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with Jane Harrison-Hohner, RN, RNP and Laura Corio, MD

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Monday, January 10, 2011

Urinary Tract Infection (UTI) Symptoms and Recurrence

Urinary tract infections (UTIs) are the third most common type of infection, surpassed in number only by respiratory and intestinal infections. Thus, many of us are all too familiar with the common symptoms of a UTI such as urgency, frequency, small amounts of urine voided, and pain with urination. Many of us may also be familiar with the problems of recurrent/frequent UTIs, or even apparent UTI symptoms for which no bacterial infection can be found. This later condition, which one urologist likes to call “The UTI That Isn’t” is a frustrating situation for women who have recurrent symptoms without good relief.

In order to best discuss “The UTI That Isn’t,” let’s take an opportunity to review some of the latest research on actual UTIs. Then we can move into an expanded discussion of the other, mysterious condition.

Why do regular UTIs seem to keep coming back?

A true UTI, by definition, is where bacteria are growing and reproducing within the urethra, bladder, or even higher in the ureters and kidneys. Urine is supposed to be sterile, so bacteria are considered intruders-even if they aren’t causing apparent symptoms. Other organisms such as chlamydia or trichomoniasis can get up the short female urethra to set up housekeeping (more about that later). The goal with treatment is to use an antibiotic to suppress or eliminate the organism responsible for the infection.

There are two types of recurring infection: re-infection and relapse. Re-infection accounts for the majority of recurring episodes. Re-infection means that a different type of organism has taken up residence. Most re-infections are readily treatable with some type of antibiotic. By contrast, relapse means a failure of the initial treatment allowing the original bacteria to re-grow. Were the bacteria resistant to the original antibiotic used? No, this would be called a treatment failure. Rather a relapse would be when the original bacteria returned within three weeks of an initially successful treatment. One review found that relapse within seven days of a single large dose of antibiotics was most linked to an infection that was also present in the ureters or kidney (Ronald, 1990). So for all these reasons, a UTI may seem to be coming back frequently.

There may be a subgroup of women in whom, culture confirmed, bacterial UTIs reoccur. Two hundred and thirty college aged women were followed for six months after having a bacterial UTI. For those women who had a history of two or more previous UTIs, their reoccurrence rate was 22% compared with 10% for the women without past UTIs. Unfortunately, neither the use of twice daily cranberry juice, or a placebo drink, did not have a beneficial effect (Barbosa-Cesnick, 2011). If a woman is doing all the right prevention strategies (e.g., urinating after sex, wiping from front to back, adequate fluid intake, etc.) and still getting frequent UTIs, I would consider ordering a kidney ultrasound to see if there is an anatomical reason such as a kinked ureter.

What is the best way to diagnose and manage a regular UTI?

A large study of 839 non-pregnant women (Little, 2009,) randomly assigned women with a suspected UTI to one of five treatment regimens. The investigators reported that about two thirds of the women had a confirmed UTI.  The use of a urine dip stick test was moderately successful at identifying those women who went on to have a urine culture that was positive for bacteria. The use of such symptoms as bad smelling urine, urine cloudiness, pain with urination and having to get up in the night was not a successful way to identify women who had bacterial UTIs.  Moreover, the use of cranberry juice or bicarbonate had no effect on reducing symptoms before antibiotics were given.

The same group of researchers (Little, 2010) published a study describing when a woman might expect her UTI symptoms to improve. Among women with the most severe symptoms, it took an average of 3.32 days for symptoms to respond to antibiotics. In women who had either infections resistant to the antibiotic prescribed, or who did not receive antibiotics, symptoms lasted 56% longer and 62% longer respectively. This suggests that prolonged symptoms can indicate a need to change medication approaches, and that it is important to start antibiotics promptly.

Interestingly, there was a group of women who had no evidence of bacteria in their urine, yet had UTI symptoms. These women had even longer duration of symptoms by 33% than women with “regular” UTIs (Little, 2010). They were given the diagnosis of “urethral syndrome.” This is one of the possible causes of “The UTI That Isn’t”. We’ll talk more about this and other possible causes in the next post.

Posted by: Jane Harrison-Hohner, RN, RNP at 6:24 pm

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