Methenamine is a urinary antiseptic used to prevent urinary tract infections (UTI) via conversion to formaldehyde in the urinary tract. Methenamine hippurate (MH) is non-inferior compared to antibiotic (ABX) prophylaxis to manage recurrent UTI (rUTI) as demonstrated in the clinical trial ALTAR. Treatments such as MH, can improve antibiotic stewardship, as the primary treatment option for UTI is antibiotics. However, MH exhibits an elevated incidence risk with respect to breakthrough UTI as defined during ALTAR. Formaldehyde is highly toxic, while also a common by product of cellular metabolism. Powerful detoxification pathways exist to overcome formaldehyde toxicity. One example is the thiol-dependent metabolism of formaldehyde to formate in bacteria. The urinalysis of ALTAR urines detected formaldehyde in 85% of participant urines who were taking MH. HPLC analysis of a subset of urines from MH and ABX ALTAR participants, determined a significant change in urine composition. This included elevated levels of formate in urines from MH users. The thiol-dependant formaldehyde detoxification system of Escherichia coli is encoded by the frmRAB operon. The genes frmAB encode the enzymes responsible for detoxification, while frmR encodes a repressor of the system. ALTAR derived E. coli isolates were screened for growth in the presence of formaldehyde with 5.8% able to grow in > 1 mM formaldehyde. Bioinformatics identified 4 frmR alleles encoding non-functional FrmR variants and two plasmid-encoded frmA homologues. Growth in artificial urine confirmed that E. coli was susceptible to methenamine-formaldehyde conversion at pH6.0 and 5.6. All strains encoding frmR alleles grew in the presence of > 1 mg/ml methenamine at pH 5.6. The identification of FDHR in a clinical context and the changes in urine composition can improve the managed use of MH. However, a mindset change is needed to accept that MH, like antibiotics, has its own associated risks, including bacterial resistance.

Advances in soft robotics, smart materials and bio-interfacing may enable the development of implantable artificial muscles (IAMs) to replace or augment biological muscles. emPOWER, a UK Research Council engineering project, is initiating foundational technologies and proof of concept for IAMs. This expert opinion piece considers IAMs in the clinical context of stress urinary incontinence. Conceptually, autologous sling tensioning by an IAM can adjustably restore urethral closure to resist fluctuations in intra-abdominal pressure. This could facilitate sling tension adjustment postoperatively, and patient control when the user anticipates greater physical need. Tailoring an IAM procedure to the individual patient's needs requires considering how to deliver the best pelvic floor configuration when upright and the extent of urethral compression necessary. emPOWER addresses both the development of IAM technologies and the needs of the patient, and has developed proof-of-principle working models for prototype contractile mechanisms (actuators). IAM innovation must meet Idea, Development, Exploration, Assessment, Long-term study for Devices (IDEAL-D) requirements and minimise the risk of complications, notably those associated with transvaginal mesh surgery. Accordingly, an IAM for treating stress urinary incontinence needs to minimise the amount of artificial material used, and contact of such material with the urethra. Placement of the implant should use minimally invasive techniques, and reduce the risk of implant infection.

