Tag Archive for: urinary tract infections

Vesico-ureteric reflux: when urine travels in the wrong direction

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Vesico-ureteric reflux, also called vesicoureteral reflux or VUR, occurs when urine flows backwards from the bladder into one or both ureters and sometimes as far as the kidneys.

Normally, each ureter enters the bladder through a short tunnel in the bladder wall. As the bladder fills and contracts, this tunnel is compressed, acting like a one-way valve. In VUR, the valve does not close effectively.

VUR itself does not always cause symptoms. Its importance is that infected urine may travel towards the kidneys, increasing the risk of pyelonephritis, renal scarring and, in a small number of higher-risk patients, long-term kidney damage.

Primary and secondary reflux

Primary VUR

Primary VUR is usually a developmental condition. The ureter’s tunnel through the bladder wall is too short or positioned in a way that prevents reliable closure. It is most commonly diagnosed in infancy or childhood.

As a child grows, the bladder and ureteric junction mature. For this reason, many cases particularly lower-grade reflux, improve or resolve without surgery.

Secondary VUR

Secondary reflux develops because pressure within the bladder is abnormally high or because the bladder does not empty properly. Causes may include:

  • posterior urethral valves or another bladder-outlet obstruction
  • dysfunctional voiding
  • constipation and bladder–bowel dysfunction
  • neurogenic bladder, including spina bifida or spinal cord disease
  • urethral stricture or an enlarged prostate in adults
  • previous bladder or ureteric surgery
  • a poorly compliant, high-pressure bladder.

Treating the underlying bladder or outlet problem is essential. Correcting the reflux alone may fail if the bladder remains unsafe or under excessive pressure.

How does VUR present in children?

Most children do not feel the reflux itself. It is commonly discovered while investigating a urinary tract infection.

Possible presentations include:

  • a fever without an obvious cause, particularly in an infant
  • recurrent urinary tract infections
  • febrile UTIs or kidney infections
  • vomiting, lethargy, irritability or poor feeding in babies
  • abdominal, loin or back pain
  • painful or frequent urination
  • urinary urgency or wetting
  • poor urinary stream or straining
  • antenatal ultrasound showing hydronephrosis or an abnormal urinary tract
  • poor growth
  • high blood pressure or impaired kidney function in more advanced reflux nephropathy.

A child with fever, vomiting, flank pain or marked lethargy may have pyelonephritis and should receive prompt medical assessment.

How does VUR present in adults?

VUR is much less commonly diagnosed for the first time in adulthood. Some adults have persistent congenital reflux that was never detected in childhood, while others develop secondary reflux due to bladder dysfunction or obstruction.

Adults may present with:

  • recurrent febrile UTIs
  • repeated kidney infections
  • loin or flank pain
  • renal scarring found on imaging
  • high blood pressure
  • protein or blood detected in the urine
  • reduced kidney function
  • pregnancy-associated urinary infections
  • lower urinary tract symptoms or incomplete bladder emptying.

Adult VUR should prompt assessment for an underlying cause such as bladder-outlet obstruction, neurogenic bladder, poor bladder compliance or dysfunctional voiding. The evidence guiding adult treatment is less extensive than the paediatric literature, so management is individualised.

How is VUR investigated?

Not every child who has one uncomplicated UTI requires an invasive reflux study. Imaging is selected according to age, clinical presentation, ultrasound findings and whether the infection is atypical or recurrent.

Urine testing

Urinalysis and urine culture confirm infection and help guide antibiotic treatment. A properly collected urine specimen is particularly important in babies and young children.

Kidney and bladder ultrasound

Ultrasound is painless and does not use radiation. It can assess:

  • kidney size and development
  • hydronephrosis or ureteric dilatation
  • bladder-wall appearance
  • congenital urinary abnormalities
  • residual urine after voiding.

A normal ultrasound does not completely exclude VUR.

Micturating cystourethrogram

A micturating cystourethrogram, also called an MCUG or VCUG, is the standard test for confirming and grading reflux.

A small catheter is placed into the bladder, contrast is introduced, and X-ray images are taken while the bladder fills and during urination. The test shows whether contrast travels backwards into the ureters or kidneys and also provides information about the bladder and urethra.

Because catheterisation and a small radiation exposure are involved, MCUG is generally reserved for children in whom the result is likely to influence management.

Contrast-enhanced voiding urosonography

In centres where it is available, contrast-enhanced ultrasound can identify reflux without ionising radiation. Availability and local expertise vary, and conventional MCUG may still be required when detailed urethral anatomy needs assessment.

