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Background: Recurrent urinary tract infections (rUTIs) are common complaints that burden the healthcare system. Reporting perceived knowledge and guidelines in concordance regarding the management of (rUTI) is essential for providing better healthcare and higher treatment rate. This study assesses the perceived knowledge, guidelines concordance, and physicians' practices toward treatment of (rUTI) among physicians with different specialties. Study Design: This questionnaire-based survey included residents, fellows, and consultants of various specialties across several regions in Saudi Arabia. Results: A total of 419 physicians were included in the final analysis. In terms of age distribution, the majority were 28-38 years of age (159, 37.9%), followed by 18-28 years (99, 23.6%). Gender distribution was nearly balanced. The sample included a significant number of residents (182, 43.4%), consultants (173, 41.3%), and fellows (64, 15.3%). OBS/GYNE shows a significant presence of females (40.6%) and is notably represented in private hospitals or clinics (52.5%) and among fellows (40.6%) and consultants (32.4%). Infectious disease physicians had the highest perceived knowledge scores (3.83 ± 0.09), followed closely by urologists/urogynecologists (3.67 ± 0.48). Urologists/urogynecologists also reported the highest satisfaction (4.24 ± 0.83) and familiarity (2.89 ± 1.11) with new rUTI guidelines. Infectious disease physicians were most confident (3.50 ± 0.71) in communicating with patients about rUTI treatment options. In terms of practices and guideline adherence, obstetricians/gynaecologists were more likely to repeat urine sample tests for suspected contamination (3.73 ± 1.00) and less likely to treat asymptomatic bacteriuria (1.33 ± 0.59) the same as UTIs compared to other physicians. They also scored highest in conducting post-treatment tests for asymptomatic patients (3.21 ± 1.37) and recommending vaginal estrogen therapy for peri- and post-menopausal women to prevent UTIs (3.59 ± 1.06) among all specialties. Conversely, urologists and urogynecologists were more likely to discuss antibiotic prophylaxis (3.79 ± 0.89) and cranberry prophylaxis (3.71 ± 0.73) with their rUTI patients. Conclusion: The findings highlight variations in knowledge, satisfaction, familiarity with guidelines, confidence in communication, and guideline concordance among different physician specialities regarding the management of UTIs and rUTIs.

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Recurrent urinary tract infections (rUTIs) are common and can significantly impact a patient's quality of life. The mainstay of treatment is antibiotic-based, which contributes to the global problem of antibiotic resistance among urinary pathogens, so many alternative therapies have been explored. In this mini-review we evaluate evidence for intravesical agents that prevent rUTI, including antibiotic and nonantibiotic options. The current evidence supports the use of intravesical agents that replenish the glycosaminoglycan layer and of aminoglycoside antibiotics as safe and effective therapies to prevent rUTI. PATIENT SUMMARY: We reviewed evidence on the use of bladder instillations to treat repeated urinary infections. Studies have shown that agents that improve the bladder surface and one specific antibiotic class are effective and safe treatments for prevention of recurrent infections.

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OBJECTIVES: Urinary tract infection (UTI) is the most common bacterial infection in infants. Current practice guidelines suggest a treatment duration of 7 to 14 days. Suboptimal therapy may increase the risk for recurrent UTIs leading to renal scarring and possibly chronic kidney disease. The primary objective is to evaluate the duration of therapy for UTIs and its association with the incidence of recurrent UTIs in a neonatal intensive care unit (NICU). The secondary objectives are to identify the risk factors and the most common organisms for recurrent UTIs. METHODS: Patients were identified via the diagnosis codes for UTIs and were included if admitted to the NICU and if they received antibiotics prior to hospital discharge. Patients were divided into 2 groups: antibiotic treatment for 7 days or fewer and antibiotic treatment for greater than 7 days. RESULTS: Eighty-six infants were included in the study. Twenty-six patients received antibiotics for 7 days or fewer, and 60 for more than 7 days. In the study, the median birth weight was 977 g and the median gestational age was 27.6 weeks. There was no significant difference in the rate of recurrent UTIs between the 2 groups (p = 0.66). However, in the subgroup analysis, the incidence was higher for patients receiving antibiotic therapy for fewer than 7 days versus 7 days (p = 0.03). CONCLUSION: There was no difference in recurrence of UTI between treatment groups (≤7 days versus >7 days), and recurrence was seen in a higher percentage of patients with a urinary tract anomaly.

