Swamy, Sheela; (2023) Missed urinary tract infection in patients with chronic recalcitrant LUTS and recurrent cystitis. Doctoral thesis (Ph.D), UCL (University College London).

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Abstract

Background: MSU culture and Urinary dipsticks as a diagnostic method for urinary infection (UTI) are discredited despite commonly used to exclude UTI in patients with lower urinary tract symptoms (LUTS). The phenotype of painful LUTS has been recast as Interstitial Cystitis (IC) or Bladder Pains Syndrome (BPS) because infection has been excluded on the evidence of these methods. Given that these all-important tests have been found insensitive and misleading, there is justification in re-examining IC/BPS to ascertain whether we have been mistaken. I studied patients with “Chronic recalcitrant bladder pain and recurrent cystitis” (abbreviated “painful LUTS”) who had been diagnosed with IC/PBS in order to re-assess their pathophysiology.// Aim: I characterised these patients using the scientific method of consilience, which scrutinised them from unrelated perspectives. These studies implied that infection was a most probable aetiological factor. Therefore, I moved on to test infection as a causal factor using Pearl’s three rungs of causation: Correlation, intervention and the counterfactual.// Methods: Data on quality of life and disease experience were obtained. Symptoms and pathophysiological variables in 146 patients presenting with painful LUTS were studied. To achieve Pearl’s specifications, an observational study studied intervention and a cross-over study analysed the counter factual of arbitrary treatment cessation. The evolution of treatment of these patients, using first generation, narrow spectrum urinary agents in protracted courses is reported. Since protracted antibiotic exposure is feared as a cause of antimicrobial resistance (AMR), I measured this in order to round off my findings// Results: The consilience studies incriminated UTI in the aetiology of painful LUTS. It is also clear that the patients suffer terribly, and this is aggravated by professional scepticism catalysed by a misinterpretation of urinalysis data. Antibiotic intervention demonstrated a regression in all disease indicators but there was resurgence of symptoms and signs during trials without treatment. The data on AMR demonstrated a rise in resistance in response to a first prescription without this increasing with persistence of the antibiotic regimen.// Conclusion: These data imply that IC/BPS (painful LUTS) is caused by a treatable urinary tract infection and are sufficient to merit a RCT. Whilst, treatment requires protracted exposure to antibiotics, my data on AMR amongst these patients is surprisingly reassuring. This requires further exploration. Contemporaneous to this thesis, other have published definitive data that refute urine culture and dipstick analysis.//

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