DMSA renal scan

A DMSA scan assesses the functioning renal cortex and can identify established renal scars. It is not required for every child but may be considered after recurrent febrile infections, in higher-grade reflux, when ultrasound is abnormal or when renal damage is suspected.

Additional assessment

Depending on the circumstances, investigation may also include:

  • blood pressure measurement
  • serum creatinine and estimated kidney function
  • urine protein assessment
  • a bladder and bowel history
  • uroflowmetry and measurement of residual urine
  • a bladder diary
  • urodynamic studies when a high-pressure, neurogenic or poorly emptying bladder is suspected
  • CT or other upper-tract imaging in selected adults.

The five grades of reflux

VUR is graded from I to V according to the international grading system.

Grade Imaging appearance General interpretation
Grade I Reflux reaches the ureter but not the kidney Mild
Grade II Reflux reaches the renal pelvis without dilatation Mild
Grade III Mild to moderate dilatation of the ureter and renal collecting system Moderate
Grade IV Moderate ureteric and collecting-system dilatation with some twisting of the ureter High-grade
Grade V Severe dilatation and tortuosity with loss of normal calyceal detail Severe

The grade is important, but it is not the only factor determining treatment. Age, recurrent infections, kidney scarring, bladder and bowel function, whether reflux affects one or both sides, and family preferences all matter.

What is the aim of treatment?

Treatment aims to:

  • prevent febrile UTIs and pyelonephritis
  • reduce the risk of further renal scarring
  • preserve kidney function
  • treat bladder, bowel or outlet dysfunction
  • avoid unnecessary medication, radiation and surgery.

It is important to understand that repairing reflux cannot reverse established renal scars. Treatment is intended to prevent further infection and injury.

Observation and conservative management

Observation is appropriate for many children, particularly those with lower-grade reflux, healthy kidneys and no recurrent febrile infections.

Conservative care may include:

  • prompt urine testing when fever or urinary symptoms occur
  • regular and complete bladder emptying
  • adequate fluid intake
  • avoiding prolonged holding of urine
  • treating constipation
  • timed voiding
  • management of daytime wetting or dysfunctional voiding
  • periodic clinical and ultrasound review.

Lower-grade reflux is more likely to resolve as the child grows. Higher grades, bilateral reflux and reflux associated with renal abnormalities are less likely to resolve spontaneously.

Continuous low-dose antibiotic prophylaxis

A low dose of antibiotic may be prescribed daily to reduce recurrent infections while waiting for reflux to improve or while deciding whether intervention is required.

Prophylaxis is more likely to be considered in:

  • infants with VUR following a febrile UTI
  • recurrent febrile UTIs
  • higher-grade reflux
  • bladder–bowel dysfunction
  • renal cortical abnormalities
  • children considered at increased risk of another kidney infection.

Antibiotics can reduce recurrent UTIs in appropriately selected children, but they do not mechanically correct the reflux. Disadvantages include medication side effects, adherence difficulties and antibiotic resistance. The need for ongoing prophylaxis should therefore be reviewed rather than continued automatically.

Treating bladder and bowel dysfunction

Constipation, urinary urgency, wetting, infrequent voiding and incomplete bladder emptying increase the risk of recurrent infection and may reduce the success of reflux treatment.

Management can include:

  • regular timed voiding
  • relaxed toilet posture
  • treatment of constipation
  • pelvic-floor or continence physiotherapy
  • medication for selected bladder conditions
  • intermittent self-catheterisation when emptying is inadequate.

In secondary reflux, treating the bladder or outlet disorder may reduce or occasionally eliminate the reflux.

When is a procedure considered?

Intervention may be discussed when there is:

  • a febrile breakthrough UTI despite appropriate prophylaxis
  • recurrent pyelonephritis
  • new or progressive renal scarring
  • persistent high-grade reflux
  • reflux unlikely to resolve spontaneously
  • difficulty tolerating or adhering to antibiotic prophylaxis
  • an anatomical abnormality requiring correction
  • significant family preference after discussion of the alternatives
  • persistent symptomatic reflux in a carefully selected adult.

The two main corrective options are endoscopic injection and ureteric reimplantation.

The STING procedure

STING stands for subureteric transurethral injection. A small telescope is passed through the urethra into the bladder under anaesthesia. A bulking material is injected beneath or within the lower end of the ureter to support and lengthen the valve mechanism.

Dextranomer/hyaluronic-acid copolymer, commonly known by the brand name Deflux, is the best-known injection material. Modified techniques such as HIT or double-HIT place the material within the intramural ureter rather than only beneath its opening.

