Author's reply

Department of Urology Moscow State University of Medicine and Dentistry, Moscow, Russian Federation

In current medical literature we often find little evidence for some issues and a lot of evidence for others. This fact reflects greater interest and respective funding available for industry–sponsored drug trials and government–funded cancer research. At the same time, some very important practical issues lack high–quality evidence. Self–induced non–commercial clinical trials often are limited by local opportunities and proper organizational meetings. In light of this, we have presented our investigational data on vaginal biocenosis and its influence on voiding dysfunctions in patients suffering from diabetes mellitus.

Current definition of asymptomatic bacteriuria is the presence of bacteria ≥105 cfu/ml in the midstream urine (or ≥103 cfu/ml if urine is sampled by catheter) without clinical symptoms of dysuria. In our study we used a practical option that might be used for the creation of clinical practice evidence and further recommendations.

Surely, on its own, diabetic cystopathy may have a strong influence on clinical symptoms causing a decrease of bladder filling sensation or bladder emptying. We investigated this issue in one of our previously published papers in which we summarized the urodynamic investigations of diabetic patients suffering from lower urinary tract symptoms. During this investigation we had faced number of sensory and motor dysfunctions of the lower urinary tract that were not easy to classify [1].

It is well known that local estrogens are improving female urethral function and urinary incontinence. Besides improving vaginal atrophy, local estrogen therapy reduces urinary incontinence, frequency, and urgency. At the same time, the meta–analysis showed that systemic estrogen therapy for post–menopausal women was associated with the development and worsening of lower urinary tract symptoms [2]. Our data showed that the influence of estrogens on lower urinary tract function might be even more complex. Surely, more studies with pre–treatment and post– treatment urodynamics are urged to clarify this issue. Proper antibiotic regimens for the treatment of uncomplicated UTIs are tremendously important. According to local standards, there is a list of recommended medications for uncomplicated lower UTI, such as: fosfomycin, nitrofurantoin, and “urological” quinolones which must be used in such cases. In our case, the list of quinolones includes levofloxacin, pefloxacin, and norfloxacin, while the usage of ciprofloxacin is limited due to the high resistance rate (up to 25% according to local authorities as well as for sulfa drugs). Ampicillin compounds are reserved for upper urinary tract infections. At the present time we clearly recognize that interventions based on local practice are prone to bias and should not be adopted by other practices. It is clear that the treatment option has to be based on clinical findings after thorough physical and instrumental examinations, which may include cystoscopy when appropriate.

References

1. Kasyan G, Pushkar D, Berketova T. Urodynamic characteristics of postmenopausal women suffering type 2 diabetes mellitus. ICS Annual Meeting, San Francisco 2009; Abst 869.
2. Cody JD, Jacobs ML, Richardson K, Moehrer B, Hextall A. Oestrogen therapy for urinary incontinence in post–menopausal women. Cochrane Database Syst Rev. 2009; 4: CD001405

Correspondence
Dr. George Kasyan g.kasyan@gmail.com

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