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Background: Urinary tract infections (UTI) affect approximately 250 million people annually worldwide. Patients often experience a cycle of antimicrobial treatment and recurrent UTI (rUTI) that is thought to be facilitated by a gut reservoir of uropathogenic Escherichia coli (UPEC). Methods: 125 patients with UTI caused by an antibiotic-resistant organism (ARO) were enrolled from July 2016 to May 2019 in a longitudinal, multi-center cohort study. Multivariate statistical models were used to assess the relationship between uropathogen colonization and recurrent UTI (rUTI), controlling for clinical characteristics. 644 stool samples and 895 UPEC isolates were interrogated for taxonomic composition, antimicrobial resistance genes, and phenotypic resistance. Cohort UTI gut microbiome profiles were compared against published healthy and UTI reference microbiomes, as well as assessed within-cohort for timepoint- and recurrence-specific differences. Findings: Risk of rUTI was not independently associated with clinical characteristics. The UTI gut microbiome was distinct from healthy reference microbiomes in both taxonomic composition and antimicrobial resistance gene (ARG) burden, with 11 differentially abundant taxa at the genus level. rUTI and non-rUTI gut microbiomes in the cohort did not generally differ, but gut microbiomes from urinary tract colonized patients were elevated in E. coli abundance 7-14 days post-antimicrobial treatment. Corresponding UPEC gut isolates from urinary tract colonizing lineages showed elevated phenotypic resistance against 11 of 23 tested drugs compared to non-colonizing lineages. Interpretation: The gut microbiome is implicated in UPEC urinary tract colonization during rUTI, serving as an ARG-enriched reservoir for UPEC. UPEC can asymptomatically colonize the gut and urinary tract, and post-antimicrobial blooms of gut E. coli among urinary tract colonized patients suggest that cross-habitat migration of UPEC is an important mechanism of rUTI. Thus, treatment duration and UPEC populations in both the urinary and gastrointestinal tract should be considered in treating rUTI and developing novel therapeutics. Funding: This work was supported in part by awards from the U.S. Centers for Disease Control and Prevention Epicenter Prevention Program (grant U54CK000482; principal investigator, V.J.F.); to J.H.K. from the Longer Life Foundation (an RGA/Washington University partnership), the National Center for Advancing Translational Sciences (grants KL2TR002346 and UL1TR002345), and the National Institute of Allergy and Infectious Diseases (NIAID) (grant K23A1137321) of the National Institutes of Health (NIH); and to G.D. from NIAID (grant R01AI123394) and the Eunice Kennedy Shriver National Institute of Child Health and Human Development (grant R01HD092414) of NIH. R.T.'s research was funded by the Deutsche Forschungsgemeinschaft (DFG; German Research Foundation; grant 402733540). REDCap is Supported by Clinical and Translational Science Award (CTSA) Grant UL1 TR002345 and Siteman Comprehensive Cancer Center and NCI Cancer Center Support Grant P30 CA091842. The content is solely the responsibility of the authors and does not necessarily represent the official views of the funding agencies.

