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

Int Urogynecol J. 2019 Mar;30(3):409-414. doi: 10.1007/s00192-018-3846-5. Epub 2018 Dec 18.


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.

Keywords: Bladder pain syndrome; Chronic UTI; Interstitial cystitis; Painful lower urinary tract symptoms; Recurrent UTI; UTI guidelines.

MeSH terms

  • Adult
  • Aged
  • Aged, 80 and over
  • Anti-Bacterial Agents / administration & dosage
  • Anti-Bacterial Agents / therapeutic use*
  • Chronic Disease
  • Cross-Over Studies
  • Female
  • Humans
  • Leukocyte Count
  • Lower Urinary Tract Symptoms / drug therapy*
  • Lower Urinary Tract Symptoms / etiology
  • Male
  • Middle Aged
  • Nitrofurantoin / administration & dosage
  • Nitrofurantoin / therapeutic use*
  • Pain / drug therapy
  • Pain / etiology
  • Pyuria / complications
  • Pyuria / drug therapy
  • Pyuria / urine
  • Recurrence
  • Retreatment
  • Symptom Assessment
  • Urinary Tract Infections / complications
  • Urinary Tract Infections / drug therapy*
  • Withholding Treatment*
  • Young Adult


  • Anti-Bacterial Agents
  • Nitrofurantoin