Recurrent urinary tract infection (rUTI) is a very common outpatient problem. However, there is a variety of practices and paucity of quality evidence as to how best these patients should be managed. This is the largest study that evaluates the utility of videourodynamics (VUD), the role of additional imaging, and cystoscopy in the complete workup of these patients with rUTI. The specific questions we wanted to address were: 1. In patients with rUTI, what is the utility of VUD? and 2. What is the role of additional imaging or cystoscopy?

This is a retrospective cohort study that was performed on 1031 consecutive patients referred for physician performed VUD from 2013-2019. All patients with rUTI were then selected for further data collection. We defined rUTI as 3 or more episodes in the past year or at least 2 in the past 6 months. Patients were excluded if they were pregnant, had indwelling catheters, performed intermittent self-catheterization or had incomplete data. Subsequent repeat VUD encounters were also excluded. Institutional ethics board approval was obtained, and data were collected and analyzed on demographics, symptoms, cystoscopy results, imaging, and VUD parameters.

After 1031 VUD were reviewed, 132 patients were included after applying exclusion criteria. The median age was 62 years (range: 18-87). There were 115 females and there were 17 (13%) men. A cause for rUTI was identified on VUD in 88 (67%) patients. Causes found included obstruction, Fowler’s syndrome, detrusor sphincter dyssynergia, and detrusor underactivity. About half of all patients were referred for VUD with rUTI as the primary indication; n=73 (55%). 

Interestingly, 88/132 (67%) patients presented with voiding symptoms. Importantly, in those with a history of voiding symptoms, 68/88 (77%) had an identifiable cause for rUTI found in VUD, compared with those without a history of voiding symptoms 20/44 (45%) p=0.00056. Gender was not predictive for finding an identifiable cause for rUTI; p=0.861.

There were 42 patients (32%) with an obvious neurogenic history. Cystoscopic abnormalities was seen in 27 patients, majority of which were of low clinical significance (inflammation, cystitis cystica). Fluoroscopy was abnormal in 19 patients (vaginal prolapse, vesico-ureteric reflux, trabeculation, diverticuli, and high residual volume). In patients investigated primarily for rUTI, there were 59 patients with additional imaging available (ultrasound or CT) with none being diagnostic for rUTI cause. No patients had malignancy found on imaging or cystoscopy.

In patients with rUTI and a history of voiding symptoms, VUD is an important investigative step to find a possible underlying cause. This step helps direct specific treatment and offers management options. We have shown that in these selected patients, a very high proportion (77%) will have some treatable VUD diagnosis. Even those without a specific history of voiding symptoms may benefit from additional VUD, as overall, 67% had a cause found. 

The addition of other imaging or cystoscopy to VUD was not helpful in diagnosing any more causes of rUTI. Importantly, no important diagnosis were found that were not explained by VUD. Nor were there any alarming diagnoses found that would be missed if these modalities were omitted, or considered subsequent to VUD.

This study confirms that VUD is useful in selected patients with rUTI, as many of these patients have identifiable and treatable causes.  Use of VUD is warranted in those with a history of voiding symptoms, as a high percentage of these patients have a diagnosis identified with VUD. Additional imaging, adjunct fluoroscopy, and cystoscopy are unlikely to be of individual benefit.