Role of Flexible Cystoscopy in the Management of Postmenopausal Women With Recurrent Urinary Tract Infections


      To evaluate office flexible cystoscopy findings in the evaluation and management of postmenopausal women with recurrent urinary tract infections (RUTIs).


      An IRB-approved, prospectively maintained database of women evaluated for RUTIs at a tertiary care center was retrospectively reviewed by an independent investigator for flexible cystoscopy (FC) findings and related treatment decisions over three consecutive years. Data reviewed in the electronic medical record (EMR) included demographics, UTI history, history of diabetes, hormone replacement therapy (HRT), prior urological surgeries, sexual activity, coital antibiotic prophylaxis use, urine culture findings, antibiotic resistance/allergies, cystoscopy, and treatment plan.


      Between 2017 and 2019, 113 consecutive postmenopausal women, mostly Caucasian, underwent flexible office cystoscopy to complete their RUTI evaluation. Eighty-four women (74%) had abnormal cystoscopy findings. The rate of overall abnormal findings on cystoscopy increased yearly, including findings of trigonitis (p = 0.022). Other abnormal cystoscopy findings, as well as post-evaluation treatment plans, did not significantly differ over time. Trigonitis was the most common (67%) finding on cystoscopy. RUTI management included exposed urethral/bladder mesh removal and/or electrofulguration of chronic cystitis areas.


      Flexible cystoscopy, as an office diagnostic procedure, can provide valuable information of underlying etiology of RUTIs and allow directed management.
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        • Foxman B.
        Epidemiology of urinary tract infections: incidence, morbidity, and economic costs.
        Am J Med. 2002; 113 (PMID:12113866): 5S-13S
        • Ikäheimo R
        • Siitonen A
        • Heiskanen T
        • et al.
        Recurrence of urinary tract infection in a primary care setting: analysis of a 1-year follow-up of 179 women.
        Clin Infect Dis. 1996; 22 (PMID:8824972): 91-99
        • Renard J
        • Ballarini S
        • Mascarenhas T
        • et al.
        Recurrent lower urinary tract infections have a detrimental effect on patient quality of life: a prospective, observational study.
        Infect Dis Ther. 2014; 4 (Epub ahead of print. PMID25519161PMCID: PMC4363217): 125-135
        • Gaitonde S
        • Malik RD
        • Zimmern PE.
        Financial burden of recurrent urinary tract infections in women: a time-driven activity-based cost analysis.
        Urology. 2019; 128 (Epub 2019 Feb 20. PMID:30796990): 47-54
        • Wagenlehner FM
        • Bartoletti R
        • Cek M
        • et al.
        Antibiotic stewardship: a call for action by the urologic community.
        Eur Urol. 2013; 64 (Epub 2013 May 29. PMID:23746854): 358-360
        • Scott VCS
        • Thum LW
        • Sadun T
        • et al.
        Fear and frustration among women with recurrent urinary tract infections: findings from patient focus groups.
        J Urol. 2021; 206 (Epub 2021 Jul 8. PMID:34233479): 688-695
        • Anger J
        • Lee U
        • Ackerman AL
        • et al.
        Recurrent uncomplicated urinary tract infections in women: AUA/CUA/SUFU Guideline.
        J Urol. 2019; 202 (Epub 2019 Jul 8. PMID:31042112): 282-289
        • Rodriguez D
        • Jaffer A
        • Hilmy M
        • Zimmern P.
        Bladder neck and urethral erosions after Macroplastique injections.
        Low Urin Tract Symptoms. 2021; 13 (Epub 2020 Aug 12. PMID:32783393): 93-97
        • Sadeghi Z
        • MacLennan G
        • Childs SJ
        • Zimmern PE.
        Is trigonitis a neglected, imprecise, misunderstood, or forgotten diagnosis?.
        Low Urin Tract Symptoms. 2019; 11 (Epub 2019 Apr 15. PMID:30989795): 182-188
        • Crivelli JJ
        • Zimmern PE.
        Vesicular cystitis: a chronic cystitis variant often unresponsive to antibiotics and electrofulguration.
        Urol Int. 2021; 105 (Epub 2020 Oct 16. PMID:33070139): 131-136
        • De Nisco NJ
        • Neugent M
        • Mull J
        • et al.
        Direct detection of tissue-resident bacteria and chronic inflammation in the bladder wall of postmenopausal women with recurrent urinary tract infection.
        J Mol Biol. 2019; 431 (Epub 2019 Apr 17. PMID:31002774 PMCID: PMC 6801050): 4368-4379
        • Hussain SA
        • Alhalabi F
        • Zimmern PE.
        Long-term efficacy of fulguration of trigonitis for recurrent urinary tract infections in women.
        Urol Sci. 2015; 26: 197-201
        • Crivelli JJ
        • Alhalabi F
        • Zimmern PE.
        Electrofulguration in the advanced management of antibiotic-refractory recurrent urinary tract infections in women.
        Int J Urol. 2019; 26 (Epub 2019 Apr 3. PMID:30943582): 662-668
        • De Nisco N
        • Chen LM
        • Santos MD
        • Palmer K
        • Orth K
        • Zimmern P.
        Understanding the pathogens responsible for recurrent urinary tract infections in postmenopausal omen.
        Neurourol Urodynam. 2018; 37 (S521-S521)
        • Wu YR
        • Rego LL
        • Christie AL
        • Lavelle RS
        • Alhalabi F
        • Zimmern PE.
        Recurrent urinary tract infections due to bacterial persistence or reinfection in women-does this factor impact upper tract imaging findings?.
        J Urol. 2016; 196 (PMID:26880409): 422-428
        • Stevens JA
        • Chavez JA
        • Christie AL
        • Zimmern PE.
        Outpatient electrofulguration for antibiotic-recalcitrant recurrent urinary tract infections in women with trigonitis alone.
        J Urin Trac Infec. 2021; 1: 101
        • Engel G
        • Schaeffer AJ
        • Grayhack JT
        • Wendel EF.
        The role of excretory urography and cystoscopy in the evaluation and management of women with recurrent urinary tract infection.
        J Urol. 1980; 123 (PMID:7354514): 190-191
        • Santoni N
        • Ng A
        • Skews R
        • Aboumarzouk OM.
        Recurrent urinary tract infections in women: what is the evidence for investigating with flexible cystoscopy, imaging and urodynamics?.
        Urol Int. 2018; 101 (Epub 2018 Jul 17. PMID:30016804): 373-381
        • Pagano MJ
        • Barbalat Y
        • Theofanides MC
        • Edokpolo L
        • James MB
        • Cooper KL.
        Diagnostic yield of cystoscopy in the evaluation of recurrent urinary tract infection in women.
        Neurourol Urodyn. 2017; 36 (Epub 2016 Mar 21. PMID:26998700): 692-696
        • Lawrentschuk N
        • Ooi J
        • Pang A
        • Naidu KS
        • Bolton DM.
        Cystoscopy in women with recurrent urinary tract infection.
        Int J Urol. 2006; 13 (PMID:16734849): 350-353
        • van Haarst EP
        • van Andel G
        • Heldeweg EA
        • Schlatmann TJ
        • van der Horst HJ.
        Evaluation of the diagnostic workup in young women referred for recurrent lower urinary tract infections.
        Urology. 2001; 57 (PMID:11377307): 1068-1072
        • Howles S
        • Tempest H
        • Doolub G
        • et al.
        Flexible cystoscopy findings in patients investigated for profound lower urinary tract symptoms, recurrent urinary tract infection, and pain.
        J Endourol. 2012; 26 (Epub 2012 Jul 30. PMID:22612791): 1468-1472
        • Nickel JC
        • Wilson J
        • Morales A
        • Heaton J.
        Value of urologic investigation in a targeted group of women with recurrent urinary tract infections.
        Can J Surg. 1991; 34 (PMID:1747838): 591-594
        • Mogensen P
        • Hansen LK.
        Do intravenous urography and cystoscopy provide important information in otherwise healthy women with recurrent urinary-tract infection?.
        Br J Urol. 1983; 55 (PMID:6850239): 261-263
      1. Ahmed H, Davies F, Francis N, Farewell D, Butler C, Paranjothy S. Long-term antibiotics for prevention of recurrent urinary tract infection in older adults: systematic review and meta-analysis of randomised trials. BMJ Open.2017;7:e015233. doi: 10.1136/bmjopen-2016-015233. PMID: 28554926; PMCID: PMC5729980.

