Positive dipstick does not preclude BTX injections

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Are dip tests needed for onabotulinumtoxinA (onabotA [Botox]) bladder procedures when no symptoms of urinary tract infection (UTI) are present? A recent study presented at the AUA annual meeting in Chicago suggests the answer may be no.

Researchers from the Cleveland Clinic Glickman Urological & Kidney Institute, Cleveland found no significant risk of adverse events when patients with a urine dip that tests positive for a UTI but who do not have symptoms of this illness receive an onabotA injection into the bladder. Such injections are used to treat neurogenic detrusor overactivity.

“Almost half of our staff have stopped screening unless patients report symptoms of a UTI” based on the results of the survey, Laura Giusto, MD, who was a fellow at the Glickman Urological & Kidney Institute at the time of the study, told Urology Times. She worked on the research with Howard Goldman, MD, and colleagues.

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The analysis not only has the potential to reduce costs of care-from the cost of the urine dip test to time spent analyzing test results and calling the patient to share the results-but also medication costs when asymptomatic patients test positive for a UTI, said Dr. Giusto, now of Chesapeake Urology, Owings Mills, MD.

Many patients who are treated with onabotA for urinary incontinence and other bladder issues are tested for a UTI with a urine dipstick prior to the procedure. The safety insert that comes with the intradetrusor onabotA injection states that an injection should not be given if the patient has a UTI at the time of the procedure. As a result, many patients are tested for a UTI with a urine dipstick in the physician’s office on the day of the procedure.

Physicians’ response to a positive dip test varies. Some surgeons choose to proceed with the procedure if the patient is asymptomatic; others postpone the procedure.

The authors conducted a retrospective review of intradetrusor onabotA injections performed between 2016 and 2018. Exclusion criteria included indwelling catheter, recent urine culture, recent course of antibiotics, or no urine dip on the day of injection. A positive urine dip was defined as any combination of positive blood, leukocyte esterase, or nitrite. A negative urine dip was defined as complete absence of any blood, leukocyte esterase, or nitrite.

In all, 335 patients who underwent onabotA injections from 2016 to 2018 met the study criteria. The majority-56.7%-received 100 units of onabotA for a non-neurogenic diagnosis (73.4%). No clinically significant demographic differences were noted between the groups.

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The overall rate of adverse events, UTIs, and urinary retention was 16%, 9%, and 3%, respectively. Compared with patients whose urine dips tested negative for UTI, those with a positive urine dip had higher rates of adverse events (18.3% vs. 12.7%) but this difference was not statistically significant.

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In both groups, the most common adverse event was uncomplicated UTI, followed by urinary retention. There was no difference in the rates of unplanned phone calls, office visits, emergency department encounters, or hospital readmissions between those who tested positive for UTI and those who did not. There were no major Clavien-Dindo-defined complications, and all adverse events were managed on an outpatient basis.

The findings suggest surgeons may consider proceeding with onabotA injection in a patient with a positive urine dip test as long as the patient does not display symptoms of UTI, Dr. Giusto said.