Advantages

  • minimally invasive
  • no abdominal incision
  • usually performed as day surgery
  • relatively short anaesthetic and recovery
  • low risk of major complications
  • can be repeated if reflux persists.

Limitations and risks

  • success is lower and less predictable than formal reimplantation
  • results are generally better for lower grades of reflux
  • more than one injection may be required
  • reflux may persist or recur
  • temporary blood in the urine, discomfort or infection can occur
  • ureteric obstruction is uncommon but important
  • reflux may occasionally appear on the opposite side
  • long-term durability is not as certain as with successful reimplantation.

Published cure rates vary considerably because they depend on reflux grade, anatomy, injection technique, material used and how success is defined. A single injection commonly corrects approximately 70–80% of refluxing ureters overall, with lower success in grades IV–V. Additional injections can increase the cumulative success rate.

Ureteric reimplantation

Ureteric reimplantation is reconstructive surgery that creates a longer tunnel for the ureter through the bladder wall, restoring the one-way valve mechanism.

The operation may be performed using:

  • an open extravesical approach
  • an open intravesical approach
  • laparoscopic surgery
  • robot-assisted surgery in selected centres and patients.

Open reimplantation has a long-established success rate of approximately 95–98% for primary VUR when performed in suitable patients.

Advantages

  • highest and most durable anatomical correction rate
  • effective for high-grade reflux
  • allows correction of some associated ureteric abnormalities
  • usually requires only one definitive operation.

Limitations and risks

  • more invasive than injection
  • longer anaesthetic and recovery
  • temporary bladder spasms, pain or blood in the urine
  • urinary infection
  • transient urinary retention, particularly after some bilateral extravesical repairs
  • ureteric obstruction
  • persistent reflux or reflux on the opposite side
  • rare need for further surgery.

Robotic or laparoscopic reimplantation can reduce incision size, but it is still major reconstructive surgery and has not made open surgery obsolete. The best approach depends on the child’s anatomy, age, surgeon’s expertise and the reason for intervention.

STING versus reimplantation

Consideration Endoscopic injection Ureteric reimplantation
Invasiveness Minimally invasive Reconstructive surgery
Typical stay Usually day surgery Often one or more nights
Recovery Generally quicker Longer
Success after one procedure Lower and grade-dependent Approximately 95–98%
Repeat treatment Sometimes required Uncommon after successful repair
Best suited to Selected low- or moderate-grade reflux and families prioritising minimal invasiveness High-grade, persistent or complicated reflux; failed injection; selected anatomical abnormalities
Main trade-off Easier recovery but less predictable cure More invasive but more reliable correction

Neither operation is automatically “best.” STING may be attractive when a minimally invasive approach is preferred and its probability of success is acceptable. Reimplantation may be more appropriate when the highest likelihood of definitive correction is important.

VUR in adults

Adults with incidentally detected reflux and no infections, renal deterioration or high-pressure bladder may not require corrective surgery.

Treatment is more likely to be considered when there is:

  • recurrent febrile UTI or pyelonephritis
  • progressive kidney damage
  • troublesome reflux-associated flank pain
  • an untreated bladder-outlet or functional abnormality
  • pregnancy planning in a patient with recurrent infections or reflux nephropathy.

The underlying bladder problem must be identified before anti-reflux surgery. Endoscopic injection can be effective in selected adults, although the supporting evidence is mainly from smaller observational studies. Ureteric reimplantation remains an option when a durable anatomical repair is required.

Women with previous VUR or reflux nephropathy who are considering pregnancy may benefit from pre-pregnancy assessment of blood pressure, kidney function, urine protein and infection risk.

Follow-up

Follow-up should be tailored to reflux grade, renal findings, treatment and infection history.

During observation

Review may include:

  • interval history of UTIs or unexplained fevers
  • height, weight and growth in children
  • blood pressure
  • urine testing when symptoms occur
  • assessment of constipation and bladder symptoms
  • renal and bladder ultrasound
  • serum creatinine and urine protein testing when renal damage is present or suspected
  • selective repeat MCUG, contrast-enhanced urosonography or radionuclide cystography
  • DMSA scanning when new scarring is suspected.

Routine repeated invasive imaging is not necessary for every child. The timing and type of imaging should be chosen only when the result is likely to alter management.

After STING

Follow-up commonly includes an ultrasound to exclude obstruction and clinical monitoring for further UTIs. A repeat reflux study may be recommended after several months, particularly in high-grade reflux, recurrent febrile infection or when confirmation of cure will affect treatment.

Any fever or urinary symptoms after injection should prompt urine testing. Flank pain, vomiting, reduced urine output or significant hydronephrosis requires assessment for the uncommon complication of ureteric obstruction.

