Urinary infections in women at

menopause
Prof.Univ. Dr. Viorel Jinga
Rector of ”Carol Davila” University of Medicine and Pharmacy Bucharest
Clinical Hospital “Prof.Dr.Th.Burghele” Bucharest
Asist.Univ.Dr. Cristian Toma
• Urinary Tract Infection
• - Dif clasf E and the most used ones are those
developed by CDC, IDSA, ESCMID, FDA

• -EAU guidelines ORENUC classification based

• : clinical presentation, anatomic level, severity, risk
factors + availability of appropriate antimicrobial
therapy
Definition of Menopause
• Menopause- Menopause is physiologic or iatrogenic
cessation of menses (amenorrhea) due to decreased
ovarian function.
• Manifestations may include hot flushes, night
sweats, sleep disruption, and genitourinary
syndrome of menopause (symptoms and signs due
to estrogen deficiency, such as vulvovaginal
atrophy).
• Diagnosis is clinical: absence of menses for 1 yr.
ESMA , SOGR, SRM
Asymptomatic bacteriuria &
Symptomatic UTIs
• Commonly found in Outpatient practice
• Symptomatic UTI ( Cystitis, Pyelonephritis, recurrent
UTI-> sepsis aso with ITU which requires
hospitalization)
• Asymptomatic Bacteriuria ABU – transient in older
menopausal women; often resolves NO Treat, not
ASO with mortality/morbidity.
• Symptomatic UTI = clinical features + evidence of
Urinary Infection
Clincal features of Symptomatic UTI ( TWO features needed)

• Acute dysuria
• Suprapubic tenderness
• Costovertebral angle pain or tenderness
• Urinary frequency
• Worsened urinary urgency
• Fever ( usually found in complicated UTI Pyelo/Sep)

Laboratory evidence
+ Urine culture (>100 000 CFU/mL) with no more than 2
uropathogens ( otherwise contamination)
 pyuria (>1o WBC/HPF)
 Uro Inf Guidelines
• ABU- type of commensal colonisation
• - studies show >>> may protect against
SUPERinfecting symptomatic UTI
• - treatment >>>given only in selected cases of proven
benefit
• EPIDEMIOLOGY
• 1-5% healthy pre-meno women
• 4-19% healthy elderly females ( menopausal)
• 15-50% in institutionalised elderly populations
(menopausal)
 Uro Inf Guidelines

• Pers without Urinary Tract symptoms + MSU with bacterial

growth>100000 CFU/mL in 2 CONSECUTIVE samples in women.
• Mrs S.A. 72 years old, retired, husband, sexually active, HT, DM2,
hyperlipidemia, knee replacement, coronary artery disease
• Visits physician for chronic urinary frequency + incontinence
• Patient known with UTI since highschool, and for 6 years with stress
incontinence.
Mrs SA – Case presentation
• Urinary frequency ( every 2-3 h)
• nocturia ( as often as 2 h)
• taught to reduce liquid input in the evening
• increasing symptoms in the last months
• started wearing dippers
• No dysuria or Hematuria
• 5 + cultures in the last 12 months with E.Coli
• worsening symptoms>>> forced Physician to give AB>>>but
NO improvement in incontinence and symptoms
• What should we do next?
Discussion
• Mrs SA has several risk factors for UTI
• 1. Menopause
• 2. incontinence
• 3. prior symptomatic UTIs
• 4. sexually active
• 5. DM 2

• BUT….
 Still ABU
• Mrs SA does not meet the criteria for symptomatic UTI
since her only symptom is worsening urinary frequency
without other UTI-specific symptoms.

• She likely has worsening of chronic urinary incontinence

and increased frequency because of continued diuretic use
or as a natural progression of her incontinence.

