RECURRENT UTIs : a Different Perspective.
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7/16/2021
RECURRENT UTIs : a
Different Perspective.
Brian T. Geary, MD
7/27/2018
OBJECTIVES
• To provide a different perspective on the
management of UTIs.
• To focus on decreasing the use of antibiotics.
• To discover some other potential causes to the
symptom profile associated with UTIs.
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FACTUAL SLIDES:
• Recurrent urinary tract infections (rUTIs), defined as
two culture‐proven UTIs in a 6‐month period or three
culture‐proven events in 1 year
• Approximately 60% of women will experience
symptomatic acute bacterial cystitis in their lifetime
• An estimated 20‐40% of women who have had one
previous cystitis episode are likely to experience an
additional episode, 25‐50% of whom will experience
multiple recurrent episodes.
• The evaluation and treatment of UTI costs several
billion dollars globally per year, reaching approximately
$2 billion per year in the United States.
https://www.urologytimes.com/view/new‐recurrent‐uti‐guideline‐what‐urologists‐need‐know
Recurrent Uncomplicated Urinary Tract Infections in Women: AUA/CUA/SUFU Guideline Jennifer Anger et al. Journal of Urology Volume 202 Issue 2,
August 2019, Page: 282‐289
FACTUAL SLIDES:
• In 2020 there were an estimated 169.36 million
women in the United States.
• 60% would be ~101.6 million
• 40% of that would be ~40.6 million
• And 50% of that would be ~20.3 million women
with Recurrent UTIs.
FACTUAL SLIDES:
Recurrent Uncomplicated Urinary Tract Infections in Women: AUA/CUA/SUFU Guideline
Jennifer AngerAnn Stapleton
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FACTUAL SLIDES:
FACTUAL SLIDES:
• IF there are ~20.3 million women with Recurrent
UTIs
• And the UA used to diagnose them is inaccurate
12% to 32% of the time
• That means that 2.4 to 6.5 million women
receive unnecessary antibiotic treatment.**
**I am not known for my math skills
FACTUAL SLIDES:
SCREENING TEST
vs
DIAGNOSTIC TEST
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The Bladder
ColoVesical Fistula
CANCER STONE
INFECTION
STENT SUTURE
IRRITATATION (Foreign Body)
#1 URGENCY
#2 FREQUENCY
#3 CONTRACTION (SPASM)
#4 Feeling of Incomplete
Emptying
The Bladder
SYMPTOMS
#1 URGENCY
#2 FREQUENCY
#3 CONTRACTION (SPASM)
#4 Feeling of Incomplete Emptying
UA/UCx
OAB (+/-) Recurrent IC
Incontinence UTIs (Interstitial Cystitis)
THE BLADDER
A muscle
Lined by a
With a
Hazmat suit
control
valve
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THE “PRIVATE” ANALOGY
THE “PRIVATE” ANALOGY
Southbound Lanes on I‐65 are
“CLOSED” for Hurricane
Evacuation
A DIFFERENT PERSPECTIVE
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THE ANNOYING
UPSTAIRS NEIGHBOR
Bladder
Bladder
Sits ABOVE the prostate Sits ABOVE the vagina
URGE INCONTINENCE
AUTONOMIC
FIGHT or FLIGHT
CONT
RELAX RACT
THE BLADDER AS A
SPECTRUM
NeuroGenic Bladder Over Active Bladder
N.G.B. “NORMAL” O.A.B.
Voids per day
Bladder Capacity
Post Void Residual
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THE BLADDER AS A
SPECTRUM
The kidney sends
down ~ 80 ml of
urine every hour
250
The Bladder
NGB
• Hyper-reflexive (squeezy)
• Atonic (floppy)
NON- NEUROGENIC
NEUROGENIC N.G.B.
N.G.B.
“Hey, I’m STARTING the
pee‐pee dance protocol!”
CAPACITY
SENSATION
“Hey, I’m SERIOUS!”
“Hey, you BETTER go pee!” 500 mL
1ST
“Hey, you SHOULD go pee.”
SENSATION
250 mL
“Hey, you COULD go pee.”
“Hey, FYI I’m filling.”
POST VOID 0 mL
RESIDUAL
You should start at 0 mL (PVR)
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“Hey, I’m STARTING the
pee‐pee dance protocol!”
REMEMBER
CAPACITY Stretch is the signal
“Hey, I’m SERIOUS!”
“Hey, you BETTER go pee!”
