Recurrent Urinary Tract Infections (UTI)

29.06.2020

Recurrent UTI or recurrent cystitis, is a matter of women, whether they are young or adult in pre-menopause, or elderly postmenopausal. Also in pregnancy, there is a significant risk of recurrent acute cystitis.

Women are the real victims of recurrent cystitis. Approximately 25% of women presenting with the first episode of bacterial cystitis will suffer recurrent UTI within 6 months, some having 6 or more infections in the year following the initial episode. Generally, we talk about recurrent cystitis when there are more than three UTIs a year or two episodes in the last six months.

Current therapeutics are sub-optimal, as the prevalence of multidrug-resistant bacteria is increasing and antibiotic treatment for acute infection does not prevent recurrences. These recurrent infections can become a significant health problem heavily impacting on the women's quality of life.

Risk factors

There are recognized factors that can increase the risk of having recurrent cystitis in young and pre-menopausal women:

  • Sexual intercourse
  • Use of spermicide
  • A new sexual partner
  • A mother with a history of UTI
  • History of UTI during childhood
  • Blood group antigen secretory status

Other factors can increase the risk in postmenopausal and elderly women:

  • History of UTI before menopause
  • Urinary incontinence
  • Atrophic vaginitis due to oestrogen deficiency
  • Cystocele
  • Increased post-void urine volume
  • Blood group antigen secretory status
  • Urine catheterisation and functional status deterioration in elderly institutionalised women

Diagnosis

Diagnosis of recurrent UTI should be confirmed by urine culture. An extensive routine workup including cystoscopy, imaging, etc. is not routinely recommended as the diagnostic yield is low in young pre-menopausal women. Otherwise, it occurs for postmenopausal elderly women in whom UTIs often have organic causes.

Prophylaxis and prevention

Prevention of recurrent UTIs includes in this order:

  • counselling regarding avoidance of risk factors (behavioural modifications)
  • non-antimicrobial measures
  • antimicrobial prophylaxis

Self-diagnosis and self-treatment

In patients with good compliance, self-diagnosis and self-treatment with a short course regimen of an antimicrobial agent should be considered (restrict the water intake 3 hours before going to sleep; one shot of fosfomycin 3000 mg sachet in the same evening, after emptying the bladder and before going to sleep). Self-diagnosis and treatment allow autonomous management of recurrent uncomplicated cystitis and an improvement in the quality of life.

Q&A section

Q: Why is Urinary Tract Infections (UTI) recurrent? 

A: Recurrent UTI occurs in young, adult or elderly women because of some risk factors. In general, the bacteria coming from the bowel, do contaminate the perineal area between the anus and the urethral outlet (vestibular area). If this contamination is massive, the bacteria can easily enter the bladder through the short urethra and start the infection. The perineal contamination itself, along with some risk factors, make the infection more likely.  

Q: How to prevent recurrent UTI?

A: Behavioural modifications should be considered to prevent recurrent UTI.

Q: Recurrent UTI when pregnant.

A: Pregnancy increases the risk of UTI because of hormone changes, irregular bowel movements, increase of perineal bacterial contamination. We manage UTIs more aggressively in pregnant women than in non-pregnant women because of fetal risk. Urine samples should be sent for culture. While awaiting the results, empiric antibiotic treatment (Nitrofurantoin, trimethoprim or cephalexin, although restrictions apply to depend on the stage of pregnancy). Quinolones, e.g. norfloxacin, should not be used during pregnancy.

Q: How is recurrent UTI treated?

A: We treat recurrent cystitis with a strategy that involves behavioural modifications and treatment of the episodes. Self-diagnosis and treatment may be considered to improve the quality of life.