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Urinary tract infections (UTIs) represent a significant challenge in clinical practice, with recurrent forms (rUTIs) posing a continual threat to patient health. Escherichia coli (E. coli) is the primary culprit in a vast majority of UTIs, both community-acquired and hospital-acquired, underscoring its clinical importance. Among different mediators of pathogenesis, toxin-antitoxin (TA) systems are emerging as the most prominent. The type II TA system, prevalent in prokaryotes, emerges as a critical player in stress response, biofilm formation, and cell dormancy. ccdAB, the first identified type II TA module, is renowned for maintaining plasmid stability. This paper aims to unravel the physiological role of the ccdAB in rUTIs caused by E. coli, delving into bacterial characteristics crucial for understanding and managing this disease. We investigated UPEC-induced rUTIs, examining changes in type II TA distribution and number, phylogenetic distribution, and Multi-Locus Sequence Typing (MLST) using polymerase chain reaction (PCR). Furthermore, our findings revealed that the induction of ccdB expression in E. coli BL21 (DE3) inhibited bacterial growth, observed that the expression of both ccdAB and ccdB in E. coli BL21 (DE3) led to an increase in biofilm formation, and confirmed that ccdAB plays a role in the development of persistent bacteria in urinary tract infections. Our findings could pave the way for novel therapeutic approaches targeting these systems, potentially reducing the prevalence of rUTIs. Through this investigation, we hope to contribute significantly to the global effort to combat the persistent challenge of rUTIs.

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INTRODUCTION: A subset of interstitial cystitis/bladder pain syndrome (IC/BPS) patients experience recurrent urinary tract infection (rUTI) associated with symptom flares. Recurrent UTI subjects with associated IC/BPS were enrolled in the first North American early clinical experience trial evaluating a new sublingual UTI preventative vaccine, MV140. It has been shown that women with rUTI develop an imbalance in the T helper 1 and 2 (Th2 over-expression) in the bladder mucosa. Our hypothesis-generating secondary analysis will suggest that this infection subcategory of IC/BPS patients develop a similar imbalance of Th1-Th2 response type to bacteria present in their urinary microbiome, leading to a bladder hypersensitivity that responds to mucosal immune modulation. METHODS: Female participants with ≥3 documented UTI/year underwent a 3-month vaccination treatment period with a 9-month efficacy period after completion of vaccine treatment (total 12 months). There were no exclusion criteria for subjects in relation to baseline urinary symptoms and/or discomfort/pain. Primary outcome was no UTI following vaccination. Secondary outcomes included change in UTI incidence, overall patient-reported subjective global assessment (SGA responder defined as moderately or markedly improved on 7-point scale), and safety. RESULTS: Sixteen subjects with IC/BPS-related symptoms and rUTI (mean age 47; range 23-74 years; mean number of UTI episodes in previous year 6.1 +/- 4.2) were eligible to be included in the Health Canada-approved MV140 vaccine study for prevention of rUTI. All subjects completed the 3-month vaccination period. One subject was lost to follow-up after their 6-month visit. Six subjects were UTI-free, while all 16 subjects had a reduction in UTI episodes compared to the year pre-vaccination. The total post-vaccination reduction in UTI episodes compared to pre-vaccination was 80% (0.1 UTI/subject/month from 0.5 UTI/subject/month, respectively). At 12 months, 13 subjects (81%) were SGA responders (moderately or markedly improved), and the responders reported a reduction in IC/BPS symptoms, with 8 subjects reporting significant or almost complete resolution of their specific long-term bladder discomfort/pain and bothersome urinary frequency or urgency. Four subjects reported mild and self-limited adverse events during vaccination period, but none were related to MV140 vaccine. CONCLUSION: Sublingual MV140 vaccine in IC/BPS patients with rUTI not only achieved UTI-free or reduced UTI incidence status but also, after approximately 9 months post vaccination, resolution of patients' long-term treatment-refractory IC/BPS symptoms. This suggests some cases of IC/BPS may be etiologically based on Th2-driven hypersensitivity to bacteria within or entering the urinary microbiome that responds to a vaccine whose mechanism of action is to normalize or balance the bladder Th1/Th2 mucosal immune system.

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Urinary tract infections (UTIs) are common in women; more than 50% of women will be diagnosed with a UTI in her lifetime. Many of these women will go on to develop recurrent UTI. Nevertheless, evidence-based prevention of recurrent UTI is under-utilized. Here, the authors provide detailed practical advice on UTI prevention with a thorough review of the evidence. Non-antibiotic prevention measures discussed include increased fluid intake, vaginal estrogen therapy, methenamine, and cranberry. Antibiotic prophyalxis for carefully selected patients is also discussed.