OBJECTIVES:Malignant upper urinary tract obstruction (MUUTO) is caused by advanced cancer. Developing MUUTO is often associated with approaching the end of life. Percutaneous nephrostomy (PCN) and retrograde ureteric stent insertion (RUS) are common interventions to treat patients with MUUTO, although neither intervention is likely to extend overall survival significantly. Little is known about patient, carer and healthcare professional (HCP) views of the MUUTO management pathway, the benefits and harms of the procedure and the treatment decision-making process. This study investigated the experiences, decision-making and priorities of patients admitted to hospital for MUUTO, and their carers, along with HCPs involved in providing care for this patient group. DESIGN:Qualitative, using semi-structured interviews. SETTING:This study was conducted across two NHS trusts in England. PARTICIPANTS:12 patients, 8 carers and 14 HCPs were interviewed. Patients were interviewed in hospital during their admission and, where possible, follow-up interviews took place 2-3 weeks later at their homes. In total, 18 patient interviews were conducted. Interviews were analysed thematically by cohort and systematically cross-referenced for areas of congruence and divergence of priorities and views. Ethical approval was obtained before study commencement. RESULTS:Most patients were admitted as emergencies and received PCNs to relieve severe pain and distress. Patients reported having little choice in the decision-making around intervention due to their symptoms and frequently described the PCN procedure as being painful. HCPs considered the availability of further cancer treatment options a rationale to support intervening for MUUTO. However, HCPs reported decision-making was often complicated by unclear prognosis and the need to address the emergency nature of patient circumstances. A lack of compassionate communication, disrespect and indignity, traumatic hospital admission and premature discharge, in addition to practical administrative difficulties caused patient and carer distress. CONCLUSIONS:Emergency admissions for MUUTO are associated with significant patient and carer distress and are complex for HCPs to manage. MUUTO patients would benefit from a specific pathway to avoid emergency admissions and to facilitate timely advance care planning discussions so that patients' wishes and HCP views can be shared and incorporated into decision-making about the appropriateness and value of PCN and RUS interventions.

Background Recent research has concluded that primary care assessment and management of lower urinary tract symptoms (LUTS) requires practical resources. Aim To develop and independently validate risk-prediction models for three common urological conditions based on a combination of simple, minimally invasive index tests in men with LUTS presenting to primary care. Design and setting A prospective, multicentre, diagnostic accuracy study with independent development and validation cohorts set in 67 general practices in England and Wales. Method A total of 601 men presenting to primary care with LUTS, 350 in the development cohort and 251 in the validation cohort, underwent index tests — validated symptom assessment, bladder diary, physical examination, serum prostate specific antigen, uroflowmetry, and post-void residual volume estimation. Invasive urodynamic studies provided a diagnostic reference standard. Risk-prediction models for urodynamic diagnoses were developed and then validated in independent cohorts. Discriminative and calibration performance of the risk-prediction models for diagnosing bladder outlet obstruction (BOO), detrusor underactivity (DU), and detrusor overactivity (DO) using the c-index, calibration slope and plot, and sensitivity and specificity of the models was undertaken. Results The BOO model from the development cohort demonstrated good discriminative performance (optimism-corrected c-index of 0.80). The models derived from the development cohort for DU and DO demonstrated moderate discriminative ability (optimism-corrected c-indices of 0.64 and 0.67, respectively). Similar estimates of c-index were observed for each model within the independent validation cohort (BOO, 0.82; DU, 0.63; and DO, 0.62). Conclusion Using a combination of simple, non-invasive index tests can accurately predict common urological diagnoses in men with LUTS, potentially facilitating earlier initiation of evidence-based treatments and improved management in primary care.

Background and objective This aim of this international expert consensus project was to clarify the appropriate use of urodynamics (UDS) in men with bothersome lower urinary tract symptoms (LUTS) who are considering prostate surgery in light of high-quality published evidence, particularly high-certainty data from the UPSTREAM study, and expert clinical experience. Methods A modified version of the Delphi method was used. Postsurgical patients, catheterised patients, and patients with neurological disease were not included. Eight questions covered UDS in specific contexts; four addressed quality assurance. Key findings and limitations Consensus was reached on the need for UDS in any of the following circumstances: if the corrected maximum flow rate is ≥13 ml/s; if bothersome urinary urgency is present; if scores are below stated thresholds for overall symptoms or voiding symptoms; if the postvoid residual volume is considered meaningfully elevated; if there is extensive comorbidity; and if incontinence (any type) is identified. Consensus was not reached on the need for UDS in men with scores below the stated threshold for the impact on quality of life. Consensus was achieved for quality assurance in terms of cross-checking UDS pressure traces and derived indices; ensuring the trustworthiness of traces by experienced health care professionals; and review within the individual clinical context. UDS was considered important when benign prostatic obstruction (BPO) is less likely and in cases in which detrusor underactivity or overactivity is more likely. In cases with severe voiding symptoms, UDS was not considered necessary to increase confidence in recommending surgery to treat LUTS. Conclusions and clinical implications UDS retains an important role in men with bothersome LUTS considering surgery for presumed BPO. Our consensus recommends specific criteria to guide selective UDS use.

