Assessment and treatment of recurrent urinary tract infections in women: development of a questionnaire based on a qualitative study of patient expectations in secondary care.

BACKGROUND: To develop a questionnaire to facilitate the inventorying of women's expectations for the assessment and treatment of recurrent urinary tract infection (UTI) in secondary care. METHODS: Semi-structured interviews were conducted among women with recurrent UTI referred to our urology department. The interviews were conducted by one interviewer, recorded, transcribed verbatim, and analyzed thematically by two researchers. We first developed 35 questions to identify potential themes, and we then tested them among women with and without recurrent UTI. Changes were made according to the feedback received. RESULTS: Six interviews were conducted before saturation was reached. Thematic analysis identified three themes: patient pathway, personal knowledge, and social implications. All respondents had received multiple antibiotic courses but no prophylactic antibiotic therapy, and although all were aware of some preventive measures, they wanted more information about their disease. However, some women were afraid to access information for fear of what they might learn. Recurrent UTI also significantly affected the daily lives all respondents. Some women expressed fears over frequent antibiotic use, and others felt that there must be something wrong with their body to have so many UTIs. Women expected the urologist to provide an explanation and to start adequate therapy for their recurrent UTI. We created a 32-item questionnaire based on these themes CONCLUSION: This study not only developed a questionnaire for use when assessing patient expectations of recurrent UTI management in secondary care but also provided novel insights into the thoughts, opinions, and expectations of women who are referred.

Antepartum urinary tract infection and postpartum depression in Taiwan - a nationwide population-based study.

BACKGROUND: Urinary tract infections (UTIs) are among the most common bacterial infections in pregnant women due to anatomic and physiologic changes in the female urinary tract during pregnancy, and antepartum UTIs can cause adverse pregnancy outcomes that may induce mental stress. There have only been a few studies, however, investigating antepartum UTIs and mental stress. As such, the present study was conducted in order to investigate the association between antepartum UTIs and postpartum depression (PPD). METHODS: We used data from the 2000-2013 National Health Insurance Research Database (NHIRD) of Taiwan. Data regarding a total of 55,087 singleton pregnancies was utilized, including data regarding 406 women who were newly diagnosed with PPD in the first 6 months postpartum. The associations between PPD and antepartum UTIs or other risk factors were examined by multiple logistic regression analysis. RESULTS: The logistic regression analysis results indicated that PPD was associated with antepartum UTIs (adjusted odds ratio [aOR] 1.27; 95% confidence interval [CI] (1.07-1.65). Furthermore, the risk of PPD was higher in women with an upper antepartum UTI (aOR 2.97 (1.31, 6.77) than in those with a lower antepartum UTI (aOR 1.21 (1.02, 1.58)). CONCLUSIONS: Antepartum UTIs, particularly upper antepartum UTIs, are significantly associated with PPD. This information may encourage physicians to pay greater attention to the mental health of women who have suffered upper UTIs during their pregnancies.

Qualitative Exploration of the Patient Experience of Underactive Bladder.

BACKGROUND: Underactive bladder (UAB) is considered the symptom complex associated with the urodynamic diagnosis of detrusor underactivity. OBJECTIVE: The aim of this research was to investigate the patient reported experience of the symptoms, signs, and impact of UAB. This research is also part of the initial qualitative phase for the development of a new patient reported outcome measure for the assessment of UAB. DESIGN, SETTING, AND PARTICIPANTS: Qualitative methods were used to understand the experience of UAB from a patient perspective, in a purposive sample of male (n=29) and female (n=15) patients aged 27-88 yr (mean: 64 yr), diagnosed with a primary diagnosis of detrusor underactivity, with or without coexisting urological conditions. Semistructured interviews were conducted in Bristol, UK. RESULTS: Male and female patients reported a variety of lower urinary tract symptoms and associated impact on quality of life. Storage symptoms of nocturia, increased daytime frequency, and urgency, and the voiding symptoms of slow stream, hesitancy, and straining were reported by over half of the patients. A sensation of incomplete emptying and postmicturition dribble were also frequently described. Most had a post void residual >30ml (n=34, 77%, median: 199ml) with many reporting urinary tract infections, a history of self-catheterisation, and some experiencing occasional acute retention episodes. These symptoms and signs can have a broad impact on quality of life including having to plan their daily activities around the location of toilets, disruption to sleep, social life, and associated effect on family and friends. CONCLUSIONS: Knowledge of the lived experience of UAB obtained in the current study will be used for the development of a new patient reported outcome measure and help inform the current working definition of UAB. PATIENT SUMMARY: The symptoms, signs, and impact on quality of life of underactive bladder are described by patients with the condition.