After reimplantation

Ultrasound is commonly performed after surgery to check drainage. Routine postoperative MCUG may not be necessary after an uncomplicated reimplantation with a reassuring recovery, but it may be appropriate after breakthrough infection, persistent hydronephrosis or an atypical clinical course.

Long-term surveillance

Patients with renal scarring, bilateral severe reflux, a solitary functioning kidney, proteinuria, hypertension or impaired renal function may require long-term follow-up into adulthood.

Monitoring can include:

  • blood pressure
  • kidney function
  • urine protein
  • recurrent infection
  • pregnancy counselling when relevant.

Even when reflux has resolved, established reflux nephropathy can remain clinically important.

When should urgent medical advice be sought?

Seek prompt medical assessment for:

  • fever with loin or back pain
  • vomiting or marked lethargy
  • reduced urine output
  • a very unwell infant
  • urinary symptoms during pregnancy
  • fever or flank pain after a reflux procedure.

Early diagnosis and treatment of pyelonephritis are particularly important in patients with known VUR.

The key message

Vesico-ureteric reflux ranges from a mild childhood condition that resolves with growth to high-grade reflux associated with recurrent kidney infections and renal scarring.

Treatment should not be based on grade alone. The safest plan considers infection history, kidney health, age, bladder and bowel function, likelihood of spontaneous resolution and the advantages and disadvantages of observation, antibiotic prophylaxis, endoscopic injection and ureteric reimplantation.

References and further reading

  1. European Association of Urology. EAU Guidelines on Paediatric Urology: Vesicoureteric reflux. EAU Paediatric Urology Guidelines
  2. American Urological Association. Management and Screening of Primary Vesicoureteral Reflux in Children. AUA Vesicoureteral Reflux Guideline
  3. National Institute for Health and Care Excellence. Urinary tract infection in under 16s: diagnosis and management (NG224). NICE guideline NG224
  4. RIVUR Trial Investigators. Antimicrobial prophylaxis for children with vesicoureteral reflux. New England Journal of Medicine. 2014;370:2367–2376. PubMed
  5. Mattoo TK, Chesney RW, Greenfield SP, et al. Renal scarring in the Randomized Intervention for Children with Vesicoureteral Reflux trial. Clinical Journal of the American Society of Nephrology. 2016;11:54–61. PubMed
  6. Läckgren G, Cooper CS, Neveus T, Kirsch AJ. Management of vesicoureteral reflux: what have we learned over the last 20 years? Frontiers in Pediatrics. 2021;9:650326. Full text
  7. Salib A, Pizzi M, Landman J, et al. Vesicoureteral reflux in adults with urinary tract infections: is there a role for treatment? Current Urology Reports. 2020. PubMed record

This article provides general education and does not replace individual medical advice. Decisions about imaging, antibiotic prophylaxis or surgery should be made with an appropriately experienced urologist or paediatric urologist.

Recurrent Urinary Tract Infections: Causes, Investigation and Prevention

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Urinary tract infections are common, uncomfortable and sometimes disruptive to everyday life. For some people, however, they keep returning despite apparently appropriate treatment.

A recurrent urinary tract infection, or recurrent UTI, is generally defined as:

  • Two or more symptomatic infections within six months; or
  • Three or more symptomatic infections within 12 months.

Recurrent UTIs are much more common in women, but they also occur in men, particularly when there is prostate disease, incomplete bladder emptying, urinary stones, catheter use or an abnormality of the urinary tract.

The key to successful management is not simply prescribing another antibiotic. We need to confirm that the symptoms are genuinely caused by infection, identify why infections are recurring and develop an individual prevention strategy.

What symptoms suggest a UTI?

A lower urinary tract infection, or cystitis, commonly causes:

  • Burning or stinging when passing urine
  • Increased urinary frequency
  • Urgency
  • Passing small amounts of urine
  • Lower abdominal discomfort
  • Blood in the urine
  • Cloudy or strong-smelling urine

Fever, shaking, flank or kidney pain, vomiting, confusion or feeling seriously unwell may indicate infection involving the kidneys or bloodstream and requires prompt medical assessment.

Is it always an infection?

Not every episode of burning, urgency or bladder discomfort is caused by bacteria. Similar symptoms may result from:

  • Genitourinary syndrome of menopause or vaginal atrophy
  • Overactive bladder
  • Interstitial cystitis/bladder pain syndrome
  • Pelvic-floor muscle dysfunction
  • Urethral or vaginal inflammation
  • Sexually transmitted infections
  • Urinary stones
  • Bladder cancer
  • Prostatitis
  • Incomplete bladder emptying

Repeated antibiotics given without confirming infection can delay the correct diagnosis and increase antibiotic resistance.