BACKGROUND:The artificial urinary sphincter (AUS) is the most common surgical procedure for persistent stress urinary incontinence (SUI) after prostate surgery, whereas the male sling is a newer alternative. OBJECTIVE:To compare the 24-mo outcomes of the sling versus the AUS. DESIGN, SETTINGS, AND PARTICIPANTS:This was an unblinded, noninferiority randomised controlled trial including men from 27 UK urological centres with bothersome urodynamic SUI after prostate surgery. INTERVENTION:Men were randomised to receive a transobturator sling (n = 190) or an AUS (n = 190). Randomisation was minimised by type of surgery (radical prostatectomy/transurethral resection of the prostate), previous radiotherapy for prostate cancer (yes/no), and centre. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS:The primary outcome was self-reported continence (a composite outcome derived from two items in the validated International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form [ICIQ-UI SF]) at 12 mo after randomisation, with a noninferiority margin of 15%, via postal questionnaire. The secondary outcomes were self-reported continence, further treatments, patient-reported measures and serious adverse events up to 24 mo. RESULTS AND LIMITATIONS:A total of 380 participants were included. In terms of continence, the sling was noninferior to the AUS at 24 mo (estimated absolute risk difference in the intention-to-treat analysis, -0.006; 95% confidence interval [CI], -0.092 to 0.080; noninferiority p = 0.001), indicating lower success in the sling group, but with a CI excluding the noninferiority margin. Incontinence symptom scores (ICIQ-UI SF) decreased from 16.1 and 16.4 at baseline to 7.9 and 7.1 in the sling and AUS groups, respectively. The mean difference was 1.4 (95% CI, 0.2-2.6; p = 0.024). Secondary outcomes favoured the AUS over the sling. By 24 mo, more men underwent further surgery after receiving a sling (n = 20, 11%) than after receiving an AUS (n = 4, 2%). CONCLUSIONS:The 24-mo results confirm that the sling is noninferior to the AUS. Symptoms and quality of life significantly improved in both groups. Overall, secondary and post hoc analyses favour the AUS. PATIENT SUMMARY:Continence levels and symptoms improve with both surgeries. Most men are satisfied with their surgery, despite not being completely dry. Almost all other results show that men who have an artificial urinary sphincter have better outcomes than those who have a sling. Trial registration International Randomised Controlled Trial Registry, ISRCTN49212975. This trial was registered on July 22, 2013, and participants were randomised between January 29, 2014, and December 28, 2017.

Aims: Dysfunctional voiding (DV) is characterised by fluctuating or intermittent urinary flow during voiding in neurologically normal individuals. Given the different definitions used and heterogeneous pathophysiologies, outcomes following sacral neuromodulation/sacral nerve stimulation (SNM/SNS) are variably reported. The aim was to identify the areas of research required to be able to accurately predict response to SNM/SNS in adults with DV. Methods The relevant literature was reviewed by a multidisciplinary panel and the findings were discussed at the ICI-RS meeting held in 2025 in the UK. The outcomes of this discussion are presented. Results DV has unique diagnostic features, typically requiring pressure-flow studies and uroflowmetry to establish the diagnosis. Further investigations such as electromyography and urethral pressure profilometry help to better understand the pathophysiology. Phenotyping the lower urinary tract dysfunction helps to identify patterns of abnormalities, and it is likely that certain groups show a better response to SNM/SNS than others, such as in Fowler's syndrome. Older age and change in body weight following implantation are associated with a worse outcome, though not specifically in DV. Studies evaluating the impact of neuropsychiatric co-morbidities on SNM/SNS outcomes show mixed results. Central dysregulation of micturition networks possibly contribute to DV and could represent an additional therapeutic target of SNM. Conclusion Precise phenotyping of individuals with DV integrating clinical, urodynamic, neurophysiological, and neuropsychiatric factors is essential to predict which adults respond best to SNM/SNS. Future research should focus on establishing criteria for patient selection and designing comprehensive prospective interventional studies to assess efficacy and complications.

