GAG Replacement vs URethral DIlAtatioN (GUARDIAN)

To Investigate and Compare The Efficacy of Urethral Dilatation Versus Glycosaminoglycan Layer Replacement in The Management Of Women With Recurrent Urinary Tract Infections

The aim of this randomised parallel trial is to compare the efficacy of Glycosaminoglycan layer replacement against cystoscopy and urethral dilatation in the treatment of recurrent urinary tract infection in pre-menopausal women. The women will be randomised to 1 of 2 arms.Arm 1 patients will receive standard treatment from the Urologists. This will involve rigid cystoscopy and urethral dilatation, under general anaesthetic. Arm 2 patients will receive standard treatment from the Gynaecologists.

Recurrence of a Urinary Tract Infection (UTI) is defined as infection, following complete resolution of a previous UTI.Recurrent UTI (rUTI) is defined as 3 or more microbiologically confirmed UTI within 12 months. rUTI is an economic problem for healthcare services. rUTI is also detrimental to the quality of life (QoL) of women who suffer the disease. 61% of women who suffer rUTI report symptoms of depression and an associated decrease in their reported QoL scores. QoL was found to improve significantly with successful treatment. E-coli is the most common bacteria causing UTI and 10% are thought to be antibiotic resistant. Consequently, new treatment strategies are required. The Glycosaminoglycans (GAG) layer is thought to be instrumental as a defence mechanism against uro-pathogens. GAG's are polysaccharides forming a gel like substance on the apical surface of the bladder wall and act as a barrier to uro-pathogens. There is now strong evidence that a reduction in the impermeability of the GAG layer is linked to rUTI. Urethral dilatation is an alternative treatment to GAG replacement in the management of rUTI. It is a treatment option more widely adopted by Urologists, although there is a paucity of data to support its use. Currently there is no standardised strategy for the management of women with rUTI. Treatments vary between GAG layer replacement (intravessical therapy with hyaluronic acid and chondroitin sulphate) or a cystoscopy and urethral dilatation. Evidence for each regime varies greatly and is of poor quality. This is a randomised study comparing GAG layer replacement with cystoscopy and urethral dilatation.

Rigid cystoscopy, performed under General Anaesthetic, followed by intervention of urethral dilatation with Hagar dilators.

Flexible cystoscopy, under Local Anaesthetic, followed by the intervention, which is 6 installations of Ialuril (a Glycosaminoglycan Layer replacement)

Patients will have a general anaesthetic and a rigid cytoscopic examination of the bladder dilated with sterile water. The urethra will be dilated from FR20 in incremental diameter increases of 2 to French 32 if possible.

Patients will undergo flexible cystoscopy and intravesical installations of Hyaluronic acid (HA) + Chondroitin Sulphate (CS) (GAGs) weekly for 4 weeks and then at 8 weeks and 12 weeks.

The change in the Quality of life (QoL) between the time of treatment and at 3, 6 and 12 months following initiation of treatment.

Following treatment is there any recorded change in the QoL questionnaire (SF-12) score from pre-treatment baseline

A record of the number, recorded in groups by their nature, of adverse events following treatment during the 12 month study.

Following treatment is there any recorded change in the Patient Satisfaction report from pre-treatment baseline

Following treatment is there any recorded change in the FSFI questionnaire score (out of 36) from pre-treatment baseline

Following treatment is there any recorded change in the HADS questionnaire score (out of 21 for anxiety and 21 for depression) from pre-treatment baseline

Inclusion Criteria: Female Pre-menopausal 3 - 3 episodes of cystitis in the last 12 months as defined by: 3 symptoms from dysuria, frequency, urgency, suprapubic tenderness, haematuria, polyuria Or less than 2 symptoms from the above list, but with cloudy urine 4 - Normal flow studies with bladder residual <150ml 5 - Normal renal tract on USS Exclusion Criteria: - Anatomical anomalies of urinary tract - Neurological condition - Diabetes mellitus - Pregnancy - Use of Immunosuppressants - Symptomatic of UTI at time of treatment