Recurrent urinary tract infections(rUTI) is one of the most common presentations in a Urogynaecology clinic. A high percentage of these women have voiding dysfunction with abnormal flow pattern and high post-void residual(PVR) urine. The impaired bladder emptying may play an important role in increasing the susceptibility to bacterial colonization and subsequent UTI. Repeated episodes of UTI results in multiple insults to the urothelium. While rUTI has not been proven to be a direct etiological factor for Interstitial Cystitis/Bladder Pain Syndrome(IC/BPS),  urothelial barrier disruption has been a known pathophysiology.
This study aims to elaborate that an untreated or undiagnosed voiding dysfunction, leads to recurrent urinary tract infections, that in turn developes in to IC/BPS and can be a conundrum for the clinicians to treat.

We present a case series of five patients, whose initial presentation was IC/BPS with pain/unpleasent sensation associated with bladder filling or urination, urgency, urge incontinence &  frequency. All had negative urine culture at presentation.Detailed clinical history revealed many episodes of culture-proven UTI, over the past two years. Cystoscopy was done in all cases. With a diagnosis of IC/BPS intra-vesical cocktail regimen was initiated. As the patients continued treatment, despite symptomatic improvement, UTI developed in all cases. That led us to perform, Urodynamic study(UDS), after treating the infection, which revealed final diagnosis of voiding dysfunction. Transperineal ultrasound & micturating cystogram was done to rule out bladder neck obstruction & vesico-ureteric reflux. Addition of treatment for voiding dysfunction along with pelvic floor rehabilitation was initiated.
Sociodemographic parameters noted were age, height, weight, BMI, parity, menopausal status, use of vaginal estrogen cream, sexual activity, and relevant medical or surgical history. Clinical parameters noted were the various lower urinary tract symptoms(LUTS), history of rUTI, presence of any genitourinary anomalies, prolapse staging.

Mean age of patients 55.6 years (range 46-63). 40%(2/5) patients were sexually active.80%(4/5)patients were postmenopausal & using vaginal Estrogen cream. All of them had history of rUTI ovar past few years. Most common symptoms were Dysuria 100% (5/5), frequency 80% (4/5), Urgency 60% (3/5), and urge incontinence 40% (2/5).  On UDS, all patients had significant PVR, 80% (4/5) had raised EMG activity suggesting dysfunctional voiding, Raised Pdet in 20%(2/5) cases, decreased cystometric capacity in 40%(2/5). None of the patients had bladder neck obstruction & vesico-ureteric reflux. None of the patients had pelvic organ prolapse. All  patients developed UTI during the treatment.

Each of the patients were begun with treatment for IC/BPS & but contracted UTI during the course of treatment, and finally had significant improvement when treatment encompassed management of their voiding dysfunction.

IC/BPS and rUTI are two of the very difficult clinical entities to treat and an undiagnosed pathology of voiding dysfunction can make their management even more elusive. The approach to manage such cases should be a symptomatic management of IC/BPS & careful evaluation to clinch the diagnosis of voiding dysfunction as the main culprit of the clinical trifacta.