Urinary Issues Evaluation and Management

Introduction to Urinary Issues

• The primary underlying causes of urinary issues include urinary tract infections, urinary tract malignancies, urolithiasis, benign prostatic hyperplasia, anatomical abnormalities, and neurological disorders that affect bladder function, as stated by the American College of Radiology 1, 2

Urinary Tract Infections (UTIs)

• Other common pathogens for UTIs include Enterococcus faecalis, Proteus mirabilis, Klebsiella, and Staphylococcus saprophyticus, according to the American College of Radiology 2
• Risk factors for recurrent UTIs include sexual activity, use of spermicidal contraceptives, and postmenopausal status with atrophic vaginitis, as reported by the American College of Radiology 2
• The American Urological Association recommends confirming diagnosis of recurrent UTI (≥3 episodes in 12 months or ≥2 episodes in 6 months) before starting prophylactic antibiotics, and ensuring eradication of previous UTI with negative urine culture 1-2 weeks after treatment 3
• Behavioral modifications such as adequate hydration, urge-initiated voiding, post-coital voiding, and avoiding spermicidal contraceptives should be implemented before starting prophylactic antibiotics, as recommended by the American College of Radiology 2
• The American Urological Association recommends continuous antibiotic prophylaxis with nitrofurantoin 50-100mg daily as the first-line prophylactic treatment for recurrent urinary tract infections caused by Enterococcus faecalis, due to low resistance rates (only 20.2% at 3 months and 5.7% at 9 months) 3
• Trimethoprim-sulfamethoxazole 40/200mg daily and trimethoprim 100mg daily may be considered based on susceptibility testing, as recommended by the American Urological Association 3
• Post-coital prophylaxis with low-dose antibiotic within 2 hours of intercourse may be considered for infections associated with sexual activity, as recommended by the American Urological Association 3
• For postmenopausal women, vaginal estrogen with or without lactobacillus probiotics may be considered, as recommended by the American Urological Association 3, 4
• Methenamine hippurate is strongly recommended for women without urinary tract anomalies who prefer to avoid antibiotics or have developed antibiotic resistance, as recommended by the American Urological Association 4
• Lactobacillus-containing probiotics, particularly L. rhamnosus GR-1 or L. reuteri RC-14, may be considered once or twice weekly, as recommended by the American Urological Association 3
• Cranberry products with a minimum of 36mg/day proanthocyanidin A may be considered, as recommended by the American Urological Association 3
• Prophylaxis should be continued for 6-12 months, and effectiveness and need for continued prophylaxis should be reassessed after this period, as recommended by the American Urological Association 3
• Fluoroquinolones should be avoided for uncomplicated UTIs due to unfavorable risk-benefit ratio, as warned by the FDA and recommended by the American Urological Association 3
• Asymptomatic bacteriuria should not be treated, as it increases the risk of symptomatic infection, bacterial resistance, and healthcare costs, as recommended by the American Urological Association 3
• Antibiotics should be chosen based on prior culture results, local resistance patterns, and patient-specific factors, as recommended by the American Urological Association 3

Benign Prostatic Hyperplasia (BPH)

• BPH may lead to urinary retention and overflow incontinence if severe, as stated by the American College of Radiology 1

Urolithiasis (Kidney/Urinary Tract Stones)

• Urolithiasis is a common benign urogenic cause of hematuria, according to the American College of Radiology 1
• Urolithiasis can cause obstruction, pain, and irritative voiding symptoms, as reported by the American College of Radiology 2

Anatomical Abnormalities

• Anatomical abnormalities such as cystoceles, bladder or urethral diverticula, and fistulae can cause urinary issues, according to the American College of Radiology 2

Urinary Tract Malignancies

• Risk factors for urinary tract malignancies include gross hematuria, male gender, age >35 years, smoking, occupational exposure to chemicals, analgesic abuse, history of urologic disease, irritative voiding symptoms, history of pelvic irradiation, chronic UTIs, exposure to carcinogens, and chronic indwelling foreign bodies, as stated by the American College of Radiology 1
• Gross hematuria has a 30-40% association with malignancy, according to the American College of Radiology 1
• Microhematuria has a 2.6-4% risk of malignancy, as reported by the American College of Radiology 1
• Malignancies can occur anywhere in the urinary tract and require thorough evaluation, according to The Journal of Urology 5

Overactive Bladder/Detrusor Overactivity

• Overactive bladder/detrusor overactivity causes urgency, frequency, and urgency incontinence, as stated by The Journal of Urology 6
• Overactive bladder/detrusor overactivity is common after prostate treatment (up to 48% prevalence), according to The Journal of Urology 6

Stress Urinary Incontinence

• Stress urinary incontinence is due to sphincter weakness or pelvic floor dysfunction, as reported by The Journal of Urology 6

Interstitial Cystitis

• Interstitial cystitis is more common in women with chronic pelvic pain and microhematuria, according to the American College of Radiology 1
• Interstitial cystitis is often difficult to diagnose, as stated by the American College of Radiology 1

Renal Parenchymal Disease

• Renal parenchymal disease is the most common benign nephrogenic cause of hematuria, according to the American College of Radiology 1

Evaluation and Management

• For proper evaluation of urinary issues, consider urinalysis and urine culture to identify infection, hematuria, or pyuria, although no specific guideline society is mentioned for this point
• CT urography (CTU) is the imaging procedure of choice for evaluating hematuria, as stated by The Journal of Urology 5
• Ultrasound is recommended for initial evaluation in certain populations, according to the American College of Radiology 2
• Cystoscopy is recommended for patients with risk factors for malignancy or aged ≥35 years with hematuria, as stated by The Journal of Urology 5

Special Populations

• In children, enuresis (bedwetting) may be related to delayed maturation of bladder control, psychological factors, or sleep disorders, according to the American Academy of Child and Adolescent Psychiatry 7
• In children, enuresis may be associated with constipation, encopresis, or sleep apnea, as reported by the American Academy of Child and Adolescent Psychiatry 7