Transvaginal Urethrolysis as a Treatment Option for Women with Recurrent Cystitis

Sunporn Boonwong, M.D.*, Atichet Sawangchareon, M.D.**, Patkawat Ramart, M.D.*

*Division of Urology, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, 10700, Thailand, **Division of Urology, Department of Surgery, Taksin Hospital, Medical Service Department, Bangkok Metropolitan Administration, Bangkok, 10600, Thailand.

ABSTRACT

Objective: To demonstrate the outcome of transvaginal urethrolysis as a treatment option for women with recurrent cystitis, which could be caused from voiding problems. In the case of a failure of non-invasive treatment, the surgical procedure to decrease outlet resistance may have a role.

Materials and Methods: Between January 2016 and December 2020, women with recurrent cystitis who underwent urethrolysis at Siriraj Hospital were retrospectively reviewed. Only women who were followed-up for more than 6 months were analyzed. Cure was defined by no clinical symptoms of cystitis, no pyuria on urine analysis, and/or negative urine culture during the follow-up period.

Results: In total, 52 women underwent transvaginal urethrolysis. The overall cure rate was observed 53.9% (28 cases) at a median follow-up time of 11.9 (6–59) months. Eighteen of the 44 cases (40.9%) who underwent a video urodynamics study showed bladder outlet obstruction, defined as a Solomon–Greenwell bladder outlet obstruction index of more than 5. None of the characteristics or urodynamics parameters showed statistically significant differences between the cure and failure groups. Postoperative urinary incontinence was reported in 14 cases (26.9%) but showed no statistical difference between the cure and failure group (p = 0.748).

Conclusion: Bladder outlet obstruction is a common cause of recurrent cystitis. Transvaginal urethrolysis may have a role as treatment for women with recurrent cystitis from voiding dysfunction who have failed non- and less-invasive treatments. Here, the overall cure rate was 53.8%. A factor associated with the cure rate could not be demonstrated in this study.

Keywords: Recurrent cystitis; voiding dysfunction; bladder outlet obstruction; detrusor underactivity; urethrolysis (Siriraj Med J 2023; 75: 343-349)

INTRODUCTION

Cystitis is an inflammation of the urinary bladder and presents with dysuria in conjunction with urinary frequency, urgency, hematuria, worsening urinary incontinence, or suprapubic pain1, and is usually associated with infection. The incidence of cystitis is significantly higher in women as a result of lower urinary tract anatomy. A study into the self-reported incidence of urinary tract

infection (UTI) showed that 10.8% of women aged 18 years old or older have reported at least one presumed UTI during the past 12 months and estimated that 60.4% of all women experience at least one episode of UTI in a lifetime.2 A study of community-acquired Escherichia coli cystitis reported that 49.2% of female patients had at least one episode of recurrent urinary tract infection (UTI) during 12-month follow-up and most of them

Corresponding author: Patkawat Ramart E-mail: patkawat.ram@mahidol.ac.th

Received 15 February 2023 Revised 10 March 2023 Accepted 11 March 2023 ORCID ID:http://orcid.org/0000-0002-3394-9349 https://doi.org/10.33192/smj.v75i5.261230

All material is licensed under terms of the Creative Commons Attribution 4.0 International (CC-BY-NC-ND 4.0) license unless otherwise stated.

were recurrent cystitis.3 After the first episode of cystitis in young women, the 6-month risk of second UTI was reported to be 26.6%.4 Moreover, genitourinary tract infection was found to be the second most common infection in a geriatric population.5

Complicated UTI, including recurrent infection, and urinary tract infection in an immunocompromised host, and/or with multi-drug resistant bacteria and in patients with a suspected anatomical or functional abnormality of the urinary tract, should be investigated.1 Therefore, recurrent cystitis is considered an unusual problem, particularly from bacterial infection. The widely accepted definition of recurrent cystitis is described as 3 or more episodes of cystitis confirmed by a positive urine culture during a previous 12-month period or 2 or more episodes of infection during a 6-month period.1 Bladder outlet obstruction (BOO) is another cause

of recurrent cystitis, so the concept of reducing outlet resistance to treat women with recurrent cystitis was proposed and studied in the past.6-8 Treatment options include biofeedback9, alpha-adrenergic antagonist9, urethral dilation, internal urethrotomy6,7, and urethrolysis.8 Specifically, urethrolysis is an outlet reducing procedure that is used to treat female urethral syndrome8 and bladder outlet obstruction after anti-incontinence procedures.10,11 The procedure can be performed by a transvaginal, suprameatal, or retropubic approach.

