Intravesical treatment of recurrent urinary tract infection in woman without self-catheterism: systematic review and meta-analysis

Abstract

Almost 50% of women have suffered from urinary tract infection (UTI) during their reproductive age, which could be classified as either a lower urinary tract infection, affecting the urethra and bladder, or an upper urinary tract infection, affecting the kidneys. The UTI results from the interaction between biological factors (reduced urethral size, proximity between urethra, vagina and anus and the oestrogen's effect loss in the vagina and periurethral structures) and behavioral factors of the host (sexual relations frequency, number of partners, new partners and the use of spermicide and diaphragm) and the microorganism's virulence.The most common physio pathological mechanism is the colonization of the vagina and the distal urethra by pathogens from the fecal flora, with 70 to 95% of the cases caused by the E. coli/ being the E. coli responsible for 70 to 95% of the cases. Subsequently, the pathogen ascends the urinary tract, populating the urethra and the urinary bladder, causing the infection. The most frequent symptoms caused by the UTI are dysuria, increase in urinary frequency, urination urgency and, in some cases, suprapubic pain and hematuria. In this context, it is possible to observe that, even after being properly treated, some patients suffer from UTI more often than others. When two or more episodes of UTI occur in a 6-month period or three or more occur in a 12-month period, the condition is classified as recurrent urinary tract infection (RUTI).The treatment strategy for RUTI depends on multiple patient`s clinical characteristics, such as the number of UTI recurrences per year, her risk factors as well as her preferences for the treatment method. However, prolonged, intermittent antibiotic therapy Is usually utilized for RUTI management.Other prophylactic options include the use of immunomodulators or cranberry. Yet, some patients persist with recurrent infectious episodes, possibly due to either being infected by multi drug-resistant bacteria or having urinary tract modifications, making the usual therapy's action and efficacy more difficult.Therefore, due to the complicated management, alternatives for treatment are being searched, such as the intravesical therapy. It consists in the appliance of medications directly in the urinary bladder, using a catheter introduced through the urethra. This method is being suggested, primarily for infections caused by multi drug-resistant bacteria or for patients with anatomical or functional changes in the urinary tract. An important effect over local pathogens is observed, while there is less systemic absorption and associated collateral effects. The drug options available for intravesical use are antibiotics such as gentamicin, polymyxin and neomycin, as well as hyaluronic acid, isolated or along with chondroitin sulfate.Even though the intravesical therapy is more invasive, it could be an effective therapeutic option for patients suffering from a difficult-to-manage recurrent urinary infection. Thus, it is still necessary to clarify the effectiveness of each of these methods in order to aid healthcare professionals in their therapeutic choice and to raise the success rates in the UTIR treatment, improving patient's quality of life.The goal of this study is to develop a systematic review, if possible, followed by a meta-analysis comparing the efficacy of intravesical therapy to conventional therapy in preventing UTI in women that suffer from RUTI and are not self-catheterized. The question that is going to be answered in this study is: What is the efficacy of the intravesical therapy with gentamicin or polymyxin or neomycin or hyaluronic acid, isolated or along with chondroitin sulfate, respectively, in preventing UTI on women that suffer from RUTI and are not self-catheterized when compared to conventional antibiotic therapy? It was structured using the PICOS(Population, Intervention, Control, Outcome, Studies) format.