Urinary tract infections (UTIs) are very common, more so in women than men. It is possible for people to experience a recurrent UTI after the first one was resolved. In rare cases, a patient can experience three or more UTIs in a 12-month period, which is the true definition of recurrent UTIs.
Recurrent UTIs can be extremely troublesome for patients and the healthcare professionals looking after them. A thorough understanding of available treatments and a good relationship with a urogynecologist can help OB/GYNs treat this issue.
Causes of Recurrent UTIs vs. Persistent UTIs
It is important to differentiate between recurrence and persistence of a UTI. Persistence indicates that the same bacteria is still present within the urinary tract two weeks after treatment with appropriate antibiotics. In these cases, the antibiotics failed to fully treat the infection; this would not be considered a recurrence.
A recurrent UTI, on the other hand, entails a new infection with a different bacteria. Or it may mean the same bacteria has come back after either more than two weeks or less than two weeks with a urine culture demonstrating no presence of the bacteria between infections.
In some cases, recurrent UTIs may be adequately managed by general practitioners, family physicians or general OB/GYNs. However, when things get complicated or treatments are unsuccessful, referral to a subspecialist called a urogynecologist may be warranted.
Urogynecologists' Key Role in Managing Pelvic Health
Urogynecologists, also known as experts in female pelvic medicine and reproductive surgery, usually spend an additional two years of training after becoming fully qualified OB/GYNs. While this training is heavily surgical, focusing on surgical treatment of prolapse and incontinence, these doctors are experts in the lower urinary tract, including the bladder and urethra.
Some urinary tract infections can spread into the ureters and kidneys, but most are focused on the bladder. As such, a urogynecologist is an ideal physician to investigate and treat a patient with recurrent UTIs.
Most urogynecologists focus their practice on urogynecology, no longer functioning as an obstetrician or even as a general gynecologist. This means that the vast majority of their patients are experiencing a similar set of complaints, giving patients the confidence that this particular type of doctor will really understand the clinical problem.
The pelvis can be a very complex place with an interplay of various organ systems — gynecologic, urologic, gastrointestinal, musculoskeletal and nervous. That means, in many cases, there is overlap in symptoms and clinical diseases. For example, an individual may have urinary incontinence, pelvic organ prolapse, chronic pelvic pain and bladder pain syndrome. Another patient, meanwhile, could experience irritable bowel syndrome, recurrent UTIs and pelvic floor muscle dysfunction. Urogynecologists use comprehensive history-taking skills, physical examinations, pelvic and abdominal ultrasounds, and urodynamics to form a full picture of the patient's clinical scenario.
Ultrasound is frequently used to assess bladder function, looking specifically for bladder pathology and post-void residual volumes. Urogynecologists also need to assess whether there are other pelvic pathologies that could be contributing factors. Problems such as fibroids, endometriosis and ovarian masses, all of which can be diagnosed on ultrasound, need to be either ruled out or understood to ensure optimal clinical decision-making.
Treating a Recurrent UTI
Once a recurrent UTI diagnosis is reached and other possibly complicating pathology is assessed, patients can be appropriately treated. Though they are not clearly proven to be effective, some relatively simple lifestyle modifications can be considered in addition to medical therapies, according to research from The New England Journal of Medicine:
- Better hydration or increased fluid intake
- Changing or modifying any contraceptives
- Voiding after intercourse if intercourse seems to be a trigger for the recurrent UTIs
- Improved vulvar hygiene
Medical therapy is aimed at the treatment of an active UTI as well as prophylaxis of subsequent UTIs. When an episode occurs, the treatment should be the same as for a typical episode of a UTI. Due to the recurrent nature, it is advisable to assess cultures and sensitivities to avoid treatment with a resistant antibiotic.
One special consideration is whether a period of 24 hours of watchful waiting and increased fluid intake yields any improvement in symptoms. This has been trialed and tested, including in research published in The British Medical Journal, as it is not uncommon for the symptoms of a UTI to resolve spontaneously in some patients.
Another possibility to weigh is whether patients with a confirmed history of recurrent UTIs can self-treat. Physicians should consider someone eligible for this approach if they prefer it and can dependably follow medical instructions. They should be advised to reach out to their healthcare providers for guidance or additional assessment at any point, particularly if the treatment does not seem to be working.
Since this approach forgoes assessment with urine culture (unless patients are given standing requisitions for urine culture), there is a chance of treatment with an antibiotic that has become resistant since a previous use.
Cautions for Antibiotic Prophylaxis
According to a guide published by the American Board of Obstetrics and Gynecology and the American Board of Urology, antibiotic prophylaxis can be considered, but this does come with many risks. These include toxicities to the antibiotics, changes to the systemic microbiome (i.e., changes in gastrointestinal health or in the reproductive tract), and secondary infectious problems such as vulvovaginitis and clostridioides difficile. Research published in The Lancet notes that antibiotic resistance is also a concern with this regimen.
When a patient is informed of the risks and benefits and consents to a prophylactic approach, a physician can consider two approaches: continuous or postcoital. The continuous approach is used in someone whose recurrent UTIs are unrelated to sexual activity. The options and regimens available are extensive, but the choice of antibiotic and regimen should be based on the susceptibility patterns of the patient's previously identified bacteria at the time of culture. Postcoital prophylaxis involves a single dose of an antibiotic following sexual intercourse. Based on the frequency of intercourse, the quantity of antibiotic consumption may be less with the postcoital approach than with the continuous approach.
When someone is starting an antibiotic prophylaxis course, it is advisable to check in with the prescribing physician a few months after initiating it to ensure that the aims are being met and no undesirable side effects are being experienced. At this point, there is little evidence that a long prophylactic course of antibiotics prevents recurrence of UTIs when they are ultimately stopped, according to research published in The Journal of Urology. This may mean patients are destined to stay on antibiotics indefinitely if they want to continue experiencing the benefit and the side effect profile is absent or tolerable.
Ultimately, recurrent UTIs can be a significant problem for patients, but they can be managed effectively with a urogynecologist's knowledge and skill. As champions of urinary tract health, urogynecologists can be considered the most effective physician that can help a patient suffering from recurrent UTIs.
