We present a case study demonstrating a novel cystoscopic approach to the treatment of recurrent urinary tract infection (UTI).  UTIs are a common infection with symptoms of dysuria, frequency, urgency, suprapubic pain or haematuria.    Recurrent UTIs is most commonly described as at least two episodes of symptomatic infection with pyuria or positive urine culture in 6 consecutive months or three infections in the past 12 months.  

UTIs are traditionally treated with antibiotics and prolonged courses of prophylaxis may be prescribed in patients with recurrent UTI.  However with the growing concerns of antibiotic resistance and the era of antibiotic stewardship alternative effective approaches to recurrent UTI treatment are needed.

Patients with recurrent UTI often have ‘trigonitis at cystoscopy’.  This is a poorly defined term but is associated with non-keratinising squamous metaplasia accompanied by minimal to severe degrees of inflammation, oedema or cystic changes of the urothelial and lamina propria [1].  Non-keratanising squamous metaplasia at the trigone however is a common finding at cystoscopy and often warrants no further management [2,3].  

Cystoscopic resection of trigonitis or squamous metaplasia is a novel treatment approach not previously described.

This is a case presentation of a 39 year old female presenting with a 1 year history of recurrent UTI.  She had had ten culture positive UTIs in this year.  Prior to the procedure she was experiencing regular dysuria, urinary frequency and urgency and three episodes of nocturia.  Urinary tract ultrasound was normal. 
She has been treated with repeated courses of oral antibiotics and trialled a 3 month prophylactic course of antibiotics.    The frequency of UTI was not improved with this treatment.  The patient has no other PMHx.  

The patient underwent trans-urethral cystoscopic resection of trigonitis and squamous metaplasia under general anaesthesia.  Pre-operative urine analysis was carried out to exclude active UTI. Prophylactic gentamicin was administered at the start of the procedure.  The bladder was distended using glycine. A monopolar cysto-resectoscope was used to resect or peel away the squamous metaplasia layer from the trigone.  The resected sample was removed from the bladder by trapping the specimen between the loop and the cystoscope and removing the cystoscope from the bladder.  Fulguration was carried out for haemostasis and treatment of areas with increased vascularity over the trigone.  The bladder was emptied and refilled 3 times to ensure adequate haemostasis.

Post-operatively the patient continued oral antibiotics for 6 week.  Fosfomycin 3mg on alternate days was given for two weeks followed by 4 weeks of co-amoxiclav 625mg TDS.  These antibiotics were selected based on patient tolerance and previous urine culture sensitivities.

Trans-urethral resection of the squamous metaplasia as demonstrated in the video lead to resolution of dysuria, nocturia and bothersome urinary frequency.  In the following 6 months after completing this treatment the patient had had no further urinary tract infections.

Transurethral resection of trigonitis and squamous metaplasia can treat recurrent UTI with improvement in associated persistent lower urinary tract symptoms.  The presence of non-keratinising squamous metaplasia should not be dismissed in symptomatic patients particularly if additional appearances of oedema, increased vascularity or cystic changes are visible.

Sadeghi Z, MacLennan G, Childs SJ, Zimmern PE. Is trigonitis a neglected, imprecise, misunderstood, or forgotten diagnosis?. Low Urin Tract Symptoms. 2019;11(4):182–188. doi:10.1111/luts.12264
Lenherr SM, Crosby EC, Cameron AP. Cystoscopic findings: a video tutorial. Int Urogynecol J. 2015;26(6):921–923. doi:10.1007/s00192-014-2614-4
Ozbey I, Aksoy Y et al Squamous metaplasia of the bladder: findings in 14 patients and review of the literature. Int Urol Nephrol. 1999;31(4):457-61.