FEMALE UROLOGY

Urinary urgency and frequency, and chronic urethral and/or pelvic pain in females. Can doxycycline help?
Burkhard FC, Blick N, Hochreiter WW, Studer UE
Department of Urology, University of Berne, Berne, Switzerland
J Urol. 2004; 172: 232-5

• Purpose: Persistent urinary urgency and frequency, and chronic urethral and/or pelvic pain in women are often a diagnostic and therapeutic challenge. This can be frustrating for patients and physicians. The search for an infectious agent often proves futile and after multiple ineffective treatment regimens patients may be classified as having interstitial cystitis or referred to a psychiatrist as the last option. We evaluated whether treatment with doxycycline of the patient and her sexual partner would be beneficial.
• Materials and Methods: Women presenting with a history of urinary urgency and frequency, and chronic urethral and/or pelvic pain often associated with dyspareunia and/or a history of recurrent urinary tract infection were evaluated. Initial examinations included urethral and cervical/vaginal swabs, serum analysis, urine examination and culture, and bladder barbitage. A total of 103 women with a median age of 46 years (range 21 to 84) and with a median symptoms history of 60 months (range 3 to 480) were included. All patients had trigonal leukoplakia at cystoscopy, in 15% an infectious organism was identified and 30% had leukocyturia. All were treated with doxycyclines, and a vaginal antimicrobic and/or antimycotic agent following the same regimen, including treatment of the sexual partner.
• Results: After treatment with doxycycline 71% of the women were symptom-free or had a subjective decrease in symptoms.
• Conclusions: Treatment with doxycycline is effective in more than two-thirds of patients complaining of persistent frequency and urgency, chronic urethral and/or pelvic pain, and dyspareunia as well as a history of recurrent urinary tract infections. In women with negative urinary cultures but a history of urgency/frequency probative treatment with doxycycline is justified and endoscopic findings may support the hypothesis of chronic infection. This should be done especially before contemplating psychiatric treatment or diagnosing the patient with interstitial cystitis. We attribute this high success rate to simultaneous treatment of the sexual partner, who may be an asymptomatic carrier, although this remains to be proved.
  
  
• Editorial Comment
  The authors review the efficacy of doxycycline therapy for one month on female patients with urinary urgency, frequency, chronic urethral and/or pelvic pain. Of note is that only 15% of the patients had an identified infectious organism. All patients have trigonal leukoplakia at cystoscopy. At the time of treatment with doxycycline the patient also underwent therapy with a vaginal antimicrobic and/or antimycotic agent. In addition, all sexual partners underwent synchronous therapy.
  The use of antibiotics in the absence of a true positive culture is a therapy that many of us have tried, in both males and female. Who can say that he has never treated a man with prostatitis with long-term antibiotics in the absence of a positive culture and then experienced a positive clinical result. The subselection of patients to receive therapy with leukoplakia is interesting. Leukoplakia has been described and discussed previously in the literature (1). In addition, it was noted that the patients had synchronous therapy with a vaginal antimicrobic or antimycotic agent and had the sexual partners treated as well. It would be interesting to subdivide the success rates between those patients who had a sexual partner that was treated and those patients who did not have a sexual partner thus obviating the need for therapy for same. Potential difference in success rate would have perhaps shed light on the ping-pong reinoculation effect with a sexual partner versus a difficult primary problem of a non-infectious nature. In addition, that patients had a synchronous therapy with a vaginal antimicotic and/or antimycrobic agent does confuse the issue to a degree. Perhaps vaginal pathology was as much to blame for the troublesome symptoms as was a primary bladder difficulty. The efficacy of doxycycline may be multi-factorial including that it is the only medication in its class that is renally excreted thus potentially achieving excellent bladder urine levels. If increased serum antibiotic levels do lend themselves to an increased therapeutic effect, then direction instillation of antimicrobial solutions in the bladder should not be discounted or forgotten in this challenging patient population (2).

REFERENCES
1. Petrou SP, Pinkstaff DM, Wu KJ; Bregg KJ: Leukoplakia of the bladder. Infections in Urology. 2003; 16: 95-105.
2. Arap M, Petrou SP: Efficacy of intermittent intravesical gentamicin sulfate solution for recalcitrant recurrent cystitis in women. Infections in Urology. 2003; 16: 45-8.

Dr. Steven P. Petrou
Associate Professor of Urology
Mayo Clinic College of Medicine
Jacksonville, Florida, USA