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It is unknown if recurrent urinary tract infection in the gynecologic population is associated with Mycoplasma and Ureaplasma genitourinary infections. The purpose of this scoping review is to highlight the literature surrounding Mycoplasma and Ureaplasma infections in the setting of recurrent urinary tract infections in the gynecologic population. MEDLINE ALL and Embase were searched to retrieve articles published in or after 1950 through 2024. Studies included were those with adults over age 18, non-pregnant, diagnosed with recurrent urinary tract infection and concurrent genitourinary infection with Ureaplasma or Mycoplasma published in English. Study designs eligible were quantitative, qualitative, and mixed methods studies. Publication types were also extended to conference abstracts and unpublished data. 2 independent investigators systematically performed title/abstract screening and full-text review using standardized inclusion criteria. For disagreements in either title and abstracts or full-text articles, consensus was reached through discussion by the 2 screeners and/or a 3rd final adjudicator. Screening and data extraction were performed on Covidence, a web-based platform for systematic review management. There were 1170 studies identified before title and abstract screening. 26 full-text articles were reviewed for eligibility. Of these, 23 full-text studies were excluded. 3 studies met full inclusion criteria and data extraction was performed on these 3 studies. There were 2 additional studies included after identification via other methods. There is a need for more recent and robust studies examining the role of Ureaplasma and Mycoplasma genitourinary infections amongst gynecologic patients with recurrent urinary tract infections.

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Objectives: To confirm the structural validity of the Recurrent Urinary Tract Infection Symptom Scale (RUTISS), determining whether a bifactor model appropriately fits the questionnaire's structure and identifying areas for refinement. Used in conjunction with established clinical testing methods, this patient-reported outcome measure addresses the urgent need to validate the patient perspective. Patients and methods: A clinically and demographically diverse sample of 389 people experiencing recurrent UTI across 37 countries (96.9% female biological sex, aged 18-87 years) completed the RUTISS online. A bifactor graded response model was fitted to the data, identifying potential items for deletion if they indicated significant differential item functioning (DIF) based on sociodemographic characteristics, contributed to local item dependence or demonstrated poor fit or discrimination capability. Results: The final RUTISS comprised a 3-item symptom frequency section, a 1-item global rating of change scale and an 11-item general 'rUTI symptom and pain severity' subscale with four sub-factor domains measuring 'urinary symptoms', 'urinary presentation', 'UTI pain and discomfort' and 'bodily sensations'. The bifactor model fit indices were excellent (root mean square error of approximation [RMSEA] = 0.041, comparative fit index [CFI] = 0.995, standardised root mean square residual [SRMSR] = 0.047), and the mean-square fit statistics indicated that all items were productive for measurement (mean square fit indices [MNSQ] = 0.64 - 1.29). Eighty-one per cent of the common model variance was accounted for by the general factor and sub-factors collectively, and all factor loadings were greater than 0.30 and communalities greater than 0.60. Items indicated high discrimination capability (slope parameters > 1.35). Conclusion: The 15-item RUTISS is a patient-generated, psychometrically robust questionnaire that dynamically assesses the patient experience of recurrent UTI symptoms and pain. This brief tool offers the unique opportunity to enhance patient-centred care by supporting shared decision-making and patient monitoring.

