2026 Urogynecology for the Advanced Practice Provider-War of the Microbial Worlds: Navigating Recurrent UTIs Across an Evolving Battlefield

Video Transcription

Video Summary

Dr. Bob Kelly, a urogynecologist at Emory, discussed the complexity of diagnosing and preventing recurrent urinary tract infections (UTIs). He emphasized that many patients have overlapping urinary symptoms from other causes, such as overactive bladder, menopause-related tissue changes, pelvic floor dysfunction, or bladder pain syndrome, so diagnosis should rely on symptoms plus urine evidence and culture when possible. He stressed that not every positive urine test needs antibiotics, especially in asymptomatic patients, and highlighted antibiotic stewardship: use short, culture-guided courses and avoid unnecessary broad-spectrum treatment.<br /><br />He explained the role of the microbiome, especially lactobacillus, and why vaginal estrogen is often highly effective in postmenopausal patients. For prevention, he recommended hydration, methenamine with vitamin C in selected patients, vaginal estrogen, and possibly cranberry supplements. He noted that D-mannose appears less effective than previously thought.<br /><br />Dr. Kelly also distinguished true recurrence from persistence, which can be caused by issues like stones or fistulas, and warned against overtesting patients who are chronically colonized. His main message: treat the patient, not just the lab result, and know when to “hold” or “fold” rather than reflexively prescribing antibiotics.

Asset Subtitle

By the end of this session, participants will be able to:

Explain the evolving microbiologic landscape of recurrent urinary tract infections, including resistance patterns and implications for clinical decision-making.
Differentiate common from atypical or complex UTI presentations and apply evidence-based strategies to workup and management in urogynecologic practice.
Evaluate current prevention and treatment modalities—including behavioral, non-antibiotic, and antibiotic options—and integrate them into individualized care plans.
Apply case-based reasoning to unique or challenging UTI scenarios such as perioperative infections, multidrug-resistant organisms, hormonal factors, and pelvic floor dysfunction contributors.
Identify opportunities for interdisciplinary collaboration (urology, ID, primary care, pelvic floor PT) to improve patient outcomes in recurrent UTI management.

Speaker: Robert Kelley, MD

Keywords

recurrent urinary tract infections

urogynecology

antibiotic stewardship

vaginal estrogen

urine culture

microbiome

UTI prevention