Missed urinary tract infection in patients with chronic recalcitrant LUTS and recurrent cystitis

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./

Sutika Paricharya - Post Natal Care in Ayurveda

Ayurveda give importance for the care of mother at every phase of her life specially when it comes to antenatal care and postnatal care. A postnatal period beginning immediately after the separation of placenta and extending up to 6 weeks, otherwise called as puerperium or puerperal period. Postnatal care certainly co-related with Sutika Paricharya explained in Ayurvedic classics. Garbhini and Sutika Paricharya are well described by our Ancient Ayurvedic scholars in their respective Samhitas. They have described dietary regimen, living style, and other required management for whole pregnancy and up to 6 month after delivery. In this stage mother should be educated to take care of herself and the new born baby. This period is of happiness and contentment, on one hand and physical and mental fatigue due to delivery, on the other hand, she become weak or emaciated after loss of blood and body fluid during delivery. Garbhini is much prone to the disease due to aggravation of Doshas. This further may be aggravated during delivery and puerperium due to loss of blood and other important Dhatus of body. Therefore she needs special and proper care during pregnancy as well as during puerperium. The regimen that helps the woman to regain her lost vitality and helps her body to revert back to prepregnant state is called Sutika Paricharya, as during this period she restores her health and strength

Cross-over data supporting long-term antibiotic treatment in patients with painful lower urinary tract symptoms, pyuria and negative urinalysis

PURPOSE: To measure the effects of an unplanned, sudden cessation of treatment in an unselected group of patients with chronic painful LUTS managed with protracted antimicrobial treatment and to report these observational data collected from a cross-over process. MATERIALS AND METHODS: The imposition of a guideline resulted in the immediate cessation of antibiotic treatment in a cohort of patients with chronic painful LUTS and microscopic pyuria. Patients were assessed before treatment withdrawal, whilst off treatment, and following reinstatement. Outcome measures included a validated symptom score, microscopic enumeration of urinary white cells and uroepithelial cells, and routine urine culture. RESULTS: These patients had reported treatment-resistant, painful LUTS for a mean of 6.5 years before treatment at this centre. Treatment was stopped in 221 patients (female = 210; male = 11; mean age = 56 years; SD = 17.81). Sixty-six per cent of women were post-menopausal. After unplanned treatment cessation, 199 patients (90%; female = 188; male = 9) reported deterioration. Eleven patients required hospital care in association with disease recurrence, including acute urinary tract infection (UTI) and urosepsis. Symptom scores increased after cessation and recovered on reinitiating treatment (F = 33; df = 2; p < 0.001). Urinary leucocyte (F = 3.7; df = 2; p = 0.026) and urothelial cells counts mirrored symptomatic changes (F = 6.0; df = 2; p = 0.003). Routine urine culture results did not reflect changes in disease status. CONCLUSION: These data support the hypothesis that treating painful LUTS associated with pyuria with long-term antimicrobial courses, despite negative urine culture, is effective. The microscopy of fresh unspun, unstained urine to count white cells and epithelial cells offers a valid method of monitoring disease. An unplanned cessation of antibiotic therapy produced a resurgence of symptoms and lower urinary tract inflammation in patients with chronic LUTS, supporting an infective aetiology below the level of routine detection