A urinary tract infection (UTI) occurs when bacteria get into the urethra (the short tube through which you urinate) and ascend into the bladder. This causes inflammation in the bladder, a condition that doctors call “cystitis”. Typical symptoms might include: burning in the urethra during urination, increased urinary urgency and frequency, discomfort in the lower abdomen, and possibly blood in the urine.
UTIs may recur because the bacteria are still present despite treatment, or there is a new bacterium that has infected the bladder. Women who have had 3 or more UTIs within a 12-month period are likely to be sent for an opinion by a urologist.
Uncomplicated and Complicated UTIs:
UTIs are uncomplicated when they occur in healthy women who have no structural problem with their urinary system and no problems getting their bladders to empty well.
UTIs are considered complicated when there is an anatomic abnormality of the urinary tract that makes it difficult to eliminate urinary bacteria. Complicated UTIs may also occur in women who have problems emptying their bladders.
How do we evaluate recurrent UTIs?
A good medical history and physical exam are important, including a pelvic examination to look for anatomic and neurologic problems.
A urine culture, especially when you have bothersome symptoms, is essential.
We often check a post-void residual (PVR) urine to see if you can empty your bladder completely. We check for signs of vaginal atrophy (lack of estrogen). Women with complicated UTIs will need additional testing. Often these women have a history of:
- A known birth anomaly of the kidneys – egg, congenital UPJ obstruction
- Prior passage of kidney stones
- Prior pelvic surgery or pelvic trauma, including complicated childbirth
- Bloody urine that persists well past the treatment of a UTI
- Problems emptying the bladder, high PVR urine
- Urine cultures that show bacteria associated with stone formation
- Bacterial persistence despite prior treatment with an antibiotic to which the bacteria was sensitive
- Prior cancer in the abdomen or pelvis
- Immunosuppression (diseases or use of steroid medications that impair your ability to fight infections)
- Neurologic conditions that might impair bladder emptying
- Diverticulitis with reports of passing air or fecal material in the urine (suggesting a fistula, i.e., a connection, between the bowel and bladder)
- Repeat bouts of pyelonephritis (infection that ascended from the bladder into the kidney)
In these instances, a CAT scan of the abdomen and pelvis may be the best way to find abnormalities that cause recurrent UTIs. A renal ultrasound may be a less expensive alternative and has no radiation exposure, but it may not give as fine detail as a CAT scan.
Office Cystoscopy (looking in the bladder with a telescope) may be necessary, especially if there was prior bladder surgery to correct incontinence or repair an injury.
Urodynamics may be required as well. This test of bladder function involves placement of a small catheter in the bladder, slow filling of the bladder with sterile water, and a recording of bladder capacity, compliance and bladder motor function.
How do we treat recurrent UTIs?
If there is an obstruction found that leads to recurrent UTIs, we would try to correct the problem – e.g., remove an obstructing kidney stone, close a fistula, or take out mesh or sutures in a bladder that was previously operated on.
If there is a problem emptying the bladder, we try to find a way to improve bladder emptying – e.g., eliminate medications that depress bladder function, teach you how to void on a schedule, offer pelvic floor physiotherapy, and teach self-urethral catheterization, if needed.
For uncomplicated UTIs, we will remind sexually active women to void after intercourse, avoid spermicide use, and perhaps try cranberry products which reduce bacterial adherence to the bladder. In post-menopausal women, the use of vaginal estrogen cream or an estrogen ring may be beneficial.
In cases of either uncomplicated or complicated UTIs, we may advise the use of antibiotics in one of several ways:
- If infections seem to always occur after sexual relations, we would suggest voiding soon after having sex and taking an antibiotic pill soon after intercourse.
- If the infections are unrelated to sexual activity, you may choose to:
- Take a 3-day course of antibiotics when you recognize the onset of UTI symptoms (we call this self-start antibiotic therapy).
- Take a suppressive (low) dose of an antibiotic for a period of time (typically for several months), and then try to stop using them. Prolonged use of antibiotics can lead to side effects and often bacterial resistance.