Fulguration For Recurrent And Chronic UTI

In your search for the best treatment approaches to recurrent UTI, you’ve likely stumbled upon discussions around fulguration. While fulguration is a fairly new concept within the UTI patient communities, urologists have been performing the procedure for decades. 

We did some digging to uncover what the research says about fulguration for chronic UTI. Unsurprisingly, the research was sparse. So we went a step further and spoke with specialists and patients to learn about fulguration from their perspectives. 

Dr. Philippe Zimmern was one of the specialists we spoke with about fulguration. We’ve peppered our video interview with him throughout this article, or you can directly access the interview through our YouTube channel.

As is the case with other recurrent and chronic UTI treatments, the approach to fulguration varies based upon the surgeon. Variations also exist in the level of improvement and time it takes for patients to heal. 

Through all the uncertainty, one thing is clear – fulguration is not a one-size-fits-all method to treating chronic UTI and should be approached from an individual situation.

Jump To Section:

• What Is Bladder Fulguration? >>>>
• How Fulguration Tools Affect Patient Outcomes >>>>
• Can Fulguration Help Heal A Recurrent UTI? >>>>
• Trigonitis, Leukoplakia, And Other Abnormal Tissues >>>>
• Risks Of Fulguration >>>>
• How To Determine If You’re A Good Candidate For Fulguration >>>>

Fulguration is the process of removing abnormal bladder tissue with the use of a specialized tool. During fulguration, one of the commonly used tools, a resectoscope, is inserted through the urethra, into the bladder. It is inserted in a similar way to a foley catheter or cystoscope. 

A camera sits near the tip of the resectoscope, allowing the surgeon a clear view of the urethra and bladder. Once an area of abnormal tissue is identified, the resectoscope emits electric energy that removes the tissue while simultaneously burning or cauterizing the area to prevent bleeding. 

Most commonly, fulguration is used in the removal of bladder tumors, but the procedure has found a place for patients dealing with recurrent UTI as well. 

If the thought of your bladder being cauterized while dealing with a painful UTI makes you cringe – we hear you. However, studies have shown that the removal of these abnormal tissues may prevent or decrease the frequency of future UTIs. 

The actual process of undergoing fulguration is unique, dependent upon the surgeon. Some procedures are completed in an outpatient setting either with or without light anesthesia. Yet, others are completed inpatient and involve an overnight stay in the hospital. 

Dr. Philippe Zimmern has shared more about how a typical fulguration day looks for a patient in his fulguration Q&A. You can download this Q&A by sharing your email address below.

The pre-op and post-op protocols may also differ. If you’ve been considering fulguration, we’ve compiled a list of questions to ask when consulting with fulguration specialists. 

The History Of Fulguration

As mentioned, fulguration was originally introduced as a method to remove bladder tumors. This technique is referred to as transurethral resection of bladder tumors (TURBT). This process was developed in 1910 by Edwin Beer, who was frustrated with the lack of progress urology was making in this area. 

After all, cystoscopies had become a common procedure, so he questioned why urologists were still removing bladder tumors by way of open surgery through the pelvic area, which came with more risks. This motivated Beer to create a modified cystoscope that included a high frequency electric current. 

The new tool proved to be successful in resecting tumors and cauterizing the tissue to prevent bleeding. Beer’s innovation is now considered, “one of the greatest advances in the history of urology,” as it paved the way for other electrofulguration methods. 

Edwin Beer’s pioneering work led to the development of today’s resectoscope, one of the tools used to fulgurate lesions in the bladder in patients with recurrent UTI. Resectoscopes have different attachment options, which are fitted to the end of the scope and are responsible for cauterizing the tissue. 

Although a seemingly small distinction, the tool and attachment used can have an impact on the outcome of surgery. 

Once a resectoscope is inserted through the urethra, the magnified wide angle lens near the end allows the surgeon to see a detailed view of the bladder. Once an abnormality is identified, the surgeon activates the electric current on the tip of the resectoscope. In the case of patients with a history of UTI, where lesions are found, the lesions are cauterized, or burned. 

The loop attachment, a wire loop at the end of the resectoscope, appears to be most commonly used during fulguration. While the loop tool is effective in covering a larger surface area, and therefore less likely to bypass areas of abnormal tissue, it has an increased risk of resecting too deep, cutting into the bladder muscle.  

An alternative to the loop tool is the rollerball attachment. This tool is a small metal ball that is rolled across the surface of the bladder tissue, cauterizing as it goes. In comparison to the loop attachment, the rollerball does not cover as large of an area at once. 

