Personalized therapy for recurrent urinary tract infections

Urinary tract infections are the most common bacterial infection in women and pose a major challenge both in everyday practice and in the clinic. Women have a significantly higher risk of these infections due to their anatomical characteristics. Recurrent urinary tract infections place a considerable physical and psychological burden on patients. The frequent use of antibiotics leads to resistance and damages the microbiome, which is why a holistic therapeutic approach is necessary. Uro-Vaxom has proven to be an effective and well-tolerated option for prophylaxis. It can therefore be used as part of all therapies for recurrent urinary tract infections. ^1-4

Recurrent urinary tract infections are defined as two infections per six months or three infections per year. ⁵ 2.4 % of all women suffer from these recurrent urinary tract infections^.6 Both young patients before the menopause and older patients can be affected. Young women usually exhibit typical signs of inflammation such as dysuria and pollakiuria. Older women, on the other hand, often no longer notice these typical symptoms of infection. They are more likely to complain of urge incontinence (OAB wet) and unpleasant urine odor, which can lead to social isolation and depressed mood.

Problematic development of resistance

Treatment typically involves antibiotics. Although simple cystitis – even in recurrence – usually involves multisensitive pathogens, the frequent use of antibiotics is a cause for concern due to the negative effects on the body’s microbiome7^{, 8} and also in view of the global increase in antibiotic resistance. For example, the resistance rates of E. coli bacteria to carbapenems are increasing throughout Europe, with large local differences. ⁹ Organizations worldwide are calling for the responsible use of ^{antibiotics10} and the use of non-antibiotic prophylactic measures is strongly recommended by professional societies. ¹¹ In Switzerland, the Federal Office of Public Health (FOPH) has developed the Strategy on Antibiotic Resistance (StAR). ¹² Preventive measures such as vaccinations are recommended here. These preventive measures aim to keep the use of antibiotics low and, if necessary, to use antibiotics in a targeted manner. The fewer antibiotics are used, the less often resistance develops^.12

Impaired defense

The decisive factor in the treatment and prophylaxis of recurrent lower urinary tract infections in women is not so much the pathogen as the defense mechanisms^.13 The infections are caused by bacterial ascension of pathogens from the local flora that are naturally present in the rectum and on the skin in the intimate area. If the vaginal flora is disturbed, they ascend through the urethra into the bladder. The short female urethra facilitates this ascension. In simple cystitis, E. coli are the most common pathogens at around 80 %, while enterococci, Klebsiella and Proteus are detected less frequently^.14 In general, drinking too little favors the development of urinary tract infections. Insufficient bladder irrigation leads to easier bacterial ascension. In sexually active women, sexual intercourse is often the trigger. Excessive intimate hygiene measures damage the natural vaginal flora. In postmenopausal women, the massive drop in oestrogen levels leads to atrophy of the vaginal skin. The consequences are a decrease in lactic acid bacteria, an increase in the pH value and the miscolonization of the vagina with intestinal and skin bacteria. These then easily ascend into the bladder. Age-related degenerative diseases such as genital descensus – especially with residual urine formation – as well as urinary and fecal incontinence also play an important role. With increasing age, other internal risk factors are added, such as immunodeficiency, multimorbidity, diabetes, rheumatological diseases with immunosuppressive therapies, obesity, mobility disorders and intimate care problems in dementia.

Search for causes

The core elements of the diagnosis initially include a specific medical history, whereby it is determined since when and how often bladder infections occur, e.g. after sexual activity or since the menopause. Do you also have pelvic inflammatory disease? Is there any faecal or urinary incontinence? Previous therapies are asked about, as well as the amount you drink. This is followed by a clinical examination. The urogenital trophism and any prolapse conditions are assessed. Pronounced pressure dolences of the urethra may indicate urethritis. Although the urine stick is well suited for screening for the presence of a urinary tract infection, it is no substitute for a urine culture, since no statement can be made about the germ and the resistance situation. Sonography of the pelvic floor and kidneys can detect pelvic organ prolapse, residual urine or urinary tract abnormalities. A cystoscopy may be indicated to rule out other factors that can cause inflammation-like symptoms, such as interstitial cystitis, tumors and foreign bodies. ¹⁵

Strengthening the defense

The treatment of recurrent bladder infections is multimodal and personalized. First, the infection is treated in a way that is appropriate to the resistance, then we support the body’s defenses in order to reduce the recurrence rate as much as possible and to achieve an improvement or complete healing of the infection in the long term. Complicating factors such as residual urine, kidney stones or faecal incontinence should be eliminated wherever possible. The key point of prophylaxis is to advise the patient. If the amount drunk is insufficient, it must be increased with the aim of achieving at least two liters of urine over 24 hours.16 We recommend specific intimate hygiene with pH-neutral wash lotions and the use of fat creams. If the mucous membranes are very thin during the perimenopause, local hormone treatment is also extremely important to build up the vaginal and bladder wall. ¹⁷ Various phytotherapeutics also support the bladder’s defense against infection: cranberry and D-mannose can be used, although the data is very heterogeneous^.11 Furthermore, preparations containing e.g. rosemary and nasturtium are used, especially in acute infections^.18 Vaginal or oral lactic acid bacteria are also useful^.19 As extended measures, we use chondroitin sulphate, glucosamine sulphate and hyaluronic acid as intravesical instillations to build up the glycosaminoglycan layer (GAG layer)^.20 Although low-dose long-term prophylaxis with antibiotics is effective, it is considered the last resort due to collateral damage to the microbiome and the development of resistance^.21

Uro-Vaxom

The immune defense can also be supported by a vaccination^.22 According to the current EAU recommendations, immunostimulation, e.g. with Uro-Vaxom®, is currently the best proven, non-antimicrobial measure against recurrent cystitis^.11 The clinical data situation is good. A meta-analysis of five randomized, placebo-controlled and double-blind studies from 1990 to 2005 showed 20 % more infection-free patients for Uro-Vaxom® compared to placebo (62 % vs. 42 %)^.23 A further meta-analysis of 17 RC studies included four studies on Uro-Vaxom®, which showed a halving of the frequency of infections compared to placebo^.22 Good safety and tolerability were demonstrated in all studies. A further prospective observational study demonstrated a significant improvement in quality of life as a result of successful infection prophylaxis with Uro-Vaxom®^.4

Conclusion

Recurrent urinary tract infections affect 2.4% of all women of all ages and are often the reason for a visit to the doctor. A multimodal and personalized therapy enables a good cure even without the use of long-term antibiotics. The decisive factors here are the treatment of possible infection-promoting or complicating factors and the restoration of the body’s natural defenses.

As part of an overall concept, the immunostimulant Uro-Vaxom® has established itself as one of the basic measures. Vaccination is also recommended as a preventive measure as part of the implementation of the Swiss Federal Strategy on Antibiotic Resistance (StAR) and leads to a reduction in antibiotic consumption.12 We use Uro-Vaxom® regularly and with good success in the treatment of patients with chronic recurrent urinary tract infections.

Information leaflet Uro-Vaxom®

Author:
Dr. med. Julia Münst
FMH Urology
Senior Physician Bladder and Pelvic Floor Center
Women’s Clinic
Kantonsspital Frauenfeld
Pfaffenholzstrasse 4
CH-8501 Frauenfeld
Phone: +41 58 144 8025
Email: julia.muenst@stgag.ch
www.stgag.ch

* The dosage regimen deviates from the Swiss Information for healthcare professionals.

Literature:

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