What is Recurrent Urinary Tract Infections (UTIs)?
Recurrent urinary tract infections (UTIs) are referred to as having two cases of bacterial bladder infection along with related symptoms in the past 6 months or three occurrences within the previous year. These types of UTIs tend to affect women more often. It’s noteworthy that treating UTIs costs roughly 3.5 billion dollars annually in the United States alone.
Typically, a UTI is identified when there are more than 100,000 bacteria-forming units in a milliliter of urine along with common acute symptoms. These symptoms might include discomfort while urinating, feeling an urgent need to urinate, urinating more frequently, or feeling pain in the lower part of your belly.
However, if someone has more than 100 bacteria units of a specific type, called Escherichia coli (E. coli), along with specific urinary symptoms, there’s a 90% chance of having a UTI. This suggests that a lower bacteria count can be used to diagnose straightforward and recurring UTIs.
What Causes Recurrent Urinary Tract Infections (UTIs)?
There are many conditions that can make both men and women more likely to get urinary tract infections (UTIs), including:
- Physical defects that mess up the flow of urine or block it
- Atrophic vaginitis, which is an inflammation of the vagina that can make a UTI more likely
- Bladder diverticula, or small pouches in the bladder that don’t empty all the way, can increase the risk of an UTI
- Cystoceles and organ drooping in the pelvic area can make women get UTIs more often
- Functional problems, like having an overactive bladder or being unable to hold your urine, can also lead to more frequent UTIs
- If the initial UTI isn’t treated properly, it can come back
- As bacteria become more resistant to antibiotics, getting UTIs becomes more likely
Older men are often more likely to get UTIs, especially if they have problems with urine flow or their bladder can’t empty all the way. Additionally, women who are sexually active can often get UTIs without having any other identifiable issues. There are also different types of lesions (wounds or injuries) that can make you more likely to have repeated UTIs. These lesions can be inside the bladder (like bladder stones or tumors), in the wall of the ureter (which is the tube from the kidney to the bladder), or outside of the urinary tract (like an inflammation or a mass).
Up to 40% of children who have a UTI for the first time are found to have vesicoureteric reflux, or backward flow of urine from the bladder to the kidneys.
Lastly, while having a weak immune system alone typically does not cause repeated UTIs, it can contribute to the overall risk.
Risk Factors and Frequency for Recurrent Urinary Tract Infections (UTIs)
About one-third of women experience a simple urinary tract infection (UTI) before they turn 24. Over half of all women have at least one symptomatic UTI in their lifetime. Furthermore, about 26% of women have a UTI come back within six months after they have been treated for the first one. Studies have shown that among women over 55 years old, 53% have had a UTI return within a year. In younger women, the figure stands at 36%.
Signs and Symptoms of Recurrent Urinary Tract Infections (UTIs)
Acute simple cystitis, also known as a urinary tract infection (UTI), typically causes symptoms such as frequent or urgent urination, pain during urination, and lower abdominal pain. If a woman experiences these symptoms but doesn’t have vaginal discharge or irritation, there’s a more than 90% chance that she has cystitis. However, if severe, this condition can bring about symptoms like fever, chills, extreme fatigue, or malaise, indicating that the infection has spread beyond the bladder.
On the other hand, pyelonephritis – kidney infection – is characterized by fever, chills, pain in the sides of the body, tenderness in the lower back area, nausea, and vomiting. Cystitis symptoms may also accompany pyelonephritis. Women who frequently experience UTIs require a pelvic examination to check for conditions like cystoceles, vaginitis, vaginal atrophy, and pelvic organ prolapse. Research indicates that the presence of blood in urine and urgent need to urinate during the first UTI are potential signs of a second UTI. Men who frequently suffer from cystitis need an assessment for a condition called prostatitis.
Older or weakened individuals might show general infection symptoms, such as fever and chills, or a change in mental status, without explicit signs pointing to a urinary tract ailment. Recurrent UTIs should be confirmed through positive urine culture results, and presence of urinary symptoms should be noted.
