EP.WE.117Colovaginal fistula from neglected vaginal pessary; Fallouts from the COVID-19 pandemic

An 86 year old lady was admitted with a one week history of feeling unwell, polyuria, dysuria, urinary and faecal incontinence. She had previously been treated for recurrent UTIs by her GP. On examination she had suprapubic tenderness but no peritonism. Observations revealed tachycardia of 122bpm with a temperature of 36.3*C. Inflammatory markers were raised with a white cell count of 22.0x106/L and CRP 129 mg/L. Urine cultures grew Pseudomonas aeruginosa. She was managed for urosepsis with intravenous antibiotics. Past medical history included vaginal pessary for uterine prolapse, congestive cardiac failure, hypertension, polymyalgia and osteoporosis. She lived alone with no package of care. On admission she improved with intravenous antibiotics however she had a perineal examination due to ongoing faecal and urinary incontinence and was noticed to be passing faeces per vaginam. A colo-vaginal fistula was suspected and she was reviewed by the gynaecologist who noted her pessary had been in-situ for up to a year and her routine appointment to have it changed was cancelled due to the COVID-19 pandemic. An MRI Pelvic scan confirmed a 3x2cm rectovaginal fistula. She was reviewed by the general surgery team and the decision was made for her to be defunctioned to prevent her episodes of recurrent UTIs and improve her quality of life. She successfully had a laparoscopic end colostomy with an uneventful post-operative period. This case highlights the harms caused from the cancellation of appointments and demonstrates a rare cause of rectovaginal fistula.

Do Various Treatment Modalities of Vesicoureteral Reflux Have Any Adverse Effects in Pediatric Patients? A Meta-Analysis

<b><i>Purpose:</i></b> Vesicoureteral reflux (VUR) is a risk factor for various renal problems like recurrent urinary tract infections (UTIs), pyelonephritis, renal scarring, hypertension, and other renal parenchymal defects. The interventions followed by pediatricians include low-dose antibiotic treatment, surgical correction, and endoscopy. This meta-analysis aimed to assess the advantages and drawbacks of various primary VUR treatment options. <b><i>Search Strategy:</i></b> The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, reference lists of journals, and abstracts from conference proceedings were all used to find randomized controlled trials. The articles were retrieved from 1985 till 2020. Twenty articles were used for the data analysis. <b><i>Criteria for Selection:</i></b> Surgery, long-term antibiotic prophylaxis, noninvasive techniques, and any mix of therapies are also options for treating VUR. <b><i>Collection and Interpretation of Data:</i></b> Two authors searched the literature separately, determining research qualifications, assessing accuracy, and extracting and entering results. The odds ratio (OR) of these studies was used to construct the forest plot. The random-effects model was used to pool the data. Also, the random-effects model was used with statistical significance at a <i>p</i> value &#x3c; 0.05 to assess the difference in side effects after treatment of VUR using different modalities. <b><i>Results:</i></b> We found no statistically significant differences between surgery plus antibiotics and antibiotic alone-treated patients in terms of recurrent UTIs (OR = 0.581; 95% confidence interval [CI] 0.259–1.30), renal parenchymal defects (OR = 1.149; 95% CI 0.75–1.754), and renal scarring (OR = 1.042; 95% CI 0.72–1.50). However, the risk of developing pyelonephritis after surgical treatment of VUR was lesser than that in the conservative approach, that is, antibiotics (OR = 0.345; 95% CI 0.126–0.946.), positive urine culture (OR = 0.617; 95% CI 0.428–0.890), and recurrent UTIs were more common in the placebo group than in the antibiotic group (<i>p</i> &#x3c; 0.05; OR = 0.639; 95% CI 0.436–0.936) which is statistically significant. <b><i>Conclusion:</i></b> Based on current research, we recommend that a child with a UTI and significant VUR be treated conservatively at first, with surgical care reserved for children who have issues with antimicrobials or have clinically significant VUR that persists after several years of follow-up.