Whenever practical, a midstream urine sample should be collected for culture before commencing antibiotics. The European Association of Urology recommends confirming recurrent cystitis with urine cultures.

Why do urinary infections keep returning?

Most UTIs are caused by bacteria, commonly Escherichia coli, travelling from the bowel or genital region into the urinary tract. Recurrence may represent reinfection with a new organism or relapse involving the same organism.

Common contributing factors in women

These include:

  • Sexual intercourse
  • Spermicide or diaphragm use
  • A new sexual partner
  • Pregnancy
  • Menopause and loss of vaginal oestrogen
  • Vaginal or pelvic-organ prolapse
  • Urinary incontinence
  • Incomplete bladder emptying
  • Diabetes
  • Previous antibiotic exposure
  • Urinary stones or obstruction
  • Catheterisation or urinary-tract procedures

Causes that are particularly important in men

Recurrent UTI in a man usually warrants further assessment. Possible contributors include:

  • Benign prostate enlargement and bladder-outlet obstruction
  • Chronic bacterial prostatitis
  • Urethral stricture
  • Urinary stones
  • High residual urine volumes
  • Catheter use
  • Previous urinary surgery or instrumentation
  • Neurological bladder dysfunction

How are recurrent UTIs investigated?

Assessment begins with a careful history and review of previous urine-culture results. The clinician may consider:

  • Urinalysis and urine culture during symptomatic episodes
  • Examination for vaginal atrophy or pelvic-organ prolapse
  • Measurement of the amount of urine remaining after voiding
  • Kidney and bladder ultrasound
  • Assessment of urinary flow
  • Blood tests, including kidney function and diabetes screening
  • Evaluation for prostatitis in men
  • Cystoscopy or CT imaging in selected patients

Routine cystoscopy or extensive imaging is not necessary for every otherwise healthy woman. Further investigation becomes more important when there is visible blood in the urine, recurrent kidney infection, persistent pain, stones, unusual organisms, poor bladder emptying, previous urinary surgery or failure of standard prevention.

Treating an acute infection

A symptomatic, culture-confirmed infection is usually treated with a short course of antibiotics selected according to:

  • The urine-culture result
  • Previous antibiotic exposure
  • Allergies
  • Kidney function
  • Pregnancy status
  • Local bacterial-resistance patterns

Suitable patients who recognise their symptoms reliably may be offered a prearranged “self-start” antibiotic course, ideally after submitting a urine sample.

A positive urine culture without urinary symptoms is called asymptomatic bacteriuria. It usually should not be treated, except in specific situations such as pregnancy or before certain urological procedures. Treating asymptomatic bacteriuria unnecessarily may increase adverse effects and antibiotic resistance without preventing future infections.

A stepwise prevention strategy

Prevention should normally begin with correction of contributing factors and non-antibiotic measures. Medication or antibiotic prophylaxis can then be introduced when the expected benefit outweighs the risks.

1. Hydration and bladder habits

For people who normally drink relatively little, increasing water intake may reduce infection frequency. One clinical trial found benefit from an additional 1.5 litres of water daily in premenopausal women whose usual fluid intake was below 1.5 litres per day.

Other practical measures include:

  • Avoiding prolonged delays in passing urine
  • Emptying the bladder after intercourse if this appears helpful
  • Treating constipation
  • Avoiding spermicides when infections are temporally associated with their use
  • Managing prolapse or incomplete bladder emptying
  • Reviewing catheter technique and necessity
  • Optimising diabetic control

Many traditional recommendations: such as a particular wiping direction, special underwear or mandatory post-coital voiding, have limited supporting evidence. They are generally harmless but should not be presented as guaranteed prevention.

2. Vaginal oestrogen

Vaginal oestrogen is one of the best-supported non-antibiotic treatments for postmenopausal women with recurrent UTIs, particularly when vaginal dryness, irritation or discomfort is present.

It may be supplied as a cream, pessary or vaginal tablet. Local treatment helps restore the vaginal tissues and protective bacterial environment. It is different from systemic menopausal hormone therapy and produces much lower systemic hormone exposure.

Temporary local irritation or spotting may occur. Women with a history of oestrogen-sensitive cancer should discuss treatment with their treating specialists. Oral oestrogen has not demonstrated the same UTI-prevention benefit.

The EAU gives vaginal oestrogen a strong recommendation for prevention in postmenopausal women.