Background/Objective:: Pelvic mesh complications have gained significant attention in recent years, with the establishment of specialist centres and guidelines to address the growing concerns. Despite appropriate placement, complications can arise, leading to physical, psychological, and social ramifications for patients. The management of these complications remains an emerging field, hindered by limited research, inadequate data, and a lack of comprehensive guidelines. This article highlights the complexities of mesh injuries and emphasises the need for a patient-centred, trauma-informed approach to care, supported by multidisciplinary and interdisciplinary teams. Methods:: The International Continence Society (ICS) formed a multidisciplinary working group, comprising urologists, urogynaecologists, colorectal surgeons, radiologists, pain specialists, and consumer representatives, to address mesh complications. Using a nominal group technique, the committee reached consensus on diagnostic and treatment pathways. The methodology focused on developing evidence-based recommendations for managing mesh complications, including pre- and post-operative care, informed consent, and trauma-informed practices. Key findings:: The working group identified significant gaps in understanding mesh complications, including outcomes following partial versus total mesh excision and the impact of combined mesh excision with anti-incontinence procedures. The findings underscore the importance of a holistic, patient-centred approach, integrating multidisciplinary care, effective communication, and trauma-informed practices. Recommendations include the establishment of standardised care pathways, pre-operative counselling, and post-operative support to optimise patient outcomes. The article also provides a detailed guide for patients on recovery after mesh removal surgery, addressing potential complications and recovery strategies. Conclusions and Clinical Implications:: Mesh complications have far-reaching consequences, necessitating a comprehensive, trauma-informed approach to care. The establishment of multidisciplinary teams, standardised care pathways, and patient-centred practices is critical to addressing the physical and psychological toll of mesh injuries. By fostering trust, improving communication, and prioritising holistic care, healthcare providers can better manage mesh complications and support patients through their recovery journey. This article serves as a call to action for improved research, data collection, and guideline development to enhance the management of pelvic mesh complications worldwide.

BACKGROUND:Urodynamics has seen, in common with any medical field reliant upon technology, many recent advances in the application of innovations. Novel and effective ideas have been developed and marketed, but relatively few have been incorporated into clinical practice. METHODS:A debate held at the International Consultation on Incontinence-Research Society (ICI-RS) meeting in Bristol, UK, in June 2025 looked at new technology and its possible inclusion into the patient pathway. RESULTS:Discussion acknowledged that new ideas have not always been comprehensively examined, assessed, or applied. The meeting considered ways to rectify this gap and proposed research that is needed to give evidence-based take-up of innovation in this field. CONCLUSIONS:We propose a tool that examines the time, costs, and a test's specificity and sensitivity for each patient group, to suggest an optimal pathway for that group. The meeting also concluded that techniques involving ultrasound and catheter-free monitoring hold promise and proposed research needed to promote the take-up of innovation in this field.

