Recurrent Urinary Tract Infections in women

Recurrent Urinary Tract Infections affects both men and women.

But the question often asked is are women more susceptible to recurrent urine infections? Even if so, How many men do you know who might have called for urgent help in this regard?

Why is urinary tract infections so recurrent? is it really recurrent or are we going wrong somewhere in our understanding and in our management of the problem?

I have very vivid memories of my early years of practise. This is the fag end of the year 2001 , my phone rang at 11.30 pm. As a doctor I was getting used to calls at odd hours. It was an old patient of mine, Neha by name.

Hi Neha, I said, all ok ?

She said, am really sorry doctor for calling you at this hour but am suffering from severe burning while passing urine…..

Ahhh….a urine infection, I thought in my mind and started to tell her how to deal with the issue….

But doctor…she interjected….. I have already started an antibiotic…..

Was Neha correct when she started the antibiotic without even letting me make a diagnosis ?

Today as I am writing this article in 2020, 2 decades have passed by but , the story remains the same. 

Even now, I receive the same calls from multiple patients showing signs of urine infection. For some this is a one time issue while for others this seems to happen more often, what we know of as Recurrent Urinary Tract Infections. 

How Common is recurrent urinary Tract Infections in women? What are the causes?

1 out of every 3 women will have a diagnosed and treated UTI or urinary tract infection by age 24 and 50 % of women will have at least one episode in their lifetime. In another study it was seen that about 27% of these first-time infections recur a 2^nd time and only 3 % a 3^rd time. 

UTI is 14 times more common in women owing to two reasons. The passage from the urinary bladder where the urine is stored to the outside world is only 4 cms long in women thus the infection needs to travel a much shorter distance as compared to men. the second reason is the proximity to the vagina and anus and both being infected areas, the chances of this infection traveling to the urine passage is quite high. 

Despite these reasons, the chances of a 2^nd time infection is quite low and that of a 3^rd time in minimal. But this doesn’t seem to match what we doctors face in clinic. As I said earlier, are we going wrong somewhere? to understand this, we need to first understand 2 terms…..recurrent UTI and Persistent UTI.

Recurrent Urinary Tract infections is said to happen when infection at least 3 times or more in one year or at least twice in 6 months, after each episode of infection being completely treated….. mark my words…..completely treated. How do we know it’s completely treated? For this all symptoms need to disappear and 2 weeks after the completed course of antibiotics, a fresh culture showed show no infection. This my friends is NEVER done. 

If the infection does not go away at 2 weeks, then it is known as Persistent infection.

Why does it happen?

Let me give you a scenario. A woman starts to have burning sensation while passing urine. She understands that it’s a urine infection. Her aunt or friend or someone else tells her to start an antibiotic because that’s what that aunt or someone was given when she had the UTI. Fair enough…the only problem being that quite often the infection is resistant to some antibiotics and this antibiotic turns out to be one of them. Because its an antibiotic, the infection and thus also the symptoms gets suppressed but does not go away. The lady stops the antibiotic and assumes the infection has gone away….. a few days or weeks later…. booom…. its back and she thinks it’s a recurrent infection when in fact the infection is persistent because it never went away. 

Consider another scenario. The same lady has the same problem. She starts the antibiotic but also contacts her doctor soon enough. The doctor asks her to give a urine sample for routine and culture examination. Because she has already taken antibiotics, the urine sample fails to show any sings of infection and the diagnosis is missed. Confused …..the antibiotic is stopped and boom…. the infection hits back again……

We will call it a reinfection and therefore recurrent UTI only and only if the repeat culture after 2 weeks showed no infection and after that the same or another organism was proven to cause the next round of UTI. 

Whew…. that was complicated !!! or was it simple once you understood …..

Let’s move onto some more simple things now.

What are symptoms of recurrent urinary tract infections?

• Pain in the lower abdomen present all the time or while passing urine or during sexual intercourse
• Frequent urination or an urge to urinate frequently but hardly a few drops come out each time or even after urinating the sensation of going back to pee remains.
• The urine might be foul smelling or dark in colour
• There might be blood in the urine
• There could be associated body aches, fever with chills, cramping or vaginal irritation. 

What are the 3 things you must do the moment you realise you might have a urine infection:

• Give a urine sample for urine routine and culture examination. A first morning sample is preferable. but you don’t really need to wait till the next morning if your symptoms are acute. 
• Speak to your doctor and start symptomatic therapy to reduce your discomfort. This could include medicines to reduce spasms or cranberry or D mannose tablets. It is important to know that although the last 2 can be useful, there might increase blood sugars and should be used with caution in diabetics.
• If symptoms are severe or if there is fever, your doctor might start you on an antibiotic even before the urine reports come in. once the reports come and we know the specific organism infecting you as well as the specific antibiotic needed, your doctor can change the antibiotic if needed. 

How and when to collect the urine sample for testing?

 As I said before, A first morning sample is preferable as it is the most concentrated and thus greater chances of finding bacteria in it. There is one more thing you need to remember while giving the urine sample and that is to catch the mid-stream urine and not the urine at the start or urination nor the stream at the end of urination but midway. This is important so as to not catch infection from surrounding skin areas. May seem funny to you but a great many reports of UTI on culture turn out to be no infection at all on repeat testing because the earlier ones were collected in a wrong way. 

