What is the best approach to manage a patient with recurrent UTIs and a history of bladder diverticula?

From the Guidelines

The best approach to manage a patient with recurrent UTIs and a history of bladder diverticula is to prioritize MRI of the abdomen and pelvis over CT for evaluating the urinary tract, given its advantage in providing more functional information and its effectiveness in diagnosing pelvic-organ prolapse and assessing the structure and complexity of urethral diverticula. This approach is supported by the American College of Radiology Appropriateness Criteria for recurrent lower urinary tract infections in females 1.

When considering imaging for patients with recurrent UTIs, it's essential to note that a history of recurrent UTI is seen in 30% to 50% of patients with urethral diverticula, and MRI best assesses the structure and complexity of urethral diverticula, allowing for accurate diagnosis and improved surgical planning 1. For patients with suspected bladder diverticula, MRI has also been shown to be accurate in diagnosis, particularly when repeat imaging is an issue 1.

Key points in managing recurrent UTIs in the context of bladder diverticula include:

• Initial management with a complete urological evaluation, including cystoscopy and imaging studies to assess diverticula.
• Use of culture-specific antibiotics for acute UTI episodes, such as trimethoprim-sulfamethoxazole, nitrofurantoin, or fluoroquinolones for complicated cases.
• Consideration of low-dose antibiotic prophylaxis for frequent recurrences, such as nitrofurantoin or trimethoprim-sulfamethoxazole.
• Non-antibiotic measures including increased fluid intake, proper hygiene, urinating after intercourse, and potentially cranberry supplements.
• Surgical intervention for large diverticula or those causing significant symptoms, with options including endoscopic management or open diverticulectomy, as supported by guidelines for managing recurrent UTIs in females 1.

The rationale for prioritizing MRI and a comprehensive management approach is that bladder diverticula create urine stasis, providing a reservoir for bacterial growth that contributes to recurrent infections, thus requiring both infection management and addressing the anatomical abnormality 1.

From the FDA Drug Label

To reduce the development of drug-resistant bacteria and maintain the effectiveness of sulfamethoxazole and trimethoprim tablets and other antibacterial drugs, sulfamethoxazole and trimethoprim tablets should be used only to treat or prevent infections that are proven or strongly suspected to be caused by susceptible bacteria Urinary Tract Infections For the treatment of urinary tract infections due to susceptible strains of the following organisms: Escherichia coli, Klebsiella species, Enterobacter species, Morganella morganii, Proteus mirabilis and Proteus vulgaris

The best approach to manage a patient with recurrent UTIs and a history of bladder diverticula is to treat the urinary tract infection with an effective antibacterial agent, such as trimethoprim-sulfamethoxazole, if the causative organisms are susceptible.

• The patient's past medical history of bladder diverticula should be considered when selecting a treatment plan.
• A CT renal tract may be useful in evaluating the urinary tract for any underlying abnormalities that may be contributing to the recurrent UTIs, but the FDA label does not directly address this. 2

From the Research

Indications for CT Renal Tract in Recurrent UTI and Retention with Past Medical History of Bladder Diverticula

• The patient's history of bladder diverticula and recurrent UTIs suggests a complicated urinary tract infection, which may require imaging evaluation 3.
• CT renal tract is a sensitive modality for diagnosing and following up on complicated renal tract infections, and can help identify significant complications or obstruction 3, 4.
• The presence of bladder diverticula may increase the risk of urinary stasis, infection, and other complications, making imaging evaluation important for early detection and management 5, 6.
• CT and MRI can help detect associated complications of UTIs, such as pyonephrosis, chronic pyelonephritis, and emphysematous UTIs, and can guide management decisions 4.
• In patients with a history of bladder diverticula, CT renal tract can help evaluate the bladder and identify potential downstream complications, such as stones, infection, and malignancy 6.

Imaging Modalities

• CT renal tract is a useful imaging modality for evaluating complicated urinary tract infections, especially in patients with a history of bladder diverticula 3, 4.
• MRI can be used as an alternative to CT in patients with iodinated contrast allergies, and can provide detailed images of the urinary tract 3, 4.
• Ultrasound can be used to rapidly diagnose bladder diverticula and other urinary tract abnormalities, but may have limitations in evaluating renal inflammation and infection 5.
• PET/CT can be used to evaluate diverticulitis of the bladder and other complications of bladder diverticula 7.