What is the recommended management for a patient with recurrent Urinary Tract Infections (UTIs), urinary retention, and a history of bladder diverticula?

From the Guidelines

The primary recommendation for a patient with recurrent UTIs, urinary retention, and bladder diverticula is a comprehensive approach including antimicrobial therapy, bladder drainage improvement, and possible surgical intervention, with a focus on addressing the underlying anatomical and functional issues to prevent continued recurrences. This approach is supported by the most recent and highest quality study, which emphasizes the importance of addressing the underlying causes of recurrent UTIs, including anatomical abnormalities such as bladder diverticula 1. The management plan should include:

• Acute UTI treatment with a 7-day course of antibiotics, such as nitrofurantoin or trimethoprim-sulfamethoxazole, based on local resistance patterns and urine culture results
• Prophylaxis in recurrent cases with low-dose antibiotics, such as nitrofurantoin or trimethoprim-sulfamethoxazole, for 3-6 months
• Addressing urinary retention with clean intermittent catheterization if significant post-void residual volumes exist
• Considering surgical intervention through diverticulectomy for large diverticula causing significant retention or recurrent infections
• Performing urodynamic studies to assess bladder function and identify any underlying obstruction The connection between these conditions is important to understand, as urinary stasis in diverticula and from retention creates an environment for bacterial growth, leading to recurrent infections 1. Treating only the infections without addressing the anatomical and functional issues will result in continued recurrences. Therefore, a comprehensive approach that addresses all three interconnected issues is essential for effective management. Key points to consider include:
• The presence of bladder diverticula is not an absolute indication for surgery, unless it is associated with recurrent UTI or progressive bladder dysfunction 1
• Surgery is recommended for patients with renal insufficiency secondary to BPH, refractory urinary retention, recurrent UTIs, or recurrent gross hematuria due to BPH 1
• Urodynamic studies should be performed to assess bladder function and identify any underlying obstruction 1

From the Research

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

• The patient's history of recurrent Urinary Tract Infections (UTIs), urinary retention, and bladder diverticula may indicate a need for further evaluation to rule out any underlying structural or pathological abnormalities 2.
• However, according to the available evidence, imaging is rarely warranted for recurrent UTIs, and the diagnosis is usually made based on clinical presentation and urine culture results 3, 4.
• The presence of bladder diverticula may be a contributing factor to the patient's recurrent UTIs, and further evaluation with imaging such as CT renal tract may be considered to assess the diverticula and rule out any other underlying abnormalities 2.
• The patient's symptoms of urinary retention may also indicate a need for further evaluation to rule out any obstructive causes, and imaging such as CT renal tract may be considered as part of the diagnostic workup 2.

Management of Recurrent UTIs

• The management of recurrent UTIs typically involves a combination of behavioral prevention methods, antibiotic and non-antibiotic treatment strategies, and holistic management approaches 2.
• Antibiotic prophylaxis may be effective in reducing the frequency of recurrent UTIs, but it is associated with a risk of increased drug resistance 3, 5.
• Non-antibiotic approaches such as cranberry products and vaginal estrogen therapy may also be considered as part of the management strategy 3, 5.
• Patient-initiated treatment and self-management strategies may also be effective in reducing the frequency and severity of recurrent UTIs 3.