1491 Hemi-Nephroureterectomy For Duplex Kidney in Children - The Resulting Effect on Renal Function

Introduction Urinary duplication systems occur in approximately 1% of the population, and may present with recurrent UTIs, incontinence, or be incidentally detected on imaging. DMSA (dimercaptosuccinic acid) imaging is used in these patients to assess split renal function. If found significantly reduced in a single moiety, children may be offered hemi-nephroureterectomy (HNU). We analysed the rate of remnant moiety loss following HNU comparing age and affected moiety. Method All HNUs performed at our paediatric tertiary centre 2005-2019 were analysed. Children &lt;16yrs, with pre– and post-operative DMSA imaging were included. Renal loss was categorised as: significant (≥50% of pre-existing function), non-significant (≥25% pre-existing function), no renal loss (&lt;25%), and complete loss (post-operative remnant moiety function ≤5%). Subgroup analysis was performed using χ² statistic. Results 73 patients were included, mean age 2.1yrs. Median pre-operative function of the affected kidney was 42%. 12 patients (16.4%) had significant renal loss, 13 (17.8%) non-significant loss and 6 (8.2%) had complete renal loss. Children &lt;2yrs had significant and complete renal loss more frequently than those aged ≥2yrs (9/35 and 5/35 vs 3/38 and 1/38 respectively, p = 0.069). Patients with upper moiety HNU (UMHNU) had higher rates of significant and complete renal loss than lower moiety HNU patients (12/53=significant, 6/53=complete vs 0/20 significant/complete, p = &lt;0.05). Conclusions HNU for duplex kidney is associated with high rates of remnant moiety damage, with ¼ of patients experiencing significant or complete renal loss. Subgroup analysis suggests this risk is higher in children &lt;2yrs or UMHNU. HNU should therefore only be reserved for symptomatic patients failing conservative management.

719 Colovaginal Fistula from Neglected Vaginal Pessary; Fallouts from the COVID-19 Pandemic

An 86-year-old lady was admitted with a one-week history of feeling unwell, polyuria, dysuria, urinary and faecal incontinence. She had previously been treated for recurrent UTIs by her GP. On examination she had suprapubic tenderness but no peritonism. Observations revealed tachycardia of 122bpm with a temperature of 36.3*C. Inflammatory markers were raised with a white cell count of 22.0x106 /L and CRP 129 mg/L. Urine cultures grew Pseudomonas aeruginosa. She was managed for urosepsis with intravenous antibiotics. Past medical history included vaginal pessary for uterine prolapse, congestive cardiac failure, hypertension, polymyalgia and osteoporosis She lived alone with no package of care. On admission she improved with intravenous antibiotics however she had a perineal examination due to ongoing faecal and urinary incontinence and was noticed to be passing faeces per vaginam. A colo-vaginal fistula was suspected, and she was reviewed by the gynaecologist who noted her pessary had been in-situ for up to a year and her routine appointment to have it changed was cancelled due to the COVID-19 pandemic. An MRI Pelvic scan confirmed a 3x2cm rectovaginal fistula. She was reviewed by the general surgery team and the decision was made for her to be defunctioned to prevent her episodes of recurrent UTIs and improve her quality of life. She successfully had a laparoscopic end colostomy with an uneventful post-operative period. This case highlights the harms caused from the cancellation of appointments and demonstrates a rare cause of rectovaginal fistula.

Oral D mannose in the prevention and treatment of recurrent urinary tract infections: A review

The results of several studies reveal that antibiotics may promote treatment resistance by causing alterations in the intestinal flora. The development of a gut reservoir of resistant bacteria promotes the development of UTIs through autoinfection. This review aims to address clinical reliability, efficacy and safety of long-term treatment with oral D mannose for the prevention of Recurrent Urinary Tract Infections (RUTI) in females. A comprehensive MEDLINE, Embase, Scopus and Cochrane search was performed for English language reports published before December 2018 using the term “recurrent urinary tract infections and D mannose” was carried out. We searched Medline, Embase, Scopus and the Cochrane Register of Controlled Trials from January 2010 to December 2018. Eligible studies did not include non-oral therapy, local (vaginal) treatment in women with recurrent UTIs. We identified eligible original articles. A few limitations of the review are the heterogeneity of the available studies, their different rational and aim, the assumption of D mannose for prophylaxis or treatment of recurrent UTIs. Oral D mannose performs well in the prevention of UTIs recurrences, significant improvement of urinary symptoms was observed, the disease- free time was longer in the groups of patients under prophylaxis with D mannose in comparison with control groups (no treatment, antibiotic prophylaxis, prophylaxis with Proanthocyanidin (PAC) etc. The review has limitations, as the studies are heterogeneous, the meta-analysis requires classifications that can also be arbitrary. Furthermore, single-arm studies are not included. Some of the authors found this evidence inconclusive, which results as a limitation of the study. D mannose prolonged the recurrence-free interval of recurrent UTIs, thus reducing the prolonged or cyclical use of antibiotics, improving clinical symptoms, with a significant difference between treatment and control groups (no treatment, antibiotic prophylaxis, prophylaxis with Proanthocyanidin). However, most clinical trials used an association of different substances commingled with D mannose, dosages and regimens of D mannose were different. For this reason, the evidence of the efficacy of D mannose remains low.