3. Methenamine hippurate

Methenamine hippurate is a urinary antiseptic rather than a conventional antibiotic. In acidic urine, it is converted into formaldehyde, which suppresses bacterial growth.

The ALTAR randomised trial found that methenamine hippurate was not inferior to daily low-dose antibiotics for preventing recurrent UTIs in women over 12 months, although the antibiotic group experienced slightly fewer infections.

Methenamine can be a useful antibiotic-sparing option for selected patients without significant urinary-tract abnormalities. It may not be suitable in severe kidney or liver impairment and must not be combined with sulfonamide antibiotics. Alkalinising urinary products may reduce its effectiveness. Medical supervision is therefore important.

4. Cranberry products

Cranberry products may modestly reduce recurrent UTIs in some women, but products and doses vary greatly. Evidence is supportive but inconsistent, and there is no universally accepted dose.

Cranberry should be considered an optional supplement rather than a replacement for investigation or proven treatment. Patients taking warfarin should discuss cranberry products with their doctor because of a potential interaction.

5. D-mannose

D-mannose has been widely promoted as preventing E. coli from adhering to the bladder lining. Earlier small studies suggested benefit, but a larger placebo-controlled trial found that daily D-mannose did not significantly reduce medically attended recurrent UTIs.

It may still be chosen by some patients, but expectations should be realistic. Current evidence is weak and contradictory.

6. Probiotics

Some vaginal Lactobacillus preparations may help restore protective vaginal flora, but results depend on the bacterial strain and formulation. Evidence remains insufficient to recommend all commercially available oral or vaginal probiotics as equivalent treatments.

Prophylactic antibiotics

When infections remain troublesome despite correcting reversible causes and trying appropriate non-antibiotic measures, prophylactic antibiotics may be considered.

Post-coital prophylaxis

A single antibiotic dose taken after intercourse may be appropriate when infections are clearly related to sexual activity. It reduces total antibiotic exposure compared with daily treatment.

Continuous low-dose prophylaxis

A low-dose antibiotic may be prescribed nightly or at another regular interval, commonly for three to six months and sometimes longer. Options may include nitrofurantoin, trimethoprim, cefalexin or intermittent fosfomycin, depending on culture results, renal function, allergies and Australian resistance patterns.

Daily and post-coital prophylaxis appear similarly effective when correctly matched to the patient’s infection pattern.

Potential disadvantages include:

  • Thrush, nausea or diarrhoea
  • Allergic reactions
  • Selection of resistant bacteria
  • Clostridioides difficile infection
  • Drug-specific toxicity

Long-term nitrofurantoin, for example, can rarely affect the lungs, liver or peripheral nerves and requires appropriate clinical monitoring. Infections may return after prophylaxis is stopped.

For these reasons, antibiotic prophylaxis should be reviewed periodically rather than continued automatically.

Bladder instillations

The correct term is bladder or intravesical instillation. A small catheter is passed into the bladder, and a solution is introduced and retained for a prescribed period.

Hyaluronic acid, alone or combined with chondroitin sulphate, is intended to replenish the bladder’s protective glycosaminoglycan layer. Studies suggest that these treatments may:

  • Reduce the number of recurrent infections
  • Increase the time before the next infection
  • Improve associated bladder pain, urgency or frequency in some patients

However, the evidence is based on relatively small and mixed-quality studies. The EAU makes only a weak recommendation for these instillations after less-invasive prevention strategies have failed.

Treatment usually requires an initial series followed by maintenance instillations. Disadvantages include cost, inconvenience, temporary discomfort and the small infection or urethral-trauma risk associated with catheterisation.

Antibiotic bladder instillation, most often gentamicin, is used off-label in selected patients, particularly those performing intermittent catheterisation or those with neurological bladder dysfunction and resistant infections. Evidence is mainly observational, and treatment should be supervised by an experienced urologist or infectious-diseases team. It is not routine first-line therapy for otherwise healthy patients.

Are vaccines available for recurrent UTIs?

Several bacterial immunoactive products are sometimes described as UTI “vaccines,” although they are different from conventional childhood vaccines and are not routinely available or approved in every country.

Examples include:

  • OM-89 or Uro-Vaxom: an oral preparation containing bacterial lysates from selected E. coli strains
  • MV140 or Uromune: a sublingual spray containing inactivated whole-cell bacteria
  • StroVac: an injectable bacterial preparation available in limited settings
  • Other experimental products, including ExPEC vaccines

MV140 has produced encouraging results in a randomised trial and observational studies. However, the EAU notes that the certainty of the overall evidence remains low and currently recommends immunomodulatory prophylaxis mainly within a well-regulated clinical-trial setting.