If urine samples obtained through the clean catch method are suspected to be contaminated, especially in women, obtaining a sample via catheter becomes necessary. As for women who repeatedly experience cystitis after treatment, efforts should be made to identify whether the cystitis is a reinfection (a new infection after a previous one was fully treated) or a relapse (reoccurrence of a previous infection that wasn’t completely cured).
- A reinfection is characterized by an interval of over two weeks between two UTI episodes, the presence of a different infection-causing strain, or confirmation of a sterile (infection-free) culture in between two UTI instances when the patient is off antibiotics.
- A relapse is determined if the interval between two UTI episodes is less than two weeks.
Recurrent infections often necessitate further investigation through urological imaging, such as ultrasound or CT scan, to assess the urinary tract.
Testing for Recurrent Urinary Tract Infections (UTIs)
For patients regularly experiencing urinary tract infections (UTIs), extensive testing isn’t typically required. Women who often get UTIs and display standard symptoms usually only need to take a urine culture test to examine their sensitivity to antibiotics. The diagnosis is largely based on patients’ symptoms.
Urine analysis is particularly important when the infection is severe or if there’s a high chance that the culprit bacteria are resistant to multiple types of antibiotics. This could be due to previous exposure to multiple drugs, recent stays in a hospital, recent antibiotic usage, or a travel history to certain countries.
Distinguishing between ongoing (different bacteria causing each instance) and relapsing (same bacteria causing repeated instances) infections is crucial. A relapsing infection could suggest a continuous source of bacteria, such as an abscess, chronic bacterial prostatitis, or an infected stone. For every new UTI occurrence, it is recommended to carry out urinalysis and urine culture.
Only a select few women are typically advised to undergo urological imaging. This would include women who have ongoing relapses, persistent blood in urine after treatment, a history of passing stones, or repeated presence of a certain bacterium known as Proteus in their urine, which is often associated with kidney stones. The best type of imaging could be either renal ultrasound or a computed tomography scan of the abdomen and pelvis.
For diagnosing UTIs in children, many methods are used to collect urine samples. However, getting a urine sample through suprapubic aspiration or catheterization might give clearer results with less contamination. If the urine sample is collected in a plastic bag, it’s important to rule out a UTI by dipstick evaluation and microscopic analysis. A UTI can usually be ruled out if there are no signs of leukocyte esterase and nitrite in a urinary dipstick test. Using a clean, voided midstream urine sample for diagnosis is only useful for toilet-trained children. If patients continue to experience symptoms despite negative results in urinary cultures, they should be evaluated for other underlying issues.
Cystoscopy, a procedure to look inside the urinary bladder and urethra using a thin, lighted instrument, is seldom used to diagnose recurrent UTIs. This is because it may potentially cause an ascending lower UTI. However, it could be advisable after surgeries to rule out possible ureteral injuries, evaluate incomplete bladder emptying, or identify possible bladder stones. In terms of irrigation fluid used during cystoscopy, one study found that patients having the procedure with 10% dextrose and water had a higher rate of UTIs compared to those utilizing normal saline.
Treatment Options for Recurrent Urinary Tract Infections (UTIs)
Treatment for simple urinary tract infections or UTIs is often done at home. In cases where the patient has typical symptoms of an acute cystitis, a type of UTI that affects the bladder, they can be prescribed antibiotics via telehealth. For patients who don’t respond to the initial antibiotic treatment or are at high risk, a urine culture is recommended to tailor the course of antibiotics accordingly. The decision to hospitalize a patient depends on individual cases and symptoms.
Before starting treatment for this type of infection, a urine culture is advised. Patients who have undergone treatment in the past three months should get urine culture and susceptibility testing, as there’s a chance they’ve developed antibiotic resistance. The same recommendation applies to patients with complicated cystitis or pyelonephritis, which is an infection that spreads to the kidneys.