The majority of studies have demonstrated that urethrolysis is an effective treatment for bladder outlet obstruction after anti-incontinence procedures and the success rate is between 58%–87%.11-14 So far, to the best of our knowledge, there has been only one study on urethrolysis as a treatment in women with recurrent cystitis8, but the surgical technique reported was different from in other studies. Therefore, this study aimed to demonstrate the outcome and role of transvaginal urethrolysis considering the same surgical techniques as other studies11-13, more specifically for the case of lower urinary tract abnormality, which is a cause of recurrent cystitis. The second aim was to identify the predictive factors that might affect the outcome of urethrolysis.

MATERIALS AND METHODS

After the study was approved by the institutional review board, the medical records of all female patients who underwent urethrolysis between January 2016 and December 2020 at Siriraj Hospital were retrospectively reviewed. Only patients who had a history of recurrent cystitis and who were followed up at least 6 months after urethrolysis were enrolled and analyzed. Most cases had failed non- and less-invasive treatment, including

alpha-adrenergic antagonist and urethral dilation, before it was decided to perform urethrolysis.

Patients who had a history of pelvic radiation, neurologic diseases with a significant abnormal neurologic examination, abnormal urinary tract findings on imaging studies, pelvic organ prolapse more than stage I on vaginal examination, and a history of past urethrolysis were excluded. Information from the medical records, including age, voiding symptoms, parity, history of vaginal surgery, diabetes mellitus, findings on vaginal examination, video urodynamics (VUDS) report, and outcome during the follow-up period were collected.

Recurrent cystitis was defined by 3 or more occurrences of clinical symptoms, including dysuria, frequency, and urgency, as well as demonstrated pyuria (White blood cells > 5 per high power field) on urine analysis (UA) and a positive urine culture for bacteria in the past year. All the cases must have failed to respond to proper antibiotics and subsequent medications, including alpha-adrenergic antagonists, bethanechol chloride, or vaginal estrogen, for at least 3 months.

To identify a cause of recurrent cystitis, careful history taking, vaginal examination, and/or video urodynamics study (VUDS) were performed. Vaginal examination indicated a loss of urethral mobility, and fixed and over- angulated urethra in all cases. If the clinical history indicated that BOO was strongly related to a past vaginal surgery, and/or vaginal examination revealed a mesh extrusion, VUDS was omitted. VUDS was performed in a sitting position on a radiolucent commode chair. The bladder outlet obstruction index for females (BOOIf), known as the Solomon–Greenwell formula, was used as a diagnostic criterion.15 If BOOIf was more than 5, the patient was diagnosed as BOO.

During pressure-flow studies (PFS), if a patient was unable to void with a urethral catheter in place, the catheter would be removed, and then the patient would attempt to void with the rectal catheter in place to measure abdominal pressure, and fluoroscopy was utilized to demonstrate the urethral anatomy. Abnormal urethral findings on the fluoroscopic examination, including distortion or disproportion, were reported (Fig 1). In cases of unsuccessfully performed PFS both with and without the urethral catheter, free uroflowmetry and post- void residual urine tests were performed and measured in a private room, and these patients were diagnosed as non-specific voiding dysfunction (NVD). All the NVD showed a loss of urethral mobility and over-angulated urethra, as well as maximal urinary flow rate (Qmax), which was less than 20 ml/sec.