500 mL
“Hey, you SHOULD go pee.”
“Hey, you COULD go pee.”
250 mL
“Hey, FYI I’m filling.”
0 mL
You should start at 0 mL
THE BLADDER AS A
SPECTRUM
NeuroGenic Bladder Over Active Bladder
N.G.B. “NORMAL” O.A.B.
Voids per day
Bladder Capacity
Post Void Residual
THE BLADDER AS A
SPECTRUM
NeuroGenic Bladder Over Active Bladder
N.G.B. “NORMAL” O.A.B.
4 or less 5 to 7 8 or more
Voids per day
2.3L – 600mL 500 – 400mL 450 – 150mL
Bladder Capacity
700mL 0mL Can vary
Post Void Residual
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THE BLADDER AS A
SPECTRUM
NeuroGenic Bladder Over Active Bladder
N.G.B. “NORMAL” O.A.B.
INSERT PICTURE INSERT PICTURE INSERT PICTURE
THE BLADDER AS A
SPECTRUM 1000 mL
800 mL
500 mL
400 mL
“Hey, I’m STARTING the
pee‐pee dance protocol!”
CAPACITY
SENSATION
“Hey, I’m SERIOUS!”
“Hey, you BETTER go pee!” 500 mL
1ST
“Hey, you SHOULD go pee.”
SENSATION
250 mL
“Hey, you COULD go pee.” POST VOID
RESIDUAL
(PVR) 150 mL
BUT WHAT
“Hey, FYI I’mIF YOU NO
filling.”
LONGER EMPTY THE
BLADDER TO 0mL?!
ELEVATED POST VOID RESIDUAL (PVR)
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ELEVATED POST VOID RESIDUAL
((PVR))
Given the Choice…
107/16/2021
GRADE I (NORMAL)
GRADE II
GRADE III
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GRADE IV
GRADE V
BLADDER PRESSURE (cmH2O)
200 100
1/4
80
180
60
1/2
40
160
1
140
120
11/2
100
80
2
60
127/16/2021
NEW OPTIONS
NEW APPROACH TO AN OLD PROCEDURE
10 – 15 min Surgery time
A
NEW OPTIONS
NEW APPROACH TO AN OLD PROCEDURE
10 – 15 min Surgery time
A
NEW OPTIONS
137/16/2021
A NOT SO CLASSIC
EXAMPLE
“A single male willing to inflict pain on another person for their own good.”
‐ Halsted’s 1890’s definition of a surgery resident.
• NOT mentioned in the definition:
– Listening patiently
– Teasing out the information
– Using “story telling” in the treatment plan
– Repetitive reinforcement
• Most urology residents do NOT enjoy the peds rotation.
– 90% of clinic patients don’t need an operation. • Mal-Rotated kidney
• Extra renal pelvis
– So many things can go “wrong” and still be • Horseshoe kidney
considered “normal” because of the anatomic • Pelvic kidney
variation of the GU system. • UPJ-Obstruction
• Incomplete ureteral duplication
– Your “grade” is dependent on how much the • Complete ureteral duplication
• Vesico-Ureteral Reflux
patient and family like you. • Ureteroceles
“FAILURE TO POTTY TRAIN”
• 5yo girl + a 1st time mother
– Neither of them happy to be there.
– They’ve been waiting, in the room for over 1 hr.
– “She was potty trained, at 18 mo, but now she’s
wetting her pants.”
POTTY TRAINING EASE
• Boys >>> Girls
– labor intensive as far as Potty Training
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“FAILURE TO POTTY TRAIN”
LABIA
Secondary Sex
Characteristics
“FAILURE TO POTTY TRAIN”
SITTING STANDING
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“FAILURE TO POTTY TRAIN”
DRY OVERNIGHT
A NOT SO CLASSIC
EXAMPLE
Avg female
urethral Avg distance from
length is meatus to outside
4 CM of labia is approx
4 CM*
8 CM
NIT & LEU (+) = 80%
NIT (+) = 30%
LEU (+) = 30%
A (+) .CC Urine Cx with NO symptoms = NO Abx
* In Central Georgia
A NOT SO CLASSIC
EXAMPLE
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#2. INFREQUENT VOIDING
Given the Choice…
#2. INFREQUENT VOIDING
A NOT SO CLASSIC
EXAMPLE
177/16/2021
A NOT SO CLASSIC EXAMPLE
QUESTIONS?
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