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BackTable / OBGYN / Article
Let’s Talk UTIs: Strategies for Diagnosing & Managing Recurrent Infections
Taylor Spurgeon-Hess • Updated Jun 10, 2024 • 34 hits
Urinary tract infections (UTIs) are not only common but often recur, posing challenges in diagnosis and management, particularly among women. Recurrence can be due to a variety of factors including inadequate treatment, anatomic abnormalities, improper hygiene habits, and more. Educating patients on signs, symptoms, and preventative strategies plays an important role in the management of UTIs. BackTable host Dr. Suzette Sutherland sits down with Dr. Anne Cameron, a pelvic medicine and reconstructive surgery specialist, to discuss the intricacies of this common condition.
This article features excerpts from the BackTable OBGYN Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.
The BackTable OBGYN Brief
• Urinary tract infections range from bladder infections (i.e. cystitis) to severe kidney infections (i.e. pyelonephritis), with distinct symptoms and severity.
• Diagnosis of a UTI requires both the presence of symptoms and confirmation via urine tests showing bacterial activity.
• Women are at a higher risk of UTIs than men, with 50% of women likely to experience an infection, compared to 10% of men. Anatomical differences, notably the shorter urethra in women, largely account for the higher incidence of UTIs in females.
• Recurrent UTIs are common, affecting about 30% of women who have had a UTI, defined clinically as three infections in a year or two within six months. These UTIs are categorized into infections from new exposure, initial treatment failures, and persistent infections with the same bacteria.
• Common risk factors for recurrent UTIs include anatomical abnormalities, residual urine, or surgeries that alter urinary function.
• Evaluation of recurrent UTIs may include a vaginal exam which can assess estrogen status and check for anatomical issues like urethral diverticulum that might cause infection recurrence.
• Patient education involves the discussion of urinary and hygiene habits; conversations should emphasize the importance of urinating after sexual intercourse and using gentle, natural personal hygiene practices.
• Providing vaginal estrogen to patients with low estrogen can help restore normal vaginal flora and prevent UTIs, in addition to improving vaginal health and comfort.
Table of Contents
(1) The “411” on UTIs: Urinary Tract Infection Symptoms & Diagnosis
(2) Causes & Risk Factors for Recurrent UTIs
(3) Discussing UTIs with Patients: Evaluation & Education
The “411” on UTIs: Urinary Tract Infection Symptoms & Diagnosis
Urinary tract infections (UTIs) encompass a range of conditions from bladder infections, known as cystitis, to the more severe kidney infections, termed pyelonephritis. Although a UTI can refer to infection anywhere within the urinary tract, the term is most often used in reference to bladder infections, or cystitis, specifically. The diagnosis of cystitis hinges on two key components; patients must exhibit symptoms (e.g. urinary urgency, frequency, discomfort) and there should be laboratory evidence of bacterial presence, demonstrated on either urine culture or dipstick tests.
The incidence of UTIs is significantly higher in women due to anatomical differences; the longer length of the male urethra protects from bacterial migration and colonization. Half of all women experience at least one UTI in their lifetime, while men face a lifetime risk of roughly 10%. Furthermore, recurrent UTIs, defined as three episodes in one year or two within six months, affect approximately 30% of women who have experienced a UTI, highlighting the need for precise guidelines on management and prevention.
[Dr. Anne Cameron]
A urinary tract infection can be an infection anywhere from the kidneys, all the way down to the bladder. What people often mean when they say, I have a UTI, is they usually mean a bladder infection or cystitis and that's a bacterial infection of the bladder. You can also have a UTI, which is a kidney infection, and a pyelonephritis, but that's a very different and much more severe infection. A UTI, to be truly a UTI, the person who is suffering has to have symptoms.
They have to have the symptoms that are associated with the infection. In terms of the bladder, that is usually urgency, frequency, bladder pain. They might feel like they're going to wet themselves and they might go very, very frequently. On top of that, the person also has to have a test that shows that they have an infection. Either a culture of their urine that proves that they have bacteria in their urine or sometimes we accept a dipstick. This is very much like pool chemicals. You dip the urine and look at the results and the results can show whether there's bacterial activity in the urine. You have to have symptoms and there has to be evidence of bacteria.
[Dr. Suzette Sutherland]
When we're talking about just the general population, how common is it, really, especially among young women or maybe postmenopausal women, how common is it that a woman gets a urinary tract infection?
[Dr. Anne Cameron]
It's unfortunately very common. Half of women in their lifetime will get a urinary tract infection. That's a very, very big problem for women in general since that's half of women. Men don't get infections as often as women do and men are closer to 10% likelihood of getting a urinary tract infection in their lifetime.
[Dr. Suzette Sutherland]
We'd like to think that whoever was responsible for designing our anatomy had everything in mind, but somehow the men have a very long urethra and with that are protected from having urinary tract infections or microbes getting into the bladder, whereas women are much more susceptible just due to normal anatomy. You were also part of, you're on the board of the Society of Urodynamics, Female Urology, and were part of looking at the official guidelines that defined what are recurrent UTIs in women and then how we should be handling that. Can you define that for us? That's a different beast many times when someone has recurrent UTIs.