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INTRODUCTION AND HYPOTHESIS: Antibiotic resistance is an unavoidable consequence of antibiotic use and growing rates of resistance are an urgent issue. Methenamine is a non-antibiotic alternative used for urinary tract infection (UTI) prophylaxis. The objective of this review is to evaluate recently published literature regarding the efficacy and safety of methenamine for UTI prophylaxis. METHODS: PubMed, Embase, and CENTRAL databases were queried in March 2023 using the following search terms: urinary tract infection, cystitis, bacteriuria, or dysuria, and methenamine. Studies prior to 2012 were excluded from this review to focus on appraisal of the most recent evidence. Prospective and controlled retrospective trials were included for review. RESULTS: A total of seven studies (three prospective and four retrospective) met the inclusion criteria for review. Two of the 3 prospective studies demonstrated no or non-inferior differences in clinical efficacy to prevent recurrent UTIs between methenamine and antibiotic prophylaxis and the third showed decreased rates of UTI with methenamine use in patients with short-term indwelling catheters compared with cranberry alone. The retrospective studies consistently supported the efficacy and safety of methenamine for UTI prophylaxis in a variety of populations and clinical settings. Adverse effects reported with methenamine were similar to comparators and included nausea, abdominal pain, and headache. CONCLUSIONS: The use of methenamine for UTI prophylaxis was shown to be effective in a variety of settings without an increased risk of adverse effects compared with prophylactic antibiotics. Larger blinded clinical trials are needed to further define the role of methenamine in UTI prophylaxis.

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Urinary tract infections (UTIs) are a common health issue affecting individuals worldwide. Recurrent urinary tract infections (rUTI) pose a significant clinical challenge, with limited understanding of the underlying mechanisms. Recent research suggests that the urobiome, the microbial community residing in the urinary tract, may play a crucial role in the development and recurrence of urinary tract infections. However, the specific virulence factor genes (VFGs) driven by urobiome contributing to infection recurrence remain poorly understood. Our study aimed to investigate the relationship between urobiome driven VFGs and recurrent urinary tract infections. By analyzing the VFGs composition of the urinary microbiome in patients with rUTI compared to a control group, we found higher alpha diversity in rUTI patients compared with healthy control. And then, we sought to identify specific VFGs features associated with infection recurrence. Specifically, we observed an increased abundance of certain VGFs in the recurrent infection group. We also associated VFGs and clinical data. We then developed a diagnostic model based on the levels of these VFGs using random forest and support vector machine analysis to distinguish healthy control and rUIT, rUTI relapse and rUTI remission. The diagnostic accuracy of the model was assessed using receiver operating characteristic curve analysis, and the area under the ROC curve were 0.83 and 0.75. These findings provide valuable insights into the complex interplay between the VFGs of urobiome and recurrent urinary tract infections, highlighting potential targets for therapeutic interventions to prevent infection recurrence.

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Management of urinary tract infection (UTI) in postmenopausal women can be challenging. The recent rise in resistance to most of the available oral antibiotic options together with high recurrence rate in postmenopausal women has further complicated treatment of UTI. As such, intravesical instillations of antibiotics like gentamicin are being investigated as an alternative to oral antibiotic therapies. This study evaluates the efficacy of the candidate intravesical therapeutic VesiX, a solution containing the cationic detergent Cetylpyridinium chloride, against a broad range of uropathogenic bacterial species clinically isolated from postmenopausal women with recurrent UTI (rUTI). We also evaluate the cytotoxicity of VesiX against cultured bladder epithelial cells and find that low concentrations of 0.0063% and 0.0125% provide significant bactericidal effect toward diverse bacterial species including uropathogenic Escherichia coli (UPEC), Klebsiella pneumoniae, Enterococcus faecalis, Pseudomonas aeruginosa, and Proteus mirabilis while minimizing cytotoxic effects against cultured 5637 bladder epithelial cells. Lastly, to begin to evaluate the potential utility of using VesiX in combination therapy with existing intravesical therapies for rUTI, we investigate the combined effects of VesiX and the intravesical antibiotic gentamicin. We find that VesiX and gentamicin are not antagonistic and are able to reduce levels of intracellular UPEC in cultured bladder epithelial cells. IMPORTANCE: When urinary tract infections (UTIs), which affect over 50% of women, become resistant to available antibiotic therapies dangerous complications like kidney infection and lethal sepsis can occur. New therapeutic paradigms are needed to expand our arsenal against these difficult to manage infections. Our study investigates VesiX, a Cetylpyridinium chloride (CPC)-based therapeutic, as a candidate broad-spectrum antimicrobial agent for use in bladder instillation therapy for antibiotic-resistant UTI. CPC is a cationic surfactant that is FDA-approved for use in mouthwashes and is used as a food additive but has not been extensively evaluated as a UTI therapeutic. Our study is the first to investigate its rapid bactericidal kinetics against diverse uropathogenic bacterial species isolated from postmenopausal women with recurrent UTI and host cytotoxicity. We also report that together with the FDA-approved bladder-instillation agent gentamicin, VesiX was able to significantly reduce intracellular populations of uropathogenic bacteria in cultured bladder epithelial cells.