To demonstrate the outcome of urethrolysis in

Fig 1. Fluoroscopic picture in a woman with recurrent cystitis demonstrated disproportion of the urethra (arrow) during a pressure- flow study.

the different types, they were categorized as clinical voiding dysfunction (CVD) and urodynamic bladder outlet obstruction (UBO). Clinical voiding dysfunction (CVD) included bladder outlet obstruction related to a past vaginal surgery, vaginal mesh extrusion, abnormal urethral findings on fluoroscopic examination, BOOIf

≤ 5 in the pressure-flow study or non-specific voiding dysfunction (NVD), while urodynamic bladder outlet obstruction (UBO) was only indicated in a case with a successfully performed pressure-flow study and BOOIf of more than 5.

For the outcome of urethrolysis, in order to make clear on the definition of cure, it was defined by no clinical symptoms and no pyuria on urine analysis during the follow-up period. Because asymptomatic bacteriuria might sometimes develop clinically significant cystitis which patients did not receive an appropriate investigation and took antibiotic by their own. In contrast, failure was defined as recurrent clinical symptoms of cystitis and demonstrated pyuria on urine analysis or a positive urine culture during the follow-up period.

Surgical technique

For transvaginal urethrolysis, a patient was positioned in the exaggerated dorsal lithotomy, and the operation was performed under general anesthesia. After the urethral catheter was indwelled and the bladder was emptied, the vagina was examined. Urethral mobility was evaluated by pulling the catheter. Bilateral incisions were made at the anterior vaginal wall, along the paraurethral area. The vaginal wall was dissected until the pubocervical fascia was identified. The fascia was punctured and disintegrated by curved-Mayo scissors and then the prevesical space was entered. In order to avoid bladder

perforation, the bladder must be emptied before puncture and the curved-Mayo scissors must be pointed laterally, close to the pubic rami. Paraurethral tissue was bluntly dissected by the index finger while the paraurethral area and prevesical space were also freed up. In the case of synthetic mesh implantation, nearly the entire mesh was removed. The urethral mobility was re-evaluated by pulling the urethral catheter and by observing an increasingly downward movement of the urethra compared to preoperative evaluation. Bleeding was checked and secured. Vaginal incisions were properly re-approximated with non-absorbable sutures without intentional overbite stitches to avoid further scarring, potentially leading to a urethral obstruction. Vaginal packing with betadine- soaked gauze was kept in place for 24 hours. At 24-hour postoperative, the vaginal packing and urethral catheter were removed and the patient was discharged.

Statistical analysis

Descriptive statistics regarding age, diabetes mellitus, and past vaginal surgery were reported using the quantity as a number and percentage. Each of the video urodynamics parameters, including maximal urinary flow rate (Qmax), detrusor pressure at a maximal flow rate (PdetQmax), voided volume (VV), and post-void residual (PVR), were reported as the median with the minimum and maximum value according to the normal distribution. To analyze the factors implicating the urethrolysis outcome, qualitative factors, including the voiding symptoms, diabetes mellitus (DM), and past vaginal surgery, were compared by using the Chi-square test and Fisher’s exact test. While the quantitative data, including age, Qmax, PdetQmax, and other urodynamics parameters, were compared by the unpaired t-test and Mann–Whitney U-test and reported as the mean or median between these two groups. All the data were analyzed using the program SPSS Inc., released in 2009, PASW Statistics for Windows, Version 18.0. Chicago: SPSS Inc. These analyses used a 2-tailed test and considered statistically significant when p < 0.05.

RESULTS

A total of 127 cases who underwent urethrolysis during 5 years in our institute were reviewed and 7 cases were excluded because of a history of pelvic radiation. Only 52 cases met the inclusion criteria. The mean age was 68.8 ± 12.5 years old and 18 cases (34.6%) complained of voiding symptoms. Diabetes mellitus (DM) was found for 16 cases (30.8%) and the median parity was 3 (0–10). Twenty-four cases (46.2%) had a history of past vaginal surgery, including pelvic organ prolapse