Background and objective Stress urinary incontinence (SUI), defined as any involuntary leakage of urine associated with physical activity, remains underdiagnosed and undertreated. This review aims to provide an updated overview of the prevalence, diagnosis, and treatment of SUI in women, drawing upon recent evidence-based literature and clinical guidelines. Methods A systematic search of the MEDLINE database was conducted to identify only the most up-to-date and relevant studies published up to February 26, 2024, including the reference ESTER systematic review. The search was limited to systematic reviews published in the preceding 1 yr. Any additional included publications were limited to those published or referenced as part of the existing/current guidelines. Key findings and limitations Diagnosis of SUI involves a comprehensive assessment, including medical history, physical examination, and in some cases, invasive urodynamics. Pelvic floor muscle training emerges as a first-line management strategy, showing efficacy in symptom improvement when good educational instructions and supervision are provided. Surgical interventions with midurethral and single-incision slings offer a second-line option, although concerns regarding mesh-related complications persist with a decrease in its use. Moreover, the long-term efficacy of single-incision slings remains to be confirmed. Urethral bulking agents, colposuspension, and autologous fascial slings are existing alternatives supported by robust evidence, albeit with a different adverse event profile. Management of complicated and severe SUI remains challenging, with autologous fascial sling and artificial urinary sphincters being established treatments, but high-quality data remain lacking. Conclusions and clinical implications Heightened awareness and accessibility to SUI treatment are imperative to address the gap between prevalence and medical care–seeking behavior. Pelvic floor muscle training and surgical interventions represent key modalities. However, a notable escalation in invasiveness and complication rates when transitioning to surgical interventions is clear and has resulted in a hesitance among patients to proceed along the treatment continuum, particularly in light of mesh-related complications. Ongoing research is necessary to optimize outcomes and ensure patient safety, particularly for complicated SUI where data on comparative effectiveness remain limited.

AIMS:Patients coming for urodynamics expect those delivering the service to be fully trained, with assurance of competence and quality. This document proposes a single UKCS Certification and Re-certification process for all health care professionals who perform or interpret urodynamics. METHODS:The Working Group of the United Kingdom Continence Society engaged with stakeholders in relevant professional societies and institutions, recirculating drafts until consensus was reached. RESULTS:A process of Certification has been designed to ensure that patients attending urodynamics undergo high quality investigations, the results of which are accurately interpreted, in order to guide both the patient and their clinicians in the patient's future management. CONCLUSIONS:The United Kingdom Continence Society strongly recommends that all urodynamic investigations are carried out by, or under the supervision of, certified individuals. This document presents such a process of Certification and Re-certification that aims to ensure that quality standards are maintained and that patients have high quality urodynamics.

Lower urinary tract symptoms particularly affect older men and their quality of life. General practitioners currently have no easily available assessment tools to diagnose lower urinary tract symptom causes. Referrals to urology specialists are increasing. General practitioner access to simple, accurate tests and clinical decision tools could facilitate management of lower urinary tract symptoms in primary care. To determine which of several index tests in combination, best predicted three diagnoses (detrusor overactivity, bladder outlet obstruction and/or detrusor underactivity) in men presenting with lower urinary tract symptoms in primary care. To develop and validate three diagnostic prediction models, and a prototype primary care clinical decision support tool. Prospective diagnostic accuracy study. Two participant cohorts, for development and validation, underwent simple index tests and a reference standard (invasive urodynamics). General practices in England and Wales. Men (16 years and over) consulting their general practitioner with lower urinary tract symptoms. Separate calculations for model development and validation cohorts, from literature estimates of detrusor overactivity, bladder outlet obstruction and detrusor underactivity prevalences of 57%, 31% and 16%, respectively. Twelve potential predictors considered for three diagnostic models. The primary outcome was diagnostic model sensitivity and specificity for detecting bladder outlet obstruction, detrusor underactivity and detrusor overactivity, with 75.0% considered minimum clinically useful performance. Three separate logistic regression models generated with index test variables to predict the presence of bladder outlet obstruction, detrusor overactivity, detrusor underactivity conditions in men with lower urinary tract symptoms. One model each was developed and validated for bladder outlet obstruction and detrusor underactivity, two for detrusor overactivity (detrusor overactivity main, detrusor overactivity sensitivity analysis 2). Age, voiding symptoms subscore, prostate-specific antigen level, median maximum flow rate, median voided volume were predictors for bladder outlet obstruction. Median maximum flow rate and post-void residual volume were predictors for detrusor underactivity. Age, post-void residual volume and median voided volume were included in detrusor overactivity main model, while age and storage symptoms subscore predicted detrusor overactivity sensitivity analysis 2. For all four models, sensitivity of 75.0% could be achieved with a specificity of 74.2%, 47.3%, 45.6% and 46.2% for bladder outlet obstruction, detrusor underactivity, detrusor overactivity main and detrusor overactivity sensitivity analysis 2 models, respectively. Similarly, a specificity of 75.0% could be achieved with a sensitivity of 71.3%, 39.8%, 33.3% and 62.7% for bladder outlet obstruction, detrusor underactivity, detrusor overactivity main and detrusor overactivity sensitivity analysis 2 models, respectively. The prototype tool (not yet intended for use in practice) is available at Primary care Management of lower Urinary tract Symptoms decision aid for lower urinary tract symptoms (shinyapps.io). General practitioner feedback during tool development and small-scale user-testing in simulated consultation scenarios was favourable. Patients supported such management in primary care. This was a prospective, multicentre study in an appropriate primary care population. Most of the index tests are possible routinely in primary care or at home by patients. The diagnostic models were validated in a separate cohort from the same population. Limitations include that target condition prevalences may differ in other populations. We identified sensitivities and specificities of diagnostic models for detrusor overactivity, bladder outlet obstruction and detrusor underactivity in routine United Kingdom practice and developed a prototype clinical decision support tool. Economic modelling, a feasibility trial and powered randomised controlled trial are needed to evaluate the Primary care Management of lower Urinary tract Symptoms tool in practice. Current Controlled Trials ISRCTN10327305. This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 15/40/05) and is published in full in Health Technology Assessment; Vol. 29, No. 1. See the NIHR Funding and Awards website for further award information.