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AIMS: This International Consultation on Incontinence-Research Society report aims to summarize the evidence and uncertainties regarding the use of hormone replacement therapy by any route in the management of lower urinary tract symptoms (LUTS) including recurrent urinary tract infections (rUTI), with a review of special considerations for the elderly. Research question proposals to further this field have been highlighted. METHODS: An overview of the existing evidence, guidelines, and consensus regarding the use of topical or systemic estrogens in the management of LUTS. RESULTS: There are currently evidence and recommendations to offer topical estrogens to postmenopausal women with overactive bladder symptoms as well as postmenopausal women with rUTIs. Systemic estrogens however have been shown in a meta-analysis to have a negative effect on LUTS and, therefore are not currently recommended. CONCLUSIONS: Although available evidence and recommendations exist for the use of topical estrogens, few women are commenced on these in primary care. There remain large gaps still within our knowledge of the use of estrogens within the management of LUTS, particularly on when it should be commenced, the length of time treatment should be continued for, and barriers to prescribing.

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ETHNOPHARMACOLOGICAL RELEVANCE: Urinary tract infections (UTIs) with pathogenic strain resistance leading to a high recurrence rate affect health quality and have become a high-priority issue due to the economic burden on the health care system. AIM OF THE STUDY: This study aimed to investigate the supportive benefits of traditional herbal medicines (THMs) for the treatment and prevention of recurrent UTIs through a meta-analysis of randomized controlled trials. MATERIALS AND METHODS: Systematic searches of databases, including PubMed/Medline, the Cochrane Library, and China National Knowledge Infrastructure (CNKI), were conducted to collect eligible studies for meta-analysis. The inclusion criteria were randomized controlled trials that investigated UTI recurrence using THM treatment. RESULTS: The results of 22 studies showed that THM treatment led to significantly fewer UTI events in the experimental group than in the control group (OR = 0.348; 95% confidence interval [CI] = 0.257 to 0.473; p < 0.001). Seventeen studies reported UTI events during the follow-up period, and the recurrence rate was lower in the experimental group than in the control group (OR, 0.326; 95% CI, 0.245-0.434; p < 0.01). Subgroup analysis further showed that compared to antibiotics alone, treatment with THM plus antibiotics significantly reduced UTI events in the acute phase (OR = 0.301; 95% CI = 0.201 to 0.431; p < 0.001) as well as in the follow-up period (OR = 0.347; 95% CI = 0.241 to 0.498; p < 0.001). However, THM treatment alone was not superior to antibiotics in the acute treatment phase (OR = 0.540; 95% CI = 0.250 to 1.166; p = 0.117) or in the follow-up period (OR = 0.464; 95% CI = 0.111 to 1.951; p = 0.295). Herbal ingredients for recurrent UTI events also showed benefits compared to placebo treatment in the acute phase (OR = 0.337; 95% CI = 0.158 to 0.717; p = 0.005) and during follow-up (OR = 0.238; 95% CI = 0.139 to 0.409; p < 0.001). CONCLUSIONS: THM combined with antibiotics is helpful for people with acute UTIs and for reinfection prevention. THMs alone, although less effective for recurrent UTIs, could be considered a therapeutic alternative to antibiotics.

