MISCELLANEOUS Treatment of Recurrent Bacterial Cystitis by Intravesical Instillations of Hyaluronic Acid Tomasz Ząbkowski,1* Beata Jurkiewicz2, Marek Saracyn3 Purpose: To evaluate the results of intravesical instillations of hyaluronic acid (HA) in the treatment of recurrent bacterial cystitis (RBC), and to assess the rate of tolerability, the rate of recurrence of RBC and side effects of treatment. Materials and Methods: The study included 23 female patients from September 2012 to May 2013, aged 28-42 years. Twenty three women with a history of RBC, received intravesical instillations of HA once weekly for 6 weeks then once monthly for 8 months. Results: In 16 (69.6%) of patients, symptoms of RBC resolved after 8 months. In 5 (21.7%) patients after 8 months of HA treatment, urgency was reduced only by 30%. Therefore, it was decided to use combined therapy of HA and alpha blockers in this cohort group. There was a specific reduction (75%) in frequent urination at day and at night without urgency. Despite the use of above mentioned treatment, in 2 (8.7%) patients, RBC was still present and therefore the treatment was discontinued. Conclusion: The use of HA protects mucosa of urinary bladder and alleviates symptoms of infection. The intra- vesical instillations of HA and combination of HA + alpha blockers seems to be an effective therapeutic alternative in patients with RBC. Keywords: anti-bacterial agents; administration; therapeutic use; drug therapy; female; recurrence; urinary tract infections. INTRODUCTION The recurrent bacterial cystitis (RBC) is character-ized by persistent symptoms like pain, urgency, and frequency. It is still a challenge to find an effec- tive, suitable therapy in clinical practice. Hyaluronic acid (HA) has a long-term positive effects on treat- ment of symptoms of RBC. The glycosaminoglycan (GAG) layer on inside surface of urinary bladder is thought to be protective against microorganisms, car- cinogenic substances, microcrystals and other agents in urine. It is also claimed that it is a natural defense mechanism, protecting epithelium of urinary bladder against irritating agents in urine. The cavities in pro- tecting layer GAG, covering the epithelium of uri- nary bladder may disturb its protecting functions and they may cause adherence of bacteria, microcrystals, molecules of proteins and iron to epithelium of uri- nary bladder wall. HA temporarily replaces the de- ficient GAG layer of the bladder wall which helps to relieve the symptoms of pain, frequency and urgency. Urinary tract infections (UTIs) are among the most com- mon bacterial infections, affecting women at a much higher frequency than men.(1,2) Estimates suggest that about a third of women will have at least one episode of UTI requiring antibiotic therapy by the time they are 24 years old, and over a lifetime a half of them will have at least one UTI.(1,3) There is also a high level of recur- rence of UTI and 25-35% of initial UTI episodes will be followed by a recurrent infection within 3-6 months.(2,4) Although UTIs have traditionally been managed by intermittent or prolonged antibiotic therapy,(2,6) increas- ingly there is a renewed interest in the mechanisms of UTI and the development into recurrent infections. MATERIALS AND METHODS Study Population In a preliminary study, 56 women suffering from cystitis were subjected to antibiotic therapy. In 23 patients, the antibiotic therapy was not efficient and there were re- currences. These patients were qualified to the treatment by intravesical instillations of HA. The study included 23 female patients from September 2012 to May 2013, aged 28-42 years. Twenty three women with a history of RBC, received intravesical instillations of HA once weekly for 6 weeks then once monthly for 8 months. Inclusion and Exclusion Criteria The inclusion criteria were: age between 20-50 years, routine negative urine examination and urine culture, normal blood chemistry tests and cystitis symptoms last over 1 month. The exclusion criteria were: preg- nancy, cystitis symptoms caused by known reasons such as bladder tumor, previous operation, acute cys- titis, urethral stenosis, incapable to provide informed consent due to neurological or psychological disor- 1 Urological Outpatient Clinic, Warsaw, Poland. 2 Children's Hospital in Dziekanow Lesny, Warsaw, Poland. 