Recurrent urinary tract infections (UTIs) are a problematic medical condition commonly presenting in general practice with both physical and psychological implications on the patient population. Patients suffering with recurrent UTIs usually present with symptoms of dysuria, nocturia and increased urinary frequency. In some cases these symptoms can progress to haematuria and overactive bladder with incontinence. 

Prolonged inflammation is commonly associated with malignant pathology. For this reason there appears to be a perceived risk of bladder cancer or alternative pathology in females presenting with recurrent UTIs. Based on the NICE guidelines (1), women over 60 years old with recurrent UTIs or women of any age who have not responded to preventative treatments are to have a non-urgent referral for cystoscopy. The aim of the study was to identify whether there were pathological findings on cystoscopy in patients of this presentation and to review whether cystoscopy is a required investigation in these cases. In our region, ultrasound is also performed prior to all cystoscopies to identify any upper urinary tract causes of recurrent UTIs such as renal stones; therefore these findings will also be interpreted in this study.

We performed a retrospective study over a 12-month period. During this period we reviewed all of the women presenting to a general cystoscopy clinic with recurrent UTIs as the sole complaint. A total of 40 patients’ notes were retrieved and all of these patients had ultrasound investigations prior to cystoscopy. Data was collated from outlook and local CDR systems for analysis.

On ultrasound, findings were normal in the majority of our patients (n=31) and abnormal in a minority of 8 patients. Abnormal ultrasound findings included: a simple cyst (n=4), a small renal stone (n=1), an angiomyolipoma (n=1), a healing pyelonephritis (n=2) and one patient who did not attend (n=1). Despite this small proportion of abnormal results, they were all benign in nature and not requiring further treatment. 

Findings were similar on cystoscopy where 32/40 had normal results and 8/40- abnormal results. 7/8 of abnormal cystoscopies were seen in those aged over 60, although all findings were benign. These included; mild trabeculation (n=1), bladder diverticulum (n=2), extensive cystitis cystica (n=1) and mild cystitis cystica (n=4). As the findings were benign, no treatment was required and all patients returned to conservative management.

From our findings over a 12-month period, all the females that fit our criteria had no signs of bladder cancer or any other sinister pathology seen on ultrasound scan or during cystoscopy. This inevitably led to conservative management of their recurrent UTIs by using a prophylactic dose of antibiotics guided by urine MSU, improving hydration with 2L fluid intake per day, reducing caffeine intake, reducing smoking and other lifestyle changes. Ultimately, these patients were discharged back to the community with no further follow up. There was little variance in pathology on ultrasound scanning compared to cystoscopy. Given these results, it can be assumed that all females independent of age presenting with recurrent UTIs only, are no more at risk of pathology than an asymptomatic patient.

Based on our results there did not appear to be any value in performing an invasive cystoscopy for women presenting with recurrent UTIs given the benign findings on cystoscopy. However, as those over the age of 60 were more likely to have findings (although benign), then a cut-off of 60 years old may still play a role in identifying benign pathology. Findings were similar in ultrasound compared to cystoscopy so there may be consideration for some centres to opt for ultrasound scanning without cystoscopy in women with this presentation as a step-down procedure. Further data collection on larger population groups or meta-analysis could further confirm our findings.

National Institute for Health and Care Excellence (2015). Urinary Tract Infection (lower) –women. Suspected recurrent UTI without haematuria in women who are not catheterized or pregnant. NICE guideline.