flow (Qmax) Voided, ml Bladder capacity, ml Normal Clinical OAB Female obstruction Detrusor OAB Amplitude of contraction 3–5 cm H2O 6–10 cm H2O 11–15 cm H2O 16–20 cm H2O 21–30 cm H2O 31–50 cm H2O 51–100 cm H2O 101–150 cm H2O >151 cm H2O Intubated flow rate (Qmax) PdetQmax, cm H2O Residual volume, ml Female obstruction
rUTI (n = 232)
SUI control p value (n = 202)
14.7±11.3 197±127 347±141 3.4% (8) 8.2% (19) 4.8% (11) 83.6% (194)
15.2±6.2 165±117 289±153 30.6% (62) 36.1% (73) 1.5% (3) 31.7% (64)
n.s.
