Current diagnosis of women with recurrent urinary tract infections (RUTIs) is based on prior documented urine cultures (at least 3 in the past year). The most recent American Urological Association (AUA) 2019 guidelines suggests that evaluation include a patient history that confirms prior UTI diagnoses, urinalysis, urine culture sensitivity, and a pelvic exam. Upper tract and lower tract imaging, cystoscopy, and urodynamic studies are reserved for circumstances in which complicating factors are suspected[1]. However, various urological abnormalities (reflux, urethral diverticulum, bladder prolapse, etc.) have been attributed to bacterial persistence leading to RUTIs in past literature and have been detected or confirmed by voiding cystourethrogram (VCUG). In addition, inflammatory lesions (trigonitis, chronic cystitis cystica, and vesicular cystitis) have been noted on cystoscopy during RUTI evaluation and have also been linked to RUTIs[2]. 

Our group has used office flexible cystoscopy and voiding cystourethrogram (VCUG) in the evaluation of women with RUTIs. Previous studies evaluating the yield of cystoscopy in women are few, with many reporting inflammatory lesions as non-specific, while VCUG studies have been limited to pediatric populations. Therefore, we aim to report the yield of office flexible cystoscopy and VCUG in the evaluation of women with RUTIs and their influence on treatment plans.

An IRB-approved, prospectively maintained database of consecutive women evaluated for RUTI was retrospectively reviewed for findings of flexible cystoscopy and VCUG by an investigator not involved in the care of these patients. Date recorded from electronic medical record included parity, gravity, BMI, age, ethnicity, race, and smoking history, duration of UTI history, history of diabetes, hormone replacement therapy (HRT), prior urological surgeries, smoking history, sexual activity and possible relationship with RUTIs, coital prophylaxis use, urine culture findings, antibiotic resistance/allergies, cystoscopy, standing VCUG findings, and treatment plan.

Standing VCUG was performed using a standard protocol (REF)[3]. Evidence of prolapse, reflux, urethral narrowing, urethral diverticulum, and post-void residual >50 mL were noted. An 18 Fr flexible scope was used to inspect the urethra, bladder neck, trigone, and the remaining bladder walls. A retroflex view of the bladder neck was also obtained. Both cystoscopy and VCUG evaluations and images were documented in patient charts. All cystoscopy procedures were performed by a single FPMRS urologist and/or a trained physician assistant

Between 2017- 2019, 124 women were evaluated for RUTIs. The patient population was mostly Caucasian (94%) with a median age of 68 and median BMI of 27.9. The majority of patients were post-menopausal (97%) and status post-hysterectomy (82%). 

Eighty-nine women (78%) had VCUG findings possibly related to their RUTIs while 87 (71%) women had cystoscopy findings possibly related to their RUTIs. Across the 2 years of data entry, the rate of overall abnormal findings on cystoscopy increased, including findings of trigonitis and cystitis cystica. Other abnormal cystoscopy and VCUG findings, as well as post-evaluation treatment plans remained relatively constant throughout the years. Trigonitis was the most common (63%) abnormality found on cystoscopy, while cystocele was the most common (39%) finding on VCUG. The most common post-abnormal VCUG treatment plans were electrofulguration of bladder trigonitis and/or cystitis (49%), mesh removal (48%), and prolapse repair (34%). Electrofulguration of the bladder was also the most common post- abnormal cystoscopy treatment procedure (62%), followed by mesh removal (61%) and prolapse repair (21%).

In this study, we reported the yield of VCUG and flexible office cystoscopy in the evaluation of women with RUTIs to be 71% and 78%, respectively. These findings suggest that both VCUG and flexible office cystoscopy should be used in the evaluation of women with RUTIs and that they can influence treatment plans.

Our findings suggest that these tools may be used to better understand the patient’s presumed etiology of RUTIs and consequently, establish a treatment plan that targets the underlying cause. While antibiotics continue to be the mainstay treatment of RUTIs, evaluation with VCUG and cystoscopy led to treatment plans such as electrofulguration, mesh removal, or prolapse repair, which aimed to resolve RUTIs rather than continuing with more antibiotics. 

The tertiary care center population included in this series included a majority of Caucasian, post-menopausal women with RUTIs, which limits generalizability. Larger studies including other ethnicities are needed.

VCUG and flexible office cystoscopy are low risk procedures in the evaluation of women presenting with RUTIs which can provide valuable information leading to a possible resolution of the RUTI condition rather than relying on antibiotics alone.

Anger, J., et al., Recurrent Uncomplicated Urinary Tract Infections in Women: AUA/CUA/SUFU Guideline. J Urol, 2019. 202(2): p. 282-289.
Crivelli, J.J., F. Alhalabi, and P.E. Zimmern, Electrofulguration in the advanced management of antibiotic-refractory recurrent urinary tract infections in women. Int J Urol, 2019. 26(6): p. 662-668.
Arbique, G.M., et al., Radiation exposure during standing voiding cystourethrography in women. Urology, 2006. 67(2): p. 269-74.