There has been a rise in UTIs over the past decade due to an aging population and increasing antibiotic resistance, all within the context of a changing health care infrastructure in the United States.¹ During the recent AUA meeting in Las Vegas, Nevada, a panel of experts, moderated by Dr Lynn Stothers, discussed management strategies for challenging cases of recurrent UTIs (rUTIs; Figure 1).

Genitourinary Syndrome of Menopause

The panel began with Dr Farzeen Firoozi, System Director of Urogynecology and Reconstructive Pelvic Surgery at Northwell Health/Lenox Hill Hospital, presenting a case involving a 75-year-old female with a history of rUTIs and persistent urinary frequency, urgency, and vaginal burning in the absence of a bacterial infection (Figure 2). Estrogen deficiency is associated with common vaginal symptoms, including dryness, burning, irritation, dyspareunia, and urinary symptoms such as urgency and dysuria. Postmenopausal estrogen deficiency contributes to increased UTI risk by reducing vaginal glycogen, decreasing lactobacilli, and creating a more alkaline vaginal environment.²

Dr Firoozi highlighted barriers to the awareness and identification of genitourinary syndrome of menopause (GSM) using findings from the Real Women’s Views of Treatment Options for Menopausal Vaginal Changes study. Among 3046 women with GSM symptoms, nearly half had not discussed their symptoms with a health care provider, 40% used over-the-counter vaginal products, and only 24% recognized their symptoms as related to menopause.³ He concluded the case by emphasizing that vaginal estrogen is a safe and effective treatment option for managing irritative GSM symptoms and can significantly reduce the incidence of rUTIs.

Next-Generation Sequencing

Next, Dr Henry Okafor, Assistant Professor at University of Tennessee Health Science Center/Erlanger Health, presented a case involving an 82-year-old female with a history of rUTIs, who was using vaginal estrogen cream but continued to experience UTI symptoms despite negative urine cultures (Figure 3). Urine cultures have been the standard diagnostic method for acute cystitis since the 19th century. However, urine cultures do have limitations, as they can miss dominant organisms that exist within biofilms, potentially leading to incomplete treatment with antibiotics. Dr Okafor introduced PCR and next-generation sequencing (NGS) as more accurate and efficient tools for analyzing urinary microbes.

PCR provides results within 24 to 48 hours by comparing the DNA of detected microbes against a predetermined list of common pathogens. NGS follows, enabling rapid sequencing of entire genomes or targeted DNA or RNA regions, which are compared with a comprehensive database of microbial species, significantly improving sensitivity.⁴ NGS results are typically available within 3 to 5 days.⁴ The utility of PCR and NGS was illustrated when the index patient was diagnosed with a Klebsiella-dominant UTI, which had been missed by standard urine culture. NGS reports include all detected species, the relative percentage of DNA copies, and the resistance genes identified in each species, helping guide targeted treatment. While NGS offers enhanced diagnostic capabilities, its limitations include high cost, complex data interpretation, and potential for overdiagnosis. Nonetheless, it can serve as a valuable adjunct in symptomatic patients with negative standard cultures.

Confounding Diagnoses in Patients With rUTIs

The panel concluded with Dr A. Lenore Ackerman, Assistant Professor at University of California, Los Angeles, who discussed the large number of women with dysuria who are treated for cystitis without a formal diagnostic evaluation (Figure 4). She illustrated this point through a case involving a 36-year-old female diagnosed with rUTIs, without obvious triggers, who was routinely treated with 14-day courses of antibiotics. The patient reported significant urgency and frequency between infections, as well as persistent dysuria.

Dr Ackerman emphasized the importance of a thorough history and physical examination, which in this case revealed pelvic floor hypertonicity and trigger point tenderness, without bladder tenderness. Labeled as one of the common “mimickers” by Dr Ackerman, pelvic floor disorders can sometimes mimic UTIs. These findings were concerning for provoked myofascial pain in the setting of negative urine cultures. She referenced a study of 250 patients presenting with lower urinary tract symptoms (LUTS). Among those labeled with “recurrent UTI,” only 6% had evidence of infection on testing and 58% had pelvic floor myofascial pain.⁵ High-tone pelvic floor dysfunction is a common cause of LUTS and is frequently mistaken for rUTIs.⁵

Dr Ackerman also presented a second case highlighting the importance of physical examination and consideration of alternative diagnoses. This involved an 84-year-old female with rUTIs and LUTS between infections, who was found on physical exam to have vaginal atrophy that was refractory to vaginal estrogen therapy. In such cases, it is important to consider lichen sclerosus and other forms of vulvar dermatitis when standard treatments for rUTIs fail. The patient underwent a punch biopsy of the vaginal vestibule, which confirmed lichen sclerosus, and she improved with treatment using topical clobetasol.

UTIs are among the most common infections encountered in clinical practice, affecting over 150 million people globally each year.⁶ This expert plenary discussion promotes greater awareness and education, reinforcing the collective commitment of the medical community to improving care for all those affected by UTIs.