These products should not be advertised as a guaranteed cure. Regulatory approval, supply and access vary, and some may be unapproved or available only through special-access pathways in Australia. Patients should discuss the evidence, cost, regulatory status and alternatives with their urologist before considering treatment.

When should you seek urgent help?

Prompt medical assessment is important if urinary symptoms are accompanied by:

  • Fever or shaking chills
  • Kidney or flank pain
  • Vomiting or inability to keep fluids down
  • Confusion, faintness or severe weakness
  • Pregnancy
  • Inability to pass urine
  • Significant visible blood or blood clots
  • Rapid deterioration or concern about sepsis

Men, children, pregnant women, immunocompromised patients and people with urinary obstruction, catheters or known kidney disease generally require earlier assessment.

The take-home message

Recurrent UTIs are real and can have a substantial effect on comfort, confidence, sexual relationships, work and quality of life. Management should go beyond repeated short courses of antibiotics.

A sensible strategy is to:

  1. Confirm symptomatic episodes with urine cultures.
  2. Exclude conditions that mimic infection.
  3. Identify stones, obstruction, residual urine, prolapse, vaginal atrophy or prostate disease.
  4. Correct reversible causes.
  5. Introduce evidence-based non-antibiotic prevention.
  6. Consider methenamine or carefully selected antibiotic prophylaxis when necessary.
  7. Reserve bladder instillations and immunoactive treatments for appropriately selected patients after an informed discussion.

Treatment should always be individualised according to the patient’s culture results, anatomy, medical history and personal preferences.

So, if you suffer with chronic or recurrent infections, ask your GP for a referral to your Brisbane, Caboolture Urologist, Dr Jo Schoeman for further advice.

References and further reading

  1. European Association of Urology. EAU Guidelines on Urological Infections. Section on recurrent cystitis.
  2. American Urological Association, Canadian Urological Association and Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction. Recurrent Uncomplicated Urinary Tract Infections in Women Guideline.
  3. National Institute for Health and Care Excellence. Urinary tract infection—recurrent: antimicrobial prescribing, NG112.
  4. Harding C, Mossop H, Homer T, et al. Alternative to prophylactic antibiotics for the treatment of recurrent urinary tract infections in women: the ALTAR non-inferiority trial. BMJ. 2022;376.
  5. Williams G, Hahn D, Stephens JH, et al. Cranberries for preventing urinary tract infections. Cochrane Database of Systematic Reviews. 2023.
  6. Hayward G, Mort S, Hay AD, et al. D-mannose for prevention of recurrent urinary tract infection among women. JAMA Internal Medicine. 2024.
  7. Infectious Diseases Society of America. Clinical practice guideline for the management of asymptomatic bacteriuria.
  8. Australian Commission on Safety and Quality in Health Care. Antimicrobial stewardship resources.

This information is intended for general education and does not replace individual medical assessment. Antibiotic choice and preventive treatment should be guided by urine cultures, kidney function, allergies, pregnancy status, local resistance patterns and current Australian prescribing guidance.

Blood in the Urine (Haematuria): When Should You See a Urologist Brisbane?

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Discovering blood in your urine can be alarming. While there are many possible causes, blood in the urine should never be ignored. Known medically as haematuria, this symptom can sometimes indicate an underlying condition requiring specialist assessment. Consulting an experienced Urologist Brisbane patients rely on can help identify the cause and provide appropriate treatment.

What Is Haematuria?

Haematuria refers to the presence of blood in the urine. It can occur in two forms:

Visible Haematuria

The urine appears pink, red or brown due to the presence of blood.

Microscopic Haematuria

Blood cells are detected only during laboratory testing and may not be visible to the naked eye.

Both forms should be assessed by a healthcare professional.

Common Causes of Blood in the Urine

There are numerous possible causes of haematuria, including:

Urinary Tract Infections

Infections affecting the bladder, kidneys or urinary tract can cause irritation and bleeding.

Kidney Stones

Kidney stones can damage the lining of the urinary tract, resulting in blood appearing in the urine.

Enlarged Prostate

An enlarged prostate can place pressure on the urinary system and may contribute to urinary symptoms and bleeding.

Vigorous Exercise

In some cases, intense physical activity can lead to temporary blood in the urine.

Kidney Disease

Various kidney conditions may result in haematuria and require specialist management.

Urinary Tract Cancers

Although less common, blood in the urine can sometimes be associated with cancers affecting the bladder, kidney or urinary tract. This is one reason why prompt evaluation by a Urologist Brisbane specialist is important.

