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Recurrent Urinary Tract Infection: Risk Factors, Treatment and Prevention

Pain, General, Women's Health | May 10, 2015 | Author: The Super Pharmacist

women, general

Recurrent Urinary Tract Infection: Risk Factors, Treatment and Prevention

 A urinary tract infection (UTI) is an infection in any part of the urinary tract. The urinary tract consists of the kidneys, ureters (which connect the kidneys and the bladder), bladder, and urethra. Most infections involve the lower urinary tract — the bladder and the urethra. An infection of the urethra is called urethritis. A bladder infection is called cystitis. If bacterial infection spreads upward to the kidneys and ureters, the condition is called pyelonephritis. Urethritis and cystitis are lower urinary tract infections. Pyelonephritis is an upper urinary tract infection and is much more serious.

The most common symptoms of UTI include dysuria (burning on urination), urinary frequency (the need to urinate more often), and urgency (a sudden, irresistable need to urinate).

UTIs can be either uncomplicated or complicated.

  • An uncomplicated UTI is an infection in a healthy patient with a normal genitourinary tract.
  • A complicated UTI is an infection associated with an abnormal genitourinary tract (eg, enlarged prostate, kidney stone, neurogenic bladder), an infection which occurs in someone who has a suppressed immune system (eg, HIV), or an infection caused by bacteria that are resistant to multiple antibiotics.

Recurrent UTI is defined as uncomplicated UTIs in 6 months or, more traditionally, as 3 positive cultures within the preceding 12 months. Recurrent UTI is estimated to affect 25% of women with a history of UTI.

  • When there is recurrent infection with the same organism despite adequate therapy, it is considered a relapse. Failure to clear or completely eradicate the pathogen despite a reasonable treatment course is considered a relapse.

Re-infection is the relatively rapid recurrence of a UTI with the same or different organism after a cure of the first infection has been documented. Re-infection is more common than relapse. 

  • When the initial infection is caused by the bacterium, Escherichia coli (E. coli), there is a higher risk of re-infection within the first 6 months.

Risk Factors for Recurrent UTIs

Risk factors in women

Adult women are 30 times more likely than men to develop a UTI. The incidence of UTI in men approaches that of women only in males older than 60 years. UTIs will occur in roughly half of women during their lifetime. The recurrent UTI rate in women is very high. After an initial UTI, more than 25% of women will have a second infection within 3–6 months. Risk factors for recurrent UTI in women include:

  • Female anatomy
  • Sexual activity
  • Contraception
  • Pregnancy
  • Menopause

Structure of the female urinary tract: The genitourinary anatomy of women predisposes them to UTIs. Their urethras are shorter, and closer to the anus, providing easier access for fecal bacteria to enter the urethra.

Sexual activity: Frequent or recent sexual activity is the most important risk factor for urinary tract infection in young women. Nearly 80% of all urinary tract infections in premenopausal women occur within 24 hours of intercourse. UTIs are very rare in celibate women. However, UTIs are not sexually transmitted infections. In general, it is the physical act of intercourse itself that produces conditions that increase susceptibility to the UTI bacteria, with some factors increasing the risk. For example, women having sex for the first time or who have intense or frequent sex are at risk for a condition called "honeymoon cystitis."

Certain contraceptives. Women who use diaphragms tend to develop UTIs. The spring-rim of the diaphragm can bruise the area near the bladder, making it susceptible to bacteria. Spermicidal foam or gel used with diaphragms, and spermicidal-coated condoms, also increase susceptibility to UTIs.

Pregnancy: Pregnant women are more susceptible to kidney infection because as the uterus enlarges it compresses the ureters and bladder. This causes urine to back up into the kidney, increasing the risk of bacterial infection.

Menopause: The risk for UTIs is highest in women after menopause. In premenopausal women, 90% of the normal vaginal flora are lactobacilli, which protect against disease causing bacteria such as E. coli. Oestrogen loss at menopause results in decreasing numbers of lactobacilli and increased risk of bacterial infection. For some women, topical oestrogen therapy helps restore healthy bacteria and reduce the risk of recurrent UTIs. Oral oestrogen replacement therapy is not helpful for UTIs. Postmenopausal women who suffer from incontinence and who have significant pelvic floor prolapse are also at increased risk for recurrent UTI.

Risk factors in men

UTIs are rare in adult males younger than 50 years but increase in incidence thereafter. Causes of adult male UTIs include prostatitis, epididymitis, orchitis, pyelonephritis, cystitis, and urethritis.

Men below 50 years of age: The incidence of true UTI in adult males younger than 50 years is low. In this population, the symptoms of painful urination or urinary frequency are usually due to sexually transmitted disease of the urethra (eg, gonococcal and nongonococcal urethritis) and prostate. However, young men who engage in homosexual behaviour with anal intercourse and young men who lack circumcision are at increased risk for recurrent UTI.