Several antibiotics are recommended for simple cystitis:
– Nitrofurantoin, taken orally twice a day for 5 to 7 days
– Trimethoprim-sulfamethoxazole, taken orally twice a day for 3 days
– Fosfomycin, taken as a single oral dose
– Pivmecillinam, primarily used in Europe, also known to treat UTIs
If the patient can’t take these antibiotics, they may be given other options such as amoxicillin-clavulanate, cefdinir, cefadroxil, and cefpodoxime. If these are also unsuitable, alternatives could include levofloxacin, ciprofloxacin, or norfloxacin.
In most cases, patients should feel better after two days of taking antibiotics. If there’s no improvement, further tests should be done to rule out other complications. Patients who have been hospitalized due to being at high risk for multi-drug resistant infection are given other antibiotics to mitigate the risk.
When it comes to dealing with recurring UTIs, recommended treatments include improving personal hygiene, sufficient hydration, increased fluid intake, and using vaginal estrogens where appropriate. There are several non-antibiotic prophylactic therapies recommended to prevent recurring UTIs:
– Cranberry products: Thought to work by providing proanthocyanidins, decreased bacterial adherence to the urothelium.
– D-mannose: May help reduce adherence of infecting organisms to the urothelial mucosa.
– Methenamine prophylaxis: Along with vitamin C, acidifies the urine to fight bacteria.
– Estrogen vaginal cream: Topical treatment reduces recurrent UTIs in those who are postmenopausal.
If conservative measures fail, antibiotic prophylaxis or preventative treatment could be considered. The idea is to give lower doses of antibiotics for a longer period of time to prevent UTI recurrence. This type of treatment can be effective, but the antibiotics can lead to bacterial resistance.
It’s noteworthy to mention that the American Urological Association (AUA) recommends cranberry prophylaxis and vaginal estrogen as non-antibiotic-based therapies for recurrent UTIs.
What else can Recurrent Urinary Tract Infections (UTIs) be?
- Atrophic vaginitis: This condition is associated with the thinning, drying, and inflammation of the vaginal tissues, often resulting in urinary symptoms due to a decrease in estrogen.
- Overactive bladder: Symptoms include frequent urination and feeling a strong urge to urinate, despite there being no signs of infection.
- Painful bladder syndrome: This condition can cause painful urination, frequent urination, and a sense of urgency to urinate, although there’s no presence of infection.
- Pelvic inflammatory disorder: Symptoms include pain in lower abdomen or pelvic area, fever, outflow from the cervix, and pain during pelvic exam.
- Prostatitis: This condition may potentially cause pain during ejaculation and may lead to a tender prostate discovered during a rectal examination.
- Urethritis: Evidence of infection-fighting white blood cells in urine without bacteria. This condition is common in sexually active women.
- Urolithiasis: The presence of stones in the bladder or distal ureter can cause similar symptoms, and kidney stones may be an infected focus.
- Vaginitis: The presence of vaginal discharge, odor, itching, and painful sexual intercourse (there are no urinary frequency or urgency symptoms.)
What to expect with Recurrent Urinary Tract Infections (UTIs)
Most repeat urinary tract infections (UTIs) don’t have long-term effects, and patients usually recover fully. The risk of death from acute uncomplicated cystitis, a type of UTI, in women is extremely low. However, each episode of a UTI can result in missing approximately 1.2 days of school or work due to the illness. Younger patients without pre-existing health conditions tend to recover the best.
On the other hand, factors that might lead to a more difficult recovery include being older in age, having had a recent procedure involving the urinary tract, recent hospitalization, recent antibiotic treatment, or already having conditions like diabetes, sickle cell anemia, or chronic kidney disease. UTIs that occur in the context of certain anatomical abnormalities such as kidney stones, blockages, swollen kidneys, a fistula between the bladder and the bowel, nerve-damaged bladder, kidney failure, or a condition where the bladder is outside the body, all tend to have a more difficult recovery.