[Dr. Anne Cameron]
Recurrent UTIs are when someone gets infections over and over again. The formal definition is someone who gets three urinary tract infections in a year or two within a six-month period. This is actually not rare. Of all the women who get a urinary tract infection, around 30% will have a recurrent urinary tract infection definition. This is not a rare problem or an uncommon event. It affects a lot of people, especially women.
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Causes & Risk Factors for Recurrent UTIs
Recurrent urinary tract infections present a complex challenge in clinical practice, often requiring a nuanced understanding of patient-specific factors. Recurrent UTIs can be stratified into three distinct groupings: true recurrent infections, infections due to inappropriate initial treatment, and persistent infections. True recurrent infections are treated but recur due to new exposure, while infections from inappropriate initial treatment remain after incorrect antibiotic use or insufficient duration of treatment. Lastly, persistent infections encompass those in which symptoms quickly return from the same organism despite appropriate initial treatment. Persistent UTIs may signal underlying urological issues, and patients may need to undergo more extensive diagnostic efforts with imaging or cystoscopy. Factors like incomplete bladder emptying, anatomical anomalies, and conditions like neurogenic bladder significantly increase the risk of UTIs, underlining the importance of tailored therapeutic strategies and patient education on proper medication adherence.
[Dr. Suzette Sutherland]
Then when we think about recurrent UTIs, I think it's always helpful clinically for me to think about three buckets. Is a woman really getting a recurrent infection? In other words, it gets treated appropriately, some time elapses, and then they just get another infection from an outside source? Was it actually inappropriately treated? Maybe they didn't get the right antibiotic. Nobody got a culture to know that she grew a multidrug-resistant organism or didn't get the antibiotic for a long enough period of time? The third category is what we call persistence of a urinary tract infection.
In other words, you have a culture. You see what the organism is, what's the right antibiotic to use. You treat it appropriately. The woman feels better, but then after a very short period of time, the infection seems to come back with the same organism. In that category, this sense of persistence, what we normally do to treat it isn't enough. We think about other higher-level urological problems that might be coming into play here that's plaguing the woman and why you can't manage these recurrent UTIs. Can you talk about that a little bit? What things as a urologist then are we really responsible for looking for?
[Dr. Anne Cameron]
This is actually a really complicated problem. This is not something that can be solved very easily. It often requires a lot of investigating and a lot of discussion with your patient to figure out. Some women get an infection, or men, and they get prescribed antibiotics. Sometimes, as you said, it's the wrong antibiotic. It was an antibiotic that did not kill or eliminate the bacteria that they have growing in their urine and that's often because they didn't get a culture. A urine culture takes the urine and grows it on a culture plate and they actually treat that culture plate with different antibiotics. They know if the organisms are sensitive to a specific antibiotic or not.
If you get a urinary tract infection treated with a random antibiotic, one that we don't know is sensitive or not, you may be using the right antibiotic and that's great, but you also might be using an antibiotic that has no ability to kill that bacteria or is only weakly able to kill that bacteria, which is an intermediate sensitivity. You may take your antibiotic and it may make you feel a little better, but your symptoms come back very quickly because the bacteria was never really gotten rid of. That's really a recurrent urinary tract infection, but it's more of a persistent variety, meaning the bacteria never really went away.
Also, some people don't take their antibiotics as prescribed. If you're given three days of antibiotics twice a day, you really need to take those antibiotics twice a day for three days. If you're skipping doses and not finishing your course, you're not getting enough antibiotic to truly get rid of the bacteria that's been bothering you and you'll get a rapid recurrence of your symptoms.
The other thing that happens is that some people don't always absorb the antibiotics correctly. Some women who have kidney problems and kidney dysfunction don't excrete the antibiotics correctly and some people who've had gastric bypass surgery sometimes don't absorb antibiotics correctly. There are a lot of different reasons that the UTI might not have been treated properly.
[Dr. Suzette Sutherland]
That's a really good point. I just want to stop right there. That's a fabulous point to make because sometimes we are treating the patient with the right antibiotic, but because of other factors that are inherent with them, it doesn't get absorbed well. That's a wonderful point to make. Thank you.
[Dr. Anne Cameron]
The other problem is that some women are just very at risk for getting infections. They may have things about their anatomy. They may not urinate properly. They may have a residual urine, meaning they don't empty their bladder well. They may have had surgery that changes the way they urinate and some women catheterize their bladder to empty their bladder. Those are all very high-risk situations. You might get reinfected very quickly because of these risk factors and a new bacteria gets introduced into your bladder.