procedures (9 cases), anti-incontinence procedures (8 cases), and combined prolapse organ prolapse with anti- incontinence procedures (5 cases). In these groups, 5 cases had bladder outlet obstruction strongly related to vaginal surgery and 3 cases had vaginal mesh extrusion, so they underwent transvaginal urethrolysis without preoperative video urodynamics study (VUDS). The remaining 44 cases had VUDS performed, including 30 cases (68.2%) with a successful pressure-flow study (PFS) and 14 cases (31.8%) with an unsuccessful PFS, which were categorized as non-specific voiding dysfunction (NVD). In the successful PFS, BOO, which was named as urodynamic bladder outlet obstruction (UBO), and non-bladder outlet obstruction were diagnosed in 18 and 12 cases, respectively. In addition, 28 of the 44 cases (63.3%) who had VUDS performed showed an abnormal urethra on fluoroscopic examination. To easily apply clinical practice, 34 cases were categorized as clinical voiding dysfunction (CVD), and 18 cases were also categorized as urodynamic bladder outlet obstruction (UBO) (Table 1).

Overall, the cure rate was observed as 53.8% (28 cases) and the median follow-up time was 11.9 (6–59) months. The cure rates between CVD and UBO were 55.9% and 50.9%, respectively, and there was no statistically significant difference between the two groups (p = 0.91). The predictive factors associated with the cure rate were analyzed but no characteristics showed a statistically significant difference (Table 2). In a subgroup analysis of UBO, there was no significant urodynamic parameters associated with the cure rate (Table 3).

There was no intraoperative bladder or urethral injury. One case required postoperative blood transfusion without any further intervention and one case had vaginal infection, which was successfully treated with oral antibiotics. During follow-up, 14 cases (26.9%) reported urinary incontinence (UI), among whom 8 had only mild symptoms, using only 1 protective pad per day, while 5 cases had severe urinary incontinence. Among the severe urinary incontinence cases, 3 were requested and scheduled for anti-incontinence procedures. The urinary incontinence rate was not statistically significant difference between the cure and failure group (p = 0.748). Interestingly, 8 of the 14 cases did not have recurrent cystitis during the follow-up period. Five cases (9.6%) that reported overactive bladder after urethrolysis required medical treatment. Four cases of the failure group underwent repeated urethrolysis because their clinical cystitis was improved during the initial 6 months of the postoperative period and voiding dysfunction was confirmed. Two cases still had recurrent cystitis postoperatively and

the remaining complained of urinary incontinence and voiding symptoms without recurrent cystitis.

DISCUSSION

Recurrent cystitis in women is considered a complicated urinary tract infection (UTI) and an unusual problem. The AUA/CUA/SUFU guideline suggests complicated UTI should be investigated to identify a possible anatomical and functional abnormality.1 Recurrent cystitis is another presentation of voiding problems, especially bladder outlet obstruction (BOO) after anti-incontinence procedures12,16, even though, the majority of cases present with storage symptoms or combined storage and voiding symptoms rather than voiding symptoms alone.8,10-12

When focusing on the treatment of recurrent cystitis from voiding problems, some cases have mixed functional and anatomical problems. Therefore, all the cases in this study had been initially treated with an alpha-adrenergic antagonist with an aim to theoretically reduce outlet resistance, but they still had recurrent episodes of cystitis. For anatomical BOO without pelvic organ prolapse, the treatment options are urethral dilation, urethrotomy, urethrolysis, and urethroplasty.17

In the past studies, the improvement rate was 80%– 100% of women with recurrent cystitis who were treated with urethral dilation using a sound dilator up to 40–45 Fr., but it needed repeat dilation.18-19 In the present study, the majority of cases had been treated with urethral dilation with Hegar dilators, but they were not improved, and then they accepted the risk from urethrolysis after counseling. Moreover, 28 cases had abnormal urethral findings on fluoroscopic examination, which confirmed that the urethral narrowing or distortion was from outside of the lumen, named “periurethral fibrosis”. Because of this reason, urethrotomy was not considered in this study, even though urethrotomy followed by urethral dilation up to 40–46 Fr. has shown excellent results in 31%–52% of cases.6,20

Most studies demonstrated that urethrolysis was an effective treatment for BOO after an anti-incontinence procedure and the success rate was 58%–87%.11-14 There was only one study of urethrolysis used for treating 40 women with recurrent frequency and dysuria demonstrated who failed medical treatment and urethral dilation, and showed that 18 of the 40 women (45.0%) reported good results at a mean follow-up time of 10.7 (range 4–36) months. Only one woman who had recurrent frequency and dysuria with recurrent UTI reported poor results that were unsatisfactory, but urethrolysis was performed using a different technique, described as releasing the posterior support along the urethra. Two cases had stress

TABLE 1. Demographic data of all the cases.