Treatment of Urinary Tract Infections with Canephron® in Germany: A Retrospective Database Analysis

Objective: The goal of the present study was to evaluate treatment with Canephron® compared to standard antibiotic treatment after diagnosis of acute cystitis or urinary tract infection (UTI), with regard to the risk of sporadic recurrent UTIs, frequent recurrent UTIs, UTI-related sick leave, additional antibiotic prescriptions, and renal complications (pyelonephritis). Methods: This retrospective cohort study was based on data from the IMS® Disease Analyzer database (IQVIA), and included outpatients in Germany with at least one diagnosis of acute cystitis or UTI with a prescription of either Canephron® or standard antibiotics between January 2016 and June 2019 and treated in general practitioner (GP), gynecologist, or urologist practices, from which the data were obtained. Multivariable regression models were used to investigate the association between Canephron® prescription and the amount of sporadic or frequent recurrent UTIs, as well as the duration of UTI-related sick leave, the number of additional antibiotic prescriptions, and cases of pyelonephritis. The effects of Canephron® were adjusted for age, sex, insurance status, and Charlson comorbidity score (CCI). Results: 2320 Canephron® patients and 158,592 antibiotic patients were available for analysis. Compared to antibiotic prescription, Canephron® prescription was significantly associated with fewer sporadic recurrences of UTI infections 30–365 days after the index date (odds ratio (OR): 0.66; 95%, confidence interval (CI): 0.58–0.72), as well as less frequent recurrences of UTI infections (OR: 0.61; 95% CI: 0.49–0.88), and also with reduced additional antibiotic prescription within 31–365 days (OR: 0.57; 95% CI: 0.52–0.63). No significant differences were observed between the Canephron® and antibiotic cohorts with regard to the likelihood of sick leave (OR: 0.99; 95% CI: 0.86–1.14), new antibiotic prescription within 1–30 days (OR: 1.01; 95% CI: 0.87–1.16), or occurrence of pyelonephritis (Hazard Ratio (HR): 1.00; 95% CI: 0.67–1.48). Conclusion: These real-world data show that Canephron® is an effective, safe symptomatic treatment for acute cystitis or UTI. It should be considered as an alternative treatment, particularly to also strengthen antimicrobial stewardship strategies.

Vitamin D Status and Its Role in First-Time and Recurrent Urinary Tract Infections in Children: A Case-Control Study

Vitamin D has emerged as a key factor in innate immunity. Its involvement in the pathogenesis of urinary tract infections (UTIs) has gained a lot of attention recently. The objective of this study is to investigate the association between serum 25-hydroxyvitamin D (25(OH)D) levels and first-time or recurrent UTIs in children. A prospective, case-control study was conducted on 101 pediatric patients, who were divided into two groups: 59 patients with UTIs and 42 age-matched healthy controls. Serum 25(OH)D was determined in each child and expressed in ng/mL. Vitamin D presented significantly lower values in study group subjects than in healthy controls (p < 0.01). Moreover, a significantly higher prevalence of vitamin D insufficiency and deficiency was found in children with UTIs (p < 0.01). Patients with recurrent UTIs presented significantly lower levels of vitamin D than those with first-time UTIs (p = 0.04). Urinary tract abnormalities did not seem to exercise an additional effect upon vitamin D levels within the study group. In conclusion, first-time and recurrent UTIs are associated with lower vitamin D levels. Further studies are necessary to validate our findings, as well as future longitudinal research regarding efficacy of vitamin D supplementation in children with UTIs.