• Antibiotics did not improve Mrs SA’s incontinence, also

suggesting that her UTI should not be categorized as
symptomatic.
Back to ABU
• Generally benign in menopausaul women
• Older women with or without bacteriuria will OFTEN have :
- specific genitourinary symptoms including worsening
urgency + incontinece + dysuria + non specific symptoms
( fatigue, weakness, anorexia)
• 1 longitudinal study Medical College of Pennsylvania
Ambulatory older patients(f+m)
• urine cultures were obtained at 6 months intervals

•30% spontaneously resolved their bacteriuria

•30% with no initial bacteriuria ->>> subsequently
developed asymptomatic bacteriuria
• Chronic incontinent and/or disabled older adults 45%
prevalence of PYURIA; 43% prevalence Bacteriuria
Hard decision

• Mrs SA her chronic Incont makes it difficult to

differentiate ABU from symptomatic UTI ( which can
be dangerous and evolve to urosepsis/pyelonephritis)

• That is why in order to evoke a treatable UTI Mrs SA

should fulfill both signs and symptoms of UTI ( >2
genitourinary signs/symptoms) + laboratory
confirmation(bacteriuria,pyuria) to establish the
diagnosis in menopausal patient.
Menopausal women
• Have fluctuations in urgency and incontinence
WITHOUT urinary infection
• Chronic dysuria – prevalent, gets worse with age
• How about NEW/Acute Dysuria???
• Institutionalized frail older adults showed significant
association between +UroCult and Acute Dysuria
(relative risk [RR], 1.58; 95% CI, 1.10–2.03), and change
in character of urine(RR, 1.42; 95% CI, 1.07–1.79)
• Of these clinical features acute dysuria(< 1 week in
duration) was the most effectively predicted lab conf of
UTI
 Establishing diag of sympt UTI in menopausal women-
urgent?
• -menopausaul women have high preval of ABU
AND
• -menop women have progressively worsening urinary incontinence
===> require assesment of new signs and symptoms.
How fast should it be done? No clear answer
• Although UTI can be serious -> several randomized controlled trials found that 25-50% women with
UTI sympt will have recovered WITHOUT using AB
• Spontaneous SYMPTOM improvement occurs in 50% community-dwelling noncatheterized women
who DELAY AB treatment

• CONCLUSION: delaying AB treatment while establishing if ABU/SYMPT UTI generally DOES NOT LEAD
to adverse outcomes
However AB overuse has serious drawbacks!
EAU Guidelines
Antimicrobial Stewardship
But why postmenopausal women have higher
risks of developing UTI and rUTIs?

• + sexual intercourse shifting to both groups

• More risk factors + more important ones
 The role of laboratory in diag
sUTIs in Menopausal Women
• Are challenging because of >>> high prevalence of bacteriuria and pyuria which
may not be important
• Urinary dipstick -easy&convenient, but with variable test characteristics
• If dipstick NEG -> a patient with a low pretest probability-> negative for leu
esterase and nitrites --- it excludes the presence of infection and mitigates the
need for Urinalysis and Ucult.
• If + -> further studies needed in patient with a high pretest probability
 Lab findings
• CLEAN CATCH Urinalsys (hard to obtain)
• At least 10 white blood cells HPF
• 100 000 CFU/ml
• labia separated, clean with antiseptic soap solution wiping
fron to back before void
• initial flow thrown away
• catch the midstream urine into a sterile container
• Difficult ( obese, lack of mobility, arthitis, etc)
When to ask for Lab testing?
• challenging for the clinician because of the chronic nonspecific
symptoms
• We shall not forget the Overactive bladder which is still
misdiagnosed or misinterpreted
• Do NOT ask for lab involvement
If 1. chronic urinary nocturia 2. incontinence 3. general sense of
lack of well being
but….WHEN?
1.Fever 2. Acute dysuria (< 1 wk)
3. new&worsening urgency 4. new incontinence 5. gross
hematuria 6.suprapubic/costovertebral angle
pain/tenderness
Tips& tricks

• Given the known transient + recurring nature of bacteriuria in

older patients --- > a test of cure should NOT be performed

• Evaluation of clinical response should be enough

Decision made. How should we treat ABU
or symptomatic UTI?
• AB -> will eradicate bacteriuria in ABU, BUT WITH severe
adverse effects such as:
• 1. higher reinfection rates
• 2. adverse microbial drug effects
• 3.isolation of increasingly resistant organisms