Micturition problems after bladder distension during hospitalization in Sweden: "I'm not ill, just damaged for the rest of my life".

BACKGROUND: Urinary retention is a common complication following hospital care, which can result in overdistension of the bladder and, at worst, chronic bladder damage and persistent micturition difficulties. OBJECTIVES: The purpose of this study was to explore patients' experiences of micturition problems after bladder distension and their effects on the patients' everyday lives. METHODS: The Swedish Patient Insurance LÖF was used to identify patients from January 2007 to June 2010 who have reported micturition problems after hospital care and have had their injuries classified as avoidable bladder damage due to overdistension. Narrative interviews were conducted with 20 volunteers and analyzed by qualitative content analysis. RESULTS: The micturition problems affected everyday life through constraints (dependence on disposables and access to toilets, clothing restrictions, limitations on social life and career), suffering (pain, infections, impaired sex life, leakage), and concerns for the future (fear of worsening symptoms and fear of losing control with age). Aspects related to having been harmed by the healthcare system were the harm could have been avoided (lack of knowledge, insufficient routines, mistrust), obstacles to overcome when reporting an injury (difficulties in obtaining knowledge about the possibility of reporting an injury, ambivalence toward reporting their healthcare providers), and a wish to improve care (raise awareness, prevent harm to others). DISCUSSION: Bladder distension is a healthcare-related injury that can cause suffering and practical, emotional, and psychosocial problems with a great impact on the life of the person affected and anxiety for the future. The healthcare system must, therefore, raise awareness and improve preventive routines.

Systematic review of the impact of urinary tract infections on health-related quality of life.

What's known on the subject? and What does the study add? Values for equivalent health states can vary substantially depending on the measure used and method of valuation; this has a direct impact on the results of economic analyses. To date, the majority of existing economic evaluations that include UTI as a health state refer to an analysis in which the Index of Well Being was used to estimate the quality of life experienced by young women with UTIs. Currently, there are no validated methods or filters for systematically searching for the type of generic quality of life data required for decision analytic models. This study is the only systematic review of quality of life in people with UTI in the literature. Twelve studies were identified which report quality of life using a variety of generic methods; the results of these papers were summarized in a way that is useful for a health researcher seeking to populate a decision model, design a clinical study or assess the effect of UTI on quality of life relative to other conditions. One research group provided previously unpublished data from a large cohort study; these scores were mapped to EuroQol 5-Dimension values using published algorithms and probabilistic simulations. The aim of this review was to identify studies that have evaluated the impact of symptomatic urinary tract infection (UTI) and UTI-associated bacteraemia on quality of life, and to summarize these data in a way that is useful for a health researcher seeking to populate a cost-utility model, design a clinical study or assess the effect of UTIs on quality of life relative to other conditions. We conducted a systematic search of the literature using MEDLINE, EMBASE, the NHS Economic Evaluations database, Health Technology Assessment database, Health Economics Evaluations database, Cost-Effectiveness Analysis Registry and EuroQol website. Studies that reported utility values for symptomatic UTI or UTI-associated bacteraemia derived from a generic QoL measurement tool or expert opinion were included. Studies using disease-specific instruments were excluded. Twelve studies were identified that included a generic measure of health-related quality of life for patients with UTIs. These measures included: the short-form (SF)-36 and SF-12 questionnaires; the Health Utilities Index Mark 2; Quality of Well Being; the Index of Well Being, standard gamble; the Health and Activity Limitation Index; and expert opinion. The authors of studies using either of the SF questionnaires were contacted for additional data. One research group provided previously unpublished data from a large cohort study; these scores were mapped to EuroQol 5-Dimension (EQ-5D) values using published algorithms and probabilistic simulations. The present review provides health researchers with several sources from which to select utility values to populate cost-utility models. It also shows that very few studies have measured quality of life in patients with UTI using generic preference-based measures of health and none have evaluated the impact of this health state on quality of life in children. Future studies ought to consider the inclusion of commonly used preference-based measures of health, such as the EQ-5D, in all patient populations experiencing symptomatic UTI or UTI-related complications.

