You’re running between rooms on another busy clinic day when a nurse stops you to tell you the 2:00 PM procedure patient’s urine dipstick is positive. “Doctor, should we reschedule?” Such a common scenario, and yet you probably will not get the same answer from every urologist, nor would they all agree which procedures need a urinalysis beforehand. Urinalysis is an imperfect test of UTI with a risk of false positives,¹ and awaiting culture results is not practical. Moreover, asymptomatic bacteriuria (ASB) is incredibly common, especially in women and geriatric patients,² a significant portion of our patient population. By definition, ASB cannot be differentiated from UTI on the basis of urine dipstick, microscopy, or culture, and requires assessment of patient symptomatology.

Urodynamics

The AUA and Society for Urodynamics, Female Pelvic Medicine & Genitourinary Reconstruction (SUFU) Best Practice Policy Statement on Urodynamic Antibiotic Prophylaxis in the nonindex patient recommends a urinalysis before each procedure.³ Moreover, it recommends that patients with active UTI be treated and rescheduled, noting that urodynamics can “falsify cystometric findings” and possibly “aggravate the underlying infection.”³ In a study of 20 patients with UTI undergoing urodynamics, 60% of detrusor overactivity and 30% of stress urinary incontinence resolved after UTI treatment.⁴ Multichannel urodynamics is an invasive and often uncomfortable procedure, so if we are going to do it, we want the results to be reliable and informative. Again, it is important to differentiate ASB from UTI, as the AUA/SUFU best practice statement approves of proceeding with the study and giving a single dose of antimicrobial prophylaxis when there is ASB.³

Cystoscopic Office Procedures

Retrospective studies have supported the safety of diagnostic cystoscopy in patients with ASB, even without antimicrobial prophylaxis.^5,6 Still, hospitalization following cystoscopy on a patient with a positive culture occurs 1.2% of the time.⁷ Aside from safety, however, there is a question of diagnostic accuracy. Patients undergoing diagnostic cystoscopy with concomitant ASB or UTI may have erythematous or bullous lesions, which may be inflammatory but can be difficult to distinguish from malignancy (Figure). This scenario can be avoided by treating the UTI ahead of time. Alternatively, you can then treat with antibiotics and repeat the cystoscopy to spare the patient a possibly unnecessary biopsy.

Figure. Cystoscopic findings in 4 patients with bacteriuria, which may represent inflammation or malignancy.

Cystoscopic Chemodenervation and Urethral Bulking

In a review of 183 patients undergoing 457 cystoscopy with onabotulinumtoxin injection (BTX) sessions, ASB was present 38.8% of the time, and when present, increased the risk of UTI over 16-fold.⁸ However, a separate cohort of 212 patients undergoing 365 BTX sessions demonstrated that a positive dipstick in the absence of UTI symptoms was associated with no difference in adverse events.⁹ While a dipstick may look the same for ASB and UTI, patients typically know their UTI symptoms even when they have baseline lower urinary tract symptoms. There are scant data on infectious risks with urethral bulking based on dipstick result. Urologists should be aware, however, that performing BTX or urethral bulking procedures during a UTI is technically contrary to Food and Drug Administration labeling and manufacturer recommendations.

Safety, Cost, and Access

Certainly, we want to be safe and avoid making patients sick. UTIs are expensive, in the US alone costing billions annually, and globally UTIs have increased in prevalence and risk of mortality over the past 30 years.¹⁰ On the other hand, patients in the US are facing unprecedented problems with appointment access across the country, many of whom travel long distances for specialty care. Rescheduling these procedures is not benign; it results in lower patient satisfaction and wasted resources, and almost half of patients who are cancelled do not reschedule. As your patient waits months and months for the next procedure spot, what are the odds her urinalysis won’t turn positive again?

SUFU is convening a Best Practice Policy Statement Panel on antibiotic usage in these procedures. Until then, risk stratification and clinical judgment based on patient factors and symptoms may be more important than the dipstick result.