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Treating rUTIs: Immunomodulation or oestrogen therapy?

In the Thematic Session “Controversies on EAU Guidelines: Neurourology, paediatric urology and infections”, Co-Chair Prof. Gernot Bonkat (CH) presented and moderated the case discussion “Vaccination and oestrogen therapy for treatment of recurrent UTIs: Does the evidence support this?”.

The case involved a 38-year old female patient, who suffered from recurrent urinary tract infections (rUTIs) since 2000 and experienced at least 5 episodes per year. She had multiple courses of antibiotic therapy (e.g. ciprofloxacin, co-amoxicillin, cefuroxime). Her symptoms included lower abdominal pain and dysuria. Physical examination showed only slight tenderness on the palpation in the lower abdomen and her visit to the gynaecologist reported normal.

Providing the evidence for vaccination a.k.a. immunomodulation, Dr. Jennifer Kranz (DE) first discussed the STEPwise approach which involved the order below which is based on the rising collateral damage of the antimicrobial prophylaxis:

  1. Behavioural modifications
  2. Non-antimicrobial measures
  3. Antimicrobial prophylaxis

Dr. Kranz also cited the EAU Guidelines, which strongly recommended the use of immunoactive prophylaxis to reduce rUTI in all age groups. Furthermore, she also discussed the role of E.coli strains to rUTIs; the current immunomodulating substances OM-89, MV 140 and StroVac; systematic reviews and a randomised controlled trial (RCT).

Dr. Kranz concluded that the use of immunoactive agents showed promising results and reduced the risk of rUTIs significantly. However, there is lack of high-quality randomised controlled trials to confirm the clinical efficacy. She added that although safety profile appears acceptable, larger-scale trials with placebo or antibiotic controls were necessary. Further research is needed, especially on other high-risk patient groups.

On evidence for hormone replacement, Prof. Florian Wagenlehner (DE) shared insights, which he stated were not to address the patient case but for post-menopausal women. He discussed the algorithm for rUTI and the effect of vaginal oestrogen on the microbiome such as Lactobacilli.

According to Prof. Wagenlehner, the mode of action is to supply the vagina with oestrogen. To do this, the glycogen storage in the vaginal epithelial cells which aids in the growth of Lactobacilli. In addition, the glycogen is metabolised by the Lactobacilli into lactic acid. This drops the vaginal pH beyond pH 4.

Prof. Wagenlehner concluded his presentation by citing the EAU Guidelines which strongly recommends the use vaginal oestrogen replacement to prevent rUTI.

Using the EAU24 app, a voting ensued among the audience. Majority opted for the use of oestrogen therapy.

Experts Prof. Bertil Blok (NL) and Prof. Guy Bogaert (BE) co-chaired the Thematic Session.

To (re)watch congress presentations, please visit the EAU24 Resource Centre.