As part of the Sunday plenary program at the 2021 AUA Annual Meeting, we will confront one of the most common challenges urologists face: when and how to intervene when the presence of bacteria in the urinary tract (UT) complicates our understanding and management of other benign urologic conditions, such as neurogenic bladder, nephrolithiasis and benign prostatic hyperplasia (BPH).

In the generation of the 2019 AUA Guidelines for the management of recurrent urinary tract infection (UTI),¹ it became clear that no definition of either “acute bacterial cystitis” or “recurrent UTI” is universally accepted. Some of this confusion stems from difficulty understanding and interpreting the presence of bacteria in a urine specimen. The previous dogma was straight forward: the healthy UT is sterile and any bacteria within that space is pathologic. But clinically we are all aware of times when bacteriuria is common, or even expected, as in catheter-dependent neurogenic bladder, high-grade anterior pelvic organ prolapse in women or bladder outlet obstruction in men with BPH. Thus, bacteriuria is not always infection and does not always need treatment.

Even the definition of bacteriuria or a “positive” clinical culture is questionable. The original quantitative threshold of >10⁵ colony-forming units (cfu)/ml urine was defined in a population of asymptomatic women and likely inappropriate to identify infection. Much lower colony counts (10² cfu) can be associated with bacteriuria on catheterization in highly symptomatic patients, but are also commonly seen in healthy individuals as well. Indeed, newer, more sensitive bacterial detection methods, such as expanded clinical cultures, polymerase chain reaction, and next-generation sequencing methods, have revealed that microbes are present in the lower urinary tracts of most individuals, even healthy, asymptomatic subjects, making bacteriuria more of a continuum than a diagnosis.²

The type of bacteria may also matter in defining infection. Certain bacterial strains may protect against pathologic infection³ or even ameliorate pain.⁴ And we are learning that repeated antibiotic treatments actually increase the subsequent risk of more severe, more resistant and more progressive infections.⁵ These data suggest that some microbes wiped out by antibiosis may have a role to play in protecting us against more adverse outcomes.

But these realizations leave us with more questions than answers. If bacteria are typically present in the urinary tract and may even be helpful, what defines a true infection? Is it a specific species? Or the expansion of a single organism at the exclusion of others? Or any type of bacteria with certain virulence factors? Is it the patient’s immune response to the microbe that makes it pathologic? Or is it the promotion of pathologic tissue damage that defines an “infection”?

And with the uncertainty about how to define infection itself, how do we know when antimicrobial treatment is necessary? Given the growing epidemic of antimicrobial resistance and a new recognition of the longer-term side effects of antibiotic treatment (“collateral damage”), are antimicrobial medications always the right approach to the management of bacteria in the urinary tract? Are there other approaches that may address the root cause of the microbial dysbiosis locally without systemic negative effects?

And lastly, what is the goal of such treatment: symptomatic relief, eradication of bacteria, avoidance of complications or the prevention of recurrent or progressive infections? These objectives may be very different for each patient population.

In this session, we will begin to face some of these highly challenging questions through an exploration of several common and frequently frustrating clinical situations. Dr. Christina Ching will discuss the management of recurrent UTI in patients with neurogenic bladder, diving into the difficulties of managing infections on a background of chronic bacteriuria. Dr. Daniel Shoskes will face the complicated case of recurrent UTI in men, with a deeper dive into the diagnosis, medical management and surgical treatment of true chronic bacterial prostatitis. Dr. Manoj Monga will confront the common situation of how to manage a non-obstructing, asymptomatic stone in patients with recurrent UTI.

In each of these instances, we can look to these experts for detailed discussion of the available evidence and the knowledge gaps that still remain. Join us for a lively discussion of these challenges that we hope will leave you better prepared to face that next consult for recurrent UTI in complicated patient populations.