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I disagree with my urologist's proposed treatment

I have a 30 year history of urinary tract problems. Two years ago I began having recurrent bacterial cystitis; within two days of coming off the prescribed antibiotics the cystitis would flare up again so I went on continuous Cephalexin for eighteen months and was virtually symptom free.I was then given an appointment to see a urologist but only saw a junior member of his team for an extremely brief consultation and it was decided I should go on a rotation of three differerent antibiotics. I later discovered that one of the three was Trimethoprim. I have taken this medicine for cystitis on several occasions in the past and it has not cleared up the infection and an alternative antibiotic has been necessary each time. I conclude that my particular strain of E. coli is resistant to Trimethoprim. After explaining this to my specialist's secretary she put my point to him and I was told " Trimethoprim is a very good medicine and he wants you to try it". The whole point of the antibiotic rotation is to minimise the chance of antibiotic resistance so is appears perverse to put me on a medicine which is already suspect. Do I HAVE to take the trimethoprim and suffer another cystitis flare up before the urologist will prescibe an alternative ? Whilst I am only a lay person I have a science degree and am well read on urinary tract problems.I have not been involved at all with decisions about my treatment. I expect I should talk to my GP about my concerns but am unsure what his attitude wil be towards challenging the specialist. I should be greatful if you would advise me on the above since it would be good to have some ammunition to back up my case when I visit my own doctor. Many thanks in anticipation. **************

Doctor's Response

Date:Jan / 2012

Thank you for your question.

Clearly, the important feature here is that you are the patient, and your viewpoints and involvement are central and paramount to a successful outcome. I dont say this lightly, but in cases of recurrent cystitis/UTI it is crucial, especially in your case where you have had the problem for many years. Firstly, I would suggest that consideration is given, if not already done so, to try and establish an underlying cause for the symptoms. As such, basic blodd tests (including glucose), renal tract ultrasound scan and probably cystoscopy (camera examination of the bladder) would be recommended (certainly in my practice). If this excludes an underlying cause, then the philosophy of management would be symptom improvement. As such, it is very important to understand this from an expectation viewpoint. Personally, if you are happy with the previous regime of antibiotic treatment, I would suggest that you should continue. Of note, there was a new randomised trial published recently, using an intravesical (bladder instillation) treatment which improved outcomes in patients with recurrent infections. Certainly, my initial experience with this treatment, in my practice, is encouraging.Clearly though, with current evidence and knowledge on this condition, there is no right or wrong answer, but would be personalised according to your wishes and confidence etc. Hence, the vital importance of patient being central to this whole issue.

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Yours faithfully,
The ThanksDr Team

Patient's Response

Date:Jan / 2012

 Thankyou for your reply. I have had all the investigations you mention and they did not discover an under lying cause. What I am really concerned about is the fact that my urologist has prescribed an antibiotic which I'm convinced my infection is resistant to. I don't want to take the Trimethoprim I have been prescribed. I am convinced if I rely on it to to combat my UTI I will suffer a cystitis attack almost immediately.I don't want to go through the pain and distress which will follow but, more importantly , I don't want to do anything which increases the resistance of my particular strain of E.coli. I don't know what the protocol is for disagreeing with a specialist; how can I, a lay person , challenge a medical professional with years of experience and expertise ? Could you please advise me how I actually proceed. Do I have to go through my own GP or should I ask to speak to the urologist on the phone ? If you had a patient who was unhappy with your decision how would you want them to behave ? I look forward to hearing nfrom you and thank you in advance Yours sincerely, **********

Accepted Answer

Date:Jan / 2012

Thank you for your question.

 I think the best thing is to arrange an appointment with a Consultant personally. Urologists are generally quite nice people and approachable/reasonable, so I suspect that your request will not fall on deaf ears. In the rare circumstance that any of my patients disagree with any advice given by my team or from myself, I normally arrange to see them personally to discuss in depth and to negotiate a joint consensus - after all this is a pathway/journey for doctor and patient alike, and sometimes a right or wrong answer is not always available. Clearly, you know your clinical situation the best and as such, I personally would see you and aim to change the antibiotics accordingly.

Thank you for using ThanksDr. I do hope this information is of use to you.
Yours faithfully,
The ThanksDr Team

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