Dipsticks and diagnostic algorithms in urinary tract infection: development and validation, randomised trial, economic analysis, observational cohort and qualitative study.

OBJECTIVES: To estimate clinical and dipstick predictors of infection and develop and test clinical scores; to compare management using clinical and dipstick scores with commonly used alternative strategies; to estimate the cost-effectiveness of each strategy; and to understand the natural history of urinary tract infection (UTI) and women's concerns about its presentation and management. DESIGN: There were six studies: (1) validation development for diagnostic clinical and dipstick scores; (2) validation of the scores developed; (3) observation of the natural history of UTI; (4) randomised controlled trial (RCT) of scores developed in study 1; (5) economic analysis of the RCT; (6) qualitative study of patients in the RCT. SETTING: Primary care. PARTICIPANTS: Women aged 17-70 with suspected UTI. INTERVENTIONS: Patients were randomised to five management approaches: empirical antibiotics; empirical delayed antibiotics; target antibiotics based on a higher symptom score; target antibiotics based on dipstick results; or target antibiotics based on a positive mid-stream specimen of urine (MSU). MAIN OUTCOME MEASURES: Antibiotic use, use of MSUs, rates of reconsultation and duration, and severity of symptoms. RESULTS: (1) 62.5% of women had confirmed UTI. Only nitrite, leucocyte esterase and blood independently predicted diagnosis of UTI. A dipstick rule--based on having nitrite or both leucocytes and blood--was moderately sensitive (77%) and specific (70%) [positive predictive value (PPV) 81%, negative predictive value (NPV) 65%]. A clinical rule--based on having two of urine cloudiness, offensive smell, reported moderately severe dysuria, moderately severe nocturia--was less sensitive (65%) (specificity 69%, PPV 77%, NPV 54%). (2) 66% of women had confirmed UTI. The predictive values of nitrite, leucocyte esterase and blood were confirmed. The dipstick rule was moderately sensitive (75%) but less specific (66%) (PPV 81%, NPV 57%). (3) Symptoms rated as moderately bad or worse lasted 3.25 days on average for infections sensitive to antibiotics; resistant infections lasted 56% longer, infections not treated with antibiotics 62% longer and symptoms associated with urethral syndrome 33% longer. Symptom duration was shorter if the doctor was perceived to be positive about prognosis, and longer with frequent somatic symptoms, previous history of cystitis, urinary frequency and more severe symptoms at baseline. (4) 66% of the MSU group had laboratory-confirmed UTI. Women suffered 3.5 days of moderately bad symptoms if they took antibiotics immediately but 4.8 days if they delayed taking antibiotics for 48 hours. Taking bicarbonate or cranberry juice had no effect. (5) The MSU group was more costly over 1 month but not over 1 year. Cost-effectiveness acceptability curves showed that for a value per day of moderately bad symptoms of over 10 pounds, the dipstick strategy is most likely to be cost-effective. (6) Fear of spread to the kidneys, blood in the urine, and the impact of symptoms on vocational and leisure activities were important triggers for seeking help. When patients are asked to delay taking antibiotics the uncomfortable and worrying journey from 'person to patient' needs to be acknowledged and the rationale behind delaying the antibiotics made clear. CONCLUSIONS: To achieve good symptom control and reduce antibiotic use clinicians should either offer a 48-hour delayed antibiotic prescription to be used at the patient's discretion or target antibiotic treatment by dipsticks (positive nitrite or positive leucocytes and blood) with the offer of a delayed prescription if dipstick results are negative.

Validity, responsiveness, and minimal important difference for the SF-6D health utility scale in a spinal cord injured population.