Possible Complications When Diagnosed with Recurrent Urinary Tract Infections (UTIs)
The risk of complications can increase due to various factors such as blockage in the urinary tract, recent procedures performed on the urinary tract, advanced age, and diabetes (especially for severe types of kidney infection). One such complication is acute pyelonephritis, a severe kidney infection, which can worsen and progress into a kidney abscess, perinephric abscess, necrosis of papillae, or a gas-forming kidney infection. The worsening of this condition might be suspected when there is no improvement in symptoms after two days of proper antibiotic treatment. In this case, further evaluation with imaging of the urinary system is necessary. Some patients with complex urinary tract infections might directly show up with bloodstream infection, severe body-wide infection, failure of multiple organs, or sudden kidney failure.
Risk Factors:
- Urinary tract blockage
- Recent procedures on the urinary tract
- Old age
- Diabetes (particularly severe kidney infections)
Possible Complications:
- Kidney abscess
- Perinephric abscess
- Necrosis of kidney papillae
- Gas-forming kidney infection
- Bloodstream infection
- Sepsis (severe body-wide infection)
- Failure of multiple organs
- Sudden kidney failure
Preventing Recurrent Urinary Tract Infections (UTIs)
To help prevent recurring urinary tract infections (UTIs), there are several steps patients can take although the proven benefit is small. They’re encouraged to drink at least 2 liters (about 8 glasses) of water every day. Research has shown that increasing daily water intake can reduce the frequency of UTI episodes.
For postmenopausal women who experience menopause-related genital and urinary changes, applying an estrogen cream to the genital area may help to lower the risk of future UTIs, unless there are conditions that make this treatment inadvisable. Other ways to help prevent UTI recurrences include careful hygiene practices like wiping from front to back after using the toilet, using plain liquid soap for washing, avoiding reusable sponges or loofahs for bathing, and going to the toilet soon after sexual activity. The effectiveness of cranberry juice in preventing UTI recurrences is yet to be confirmed.
In cases of repeated UTIs, doctors might suggest medication as a preventive measure, but only after other preventive strategies have been tried and only for women known to have recurring UTIs. While this may be helpful, the potential side effects could outweigh the benefits as UTIs often don’t lead to severe problems. Side effects may include drug toxicity, resistance to antibiotics, disturbance of the normal gut bacteria, and certain infections such as Clostridioides difficile.
In women who often get UTIs after sexual activity, they might be advised to take antibiotics after sexual activity to reduce the chances of side effects without reducing the drug’s effectiveness or leading to antibiotic resistance. In other cases, continuous medication is recommended. The same drugs are usually prescribed for both continuous and post-sexual activity treatment plans. The need for medication should be reassessed every 6 months.
Factors like personal hygiene could also contribute to repeated UTIs. However, there isn’t strong evidence that shows lifestyle changes can help reduce UTIs significantly. Here are some advice for personal hygiene habits:
* Always wash your hands before using the toilet or taking a shower to avoid spreading bacteria to your body’s genital area.
* Wipe from front to back: After using the toilet, wipe from the vagina towards the anus. This is because many urinary infections are caused by bacteria that are normally found around the anus and rectum. So, wiping from the anus towards the vagina can move these bacteria closer to the bladder and urinary tract, which could lead to infection. This is also the recommended method of wiping after a bowel movement.
When using toilet paper or baby wipes after urinating, only use a wipe once to avoid spreading more bacteria to your genital area. It’s worth noting that baby wipes, which are safe for babies, are healthier options than toilet paper and can be carried conveniently for use outside the home.
Taking baths might not be the best option since the bathwater can capture bacteria from your skin, allowing them to reach the vagina. Think about it, you probably wouldn’t drink your bathwater, so why use it to wash your sensitive genital area? If you prefer baths over showers, skip the bubble baths or cosmetic bath additives which could irritate the sensitive skin in the genital area. Instead, opt for showers which are less likely to introduce bacteria to the vagina and urethra.
