Recurrent Urinary Infections

1. Do I have a urinary tract infection? How common is this problem?

Urinary tract infections (UTI) in women are a common occurrence. 1 in 2 women will experience a UTI at some point in the lives, and up to a quarter of these women may experience multiple repeated urinary infections.

The majority of women with uncomplicated UTI will usually experience a burning sensation on urination. This is often associated with (1) frequent and urgent visits to the bathroom to urinate; (2) small volumes of urine being passed each time; (3) lower abdominal pain or discomfort; and / or (4) passage of bloody urine. In atypical cases, the bacterial infection in the bladder may ascend up the ureters to affect the kidneys, known as acute pyelonephritis. In this scenario, fever, chills and flank pain may be experienced. If the female notices associated vaginal discharge, itch or foul odour, this is likely due to inflammation of the vagina (vaginitis) or urethra (urethritis).

2. What causes females to experience recurrent urinary tract infections?

The most frequent route for bacteria to gain entry into the female urinary tract are ascending infections of bacteria from the peri-anal area or the vagina, often after sexual intercourse. Commonly identified types of bacteria in typical female UTIs include Escherichia Coli; Proteus; Klebsiella, Pseudomonas and Enterococcus.

Illustration
Fig 1: E.coli bacteria is frequently responsible for urinary tract infections.

Patients who experience 2 or more urinary tract infections within a 12-month period are diagnosed with having recurrent urinary tract infections. Common causes for such recurrent infections include:

  1. • Incomplete bladder emptying, with significant urine volumes left after urination
  2. • Presence of stones or tumours in the urinary tract, providing “safe harbours” for bacteria to repopulate after courses of antibiotic treatment
  3. • Bacterial resistance to conventional oral antibiotics
  4. • Loss of oestrogen in post-menopausal women, allowing bacteria to adhere more easily to the lining of the urinary tract
  5. • Obstructed urination eg. stricture of the urethra, reflux of urine back into the kidneys
  6. • Conditions causing compromised host immunity eg. diabetes, pregnancy, oral steroid use, patients with kidney transplants, and the frail elderly

3. What should I do if I think I may have a urinary tract infection?

You should consult your family doctor, gynaecologist or urologist immediately when you start to experience the abovementioned symptoms. If this is your first episode of UTI symptoms, your doctor will usually ask you a detailed medical history to identify possible causes. He will ask you for a sample of your urine to send to the laboratory for urine analysis and culture. If you are not having high fevers, he will usually prescribe a short 3-5 day course of oral antibiotics to treat the likely bacteria in your urinary tract. Once your urine culture result is available, he may contact you to substitute your treatment to the most appropriate antibiotic to optimize eradication of the offending bacteria.

4. If my UTI symptoms keep recurring despite antibiotics, what should I do?

If you continue to experience recurrent UTI symptoms more than twice in a 12-month period despite completing the appropriate antibiotics, you should request for further evaluation of your urinary tract. Your family doctor will usually refer you on to a urologist, who will arrange some/ all of the following tests to identify correctable causes:

  1. • Repeat urine culture & antibiotic sensitivities
  2. • Uroflowmetry and residual urine measurement after urination to look for abnormalities of bladder emptying
  3. • CT urogram (Fig.2A) with contrast to identify any abnormalities in the urinary tract eg. stones, urinary reflux into the kidneys etc (ultrasonography is an alternative for pregnant females)
  4. • Flexible cystoscopy (Fig. 2B) to look for presence of bladder tumours or ulcers, in women with smoking history or above the age of 50 years ( this is usually a painless procedure performed under local anaesthesia in women)
  5. • Voiding cystourethrogram to confirm presence of diverticulum (abnormal pouches) of the urethra, or abnormal connections between bladder and the large intestine (colovesical fistula) where these are suspected

Once the abnormality in the urinary tract is identified, appropriate treatment may then be advised and commenced to prevent future recurrences.

5. Are there any measures to prevent such recurrences of UTI from occurring?

Yes! In women aged between 25-45 years, UTIs most commonly occur within 1-2 days after sexual intercourse. If this is a repeated pattern, such females should observe the following measures to minimize recurrent infections:

  1. • Empty the bladder and wash the vagina after sexual intercourse
  2. • Consider alternative forms of contraception to diaphragms or spermicidal lubricants
  3. • Take one tablet of antibiotic before or after sexual intercourse

In postmenopausal women with recurrent UTIs, they should consider their urologist or gynaecologist to assess the vagina and cervix to rule out early cancers or atrophic vaginitis. In the latter, topical oestrogen creams can improve the health of the vaginal lining and reduce the incidence of colonization by aggressive bacteria.

In women whose UTIs are not related to sexual intercourse, they may consider self-directed therapy. Here, patients are given a 3-day course of antibiotics by their doctors to keep on standby, and they can start treatment immediately once they recognize the onset of their familiar UTI symptoms. However, they must consult their doctors should their symptoms persist after the course of antibiotics has ended. Another popular remedy is to take regular cranberry juice / supplements, although this practice has still not been scientifically proven to reduce the incidence of UTIs3.

In summary:

  1. • 1 in 2 women will experience urinary tract infections in their lifetime
  2. • Women who experience 2 or more episodes of symptomatic urinary infections within a 12-month period should consult their urologist for an evaluation of their urinary tract to rule out correctable causes
  3. • UTI after sexual intercourse in women is a common scenario, and such episodes can be minimized by emptying the bladder, washing the vagina and / or taking preventive antibiotics after intercourse

References:

  1. 1. Dason S, Dason JT, Kapoor A. Guidelines for the diagnosis and management of recurrent urinary tract infection in women. Canadian Urological Association Journal 2011; 5(5): 316-322.
  2. 2. Kodner CM, Thomas Gupton EK. Recurrent urinary tract infections in women: diagnosis and management. American Family Physician 2010; 82(6): 638-643.
  3. 3. Jepson RG, Williams G, Craig JC. Cranberries for preventing urinary tract infections. Cochrane Database of Systematic Reviews 2012; DOI: 10.1002/14651858.CD001321.pub5.
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