Periurethral vs Intravaginal Estrogen for Prevention of Recurrent Urinary Tract Infections (TAPER)

Periurethral vs Intravaginal Estrogen for Prevention of Recurrent Urinary Tract Infections: TAPER (Techniques of APplying Vaginal Estrogen for Prevention of Recurrent Urinary Tract Infections) Trial

Due to rising antibiotic resistance, there has been a focus on non-antibiotic prophylactic measures for postmenopausal patients with recurrent urinary tract infections (rUTI), one of which is the safe and efficacious option of vaginal estrogen therapy. Standard application of vaginal estrogen cream entails intravaginal application of the cream twice a week, but some providers counsel patients with rUTI to apply a small, pea-sized amount to the periurethral area. This ideally reduces the amount of vaginal estrogen used while attaining a similar effect. However, to date, there is no data to prove that the periurethral technique of application is similar or non-inferior to intravaginal application in preventing UTI.

The experimental group will apply estradiol cream in a different location (periurethral) and at a smaller dose (0.5 gram) compared to the control group.

Questionnaire assessment of urinary symptoms and symptom distress (Urogenital Distress Inventory, Short Form), total score range 0-100 with higher numbers representing worse urinary symptoms

Questionnaire assessment of vaginal symptoms and bother using 5-point Likert scale, developed by research team

Questionnaire assessment of sexual function (Female Sexual Function Index-6) with scores ranging from 2 to 30, with 19 and below denoting sexual dysfunction.

Questionnaire assessment of patient experience using 5-point Likert and open-ended questions, developed by the research team

Inclusion Criteria: Postmenopausal (definition: No menses for 1 or more years or surgical menopause (bilateral oophorectomy). If there is a past history of hysterectomy, patient must be age 56 or older (95th percentile for age at menopause) or have laboratory evidence of menopause (ie. FSH >30)) Meets criteria for recurrent urinary tract infections (UTIs) with 2 or more UTI in 6 months or 3 or more UTI in 1 year May include patients who used vaginal estrogen previously if they have stopped use for 3 or more months prior to inclusion into study. Patients must be recommended vaginal estrogen as part of normal clinical care for prevention of recurrent UTI Exclusion Criteria: Current use of vaginal or oral estrogen products Inability or refusal to use vaginal estrogen Daily antibiotic use Significant vaginal stenosis (eg. due to lichen sclerosis, radiation or obliterative prolapse surgery) that would prohibit use of a vaginal applicator (ie. genital hiatus <1cm) Inability to use vaginal applicator and without caregiver who can administer (eg. provider-managed pessary use, significant arthritis) Frequent (1x weekly or more frequent) use of bladder instillations containing an antibiotic Known hydronephrosis as a result of incomplete bladder emptying Use of intermittent or indwelling urinary catheterization Known bladder stones, mesh erosion into bladder, or foreign object in bladder Unable to consent for self History of or at high risk for estrogen-dependent malignancy