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INTRODUCTION AND HYPOTHESIS: The development of recurrent urinary tract infections (rUTIs) is not completely understood. This review is aimed at investigating the connection between genetics and rUTIs and summarizing the results of studies that have documented variations in gene expression among individuals with rUTIs compared with healthy individuals. METHODS: A systematic search was conducted in Cochrane, Ovid, and PubMed, limiting the results to articles published between 1 January 2000, and 5 July 2022. Only studies comparing the difference in gene expression between individuals with rUTI and healthy individuals utilizing molecular techniques to measure gene expression in blood or urine samples were included in this systematic review. Gene network and pathways analyses were performed using Cytoscape software, with input data obtained from our systematic review of differentially expressed genes in rUTIs. RESULTS: Six studies met our criteria for inclusion. The selected studies used molecular biology methods to quantify gene expression data from blood specimens. The analysis revealed that gene expressions of CXCR1 and TLR4 decreased, whereas CXCR2, TRIF, and SIGIRR increased in patients with rUTI compared with healthy controls. The analysis demonstrated that the most significant pathways were associated with TLR receptor signaling and tolerance, I-kappa B kinase/NF-kappa B signaling, and MyD88-independent TLR signaling. CONCLUSIONS: This systematic review uncovered gene expression variations in several candidate genes and identified a number of underlying biological pathways associated with rUTIs. These findings could shift the treatment and prevention strategies for rUTIs.

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Urine is not sterile but contains a complex urinary microbiome that is established as early as infancy and gradually refines with age. There are great differences in urinary microbiome of different ages and gender. At present，the core urinary microbiome of children has not reached a consensus. The urinary microbiome plays an important role in maintaining the integrity of urothelium，reducing the overgrowth of pathogenic bacteria，and local immune function. Changes in microbial diversity and composition are associated with various diseases of the urinary system，especially in urinary tract infections. In recent years，research on the relationship between urinary microbiome composition，microbiome，and urinary tract infection in children has been deepening. Therefore，this review aims to provide an overview of the urinary microbiome and its role in urinary tract infection in children，and to summarize the methods of intervening and reshaping the urinary microbiome in children to prevent recurrent urinary tract infections.

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In the differentiation and treatment of recurrent urinary tract infection （rUTI） from the perspective of the seminal orifice， it is proposed that the urinary tract belongs to the category of "seminal orifice"， and the physiological process of urination is closely related to the function of the seminal orifice. From the three dimensions of orifice body， orifice pivot and orifice spirit， the physiological relationship between seminal orifice and the function of five zang-organs （脏） is constructed， that is， lung heat， yin damage and pathogen counter-restriction lead to malnutrition of orifice body； burning heart fire and spirit disorder lead to unfavorable orifice spirit， and kidney deficiency， liver constraint and spleen stagnation lead to unfavorable orifice pivot. In the early stage of rUTI， there is usually unfavo-rable orifice pivot， for which the treatment principle should be treating the root and the branch simultaneously， consi-dering both deficiency and excess， and paying attention to the management of accompanied symptoms. Zishui Qinggan Beverage （滋水清肝饮） and Modified Shenzhuo Decoction （肾着汤加减） are often selected based on syndrome differentiation. In the middle stage， lack of nourishment of the orifice body and unfavorable orifice spirit and pivot coexist， and the treatment should be draining the orifice and unblocking strangury， commonly withmodified Qingxin Lianzi Beverage （清心莲子饮）. In the late stage， loss of nourishment of the orifice body is the main pathogenesis， and it is necessary to further nourish the orifice body to prevent recurrence， and modifed Wuzi Yanzong Pills and Erxian Decoction （五子衍宗丸合二仙汤） is often used. Furthermore， the specific medicinals should be selected targeting at the orifice body， orifice pivot， and orifice spirit， so as to nourish orifice body by dispelling external pathogens and rectify healthy qi， to drain orifice pivot by freeing emotions and minds and unblocking qi movement， and to calm orifice spirit by unblocking heart and kidney and nourishing heart spirit.