While this has a risk of abnormal tissue being overlooked, the tool does allow more precision. In general, the rollerball has fewer risks than the loop tool because it does not require cutting into the tissue.

Laser Tools

Laser tools may also be used to destroy abnormal bladder tissues. The results of side-firing vs. end-firing laser are much more distinct than those of loop vs. rollerball: 

• 68% of patients who had a cauterization procedure using a side-firing laser had significant improvement in lower urinary tract symptoms. 

• 81% of patients who had a cauterization procedure using an end-firing laser reported that their symptoms worsened or failed to improve .

It’s clear to see which laser tool comes out on top. 

There are debates around which type of tool is more effective, as each comes with benefits and risks. And while it’s unusual for patients to inquire about what tools their surgeon uses during a procedure, when it comes to fulguration, it may be worth asking. 

So, can fulguration help heal a recurrent UTI? To put it simply, fulguration may be effective by destroying biofilms and bacterial reservoirs embedded in the bladder wall. While it may be effective, it’s important to manage expectations as every person responds individually.

"For anyone considering Fulguration, I can’t stress enough that it is not a quick-fix magic cure. You may come out of the procedure and need only two weeks of antibiotics post-op but have an up and down recovery for a few months. You may come out of the procedure needing additional treatments for your UTI symptoms. But understand that no recovery is the same. The recovery isn’t easy for some and it is mentally challenging but it’s worse if you go in with a mindset of thinking it is a quick fix or a guaranteed cure." Jessica Sian Saunders, Bladder Fulguration support group administrator

Because it can be difficult for antibiotics and other antimicrobial treatments to penetrate biofilm and bladder tissue, fulgurating superficial, abnormal layers of tissue may help to speed up the eradication of an embedded infection. 

Unfortunately, when it comes to statistically analyzing the data, we’re limited to the few studies around fulguration outcomes that currently exist. To add to this limitation, some studies use a measure of how many culture-positive UTIs participants have per year after fulguration as a determination of success. 

This is an issue because standard cultures are often unreliable in detecting UTIs even when symptoms are present. 

So in an effort to place culture limitations aside, the studies we’ve reviewed here also take patient symptoms into account. Therefore, ‘success’ is defined as a decrease in frequency of UTIs or symptom improvement. 

The understanding of how removing tissue abnormalities in the bladder results in fewer lower urinary tract symptoms (LUTS) and UTIs is still limited. To understand the theories around fulguration and UTIs, we first need to explore more about these abnormal tissues.

A healthy bladder is smooth throughout, making it difficult for bacteria to attach. But when abnormal tissues develop, bacteria can more easily adhere. As one specialist puts it, think of these abnormalities as ‘velcro of the bladder’.

In an effort to make it more difficult for bacteria to attach, the ‘velcro’ is removed through fulguration. 

You may be familiar with some of these tissue abnormalities: trigonitis, leukoplakia, vesicular cystitis, and Hunner’s ulcers. 

Although the cause, appearance, and success of fulguration varies between these tissue changes, the symptoms they cause have significant overlap. 

While not an exhaustive list, symptoms may include the following:

• Chronic or recurrent UTI
• Urinary frequency
• Urinary urgency
• Stress, urge, or other forms of incontinence
• Pain with urination (dysuria) 
• Nighttime urination (nocturia)
• Pelvic pain

We’ve broken down the following section into various types of bladder tissue abnormalities as well as how patients with these tissue changes may respond to fulguration. 

It’s important to note that study results do not always translate to how individual patients may respond to a treatment in the ‘real world.’ In the studies this article is based on, tissue abnormalities are typically the only urological condition participants were diagnosed with. 

For individual patients, consideration of other urological conditions may be necessary when looking into fulguration as a treatment for recurrent UTI. 

Trigonitis

The most common abnormality fulguration specialists come across, trigonitis, gets its name from the location of the bladder in which the tissue changes occur – the trigone. As you may have suspected, the trigone has a triangular shape. 

Simply put, trigonitis is inflammation (itis) of the bladder trigone. The type of tissue change most documented in this region of the bladder is called non-keratinizing squamous metaplasia. The importance of this term will be discussed soon. 

Fulguration for Trigonitis: UTI Symptom Response

In a review of 40 women with trigonitis, 23% and 73% had zero and fewer than three episodes of UTI symptoms per year, respectively, following fulguration. It should be noted that 38% of participants were on antibiotics for UTI in the six months following fulguration. However, no patients remained on antibiotics after the six month follow-up cystoscopy. 

Trigonitis is so common, occurring in 72% of women, that it’s often found in bladders of females who do not have any urinary symptoms. 