Once your doctor has started you on the antibiotic, make sure you complete the full course even if the symptoms have subsided early and most important, 2 weeks after that you must repeat the urine test to ensure that the infection has completely gone away. 

What are the reasons for recurrent UTI happening beyond the misdiagnosis that I have spoken about?

• Maternal history of UTI surprisingly can increase chances
• And so does Diabetes as does Obesity
• If there is laxity of vaginal wall causing the bladder wall to sag, urine may collect there increasing chances of infection
• The same also happens if there is obstruction in the flow of urine due to narrowing of the urine passage. 
• The lack of estrogen also leads to recurrent urine infection in post menopausal women. 
• Beyond this there are some behavioural factors which influence the incidence of recurrent UTIs. I will discuss them in the end more as preventive measures. 

From the point of investigations, I have already spoken about urine examination as the main method of investigation. Beyond this 2 more investigations are helpful to determine why the infection may be recurring.

• Normally after passing urine very little urine remains behind in the bladder. An ultrasound scan can tell us the volume of urine left behind and from there we can then proceed to find out why that’s so and treat the cause.
• A test called uroflowmetry tells us about the flow of urine and if there is narrowing of the passage then this test will pick it up and then again, we can proceed to solve the problem. 
• There are of course other more technical tests which can be done but those are beyond the scope of this podcast and best left to the experts to advise and perform. 

Regarding treatment I have already spoken about how a culture is necessary to choose the right antibiotic and how the culture needs to be repeated. The primary reason for the recurrence also needs to be treated whether its diabetes or local estrogen cream supplementation in post-menopausal women or sagging bladder walls. Sometimes the doctor will put you on long term antibiotics extending even up to months but as I always say….. your doctor knows best. 

Is there something you can to reduce your chances of getting recurrent UTI ?

Here are 10 behavioural changes that can help  :

• Water drinking 
  • Yes, what your mother or doctor told you is true. It has been shown that women who drink minimum 1.5 litres of water everyday have lesser chances of UTI than those who do not. So, drink up!!
• Wiping from front to back 
  • Always wipe from the front to the back after using the bathroom so that germs from the rectum and vagina do not infect the urinary tract. 
• Take showers and avoid prolonged baths. Bath water may fairly quickly become contaminated by the bather’s own skin florae. Sitting in a tub allows bacteria to reach the bladder opening area
• Use tampons for periods. Tampons are advised during the menstrual period rather than sanitary napkins or pads because they keep the bladder opening area drier than a sanitary pad, thereby limiting bacterial overgrowth
• Do not try and hold back urine. Try and evacuate every 4 hours when awake. 
• Do not wear tight clothing. Wear natural fibres that breathe
• Do not use vaginal douches as they kill the natural bacterial flora and actually cause more infection.
• Empty your bladder after intercourse 
• Do not use contraception that uses spermicidal jelly because that too destroys the good bacteria
• Avoid multiple sexual partners

Should recurrent urinary tract infections be handled by a gynac or a urologist?

I have been asked this question on multiple forums and the simple answer is, either of them is capable of handling your infection. However, what usually happens is that while most women will have their regular gynac but you don’t really have your friendly neighbourhood urologist fixed. Uncomplicated UTIs can be easily handled by your gynac and he or she also know your history the best since you have been visiting for some time. If your gynac feels there are gaps which he or she can’t fill or investigations are needed which we gynacs don’t perform, like for e.g. uroflowmetry, then we ourselves refer you to a urologist and then we work together as a team to solve your problem. 

To all you women who are about to get married or leave for your honeymoons, you need to aware of a term called Honeymoon cystitis. This is acute urine infection which can happen after any intercourse but is very common after the first sexual act. Its called honeymoon cystitis because the symptoms are seen during honeymoon either because of the first act of intercourse happening then or just a day or two before leaving for honeymoon. Its always advisable to pass urine after intercourse is over as it flushes out the organisms and reduces the chances. 

This post can’t be complete before busting one last myth and that is does using a public toilet increase chances of developing a UTI

• We all know of women who swear they developed Urinary tract infection because they used a public toilet or who hold their urine to death but won’t pee in a public one. Well there is good news for all such women out there. There is no evidence to show that using a public toilet seat increase the chances of recurrent urinary tract infections. If you wish however you can wipe the seat before using but that’s only for mental satisfaction. In fact, it is said that the more dangerous germs are lurking on public toilet sinks, tap handles, and paper towel dispensers or buttons on hand driers. Some women are also scared that they will contact germs like chlamydia or gonorrhoea which are STDs or sexually transmitted diseases from a public toilet seat. As said by Abigail Salyers, PhD, president of the American Society for Microbiology and I quote “To my knowledge, no one has ever acquired an STD on the toilet seat — unless they were having sex on the toilet seat!”

So there ladies, that’s all the facts, figures, advise and myth busting related to recurrent urinary tract infection. So the next time, remember this podcast before you reach for that antibiotic even before making a diagnosis or loosely label your urine infection as recurrent. A woman educated about urinary tract infection means one less phone call in the middle of the night so this podcast I guess is in my own interest 😊 

Also read: 

Urinary Incontinence in women – Causes and Solutions.

This brings me to the end of yet another discussion. This discussion is also available as a podcast – check out here.

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