3 Military Institute of Medicine, Warsaw, Poland. *Correspondence: Szaserów 128, 00-909 Warsaw, Poland. Tel: +48 791 533555. E-mail: urodent@wp.pl. Received November 2014 & Accepted April 2015 Miscellaneous 2192 ders, poor compliance and severe alcoholism or drug addiction, a known sensitivity to any component of the HA preparation used for bladder instillation. Woman (28 > years old) recruited for the study were referred to the outpatient clinic of the author’s insti- tution specifically for the treatment of RBC, and had been followed in the department for this problem for at least a year. All patients had a thorough clinical and radiological evaluation. The former was designed to exclude patients with urethral stenosis or external gen- itourinary abnormalities. The radiological examination included ultrasonography, and flexible cystoscopy. Treatment Twenty three women (mean age 35 years, range 28-42, SD 4.16) with a history of RBC, received intravesical instillations of HA (40 mg in 50 mL NaCl solution) once weekly for 6 weeks then once monthly for 8 months. In 5 (21.7%) patients after 8 months of HA treatment, ur- gency was reduced only by 30%. Therefore, it was de- cided to use combined therapy of HA and alpha block- ers (tamsulosin 0.4 mg once daily) in this cohort group (Figure 1). The HA instillations were administrated using a sterile single-use catheter and a sterile instil- lation gel. The patients were recommended not urinat- ing for at least 1 to 2 hours. No prophylactic antibiotic was given before, during, or after bladder instillations. Outcome Measures There were 3 follow-up times from starting HA instil- lations. After 6 weeks, 3 months and 8 months of treat- ment, presence of UTI was checked by urine culture taken before catheterization and instillation. In addi- tion, patients rates their pre- and post- treatment as well as their present symptoms, and the level of pain was de- termined on a 100 mm visual analog scale (VAS, 0-10). All of the patients were asked to comment on their personal benefit on quality of life. Response to therapy was assessed using a questionnaire administrated to all patients at baseline and at each hospital visit. The ques- tionnaire assessed day- and night-time urinary frequen- cy. All patients were given a diary and asked to record relevant symptoms between visits. The primary out- come measures were the number of UTIs per patient per year and the mean time to UTI recurrence at the report- ed longest follow-up. The secondary outcome measures were 24h urinary frequency (number of voids in one day) and the Pelvic Pain and Urgency/Frequency (PUF) symptoms assessed using the PUF symptom scale. Statistical Analysis For the statistical analysis, the number of UTIs was calculated for the retrospective (before HA) and pro- spective (after HA treatment) phases of the study. Continuous variables were compared using the Wil- coxon rank-sum test. The time to recurrence of infec- tion before and after HA therapy was analyzed using a Kaplan-Meier survival function; in the retrospective as- sessment (before HA) this was defined as the mean time elapsed between each infection, and in the prospective assessment (after HA) as the time elapsed between the first HA instillation and the first recurrent infection. Differences in continuous variables were expressed as mean difference (MD) with 95% confidence intervals (CI). RESULTS Twenty-three patients were included (mean age 35 years old) who had been attending the outpatient clinic for about one year. The patients had a long history of recurrent UTIs. The most common pathogens identified during infections were: Escherichia coli, Enterobacter species, Enterococcus species, Klebsiella species, and Proteus mirabilis. All patients received antibiotic treat- ment, the most common antibiotics used were: amoxi- cillin/clavulanic acid (40%), ciprofloxacin (30%), and cotrimoxazole (20%) (Figure 2). In 16 (69.6%) patients, symptoms of RBC resolved after 8 months. In 5 (21.7%) patients after 8 months of HA treatment, urgency was reduced only by 30%. Therefore, it was decided to use combined therapy of HA and alpha blockers in this co- hort group. There was 75% reduction in frequent urina- tion at day and at night without urgency. Despite the use of above mentioned treatment, in 2 (8.7%) patients, RBC was still present and therefore the treatment was inter- rupted (Figures 3 and 4). The remaining cohort group of twenty one (91.3%) patients decided to continue the treatment and there are no side effects. The tolerability of HA and HA + alpha blockers treatment was good. Figure 1. Overview of the study and results. Figure 2. The type of pathogens identified during infections. Treatment of Bacterial Cystitis by Intravesical Hyaluronic Acid-Ząbkowski et al. Vol 12 No 03 May-June 2015 2193 The meta-analysis showed a significant difference between the two group within the results on UTI rates per patient per year (a group treated by HA and a group treated by combined therapy) (MD = 3.41, 95% CI: 4.33-2.49, P < .00001). It was reported out- comes on 24-h urinary frequency measured as 3-day voids (number of voids in 3 days), which were not significantly improved after therapy (MD = 2.53, 95% CI: 8.43-1.25, P = .15), but a significantly better PUF total score (MD = 7.17, 95% CI: 9.86-4.48, P < .00001) was detected in a group treated only by HA. Over the course of 9.5-month intravesical instillation with HA, 2 patients had a recurrence. In the extended follow-up (mean 12.5 months) none of the patients had a recurrence. Of patients, 21 (91.3%) were recurrence free after 9.5-month treatment. It was reported 95% de- crease in the number of recurrences per year (rate of UTI: pre-treatment 4.1 ± 1.51 per patient/year vs. 0.2 ± 0.4 post-treatment, P < .001). Frequency score de- creased from 7.56 ± 1.57 to 3.12 ± 2.11 (P < .001). Urgency score decreased from 7.21 ± 3.02 to 3.21 ± 2.23 (P < .001). Patient outcomes, expressed in terms of mean day- and night-time voids and mean pain scores showed no change in the average level of day- time voids, but did indicate an improvement in the av- erage number of night-time voids. The percentage of patients improved, the magnitude and the duration of response were all measured by VAS, based on symp- tom response. Of patients, 91.3% reported an improve- ment ≥ 2 on the VAS score at the end of follow-up; 5% of patients experienced no change in symptoms. The absence of recurrent UTI was compared before and after HA instillations by plotting Kaplan-Meier curves for each period. Based on the follow-up for patients with or with no recurrence the median time to recurrence after the first instillation of HA predicted by the model was 478 days; the median time to recurrence before HA was 83 days, which shows a significant difference (P < .0001). DISCUSSION This study demonstrates clear evidence that instill- ing HA into the bladder of woman with a history of recurrent UTIs is feasible and well accepted by pa- tients, and significantly reduces the incidence of re- current lower UTIs. In 13 of 17 patients, symptoms of RBC resolved. The phase of HA treatment last- ed about 10 months, with weekly administrations for the first month followed by monthly treatments for 8 months. This regimen was based on pragmatic experi- ence with HA therapy in patients with UTI at the au- thors’ hospital, during which one patient had a recur- rence UTI. However, the protective effect of HA was maintained even after direct treatment had stopped. Contemporary treatment options for women with a history of recurrent UTI usually include intermittent or prolonged antibiotic therapy, with variations in spe- cific antibiotics, their dose, and duration of therapy.(1,5) Alternatively, estrogen replacement therapy has been suggested as a strategy to decrease the incidence of recurrent UTIs in postmenopausal women, by revers- ing the changes in vaginal pH, and this is an example of an intervention not based on antibiotics.(6,7) Raz and Stamm(7) found that in women treated with intravaginal estriol cream there was a reduction in UTI recurrence and at 6 months ≈80% of the treated patients remained infection-free. However no menopausal women were included in the present study and hence these patients would be ineligible for this antibiotic-free treatment. The third therapeutic approach targets bacterial ad- herence to bladder mucosa. The most successful have used cranberry juice, effective through its phenolic components.(8) The principle of GAG substitution for preventing UTIs was shown experimentally in animals for heparin,(9) and for sodium pentosan polysulphate.(10) In the study of Sinanoglu and colleagues on compar- ison of intravesical administration of chondroitin sul- fate and colchicine in rat protamine/lipopolysaccharide induced cystitis model, it was reported that colchicine may be an alternative to other treatment modalities for painful bladder conditions such as interstitial cystitis. Intravesical administration of colchicine decreased leu- cocyte and mast cell infiltration to the same extent of chondroitin sulfate in protamine sulfate and lipopoly- saccharide induced bladder inflammation in rat.(11) We demonstrated that, bladder instillations of HA reduce Figure 3. Number of patients continuing the treatment. Figure 4. Results of recurrent bladder cystitis treatment by hyaluronic instillations. Treatment of Bacterial Cystitis by Intravesical Hyaluronic Acid-Ząbkowski et al. Miscellaneous 2194 the incidence of recurrent UTI, possibly through a protective effect on the GAG layer, and may offer an alternative to the widespread use of antibiotics, which are not always successful or well accepted by patients. CONCLUSION The use of HA protects mucosa of urinary bladder and alleviates symptoms of infection. The intravesical in- stillations of HA seems to be an effective therapeutic alternative in patients with recurrent bacterial cystitis. However, it is a very expensive method of treatment. CONFLICT OF INTEREST None declared. REFERENCES 1. Foxman B. Epidemiology of urinary tract infections: Incidence, morbidity and economic costs. Am J Med. 2002;113(Supl. 1A):5S-13S. 2. Ronald A. The etiology of urinary tract infection: Traditional and emerging pathogens. Am J Med. 2002;113:14S-9S. 3. Foxman B, Barlow R, d’Arcy H, Gillespie B, Sobel JD. Urinary tract infection. 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