Perhaps trigonitis in itself is not harmful, but rather predisposes people to developing a chronic infection because the bladder is no longer smooth. 

Leukoplakia

Leukoplakia is considered to be extremely rare, occurring in as few as 1 in every 10,000 patients admitted to the hospital. However, some researchers have speculated that it’s more common than originally believed. 

Leukoplakia occurs when bladder tissue transforms and is covered in a layer of keratin, which gives leukoplakia the term keratinizing squamous metaplasia (KSM), as opposed to the non-keratinizing squamous metaplasia of trigonitis.

You can view an image of bladder leukoplakia during cystoscopy to see the tissue change.

A note of importance for this keratinizing tissue is that it can come with an increased risk of cancer. 

One study has placed the rate of KSM developing into cancer at upwards of 42%. However, the data is unclear on the true risk of leukoplakia developing into transitional cell carcinoma. 

In fact, another study determined the risk of leukoplakia developing into cancer was only 0.8%, and the researchers concluded that KSM did not increase this risk. 

If your surgeon identifies leukoplakia in your bladder, it is important for them to have a sample sent to pathology to rule out malignancy, but the finding is not cause for panic.

Fulguration for Leukoplakia: UTI Symptom Response

In a retrospective study of 92 females with confirmed leukoplakia, 64% reported an improvement in their moderate-severe symptoms such as frequency, retention, and urgency. 52.5% of patients reported complete resolution of pain after fulguration. 

The researchers noted that patients with multiple organisms or organisms with high antibiotic resistance were less likely to improve, both symptomatically and during follow-up cystoscopy. This is an important finding, as many UTIs are polymicrobial. 

The researchers took data collection one step further and asked about quality of life. 57% of patients reported that their quality of life had also improved. However, 16% stated their quality of life had deteriorated following fulguration.  

Antibiotics for Leukoplakia

Fulguration may not be the only effective treatment for leukoplakia. One study looked at the effects of doxycycline and antibacterial and antifungal vaginal suppositories on female patients with leukoplakia. 85% of the participants did not have detectable bacteria on standard urine culture, which is no surprise given the known limitations of this test. 

Despite the negative culture results, 71% of patients were either considered cured or improved after treatment. 

For those who were sexually active, their sexual partners were also treated with an oral antibiotic. The fairly high positive response to this multifactorial treatment further supports the role the vaginal microbiome and sexual health of a partner can have on bladder health. 

Only recently acknowledged as its own form of cystitis, vesicular cystitis (VC) refers to groupings of clear lesions, which look like raised bubbles when viewed during a cystoscopy. Not quite as rare as leukoplakia, VC is present in about 4% of women with recurrent UTIs. 

Primarily, VC lesions are located on the walls of the bladder, rather than the trigone. According to the single study that has been completed with patients who have vesicular cystitis, out of the 18 patients, no lesions on the trigone area were present. This is an interesting finding given other lesions on the trigone are so common. 

Fulguration for Vesicular Cystitis: UTI Symptom Response

In a study that included patients with vesicular cystitis (VC) and cystitis cystica (similar to VC but located near the trigone) undergoing a second fulguration, 41% of women reported improvement in symptoms. If fulguration failed a second time, many of the patients underwent a third fulguration in which an additional 46% achieved success.

Interestingly, all participants in this study were post-menopausal females, an unintentional occurrence. And in the only VC-specific study that we mentioned above, all female participants were also post-menopausal. This may support the theory of tissue morphing due to hormonal changes – at least when it comes to vesicular cystitis.    

Hunner’s Ulcers 

Considered to be the definitive marker of interstitial cystitis by some clinicians, Hunner’s ulcers are areas of severe inflammation with possible bleeding within the bladder wall. Unlike trigonitis, leukoplakia, and vesicular cystitis, these lesions are not raised. 

Like other tissue abnormalities within the bladder, Hunner’s ulcers are also quite rare. Yet, the rate of occurrence ranges all the way from 5-57%! UTI experts have surmised that the longer a stressor to the bladder exists, such as bacteria, structural defects, and more, the higher the likelihood that Hunner’s ulcers may develop. 

Fulguration for Hunner’s Ulcers: UTI Symptom Response

In a study that looked at fulguration for Hunner’s ulcers, pain and urgency scores decreased by an average of 7.9 and 6.3 points on a 10-point scale, respectively. Frequency and nighttime urination (nocturia) scores decreased similarly. 

While immediate improvements were promising, 46% of the patients required one to four additional treatments within eight months. And patients who reported urgency and frequency as a primary complaint, as opposed to pelvic pain, appeared to have lower rates of improvement. 