        • Beerepoot MA
        • ter Riet G
        • Nys S
        • et al.
        Lactobacilli vs antibiotics to prevent urinary tract infections: a randomized, double-blind, noninferiority trial in postmenopausal women.
        Arch Intern Med. 2012; 172 (PMID:22782199): 704-712
        • Costelloe C
        • Metcalfe C
        • Lovering A
        • Mant D
        • Hay AD.
        Effect of antibiotic prescribing in primary care on antimicrobial resistance in individual patients: systematic review and meta-analysis.
        BMJ. 2010; 340 (PMID:20483949): c2096
        • Malik RD
        • Wu YR
        • Christie AL
        • Alhalabi F
        • Zimmern PE.
        Impact of allergy and resistance on antibiotic selection for recurrent urinary tract infections in older women.
        Urology. 2018; 113 (Epub 2017 Nov 28. PMID:29196069): 26-33
        • Chen Z
        • Bates L
        • West NT
        • Moore KH.
        A 9-year audit of the efficacy of diathermy for cystitis cystica.
        Urogynaecologia. 2019; 31
        • Le D
        • Crivelli JJ
        • Ma R
        • Sun-Mitchell S
        • Kribs C
        • Zimmern PE
        Risk factors and their impact on long-term outcomes of women with antibiotic-recalcitrant recurrent urinary tract infections undergoing cystoscopy with fulguration.
        Int J Intell Technol Appl Stat. 2022; 15: 47-61
        • Wang C
        • Zimmern PE
        • Lemack G.
        Long-term results of transurethral endoscopic excision using the holmium laser for urethral perforation of synthetic slings.
        Low Urin Tract Symptoms. 2019; 11 (Epub 2018 Jun 28. PMID:29956499): O103-O110