It can be really hard to figure out because E. coli is the most common urinary tract infection, 90% of all UTIs, and someone having two E. coli UTIs back to back doesn't really mean that it's a persistent infection. It could be just two brand new different E. coli infections. It can be a little hard to figure out, but it's really important to get cultures so at least we can compare infections and know if they're the same organism or if they're a different organism.
[Dr. Suzette Sutherland]
Right. When we're thinking about then recurrent UTIs, you did mention some things here that we're looking for as a urologist to say, "Why would there be a persistence?" We're looking, as you already mentioned, are they emptying their bladder okay? Is there something wrong anatomically that they're not draining well? Maybe they have hydronephrosis for some reason or do they have a kidney stone? Those are the main things that we might get some imaging or otherwise look inside the bladder with a cystoscope. I wanted to ask, though, too, if we look at this other population of patients who have some more complicated things that might be neurogenic bladder and have to have a catheter, what's the rate of UTIs with a catheter? Can you speak a little bit more to this idea of chronic colonization and what we should be doing with that?
Discussing UTIs with Patients: Evaluation & Education
When addressing recurrent urinary tract infections (UTIs), it is crucial to first confirm the diagnosis through positive cultures, distinguishing them from conditions like interstitial cystitis. A thorough assessment includes evaluating bladder emptying with a post-void residual, conducting a vaginal exam to check the estrogen status and for any anatomical factors like urethral diverticulum that could contribute to infections.
Educating patients on proper hygiene practices is essential; clinicians should encourage patients to urinate post-intercourse and to use gentle, non-aggressive hygiene measures to avoid disrupting the vaginal flora. Clinicians serve an important role in dispelling myths and reducing stigma by explaining that recurrent UTIs are often due to factors beyond personal hygiene, such as genetic predispositions or hormonal changes. For patients with low estrogen, vaginal estrogen products can significantly prevent UTIs and improve vaginal health. Alternatives like cranberry supplements or methenamine offer options for those avoiding hormones. These strategies emphasize a tailored, evidence-based approach to managing recurrent UTIs, enhancing patient understanding and care.
[Dr. Anne Cameron]
At the start, I make sure that she really is having urinary tract infections because interstitial cystitis and other bladder conditions can mimic this. If I'm convinced that these really are urinary tract infections, we have positive cultures, then I make sure that she is emptying her bladder. I do that with a post-void residual. That's easy. I will do a vaginal exam because I want to assess the estrogen status of her vagina. I want to look for things like a cystic seal that might be impairing voiding. I also check for a urethral diverticulum that can be a source of recurrent UTIs and also assess her voiding habits with a history.
How often is she going? Is she emptying her bladder after sexual intercourse? You don't need to urinate before you have sex, but you do need to pee afterwards. I often ask them about their bowel habits and their wiping habits as well as their hygiene habits because many women, although they won't tell you this upfront, are doing very aggressive hygiene measures that are really not helpful. I really emphasize here that I also try to de-stigmatize recurrent UTIs. Many of these women think that they are doing something wrong. They think that they are dirty, that they are themselves the because of these UTIs because that's what's out there in the lay press. I really try to reassure these women that the more they wash, the more they douche, the more they soap, the more UTIs they are going to get. This is not their fault. They have a risk factor, whether it be a genetic risk factor or hormonal risk factor that's causing these UTIs, and I really try to take the blame away from them. It's not the way they're wiping. It's not the way they're urinating. This is just bad luck for that poor woman.
My first education piece is hydration. If she has a low estrogen state in her vagina, my first step is to introduce vaginal estrogen either via the cream, the ring, or the tablets because this has excellent evidence to support its prevention of recurrent UTIs and restoration of the normal vaginal flora. This also has positive side effects such as vaginal comfort, decreased vaginal symptoms, and better comfort with sexual activity. This is a win-win strategy. In other women who prefer to avoid estrogen products, I will then discuss the supplements and that would be either the cranberry supplements or the methanamine. Those would be my starting point for those patients. That's where I start and I go over good practices. Good hygiene practices are things like urinating after sexual activity, after having a bowel movement, using a different piece of tissue in the front and in the back, but there's front to back to front wiping really doesn't matter. That's been proven to not really be impactful and I really just try to de-stigmatize it at this point in time.
[Dr. Suzette Sutherland]
Yes, those are all great recommendations and that's a similar strategy I would say that I would use as well. Again, going back to what I said previously, I like that especially speaking with women, reminding them that they do have three compartments down in the perineal area and the pelvic area and attention needs to be paid to all three of those compartments, the bladder, the vagina, and the bowel.
Podcast Contributors
Dr. Anne Cameron
Dr. Anne Cameron is a urologist and assistant professor with University of Michigan Medical School in Ann Arbor.
Dr. Suzette Sutherland
Dr. Suzette Sutherland is the director of female urology with UW Medicine in Seattle, Washington.
Cite This Podcast
BackTable, LLC (Producer). (2023, December 27). Ep. 42 – Recurrent UTIs: Controlling Those Nasty Little Bladder Infections [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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