Does methenamine hippurate decrease urinary tract symptoms in community adult women: a systematic review and meta-analysis

Background: Urinary tract infections (UTIs) are often treated with antibiotics and are one of the major sources of antibiotic overuse. Aim: To systematically review randomised controlled trials (RCTs) of community adult women with a history of recurrent UTIs using methenamine hippurate (hippurate) as treatment or prophylaxis. Design and setting: A 2-week systematic review of women (>18 years) with recurrent UTIs using hippurate against placebo, no treatment, or antibiotics. Methods: We searched 3 databases, clinical trial registries and citing-cited references of included studies. Results: We included 6 studies comprising 557 participants: 5 published and one unpublished trial record with results provided; 3 compared hippurate vs placebo or control, and 3 vs antibiotics. The risk of bias was high, mostly from incomplete reporting. For the number of patients remaining asymptomatic, hippurate showed a non-significant trend of benefit vs antibiotics over 12 months (RR 0.65, 95%CI 0.4-1.07, I249%); also vs control over 6/12 months (RR 0.56, 95%CI 0.13-2.35, I293%); and a non-significant trend vs any antibiotic for abacteruria, (RR 0.80, 95%CI 0.62-1.03, I223%). Similar non-significant trends of benefits for hippurate for the number of UTI or bacteriuric episodes. Non-significant difference in the number of patients experiencing adverse events between hippurate and any comparator, with a trend towards benefit for the hippurate. Antibiotic use and resistance were not consistently reported. Conclusion: There is no sufficient evidence to be certain of benefit for hippurate. Further research is needed to test it and consider its use as an alternative for antibiotic treatment for UTI.

The Urinary Microbiome in Postmenopausal Women with Recurrent Urinary Tract Infections

ABSTRACTRecurrent urinary tract infections (UTI) are highly prevalent in postmenopausal women, where vaginal estrogen and prophylactic antibiotics are used for treatment. The etiology of recurrent UTIs is not completely known, but the urinary microbiome is thought to be implicated. Thus, we aimed to compare the “steady state” urinary microbiome in three groups of menopausal women who were all using topically-applied vaginal estrogen: 1) women with recurrent UTIs on daily antibiotic prophylaxis; 2) women with recurrent UTIs not on antibiotic prophylaxis; and 3) age-matched controls without recurrent UTIs. Here we present a cross-sectional analysis of baseline data from 64 women enrolled in a longitudinal cohort study. Catheterized urine samples were collected > 4 weeks after last treatment for UTI. Samples were evaluated using expanded quantitative urine culture (EQUC) and 16S rRNA gene sequencing. With EQUC techniques, there were no significant differences in the median numbers of microbial species isolated among groups (p=0.96), even when considering Lactobacilli (p=0.72). However, there were trends towards different Lactobacillus species between groups. With sequencing the overwhelming majority of urinary samples contained Lactobacilli, with non-significant trends in relative abundance of Lactobacilli among groups. Using a Bayesian regression analysis for compositional data, we identified significant differences in anaerobic taxa that were associated with phenotypic groups. Most of these differences centered on Bacteroidales and the family Prevotellaceae, though differences were also noted in Actinobacteria and certain genera of Clostridiales. Associations between anaerobes within the urinary microbiome and recurrent UTI warrants further investigation.IMPORTANCEIn menopausal women with recurrent urinary tract infections (UTIs) compared to those without, the abundance of Lactobacillus within the urinary microbiome is not significantly different when vaginal estrogen is regularly used. In this population, Lactobacillaceae were identified in 97% of urine samples using culture-independent techniques. However, with expanded urine cultures, women with recurrent UTIs taking daily antibiotics had a disproportionately low amount of L. gasseri/L. acidophilus compared to the other phenotypic groups. These findings support the theory that certain Lactobacillus species may be more important than others in the pathophysiology of postmenopausal recurrent UTIs. Furthermore, when using culture-independent techniques to explore urinary microbiota across phenotypic groups, we identified differences in multiple anaerobic taxa. Taken together, these results suggest that altered ratios of anaerobes and certain Lactobacillus species within the urinary microbiome may be implicated in postmenopausal recurrent UTI.