Similarly, 57% of participants in another study required repeat fulguration within 48 months. After repeat fulguration, 77% reported improvement and 15% reported a worsening of symptoms. 

Why Do Abnormal Bladder Tissues Develop?

A few theories have developed as to why these bladder tissues begin morphing in the first place. The most obvious, of course, being persistent or embedded bacteria within the cells of the bladder wall.

As bacteria burrow into the tissues and develop intracellular bacterial communities (IBCs), the attempt to exfoliate or shed these cells and bacteria may result in tissue changes. Not only can bladder infections cause these changes, but vaginal infections can also irritate the trigone area of the bladder, resulting in trigonitis.  

People who use catheters, vaginal contraception, or douche are also at risk of developing trigonitis due to the proximity of these irritants to the urethra.

Possibly the most discussed theory as to why these abnormalities occur, and are primarily present in females, is hormonal changes. Specific to the bladder trigone, estrogen receptors have been identified and cyclical changes have been observed. 

To further support the hormone theory, up to 71% of males who have received estrogen therapy developed urethral squamous metaplasia. 

Trigonitis, leukoplakia, and other abnormalities may not only be caused by an infection, but they may in turn leave the bladder vulnerable to recurrent UTIs.

The general risk of fulguration is considered low, however, like any medical procedure, risks still exist. If considering fulguration, discuss all possible risks with your surgeon and make sure you have a good understanding of them. 

Some of the known possible risks of fulguration include cutting too deep into the bladder tissues, introducing bacteria via the catheter or scope, urinary retention, or a reaction to the anesthetic or drugs used. 

Dr. Angelish Kumar has discussed some of these risks with us. She pointed out that risks increase in line with how much of the bladder surface area is cauterized. 

Unfortunately, aside from the study comparing two types of laser tools, no studies on fulguration for UTI symptoms have tracked the likelihood of symptoms worsening. 

Patients are categorized as either having success or failure. Without more data, we are unable to determine the distribution of unchanged vs. worse in the ‘failure’ category. 

If we consider quality of life deterioration as an indicator of symptom impact, a worsening of UTI symptoms may very well be a risk of fulguration. 

"When I began hearing about fulguration, I knew it was something to explore further, but I wanted to make sure I took the time to really understand the possible outcomes. In the year since I first learned of fulguration, I’ve spoken with patients who had the procedure, I’ve read all I can, and I’ve carefully considered who would perform the surgery. While I don’t yet know how fulguration will impact my chronic UTI, I feel I am well prepared for whatever may occur because of the steps I’ve taken. The prospect of fulguration is exciting, but I’d encourage anyone considering it to take the time to learn about it and understand how it may impact them.” Erin Alfano, chronic UTI patient

Chronic or recurrent UTI can have a big influence on mental health. Because no UTI or LUTS treatment is guaranteed to help, the impact of a failed fulguration (or other treatment) may need to be carefully considered. Discussing these possible outcomes with someone trained in health psychology may be beneficial. 

What To Expect After Fulguration

Researchers and fulguration specialists report an average of six months for patients to fully heal from the procedure. This is why a six-month follow-up cystoscopy is typically recommended. 

For the patients who have improved with fulguration, some report feeling an improvement in as little as six weeks, while others report months. Abnormalities found during the procedure or cystoscopy may influence this timeline.

Aside from the more common tissue abnormalities discussed here, patients have reported their fulguration specialists incidentally finding polyps, Skene’s gland infections, crystals, and other anomalies. 

During the healing period, an increase or change in symptoms early on is extremely common. 

"Many patients will do quite well with no or minimal symptoms. These symptoms range from urgency, frequency, all the way to bladder or suprapubic pain, and they will resolve in a matter of days. Others have more intense symptoms and those may last long." Philippe Zimmern, M.D.

During fulguration, superficial layers of tissue are cauterized, or burned, from the bladder wall. This injury and subsequent healing to the bladder can result in scabs, eventually dropping off and releasing with the urine. This time in the healing period can be frightening, but for most the symptom increase is temporary. 

To lower the risk of developing an infection, many specialists prescribe antibiotics immediately following fulguration. The type, dosage, and length are dependent upon the specialist and patient. UTI home remedies may also be recommended in preventing a UTI during recovery. 

What Sets Fulguration Specialists Apart?

We’ve stressed the importance of the tools used during fulguration, but the skill and experience of the surgeon are also extremely important. 

So, what makes a fulguration specialist different from other urologists or urogynecologists? 

In chatting with fulguration specialists and patients alike, they all acknowledged that how a cystoscopy is performed and interpreted is a crucial point in the process. 

