By Karyee Chow, Consultant Urologist

Urinary tract infections (UTIs) are a common health issue, particularly among women. When these infections occur repeatedly, they are termed recurrent UTIs. For many women, recurrent UTIs can be a frustrating and painful experience, significantly affecting their quality of life. Understanding the causes, symptoms and treatment options for recurrent UTIs is crucial for managing and preventing these infections.

Definition of recurrent UTIs

A recurrent UTI is typically defined as having two or more UTIs in a six-month period or three or more UTIs in a year. UTIs occur when bacteria, most commonly Escherichia coli (E. coli), enter the urinary tract and multiply, leading to an infection. While most UTIs affect the bladder (cystitis), they can also involve the kidneys (pyelonephritis), which can be more serious.

Causes of recurrent UTIs

Several factors contribute to recurrent UTIs in women. Anatomically, women are more prone to UTIs due to their shorter urethra, which allows bacteria easier access to the bladder. Other factors include:

• Sexual activity: Sexual intercourse can introduce bacteria into the urinary tract, increasing the risk of infection.

• Menopause: Hormonal changes during menopause can reduce the protective vaginal flora, making the urinary tract more susceptible to infection.

• Use of spermicides: Chemicals found in condoms that kill sperm can disrupt the balance of good bacteria in the vaginal area, leading to a higher risk of UTIs.

• Urinary tract abnormalities: Structural abnormalities or blockages in the urinary tract can lead to incomplete bladder emptying, creating an environment where bacteria can thrive. The presence of urinary tract stones can be associated with urinary tract infections. The presence of foreign bodies (such as a catheter) can increase the risk of infections.

• Genetics: Some women may be genetically predisposed to recurrent UTIs due to inherited traits that affect immune function or the structure of their urinary tract.

• Biofilm: Bacteria can be protected within a self-produced biological structure (matrix) within the urinary tract making it difficult to eradicate. 

Symptoms of a UTI

The symptoms of a UTI may include:

• A strong, persistent urge to urinate

• A burning sensation during urination

• Passing frequent, small amounts of urine

• Cloudy or strong-smelling urine

• Blood in the urine (haematuria)

• Pelvic, lower abdominal and back pain

• There may be a high fever, shivering and nausea or vomiting

Assessment and investigations

When assessing recurrent UTIs, a healthcare provider will usually take a detailed medical history and perform a physical examination. They may ask about the frequency of infections, sexual habits, contraceptive use and any underlying health conditions. To confirm the diagnosis and identify the specific bacteria causing the infection, a urine culture is often performed. In cases of recurrent UTIs, additional tests such as imaging studies (eg ultrasound or CT scan) or a cystoscopy (a camera to look inside the bladder) may be necessary to rule out any structural abnormalities or other underlying issues.

Advice and treatment

The treatment of recurrent UTIs typically involves a combination of lifestyle modification, over the counter remedies and medications including antibiotics. Lifestyle changes play a significant role in prevention.

These include:

• Hydration: Drinking plenty of water helps flush bacteria from the urinary tract.

• Urination habits: Urinating regularly and fully emptying the bladder reduces the risk of bacterial growth.

• Hygiene practices: Wiping from front to back after using the toilet helps prevent the spread of bacteria from the anal area to the urethra.

• Post-coital urination: Urinating after sexual activity can help flush out any bacteria introduced during intercourse.

• Taking showers rather than baths: Sitting in bath water may allow bacteria to enter the bladder through the urethra. Certain soaps and oils may also irritate the urethra.

• Avoiding constipation: Any bowel disturbance can increase the risk of bacteria from the gut getting into the urinary tract.

Over-the-counter remedies that may help with UTIs include:

• Cystitis sachets: Sodium or potassium citrate increase the pH of urine and may ease the symptoms of an infection.

• Cranberry extracts: These act by preventing bacteria sticking to the bladder. Choose supplements that have a high concentration of the beneficial ingredient proanthocyanidins (PAC). 

• D-mannose: A natural sugar that binds E. coli in the urinary tract, preventing it from causing an infection.

• Probiotics: Improve the balance of gut and vaginal flora which reduces the overgrowth of bacteria that cause infections.

Medications that may be prescribed:  

• Oestrogen replacement therapy: For women going through menopause, topical or oral oestrogen therapy can improve the health of vaginal tissues and flora which can reduce infections.

• Methenamine (hipprex): this drug has anti-bacterial properties in the urinary tract and can be used to prevent UTIs.

• Antibiotics: antibiotics can be employed in different ways to help: 

• a long course may be recommended if there is suspicion of a biofilm protecting the bacteria

• a daily low dose can be prescribed for a period of time as a preventative measure

• a single tablet around the time of intercourse if this is a trigger for the infections

• self-start course where the patient has a supply of antibiotics to start when they experience symptoms.

• Vaccines: There are now vaccines that stimulate the immune system against the bacteria that causes infections.

• Drugs instilled directly into the bladder: These drugs improve the integrity of the lining of the bladder which can help reduce infections.

In summary, recurrent UTIs are a common and bothersome issue for some women, but with proper assessment, treatment and preventive measures, they can be effectively managed. If you experience frequent UTIs, it is essential to consult with a healthcare provider to develop a tailored plan to reduce the risk of recurrence and maintain your urinary health.

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