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Background: Extended-spectrum cephalosporin-resistant Enterobacterales (ESCrE) are an increasingly important cause of community-onset urinary tract infections (UTIs), including recurrent infections. We evaluated risk factors for recurrence among patients with community-onset ESCrE UTI. Methods: This retrospective cohort study included adults with community-onset ESCrE UTI in the Duke University Health System from April 2018 through December 2021. ESCrE UTI recurrence by the same species was assessed 14-180 days (ie, 6 months) after completion of antibiotic treatment. We evaluated the relationships between candidate risk factors and time to recurrence using Cox proportional hazards regression models. Results: Among 1347 patients with community-onset ESCrE UTI, 202 (15.0%) experienced recurrent infection during the 6-month follow-up period. Independent risk factors for recurrence included neurogenic bladder (adjusted hazard ratio [aHR], 1.8 [95% confidence interval {CI}, 1.2-2.6]; P = .005), prior history of UTI (aHR, 2.4 [95% CI, 1.7-3.3]; P < .001), and fluoroquinolone nonsusceptibility of the index UTI (aHR, 1.5 [95% CI, 1.1-2.1]; P = .02). Klebsiella pneumoniae infection was associated with recurrence in univariate analysis (HR, 1.6 [95% CI, 1.1-2.1]; P = .007) but not multivariate analysis (aHR, 1.4 [95% CI, 1.0-1.9]; P = .06). Inappropriate initial or definitive antibiotic therapy was not predictive of ESCrE UTI recurrence. Conclusions: Recurrence of community-onset ESCrE UTI was common and associated with several patient and pathogen-level risk factors. Future studies should evaluate microbial risk factors for recurrence and improve the management of ESCrE UTI.

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Introduction: Duplication of the renal collecting system, known as the duplex collecting system, is a common congenital anomaly of the urinary tract. It can be partial or complete and affects 0.7-4% of the population, with a higher incidence in females. Ureteroceles are cystic dilations of the distal ureter and are often asymptomatic, particularly in adults. Case presentation: The authors present a case of a newly diagnosed partial duplex collecting system of the left kidney and left intravesical ureterocele, which was diagnosed for the first time at the age of 47 years, along with a history of symptoms suggestive of recurrent urinary tract infection and a urethral calculus which was surgically managed 5 years ago. Clinical discussion: The presence of a duplex collecting system can be observed even in males, with the possibility of recurrent urinary tract infection and the rare occurrence of an intravesical ureterocele. While ureteroceles are typically considered a congenital condition, they can also be diagnosed in adults. Conclusion: A partial duplex collecting system of the left kidney with left intravesical ureterocele in the age of 47 years in a male is a rare occurrence. Diagnosis and management of such urological cases can be challenging especially in a resource limited setting, which can be mitigated by awareness of unusual presentations, proper antenatal care, and access to proper diagnostic tools.

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BACKGROUND: Clinical guidelines developed by urologic, urogynecologic, and gynecologic associations around the globe include recommendations on nutrition-related lifestyle and behavioral change for bladder storage conditions. This study identified and compared clinical guidelines on three urological conditions (interstitial cystitis/bladder pain syndrome (IC/BPS), overactive bladder, and stress urinary incontinence) affecting adult women. METHODS: A three-step process was employed to identify the guidelines. Next, a quality assessment of the guidelines was conducted employing the Appraisal of Guidelines Research and Evaluation (AGREE II) International tool. (3) Results: Twenty-two clinical guidelines, prepared by seventeen groups spanning four continents, met the inclusion criteria. The AGREE II analyses revealed that most of the guideline development processes complied with best practices. The most extensive nutrition recommendations were for women with IC/BPS. Dietary manipulation for the other two storage LUTS primarily focused on the restriction or limitation of specific beverages and/or optimal fluid intake. (4) Conclusion: Clinical guidelines for IC/BPS, overactive bladder, and stress urinary incontinence include nutrition recommendations; however, the extent of dietary manipulation varied by condition. The need to ensure that clinicians are informing patients of the limitations of the evidence supporting those recommendations emerged. Furthermore, given the need to treat nutrition-related comorbid conditions as a strategy to help mitigate these three urological disorders, the value of referral to a dietitian for medical nutrition therapy is apparent.

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