Similar to how some doctors are unfamiliar with or unwilling to acknowledge the issues with standard urine cultures, many doctors do not recognize the significance of some of these abnormal tissues. 

This could be due in part to the American Urological Association (AUA) not having any published guidelines around trigonitis, the most common tissue abnormality. 

What’s more, when the camera is inserted during a cystoscopy, often the trigone is bypassed altogether. Dr. Cüneyd Sevinç, a fulguration specialist in Turkey, demonstrates what urologists see when the cystoscope first enters the bladder. You can see how easily the trigone area can be missed if not intentionally viewed.

Warning, the linked video contains images of external female genitalia and the internal urethra and bladder. 

According to the fulguration specialists we’ve interviewed, many doctors overlook trigonitis and leukoplakia, even if they are visible. They may collect a biopsy to test for and rule out cancer, but the rest of the lesion(s) remain. 

“I believe in personalized medicine for UTI, in the sense that each patient's UTIs are different and each patient is at a different place. Diagnosis, treatment, and prevention should be tailored accordingly, and take into account patient preferences and the pros and cons of various approaches.” Dr. Cüneyd Sevinç

When other bladder abnormalities are not detected, doctors may notate the presence of trigonitis, leukoplakia, and other indications of cystitis, but are unlikely to recommend a specific treatment. 

Because of these potential oversights, it may be helpful to request your doctor record your cystoscopy. This will allow you to get a second opinion if necessary. 

Now that you’ve familiarized yourself with fulguration for chronic and recurrent UTI, you may decide to speak with fulguration specialists to gain an understanding of their approach. 

As a starting point, we’ve provided a list of questions that may be helpful to ask during your appointment:

• Will a cystoscopy be performed prior to fulguration to confirm whether any abnormal tissue is present?
• Do you perform any other diagnostic tests prior to recommending or performing fulguration?
• Will the procedure be performed in-office or at a surgical facility?
• What type of anesthesia or sedation will be used?
• What tool do you use to fulgurate any abnormal tissue you may find?
• Do you have any information about success rates? Is success considered removal of all lesions or an improvement of symptoms and the frequency of UTIs? 
• Will I have a catheter inserted after the procedure and how long will it remain?
• What steps do you take to help prevent a UTI following surgery?
• How long will I likely stay in the hospital? If traveling, when will I be able to travel back home?
• Considering my personal health history, do you feel I am a good candidate for fulguration?
• Considering my personal health history, what are the risks of complications?

With all of the discussion around fulguration within patient communities, the idea of undergoing a 30-minute procedure to resolve or improve your UTI symptoms can sound appealing. But it’s important to remember that your individual situation may differ from another UTI patient, even if your symptoms are similar. 

Many factors can play into why someone may develop a UTI or lower urinary tract symptoms. And while the data shows that abnormal tissues do have a correlation with UTI, these tissues may not be present in everyone or may not be the sole cause of symptoms. 

The indications that someone might be a good candidate for fulguration are different according to each fulguration specialist. 

Read about how fulguration can be utilized for other purposes here.

All fulguration specialists in our community consider a history of UTIs unresolved by antibiotics to be a defining characteristic of someone who may benefit from fulguration. 

But what is considered a ‘history of UTIs unresolved by antibiotics’?

The official definition of recurrent UTIs is two or more UTIs within 6 months or three or more per year. However, some specialists recommend not waiting that long before addressing infections with fulguration.

Because antibiotics are often unable to penetrate the bladder tissue, once bacteria become embedded they can continue to multiply. 

Fulguration specialists familiar with this process recommend waiting no longer than 3-12 months after a persistent UTI begins to check for and remove lesions that may be harboring bacteria, even if on long-term antibiotics. 

Read Ally’s story, ‘An Embedded UTI: More Debilitating Than When it Hurts to Pee’ here.

Steps For Researching Fulguration

Fulguration may be beneficial for treating a chronic or recurrent UTI. But it’s important to consider whether fulguration may be right for your individual situation. In collecting information that may help you to make a decision, you may consider some of the following steps. 

1. Review the studies we referenced in this article by clicking on the links. We weren’t able to include every detail, so in addition to the success rates you may want to read additional information about the participants, such as age, other conditions, and more. 
2. Reach out to multiple fulguration specialists to discuss your history and their approach to fulguration. You can review our list of recommended questions to help guide you. You may find that your needs align more closely with one specialist.
3. Join support groups and review or participate in discussions with people who have had fulguration. This will help you gain an understanding of what to expect if you choose to pursue it. You may also establish a community of people who are going through or have gone through similar experiences. 

To get answers to commonly asked questions about chronic and recurrent UTI, visit our FAQ page.