• And there is no difference between genitourinary morbidity and

mortality between therapy vs non therapy
• Thus screening or treating for ABU in community dwelling
menopausal women or institutionalized ones is not
 BUT if symptomatic UTI is
present?
• If menopausal woman -> complicated cystitis, complicated pyelonephritis

• Choice of AB should be done by

• 1.bacterial pathogen
• 2.Local resistance rates ( Occident vs Est)
• 3.Adverse effect profile
• 4.Co-morbidities

• Frequent pathogens in menopausal women: E.COLI, Klebsiella P, Proteus M

and Enterococcus faecalis
• FQ resistance is highest for patients>65y
• FQ the most commonly AB in ambu care ( USA)
 Treatment
• 3 days of Trimethoprim-sulfamethoxazole for healthy
women
• FQ 1st line only in TS resistant communities

• Recent revised guidelines place Nitrofurantoin NF as

one of the 1st line agents for UTIs

• FDA states that NF is CI in patients with

GFR<60mL/min/1,73m2, but recent data support
safety even for GFR 40>
Treatment
• For more highly resistant bact isolates Fosfomycin may be
effective

• VRE and MRSA and ESBL are usually susceptible to F and although
the bacterial efficacy is lower than other 1stline agents it is an
appealing oral alternative

• When all oral possibilities have been ruled out ->>>>>>>>

refferal to infectious disease physician >>>>>> short course
parenteral AB outpatient practice
instead of hospitalization
Management of rUTI
• Recurrent symptomatic UTI -> chronic suppressive AB
for 6-12 months are effective at reducing
symptomatic UTI

• NF 50mg daily – minimal adverse effects, no growth

of NF resistant fecal flora after 1 year of treatment

• 6 months of TS 40/200mg / 100mg T /100mg NF, but

TS resistant E.Coli fecal isolat were more common in
patients treated with T-based regimens
Prevention =>
• sexually active postmenopausal women have
higher incidence of sympto UTI ( especially with
new partners)
• STIs can also cause urinary symptoms ( if vaginal
discharge is present an STI evaluation should be
made)
• advice: early postcoital voiding, increase fluid
intake during daytime
• A trial of postcoital AB prophylaxis can be
considered ( it works in younger women)
 Prevention

• 300ml of cranberry juice cocktail could reduce laboratory evidence of UTI at 6

months. EAU does not have enough evidence

• a daily dose of 2 g D-mannose was significantly superior to placebo and as effective

as 50 mg nitrofurantoin in preventing

• Oral estrogen therapy has not been found to be effective

• vaginal estrogen cream reduced UTI

• Of course – ASSESMENT of predisposing conditions to UTI, such as pelvic organ

prolapse, bladder lessions, K stones etc
Conclusions – do not
Conclusions- do not treat
• 3.3.6.4.2 ABU in post-menopausal women Elderly women have an
increased incidence of ABU [88]. Four RCTs compared antibiotic treatment
of ABU with placebo controls or no treatment, in a post-menopausal
female population, with different antibiotic doses and regimens [65-67,
70]. Women in these studies were mostly nursing home residents, which
may bias the results of this analysis. Three RCTs reported on the rate of
symptomatic UTIs (average RR 0.71, 95% CI 0.49 to 1.05; 208 women) and
the resolution of bacteriuria (average RR 1.28, 95% CI 0.50 to 3.24; 203
women) [34, 40, 46], with no significant benefit of antibiotic treatment.
Therefore, ABU in post-menopausal women does not require treatment,
and should be managed as for pre-menopausal women.
Conclusions
Conclusions
• Difficult to select antibiotic therapy, if it is necessary

• establishing a diagnosis of symptomatic UTI requires careful

assesment

• new onset dysuria is one of the best indicators of sympt UTI

• Establish AB therapy by taking into account AB adverse effects,
potential interact with pers medication and patients
comorbidities.
 Refferences
• EAU Urological Infection Guidelines
• Obstetrics and Gynecology Clinical Practice Guidelines
• Urinary infections in older women JAMA. 2014 February 26; 311(8):
844–854. doi:10.1001/jama.2014.303
• Clinical Practice Guideline for the Management of
Asymptomatic Bacteriuria: 2019 Update by the Infectious Diseases
Society of America