Symptoms That May Accompany Haematuria

Depending on the underlying cause, patients may also experience:

  • Pain during urination
  • Frequent urination
  • Lower abdominal discomfort
  • Back or flank pain
  • Difficulty passing urine
  • Fever or chills

These symptoms can provide valuable clues during diagnosis.

How Does a Urologist Brisbane Diagnose Haematuria?

A comprehensive evaluation may include:

Medical History and Physical Examination

Your specialist will discuss symptoms, medical history and risk factors.

Urine Testing

Urinalysis helps identify infection, blood cells and other abnormalities.

Blood Tests

Blood tests may assess kidney function and identify underlying conditions.

Imaging Studies

Ultrasound or CT imaging can help detect stones, tumours or structural abnormalities.

Cystoscopy

A cystoscopy allows a Urologist Brisbane specialist to examine the inside of the bladder using a small camera.

Why Early Investigation Matters

While haematuria can sometimes result from minor conditions, it may also be an early warning sign of a more serious problem. Early diagnosis often leads to more effective treatment and improved outcomes.

Delaying assessment can allow certain conditions to progress and become more difficult to treat.

When Should You Seek Medical Advice?

You should arrange an appointment if:

  • You notice visible blood in your urine
  • Blood is detected during routine testing
  • Haematuria occurs repeatedly
  • You experience pain or urinary symptoms
  • You have a history of smoking or urinary tract conditions

Speak with a Urologist Brisbane Today

If you have noticed blood in your urine or have concerns about your urinary health, our experienced team is here to help. We provide thorough assessments, advanced diagnostic services and personalised treatment plans to identify the cause and protect your long-term health. Contact our clinic today to book a consultation with a trusted Urologist Brisbane specialist.

Microbiome of the Male Reproductive System: The Hidden Factor in Men’s Health

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When most people think about the microbiome, they imagine gut bacteria affecting digestion and immunity. But did you know that the male reproductive system also has its own unique microbiome? This hidden ecosystem of microorganisms plays a surprising role in fertility, hormone balance, and overall sexual health.

What Is the Male Reproductive Microbiome?

The male reproductive microbiome refers to the community of bacteria and other microorganisms living in the penis, testes, prostate, and semen. While it’s less studied than the gut microbiome, research shows that these microbes are crucial for maintaining reproductive health.

A balanced microbiome supports sperm quality, prevents infections, and even influences the immune environment of the reproductive tract. On the other hand, imbalances sometimes caused by antibiotics, poor hygiene, infections, or lifestyle factors can lead to fertility issues and other complications.

How the Microbiome Affects Fertility

Studies suggest that an unhealthy male reproductive microbiome may contribute to:

  • Reduced sperm motility: making it harder for sperm to reach the egg.

  • Decreased sperm count: fewer sperm can lower the chance of conception.

  • DNA fragmentation: damaged sperm DNA can affect embryo quality.

  • Inflammation: chronic inflammation in the reproductive tract can impair fertility and sexual health.

Even small changes in microbial balance can have a measurable impact on reproductive outcomes, highlighting why men’s microbiomes deserve attention.

Factors That Influence the Male Microbiome

Several lifestyle and environmental factors can disrupt the delicate balance of microbes:

  • Antibiotic use: kills both harmful and beneficial bacteria.

  • Diet: processed foods, sugar, and alcohol can negatively impact microbial health.

  • Hygiene: poor genital hygiene can allow harmful bacteria to thrive.

  • Sexual activity: sexually transmitted infections can alter microbial balance.

  • Chronic stress: stress hormones can influence bacterial populations and immunity.

Maintaining healthy habits is essential for keeping the microbiome in check.

Supporting a Healthy Male Microbiome

Here are practical ways men can support their reproductive microbial health:

  1. Balanced diet: Include fiber-rich fruits, vegetables, fermented foods, and lean protein.

  2. Probiotics: Supplements or natural sources (like yogurt or kefir) can help maintain beneficial bacteria.

  3. Safe sexual practices: Use protection and get regular STI screenings.

  4. Gentle hygiene: Avoid harsh soaps; washing with mild cleansers is best.

  5. Lifestyle management: Reduce alcohol, quit smoking, manage stress, and exercise regularly.

Why It Matters

The male reproductive microbiome is more than just a scientific curiosity, it’s a critical component of sexual and reproductive health. By understanding and supporting this hidden ecosystem, men can improve fertility, reduce infection risk, and even support hormone balance and overall wellness.

Conclusion:
Men’s health isn’t just about testosterone, erections, or sperm count, it’s also about the microscopic world living inside the reproductive system. Paying attention to the male reproductive microbiome is a small step with potentially big benefits for fertility, sexual function, and overall health.