Avoid reusable sponges or loofahs, including nylon ones, as they can’t be sufficiently cleaned or sterilized, causing them to harbor bacteria. This is particularly important for women who are prone to infections like UTIs. When washing, use a mild liquid soap, because bar soap is typically covered in bacteria because of exposure to air and the bathroom environment. Additionally, regular body wash is harsh for the delicate tissues in the genital area. Avoid products with perfumes, astringents, creams, or other chemicals which can irritate. You can use gentle baby soap or shampoo for your genital area.
Washcloths are the cleanest way to apply soap. Use a clean, soft cotton or microfiber washcloth. After washing and drying, keep them in clean, resealable plastic bags. You might want a second washcloth for the rest of your body after washing your genital area. Always clean your bladder area first to prevent spreading bacteria from other parts of your body to the bladder.
Don’t use personal hygiene products such as douches, feminine hygiene sprays, cosmetics, perfumes, medicated towelettes, or similar products in the vagina or urethral area unless approved by your doctor. During your period, use tampons instead of sanitary napkins or pads, as tampons can help maintain better hygiene and reduce bacterial growth.
Avoid holding in your pee for long periods of time. Try to empty your bladder every 4 hours during the day, even if you don’t feel the need. Wearing tight clothes like pantyhose, bathing suits, or tight slacks for long periods can cause the skin around the vagina to fold, increasing the chances of bacterial contamination of the urethra.
Remember to drink a lot of water. Start by drinking an extra glass of water with each meal. If your urine looks darker than pale yellow, it means you’re not drinking enough water and should increase your intake. Although you can substitute cranberry juice with other beverages, cranberry juice is beneficial, especially for those with UTIs. Take more vitamin C, as it may help boost your body’s resistance to infection.
Avoid foods that irritate the bladder such as caffeine, coffee, tea, alcohol, hot spices, artificial sweeteners like aspartame, chocolate, cola drinks, and high-potassium foods like bananas and oranges. Certain exercises or tasks, like prolonged biking, motorbiking, horseback riding, and similar physical activities can increase the risk of bladder infections.
After sex, empty your bladder and drink 2 extra glasses of water. You may be advised to take a urinary antiseptic or antibiotic post-sex. An estrogen vaginal cream can help keep the tissues around the urethra healthy and more resistant to infection if you’re menopausal.
If your doctor has prescribed an antibiotic as prevention, make sure to follow the instructions carefully. Sometimes, you might need to take medication for up to 1 year or more, depending on the nature and severity of the UTI. Some patients might need a small dose either daily at bedtime to prevent most UTIs and give the bladder a chance to heal, or only when they think they’re getting an infection.
If you follow these suggestions and still get an infection, seek medical help promptly. Your doctor may require a urine sample and may also recommend additional tests or treatments if needed. Should simpler measures prove inadequate, they might suggest sterilizing your washcloths.
Here are the steps for sterilizing washcloths:
1. Wash the washcloths with hot water and soap or detergent.
2. Boil the washcloths in water for at least 20 minutes.
3. Allow the washcloths to dry, either in the open air or using a clothes dryer.
4. Once dry, put each washcloth in its own sealable plastic bag.
5. Leave the bags unsealed and place them in the microwave, with a large glass of cold water in the middle.
6. Microwave on high for 5 minutes, replace the hot water with a new glass of cold water, and microwave again for another 5 minutes.
7. Let the bags cool down before sealing them.
This method sterilizes the washcloths with microwave radiation, killing the bacteria. The glass of water in the microwave absorbs the heat and prevents the bags from melting and the washcloths from catching fire.
In summary, to prevent UTIs:
* Wipe from front to back.
* Wash your hands before using washcloths, tissues, or toilet paper for wiping or cleaning.
* Use a clean, gentle liquid soap because it’s cleaner than bar soap.
* Only wipe once with each washcloth or tissue.
* Clean the bladder area first when washing to prevent bacterial contamination from other body parts.
* Don’t use the washcloths for any other purpose except to clean the area around the urethra.
* Drink more water and take vitamin C. Drinking cranberry juice or taking cranberry pills can also help.
* Consider using an estrogen cream twice a week (or as prescribed by your doctor) if you’re past menopause.