Introduction. The antibiotic trimethoprim has been used to treat urinary tract infection (UTI) since ~1962. Alongside the nitrofurantoin, there are still justified reasons for trimethoprim use, especially in non-pregnant women. Trimethoprim resistance is commonly the result of acquiring the trimethoprim-insensitive dihydrofolate reductase gene: dfrA. Assessment of clinical Escherichia coli isolates from two clinical trials, AnTIC and ALTAR, identified carriage of two copies of dfrA.Hypothesis. The hypothesis tested here was that dual dfrA carriage provided E. coli with a growth advantage.Methodology. Two hundred and seventy-eight clinical isolates from AnTIC/ALTAR were assessed for dfrA carriage. Microplate-based growth assays assessed growth behaviour with and without 64 mg l-1 trimethoprim. Allelic replacement of dfrA5 with five other alleles was also performed.Results. One hundred and four isolates (37%) were identified to carry a total of 112 dfrA genes. Eight isolates (2.9%) carried two copies of dfrA. Comparison of dfrA + to dual dfrA carriage could be differentiated by their growth behaviour when exposed to trimethoprim but had comparable MIC (>512 mg l-1). Analysis of all dfrA + isolates determined that the growth behaviour exhibited an allelic bias. Allelic replacement of dfrA5 with dfrA1, dfrA7, dfrA8, dfrA14 and dfrA17 demonstrated that the growth behaviour was dfrA specific.Conclusion. This analysis determined that the dual carriage of two dfrA alleles generated a growth advantage to E. coli. However, the growth behaviour was dictated by allele carriage and not specifically dual carriage, as single carriage isolates also possessed the identified phenotype. This data suggests that there is a potential clinical impact dictated by dfrA allele carriage that could improve clinical decisions on management strategies of UTI.