OBJECTIVE: To determine the feasibility, acceptability, discriminative validity, responsiveness, and minimal important difference (MID) of the SF-6D for people with spinal cord injury (SCI). METHODS: A total of 305 people with SCI completed the SF-36 health status questionnaire at baseline and at subsequent occurrence of a urinary tract infection (UTI) or 6-month follow-up. Normative SF-36 data were obtained from the Australian Bureau of Statistics. SF-36 scores were transformed to SF-6D utility values using Brazier's algorithm. We used UTI as the external criterion of clinically important change to determine responsiveness and two categories of the SF-36 transition question ("somewhat worse" and "somewhat better") as the external criterion to determine the MID. Derived SF-12 responsiveness was also assessed. RESULTS: The mean SF-6D values were: 0.68 (SD 0.21, n = 305) all patients; 0.66 (SD 0.19, n = 167) tetraplegia; 0.72 (SD 0.26, n = 138) paraplegia; 0.57 (SD 0.15, n = 138) with UTI. The Australian normative SF-6D mean value was 0.80 (SD 0.14, n = 18,005). The SF-6D was able to discriminate between SCI and the Australian normative sample (effect size [ES] = 0.86), tetraplegia-paraplegia (ES = 0.23), and it was responsive to UTI (ES = 0.86 SF-36 variant, ES = 0.92 SF-12 variant). The MID for respondents who reported being somewhat worse or somewhat better at follow-up was 0.03 (SD 0.17, n = 108/305), while the MID for only those who were somewhat worse was 0.10 (SD 0.14, n = 58). CONCLUSIONS: The content of the SF-6D is more appropriate than that of the SF-36 for this physically impaired population. The SF-6D has discriminative power and is responsive to clinically important change because of UTI. The MID is consistent with published estimates for other disease groups.

Validation of a patient-administered questionnaire to measure the activity impairment experienced by women with uncomplicated urinary tract infection: the Activity Impairment Assessment (AIA).

BACKGROUND: To validate a questionnaire to assess the activity impairment associated with uncomplicated urinary tract infection (uUTI). METHODS: The Activity Impairment Assessment (AIA) assesses the amount of time an individual's work or regular activities have been impaired as a result of their UTI. The measure was completed by 276 women with uUTI who had participated in a prospective, open-label, non-comparative multi-centre clinical trial of CIPRO XR (extended-release ciprofloxacin). Baseline scores on the King's Health Questionnaire (KHQ) and clinical symptom evaluations were collected for validation purposes. RESULTS: An exploratory factor analysis showed that all items loaded > 0.84 on a single component. This uni-dimensional structure was supported by Rasch analysis. The AIA was found to have excellent levels of internal consistency (Cronbach's alpha = 0.93), convergent validity (all rs > .70) and divergent validity (rs = .078). The AIA displayed excellent discriminant validity in relation to clinical evaluations, and was found to be responsive to change across all clinical evaluations. CONCLUSION: The unidimensional AIA shows high levels of internal reliability, convergent and divergent validity, discriminant validity and responsiveness. It is an excellent tool for measuring activity impairment in UTI.

Assessing health care needs and clinical outcome with urological case complexity: a study using INTERMED.

Urinary tract symptoms and, particularly, urinary incontinence are often chronic and complex conditions that cause diagnosis, treatment, and management problems. In many cases, psychosocial factors contribute to the development of a chronic condition. The authors investigated whether INTERMED, an instrument for assessing case complexity and health care needs, was able to identify such complex cases, to estimate the amount of comorbidity, and to predict clinical outcome for 31 consecutive patients suffering from urinary tract symptoms. To assess clinical outcome, the authors used the American Urologic Association Symptom Score, the Brief Symptom Inventory, and the Hospital Anxiety and Depression Scale. On the basis of the patients' INTERMED scores, the authors distinguished between low-complexity patients (INTERMED score <21, N=25, 80.6%) and high-complexity patients (INTERMED score >or=21, N=6; 19.4%). Low-complexity patients had fewer depressive and anxiety symptoms, less distress, and better clinical outcome at their 3-month follow-up than high-complexity patients. The data confirmed the ability of the instrument to detect patients at risk of complex urinary tract symptoms and to predict clinical outcome.

The prevalence of urogynecologic disorders.

Although the field of urogynecology spans a wide range of lower urinary tract disorders, urinary incontinence and urinary infections remain the two most common disorders of the urinary tract encountered by the health care provider practicing obstetrics and gynecology. Both problems have a higher prevalence in the older population, and in addition they both have a predilection for recurrence. Together they account for considerable personal and public expense, as well as untold individual emotional and physical distress. Much remains to be learned before significant measures can be initiated to prevent the problems. Urinary incontinence is particularly challenging because it is a manifestation of so many other disorders or their treatment.