What is the treatment for a 28-year-old woman with recurrent Urinary Tract Infections (UTIs) and a tender anterior vaginal mass?

Treatment for a Woman with Recurrent UTI and Tender Anterior Vaginal Mass

The tender anterior vaginal mass in a woman with recurrent UTIs should be surgically excised as it is most likely a urethral diverticulum requiring definitive treatment to resolve the recurrent UTI pattern.

Understanding the Presentation

A 28-year-old woman with recurrent UTIs and a tender anterior vaginal mass presents a specific clinical scenario that requires targeted management. This presentation strongly suggests a urethral diverticulum, which is an outpouching of the urethra that can:

• Collect urine and become infected
• Harbor bacteria leading to recurrent UTIs
• Present as a tender mass in the anterior vaginal wall
• Cause symptoms that don't respond to standard UTI treatments

Diagnostic and Treatment Algorithm

1. Confirm the diagnosis:

   • Physical examination to characterize the anterior vaginal mass
   • Imaging studies (MRI preferred) to confirm urethral diverticulum
   • Urine culture to identify causative organisms for current infection

2. Initial management:

   • Treat active UTI based on culture results
   • First-line options include:
     • Nitrofurantoin 100 mg twice daily for 5 days 1
     • Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 3 days 1, 2
     • Fosfomycin 3g single dose 1

3. Definitive treatment:

   • Surgical excision of the urethral diverticulum
   • Surgical approaches include transvaginal diverticulectomy with layered closure

4. Post-surgical management:

   • Short course of antibiotics to prevent post-operative infection
   • Follow-up to ensure complete resolution

Management of Recurrent UTIs

While awaiting definitive surgical management, the following strategies can help manage recurrent UTIs:

• Antibiotic prophylaxis options (if needed temporarily):

  • Low-dose post-coital antibiotics if infections are related to sexual activity 3
  • Daily antibiotic prophylaxis with nitrofurantoin 50-100 mg daily 3, 4

• Non-antibiotic alternatives:

  • Methenamine hippurate 3, 1
  • Lactobacillus-containing probiotics 3, 1

Important Considerations

• Avoid treating asymptomatic bacteriuria as this promotes antibiotic resistance without clinical benefit 1
• Obtain urine cultures before starting antibiotics to guide targeted therapy 1
• Complete the full course of prescribed antibiotics even if symptoms improve quickly 1
• Consider patient-specific factors such as allergies and previous culture results when selecting antibiotics 1

Common Pitfalls to Avoid

1. Misdiagnosis: Failing to recognize that the tender anterior vaginal mass is likely a urethral diverticulum, not a cystocele or other pelvic organ prolapse

2. Inadequate treatment: Treating only the UTI symptoms without addressing the underlying anatomical abnormality (diverticulum)

3. Overuse of antibiotics: Relying solely on repeated or prolonged antibiotic courses without definitive surgical management

4. Delayed referral: Not promptly referring to urology or urogynecology for surgical evaluation and treatment

The presence of a tender anterior vaginal mass in a woman with recurrent UTIs strongly suggests a urethral diverticulum that requires surgical management for definitive treatment and prevention of future infections.