AIMS:Recurrent urinary tract infections are a common medical problem and current guidelines recommend both antibiotic and non-antibiotic preventative treatments. However, for a significant proportion of patients with this condition these second-line treatments are not effective. As a result, there has been recent focus on more targeted treatment such as intravesical instillations and bladder fulguration procedures. We aim to report discussions regarding these targeted treatments for recurrent urinary tract infections that took place at the International Consultation on Incontinence - Research Society meeting in Bristol 2025. METHODS:We undertook a think-tank session during this multi-disciplinary meeting specifically designated for discussion regarding targeted treatments for UTI prevention. We discussed the incidence and prevalence of recurrent UTIs in the general population and recognise that up to 25% of patients are not adequately treated with currently recommended preventive strategies. We also explored the increasing knowledge base surrounding the urinary microbiome and discussed the concept of chronic urinary tract infection. Finally we outlined the current evidence to support the use of the targeted treatments of intravesical instillation of both antibiotics and glycosaminoglycan (GAG) replacement compounds and the surgical procedure of bladder fulguration. This led to the generation of research ideas which hope to shape future UTI research within this topic area. RESULTS:We describe the discussions that took place and document the important research questions that were generated during the International Consultation on Incontinence-Research Society meeting in Bristol 2025. CONCLUSIONS:Although the use of targeted treatments is becoming more widespread the evidence base is currently insufficient for strong guideline recommendation. This must be balanced against the significant need for second-line treatments when current guideline recommended treatments are unsuccessful, particularly in the design of clinical pathways for patients with refractory recurrent UTIs.

AIMS:Urinary tract infections are one of the most common reasons for antibiotic prescription. The widespread use of antibiotic treatments contributes to the global health problem of antimicrobial resistance development. To slow down the progression of antimicrobial resistance, it is essential that we explore nonantibiotic preventive treatments for this common condition. We aim to report discussions regarding nonantibiotic preventive strategies for recurrent urinary tract infections in both catheterized and non-catheterized patients that took place at the International Consultation on Incontinence-Research Society meeting in Bristol in 2024. METHODS:We undertook a think-tank session during this multidisciplinary meeting specifically designated for discussion regarding both established and emerging nonantibiotic treatments for UTI prevention in both catheterized and non-catheterized patients. This led to the generation of pertinent research questions, which hope to shape future UTI research. RESULTS:We describe the discussions that took place and document the important research questions that were proposed during the International Consultation on Incontinence-Research Society meeting in Bristol in 2024. CONCLUSIONS:There is a range of established UTI preventative strategies for UTI prevention in both catheterized and non-catheterized patients. Emerging UTI prevention treatments have varying levels of evidence to support their use, and in many areas, further research is needed to establish their place in clinical pathways.

Objectives To estimate the cost-effectiveness of methenamine hippurate compared with antibiotic prophylaxis in the management of recurrent urinary tract infections.Design Multicentre, open-label, randomised, non-inferiority trial.Setting Eight centres in the UK, recruiting from June 2016 to June 2018.Participants Women aged ≥18 years with recurrent urinary tract infections, requiring prophylactic treatment.Interventions Women were randomised to receive once-daily antibiotic prophylaxis or twice-daily methenamine hippurate for 12 months. Treatment allocation was not masked and crossover between arms was allowed.Primary and secondary outcome measures The primary economic outcome was the incremental cost per quality-adjusted life year (QALY) gained at 18 months. All costs were collected from a UK National Health Service perspective. QALYs were estimated based on responses to the EQ-5D-5L administered at baseline, 3, 6, 9, 12 and 18 months. Incremental costs and QALYs were estimated using an adjusted analysis which controlled for observed and unobserved characteristics. Stochastic sensitivity analysis was used to illustrate uncertainty on a cost-effectiveness plane and a cost-effectiveness acceptability curve. A sensitivity analysis, not specified in the protocol, considered the costs associated with antibiotic resistance.Results Data on 205 participants were included in the economic analysis. On average, methenamine hippurate was less costly (−£40; 95% CI: −684 to 603) and more effective (0.014 QALYs; 95% CI: −0.05 to 0.07) than antibiotic prophylaxis. Over the range of values considered for an additional QALY, the probability of methenamine hippurate being considered cost-effective ranged from 51% to 67%.Conclusions On average, methenamine hippurate was less costly and more effective than antibiotic prophylaxis but these results are subject to uncertainty. Methenamine hippurate is more likely to be considered cost-effective when the benefits of reduced antibiotic use were included in the analysis.Trial registration number ISRCTN70219762.