† BOO or bladder outlet obstruction.

‡ VUDS or video urodynamics study.

§ NVD or non-specific voiding dysfunction was defined as a loss of urethral mobility and overangulated urethra on vaginal examination and a maximal urinary flow rate (Qmax) < 20 ml/sec on free uroflowmetry and an unsuccessful pressure-flow study with and without a urethral catheter.

¶ BOOIf or bladder outlet obstruction index for female defined by Solomon–Greenwell.

†† UBO or urodynamic bladder outlet obstruction was indicated in successful PFS and BOOIf > 5.

‡‡ Qmax or maximal urinary flow rate.

§§ PdetQmax or detrusor pressure at the maximal urinary flow rate.

urinary incontinence after urethrolysis.8 In our study, the overall cure rate, defined by no clinical symptoms and no pyuria on urinalysis during the follow-up period, was 53.8%.

Some studies mentioned that urethrolysis may be reasonable for clinical BOO without urodynamic

proof by using a history of vaginal surgery, fixed or hypersuspended urethra on physical examination, or trabeculation on cystoscopy.12,13 The outcomes were similar between clearly defined urodynamic BOO and the inability to generate detrusor contraction on the UDS.12 This study also demonstrated that both CVD and UBO

Treatment outcome

Characteristics

Total

(n = 52)

Cure

(n = 28)

Failure

(n = 24)

P-value

TABLE 2. Characteristics associated with the cure rate.

TABLE 3. Subgroup analysis of the pressure-flow study parameters in urodynamic bladder outlet obstruction (UBO).

† Qmax or maximal urinary flow rate.

‡ PdetQmax or detrusor pressure at the maximal urinary flow rate.

§ BOOIf or bladder outlet obstruction index for females defined by Solomon–Greenwell.

had the same cure rate. It is a matter of fact that the female lower urinary tract anatomy and function is unreliable, and so it is difficult to initiate the most appropriate criteria for bladder outlet obstruction upon urodynamics study as in males.21 So, clinical information, including the patient’s history and precise vaginal examination, may be an important key. Unfortunately, the present study could not demonstrate any factor associated with the cure rate.

Previous studies have reported various postoperative urinary incontinence rates, ranging from 0% to 38.9%11-13,22,

depending on the population and surgical technique. The postoperative urinary incontinence rate in our study was 26.9%. Postoperative overactive bladder (OAB) is another problem that impacts the quality of life and individual satisfaction.12,23 About 50% of cases had OAB symptoms after urethrolysis, and preoperative overactive bladder and/or detrusor overactivity (DO) are indicators of poor postoperative satisfaction.23 Our study showed that 9.6% of cases had OAB symptoms that required medical treatment. Interestingly, postoperative OAB in our study was low because if our patients had both

OAB symptoms and recurrent cystitis, they were not diagnosed as OAB. Moreover, the repeat urethrolysis rate was widely different from that in past studies because of the different indications and diagnoses. In our study, only 4 cases were classified as failed urethrolysis at more than 6 months postoperatively; however, they had some symptoms improvement. After re-evaluation, they agreed to repeat urethrolysis.

The strengths of this study include that we studied in more specific conditions voiding dysfunction causing recurrent cystitis, and the surgical procedure was performed by a single surgeon with the same surgical technique, and also that no previous urethrolysis was performed in the cohort population. The limitations were the retrospective design of this study, which meant there were some missing data and only a small number of enrolled cases.

In conclusion, after the failure of non- and less- invasive treatments, urethrolysis may be a treatment option for women with recurrent cystitis from voiding problems. The overall cure rate was 53.8% in this study. Either clinical or urodynamic bladder outlet obstruction can be used as an indication for urethrolysis and here showed a comparable cure rate. No factor associated with the cure rate was demonstrated.

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