Roundtable on Complex UTI at the 2025 IUGA Annual Meeting

Dr. Leon Plowright Urogynecology and Reconstructive Pelvic Surgeon Recurrent urinary tract infections (rUTIs) represent a persistent clinical challenge with significant patient burden, particularly among women and vulnerable populations such as those who are postmenopausal or pregnant. The presenters during this roundtable discussion challenged our current care models for diagnosis and treatment rUTIs.   New evolving information would favor a more nuanced or individualized approach- one in which the interplay between host response and bladder Microbiome is considered. Our expert panel provided new insights into the evolving science of UTI diagnosis, host-pathogen interactions, and promising immunotherapeutic approaches. Limitations of Traditional Diagnostics Conventional diagnostics—including urine dipsticks and cultures—are increasingly being recognized as inadequate. Dipsticks have sensitivity akin to a coin toss, while even modern urine cultures fail to detect the full diversity of microbial species within the bladder, which may contain up to 600 bacterial species. With only a 5% overlap in microbiota between health and disease, defining a single causative pathogen becomes nearly impossible. This diagnostic uncertainty complicates clinical decisions, especially for patients with persistent symptoms but negative laboratory findings. In one retrospective analysis, patients showed dramatic symptomatic improvement and reductions in white blood cell counts after treatment, despite limited microbiological confirmation. The Rise of AI and Urine Microscopy Given the inadequacy of traditional urine cultures urine microscopy is under consideration. Fresh-phase contrast microscopy of urine sediment, performed within one hour of collection, may be a valuable but underutilized diagnostic tool. The presenter points out that the technique is time-consuming and operator-dependent. To overcome these barriers, researchers have developed a machine learning algorithm capable of automated microscopy with 90% accuracy across over 1,800 validated images. This AI-driven model could provide scalable, rapid diagnostics by identifying neutrophils, epithelial cells, and red blood cells. Furthermore, super-resolution microscopy further revealed that phagocytosed bacteria within neutrophils may serve as real-time indicators of immune activation, providing a possible link between symptoms and underlying infection. The Vaginal-Bladder Microbial Axis The vaginal and bladder environments are intimately connected. Multiple studies have confirmed that Lactobacillus-dominated flora in both sites correlate with health, while dysbiosis—such as bacterial vaginosis (BV)—is a known risk factor for rUTI. Vaginal microscopy has revealed surprising findings, including complete absence of lactobacilli in some symptomatic women, even premenopausal. Interventions such as vaginal estrogen therapy help restore epithelial integrity, lower vaginal pH, and promote beneficial microbial populations. Probiotics and acidic vaginal agents (e.g., lactic acid) are under study, although their efficacy may depend on the baseline vaginal environment. These insights highlight the need for proactive assessment of vaginal health in women with recurrent UTIs. Pregnancy and Chronic UTI In pregnancy, UTIs remain a potentially serious complication. Routine dipsticks and culture often miss true infections. In one maternal mortality case, pyelonephritis led to a fatal renal abscess after culture-negative but symptomatic episodes were not treated. At a dedicated chronic UTI clinic, microscopy-guided management using narrow-spectrum antibiotics and methenamine proved effective and safe in over 250 pregnancies. Interestingly, preconception immune profiling showed that women with lower urinary white blood cell counts were less likely to flare during pregnancy, suggesting potential for personalized risk stratification. Sublingual Immunotherapy There is currently ongoing research exploring UTI vaccines and bacteriophage drugs. Sublingual bacterial vaccines such as MV140 represent a novel, non-antibiotic strategy to prevent rUTIs. These sprays deliver heat-inactivated E. coli, Klebsiella, Enterococcus, and Proteus directly to the oral mucosa, stimulating both innate and adaptive mucosal immunity—particularly in the genitourinary tract. A recent multicenter RCT published in NEJM demonstrated that MV140 significantly reduced the number of UTI episodes, prolonged time to recurrence, improved quality of life, and decreased antibiotic use. More than 50% of vaccine recipients were UTI-free at 9 months. Conclusion This session underscored a pivotal evolution in the management of recurrent urinary tract infections (rUTIs)—from a traditional model focused on pathogen eradication to a more nuanced approach centered on host optimization. Advancements in understanding the female urogenital microbiome have emphasized the protective role of vaginal health, the value of immunomodulatory strategies, and the promise of AI-enhanced diagnostics. For urogynecologists, this paradigm shift offers the opportunity to deliver more effective and personalized care while supporting antimicrobial stewardship and reducing reliance on antibiotics.