Urology Conditions
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      2. Urology Conditions

      Recurrent UTI

      Brief Overview: UTIs are the most common human bacterial infection with a huge economical impact. $3.5billion dollars annually in the US. Can be a mild infection with potential progression to urosepsis which is life-threatening. It can be lower urinary tract only, confined to the bladder and/or urethra, or extend up into the upper urinary tract involving ureters and/or kidneys. Recurrent UTIs are defined as 3 or more positive urine cultures within 12 mo. May be different bacteria each time or reinfection with the same pathogen. *Asymptomatic bacteria is 2 consecutive urine specimens with isolation of the same pathogen in the absence of symptoms.*

      Prevalence: More common in females than males. Males are more resistant due to longer urethra, the antibacterial nature of prostatic fluid, and a drier periurethral environment. 44% of women who have a UTI will have a 2nd infection, 5% will go on to have a 3rd. Most UTIs in men are considered complicated, uncomplicated would be an isolated infection in a young healthy male. The risk of rUTI in men increases to >10% if over age 65.

      Etiology: The most common pathogens are ecoli, klebsiella, enterococcus, proteus mirabilis, and pseudomonas. The most common spread is ascending, from the urethra and extending upwards. UTI occurs as a result of inadequate host defense mechanisms and bacterial virulence.

      Risk Factors:

      • Behavioral- Sexual intercourse, dysfunctional voiding
      • urinary tract obstruction-medullary sponge kidney, diverticuli, ureteral obstruction, vesicoureteric reflux, bladder neck contracture, urethral stricture, BPH
      • Physiologic- diabetes, pregnancy, neurological disease, postmenopause (atrophic vaginitis, decreased lactobacilli, incontinence, cystocele)
      • Indwelling urethral catheter
      • Uncircumcised males
      • Urinary calculi
      Commonly Associated Conditions: see above
      Common Symptoms:
      • Simple UTI- general malaise, frequency, urgency, urge incontinence, dysuria, suprapubic pain/pressure, cloudy urine, foul smelling urine, hematuria
      • Pyelonephritis-fever, chills, flank pain

      Physical Findings: suprapubic pain. CVA tenderness with pyelonephritis. Men may have tender, boggy prostate gland upon DRE.

      Common Labs, Imaging, and Tests:

      • UA C&S. Midstream clean catch. If uncircumcised, retract the foreskin and cleanse. Value in collecting catheter urine specimen if recurrent infection to differentiate if contamination is likely (morbid obesity, elderly, fecal incontinence)
      • Molecular UTI panels
      • Renal ultrasound vs CT Urogram for contributing factors such as urolithiasis, urinary tract obstruction, and structural issues such as diverticuli.
      • Cystoscopy for direct visualization of the bladder lining, diverticuli, stones, foreign body, etc.
      • PVR for evaluation of emptying. Incomplete emptying high risk for rUTI.
      • Pelvic exam for females evaluating for vaginal tissue atrophy, discharge, pelvic organ prolapse
      Common Medications:
      • Acute infection-empiric antimicrobials, complicated infection typically treated 10-14d, longer if suspected prostatitis.
      • Prevention-intravaginal or topical estrogen in postmenopausal females
      • Supplements such as cranberry tablets BID, d-mannose, and probiotics-hard to find clinical studies to support
      • Alternatives for recurrent infections:
        • Self-start treatment-start 3-7d course as soon as symptoms start, contact prescriber if persist after 48hrs
        • Postcoital prophylaxis
        • Continuous prophylaxis. Typically rotate q90-180d to mitigate resistance. Commonly used-cephalexin, nitrofurantoin (PF risk, annual CXR if long-term use), doxycycline, and TMP (ok to use w/ sulfa allergy). Attempt antibiotic holiday as soon as possible.

      Common Treatments: Treat any contributing factors such as stones when possible.

      Potential Complications and Contraindications: Urosepsis, pyelonephritis, renal abscess, emphysematous pyelonephritis(diabetic or immunocompromised)

      General Health and Lifestyle Guidance:

      • The standard recommendation of 6-8 8oz glasses of water daily. Avoid irritants such as alcohol, caffeine, and sugar.
      • Infectious disease guidelines recommend against re-culture or “test of cure”
      • Void after intercourse. Hand and oral hygiene before and after sexual activity.
      • Wipe front to back.
      • Avoid tub baths
      • Avoid “calling in for antibiotics”. Recommend testing with cultures each time symptomatic. Avoid overtreating asymptomatic bacteriuria. Home test kits can be a real challenge here.
      • Avoid constipation by eating a high-fiber diet, hydration, and daily exercise.
      Suggested Questions to Ask Patients:
      • Are you hydrated?
      • Do you have an indwelling foley? Review daily care.
      • Are you at high risk for stones? Review general stone prevention.
      • Are you completing antibiotics as prescribed?
      • Do you feel that you are emptying your bladder?
      Suggested Talking Points:
      • Often, patients can have inflammatory symptoms with high caffeine intake and poor hydration that will resolve with treating accordingly -avoid irritants and increase water intake.