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Help! What should I be looking for to appropriately treat my frequent urinary tract infections (UTIs)?  

Jamie is a 30-year-old overall healthy woman who eats healthy, drinks plenty of water, and exercises 3-4 days per week. She is currently single but has a male friend who comes into town every few months to visit. Unfortunately, Jamie has been dealing with urinary tract infections (UTIs) every 1-2 months regardless of whether her male friend comes into town or not. She is frustrated as she keeps going to her physician and is treated with the same antibiotics over and over again, which doesn’t seem to be addressing the issue. 

Helen is a 55-year-old female who is currently going through menopause. She has noticed increased burning and frequency of urination about every 2 months. Her doctor keeps a prescription of antibiotics ready for her to fill, so she doesn’t have to go in for an appointment to have her urine tested. She is wondering if there is anything else that can be done to help reduce the frequency of her infections.  

Unfortunately, about 60% of women will experience a sudden, onset urinary tract infection within their lifetime and up to 50% of women will experience multiple infections.1-3 

According to the American Urological Association (AUA), Canadian Urological Association (CUA), and Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction (SUFU), there is a guideline for recurrent uncomplicated urinary tract infections in women. For the purposes of the guideline, recurrent UTIs were defined as two “acute bacterial cystitis within 6 months or three episodes within 1 year”. Acute bacterial cystitis refers to an infection that has been confirmed with a culture with a bacteria associated with sudden onset of painful urination, urinary urgency and frequency, blood in the urine, and incontinence that is new or worsening. Keep in mind, these guidelines only apply to non-pregnant women who are not immunocompromised and do not have abnormalities of the urinary tract. These guidelines also do not apply to women who self-catheterize, have indwelling catheters, or systemic infection.4 

According to the guideline, a woman who appears to have recurrent UTIs should be asked thorough questions by her provider, receive a pelvic examination (with patient consent of course) and receive a urinalysis and urine culture with each infection prior to beginning treatment. Invasive testing, such as a cystoscopy, which is when a tube with a camera is inserted in the urethra to better view the inside of the bladder, and imaging should not be performed frequently.4 If a patient does not have symptoms, called asymptomatic in the medical world, they should not receive urine testing or be treated even if bacteria is found.4 Keep in mind, it is normal to have a healthy combination of bacteria in the urinary tract. Not all bacteria are bad!  

If a patient does have symptoms, she should be treated with an antibiotic that specifically treats the bacteria in her urine, not just a general antibiotic. Antibiotics should be given in as short of a duration as possible, typically this is no longer than seven days.4 The usual culprit of infection is  

E. coli, but others can play a role, including Enterobacteriaceae, P. mirabilis, K. pneumoniae, and S. saprophyticus.5-6 

Also, women who are around menopause (peri-menopausal) and post-menopausal should be recommended to use vaginal estrogen to reduce the risk of future UTIs. Keep in mind, oral or other systemic estrogen therapy, such as the patch, have not been shown to reduce UTI. In most cases, you can use vaginal estrogen in addition to other forms of estrogen therapy.4 

Overall, please remember it is important to find a medical provider that will listen and work with you to determine the best individualized plan of care for you and your body. While these are guidelines, there may be exceptions to provide the best care for you. Don’t be afraid to ask questions as your provider should be able to explain his or her thought process. Most importantly, you should feel heard and be comfortable with the plan of care presented to you!  

 

Written by: Jordan Schmidt, PT, DPT  

 

References:  

1. Foxman B: Urinary tract infection syndromes:occurrence, recurrence, bacteriology, risk factors, and disease burden. Infect Dis Clin North Am 2014; 28: 1.  

2. Geerlings SE: Clinical presentations and epidemiology of urinary tract infections. Microbiol Spectr 2016; 4.  

3. Gupta K, Trautner BW: Diagnosis and management of recurrent urinary tract infections in non-pregnant women. BMJ 2013; 346: f3140.  

4. Anger J, Lee U, Ackerman AL, et al. Recurrent uncomplicated urinary tract infections in women: AUA/CUA/Sufu guideline. Journal of Urology. 2019;202(2):282-289. doi:10.1097/ju.0000000000000296  

5. Behzadi P, Behzadi E, Yazdanbod H et al: A survey on urinarty tract infections associated with the three most common uropathogenic bacteria. Maedica (Buchar) 2010; 5: 111.  

6. Colgan R, Williams M: Diagnosis and treatment of acute uncomplicated cystitis. Am Fam Physician 2011; 84: 771.  

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