Men above than 50 years of age: In men older than 50 years, the incidence of UTI rises dramatically (range, 20-50% prevalence) because of enlargement of the prostate, debilitation, and subsequent instrumentation of the urinary tract.

Can Recurrent UTIs Be Prevented?

Preventive strategies for recurrent UTIs include lifestyle modifications, continuous antimicrobial prophylaxis, post-coital prophylaxis, acute self-treatment, vaginal oestrogen, cranberry derivatives, and glygosaminoglycan (GAG) replacement therapy.

Lifestyle modifications: Women using spermicide-containing contraception should be offered an alternative form of contraception.

Antimicrobial prophylaxis: A Cochrane review15 of 19 trials including 1120 patients showed that antibiotics are better than placebo in reducing the number of clinical and microbiological recurrences in pre- and postmenopausal women with recurrent UTI.  No antibiotic was superior. Choice of antibiotic should be based on community patterns of resistance, adverse side effects, and local costs. Three management strategies for antibiotic prophylaxis are in current use. These include continuous antimicrobial prophylaxis, post-coital prophylaxis, and patient-administered self-treatment.

Continuous prophylaxis: Patients with > 3 infections annually should be offered a regimen of continuous, low-dose prophylaxis or post-coital prophylaxis. Continuous prophylaxis can be given daily at bedtime. Some authors suggest prophylaxis on alternate nights or 3 nights per week. One study shows that weekly prophylaxis is better than monthly prophylaxis.

Post-coital prophylaxis: According to one study, sexually active women who took post-coital ciprofloxacin had outcomes similar to women who took ciprofloxacin daily. A causal relationship between infections and intercourse can be suspected when the interval is consistently between 24 and 48 hours. Two studies suggest that for sexually active women with UTI related to sexual intercourse, the post-coital approach may be the best option. Another study notes that a major advantage of post-intercourse prophylaxis is that it produces fewer side effects because women take only one-third the amount of antibiotic used in daily prophylaxis.

Acute self-treatment: For patients with < 2 UTIs per year, the acute self-treatment approach may be useful. The self-start therapy is ideal for women who are not suitable candidates for long-term daily prophylaxis or who are unwilling to take it. The patient identifies episodes of infection on the basis of symptoms, performs her own culture, and initiates a standard 3-day course of empiric treatment. This strategy should be restricted to those women who have clearly documented recurrent infections and who are motivated and compliant with medical instructions.

Oestrogen Use in Postmenopausal Women: Evidence from several studies shows that in postmenopausal women with recurrent UTI, vaginal oestrogens reduce the number of UTIs. Studies have not provided sufficient evidence to recommend a particular type or form of vaginal oestrogen. 

  • Creams are less expensive and possibly more effective but can be more difficult to apply for some women and can produce adverse effects (e.g., itching, burning, occasional spotting).
  • Estradiol vaginal tablets may have fewer side effects but are more expensive. According to a recent Cochrane review, there was no significant difference in the number of women with UTI following treatment with oral oestrogens versus placebo.
  • The vaginal ring is also more expensive and may require a trained professional to place it correctly. 

Cranberries, Blueberries, and Lignonberries: Cranberries, blueberries, and lignonberries are three fruits that appear to have protective properties against UTIs. These fruits contain compounds called tannins (or proanthocyanadins). Tannins may prevent E. coli bacteria from adhering to cells in the urinary tract, thereby inhibiting infection. Cranberry juice is the best-studied home remedy for UTIs. 

A recent Cochrane review of 10 studies with a total of 1049 subjects concluded that there was some evidence from 2 good quality studies that cranberry juice may decrease the number of symptomatic UTIs over a 12 month period in women with recurrent UTIs. It is not clear what the optimum dosage is for cranberries, or whether it is best to use juice or tablets. Some research recommends drinking at least 1- 2 cups of cranberry juice daily, or taking at least 300 - 400 mg in tablet form twice daily.

Other potential treatments: The inner lining of the bladder wall is coated with a thick layer of glycosaminoglycans (GAGs) that acts to prevent bacteria and other irritants from attaching to the bladder's inner surface. There is strong evidence that different chronic inflammatory bladder diseases, such as recurrent UTI, disrupt this protective GAG layer. Current findings provide clinical evidence that bladder instillations using the GAG's, hyaluronic acid and chondroitin sulfate, can be used to prevent urinary infection in women complaining of recurrent UTIs. Unlike traditional antibiotic therapy which acts to destroy bacteria, treatment with hyaluronic acid and/or chondroitin sulfate repairs damage to the GAG layer so it can remain effective in preventing bacterial penetration.

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