Notes from a Doctor's Practice

Urinary tract infections (UTIs) can ruin vacations, honeymoons and result in an urgent care visit. The good news is: yes, they are a problem but there is no evidence that chronic UTIs lead to issues such as high blood pressure or kidney disease. Let's talk about why chronic UTIs happen and what to do about them.

Most recurrent UTIs are thought to represent re-infection rather than relapse though that is not always the case.

Who gets recurrent UTIs and how common is it? Recurrent UTIs are common among young, healthy women with anatomically and physiologically normal urinary tracts. In a study of college women with their first UTI, 27 percent experienced at least one recurrence within the six months following the initial infection and 2.7 percent had a second recurrence during this same time period. When the first infection is caused by Escherichia coli, women appear to be more likely to develop a second UTI within six months than those with a first UTI due to another organism.

Why does it happen? The bacterial causes of recurrent UTI are assumed to be the same as with a single infection. Most bacterial causes of UTI originate in the rectum, colonize the periurethral area and urethra, and ascend to the bladder. What is interesting is that evidence suggests that changes of the normal vaginal bacteria, especially the loss of lactobacilli, may predispose women to colonization with E. coli and to UTI. This is the reason we tell you not to douche, and not to use perfumed soaps or take long baths with bubble bath. Here is another opportunity to try Probiotics (with Lactobacilli) as well.

Reinfection versus relapse: For most physicians it is often impossible to distinguish between a relapse and reinfection.  A recurrent UTI is classified as a reinfection if the recurrence is caused by a different strain of bacteria than the one responsible for the original infection. In clinical practice, a recurrent UTI is defined as a relapse if the infecting strain is the same and the recurrence occurs within two weeks of the completion of treatment for the original infection. By contrast, a recurrent UTI arising more than two weeks after treatment is considered to be a reinfection, even if the infecting pathogen is the same as the original. The majority of recurrences of UTIs appear to be reinfections. In fact, long-term studies have shown that E. coli strains are capable of causing recurrent UTI one to three years later, despite appropriate treatment and disappearance of the organism in repeated urine cultures prior to the development of the next infection. However, most recurrences occur in the first three months after the initial infection.

Risk factors:  

1) Biologic or genetic factors: Women with recurrent UTI have been shown to have an increased susceptibility to vaginal colonization with bacteria compared with women without a history of recurrences. This difference is partially explained by the ability of the bacteria to stick to uroepithelial cells in some women and this appears to be genetic.

2)  Behavioral risk factors:  Sexual intercourse, diaphragm-spermicide use, and a history of recurrent UTI are strong risk factors for UTI. Even spermicide-coated condom use results in an increased risk of UTI. Recent antibiotic use, which adversely affects vaginal flora, also is strongly associated with an increased risk of UTI. The strongest risk factor is the frequency of sexual intercourse. Other risk factors include: having a new sex partner during the past year, having a first UTI at or before 15 years of age and having a mother with a history of UTIs

3)  Pelvic anatomy: Pelvic anatomy may predispose to recurrent UTI in some women, especially those who do not have other risk factors for UTI. As an example of this, the distance from the urethra to anus was significantly shorter in patients with recurrent UTIs in some studies.

4)  Postmenopausal women:In postmenopausal women factors that affect bladder emptying contribute to chronic/recurrent UTIs, with the main risk factors in those women being urinary incontinence, and the presence of a cystocele (bladder prolapse).

How can you prevent these from happening? A number of strategies have been used in an attempt to prevent recurrent UTIs. Although many approaches have not been adequately tested in studies, it is reasonable to consider them.

1)   Contraception: Women with recurrent UTIs who are sexually active or who use spermicides (particularly when used with diaphragms), should be counseled about the possible association between their infections and the use of spermicides.

2)   Voiding after intercourse and drinking lots of water:  Voiding right after intercourse and more liberal fluid intake may reduce the risk of recurrent

3)  Cranberry juice: Cranberry juice has been touted as an effective home remedy for preventing UTI. How does it work? Well studies have shown that cranberry juice inhibits adherence of bacteria to uroepithelial cells. How much do you have to drink? In some clinical trials consuming 300 ml of Cranberry juice decreased the chance of getting a UTI. In others, 50 mL 5 days a week decreased the frequency of UTI at six months,

4) Taking antibiotics to prevent recurrent UTI:  Antibiotic prophylaxis has been shown to be effective in reducing the risk of recurrent UTI in women. Prophylaxis has been advocated for women who experience two or more symptomatic UTIs within six months or three or more over 12 months. Individual decisions to be made with your doctor are whether you should use continuous antibiotics, or just antibiotics after intercourse... both of which are effective for prevention.

When you need to see a Urologist? Procedures such as urography and cystoscopy have not been shown to be necessary in women with recurrent UTIs. An evaluation by a Urologist for women with recurrent UTI generally results in unnecessary expense and potential toxicity. Having said that, further evaluation by a Urologist is recommended if there is suspicion about structural or functional abnormalities of the genitourinary tract.

Dr O.