Abstract
PurposeTo measure the effects of an unplanned, sudden cessation of treatment in an unselected group of patients with chronic painful LUTS managed with protracted antimicrobial treatment and to report these observational data collected from a cross-over process.Materials and methodsThe imposition of a guideline resulted in the immediate cessation of antibiotic treatment in a cohort of patients with chronic painful LUTS and microscopic pyuria. Patients were assessed before treatment withdrawal, whilst off treatment, and following reinstatement. Outcome measures included a validated symptom score, microscopic enumeration of urinary white cells and uroepithelial cells, and routine urine culture.ResultsThese patients had reported treatment-resistant, painful LUTS for a mean of 6.5 years before treatment at this centre. Treatment was stopped in 221 patients (female = 210; male = 11; mean age = 56 years; SD = 17.81). Sixty-six per cent of women were post-menopausal. After unplanned treatment cessation, 199 patients (90%; female = 188; male = 9) reported deterioration. Eleven patients required hospital care in association with disease recurrence, including acute urinary tract infection (UTI) and urosepsis. Symptom scores increased after cessation and recovered on reinitiating treatment (F = 33; df = 2; p < 0.001). Urinary leucocyte (F = 3.7; df = 2; p = 0.026) and urothelial cells counts mirrored symptomatic changes (F = 6.0; df = 2; p = 0.003). Routine urine culture results did not reflect changes in disease status.ConclusionThese data support the hypothesis that treating painful LUTS associated with pyuria with long-term antimicrobial courses, despite negative urine culture, is effective. The microscopy of fresh unspun, unstained urine to count white cells and epithelial cells offers a valid method of monitoring disease. An unplanned cessation of antibiotic therapy produced a resurgence of symptoms and lower urinary tract inflammation in patients with chronic LUTS, supporting an infective aetiology below the level of routine detection.
Highlights
Recalcitrant chronic bladder pain and symptoms of recurrent cystitis in patients with negative urinalysis present a worrying management problem
Some patients (20%) could be discharged after only 6 months, we found that it took an average of 383 days [95% confidence interval (CI) = 337–428] to achieve symptom resolution without the need for further antibiotic treatment
We continue treatment until symptom control is optimal and pyuria has cleared before testing treatment withdrawal; we restart the treatment if relapse occurs
Summary
Recalcitrant chronic bladder pain and symptoms of recurrent cystitis in patients with negative urinalysis present a worrying management problem. The treatment of painful lower urinary tract symptoms (LUTS) is a significant challenge, and there are few quality data to guide clinicians. The evidence for oral or intravesical therapies for painful bladder symptoms is poor [1]. Acute symptoms of cystitis and negative urinalysis are often exposed to multiple, short courses of antibiotics in primary care without evidence of benefit [5]. While there are published guidelines for managing acute and recurrent urinary tract infection (UTI) [6], there are none for patients who may be suffering a chronic form of the disease.
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