As a board certified Ob/Gyn and fellowship-trained Urogynecologist and Female Pelvic Reconstructive Surgeon, I specialize in treating some of the most common yet stigmatized pelvic floor conditions that women face. The pelvic floor is a complex system of muscles that house important organs, including your bladder, reproductive system, and bowel. How many times have you heard someone openly speak about urinary incontinence or pelvic organ prolapse? My bet is not many, but over 60% of women will develop a disorder like these at some point in their life.
One of the most common issues my patients come in to see me for is related to their genitourinary tract. Yes, it’s the dreaded urinary tract infection (UTI). You’re probably here because you’ve been experiencing a UTI that just won’t go away. This is something we call a chronic or recurrent UTI. I promise, there’s hope.
Key Facts About Chronic UTIs
First off, let’s define what exactly a UTI is. A UTI is a bacterial infection of the lower and/or upper genitourinary tract that includes your urethra, bladder, ureters, and kidneys. UTIs are considered chronic if they occur two or more times in a six-month period or 3 or more times in a single year. Over 50% of women experience a UTI at some point in their lives, and 20-30% of them experience chronic UTIs, so please know that you are not alone!
Potential Causes
Recurrent UTIs aren’t caused by the luck of the draw. There are a few potential causes, some more complex than others. Let’s get into it.
Sex and Hygiene
You are probably most familiar with these “causes”, but I would like to start off by saying there is no official evidence that has proven a link between them and UTIs. With that said, the following activities can often increase your risk for developing a UTI, either by disturbing the natural flora of your urinary and bowel tract or harboring environments for bacteria growth.
- Frequent sex, often with more than one partner
- Not peeing after sex
- Some forms of contraception, like spermicide
- Not drinking enough water
- Not urinating often enough or emptying the bladder completely
- Wiping back to front instead of front to back
- Wearing tight, non-breathable underwear
- Heavy use of antibiotics disrupt your natural flora
- Using fragrant soaps to clean your pelvic area
- Not thoroughly cleaning your body
Anatomy
It is possible that the cause of your chronic UTI is completely out of your control. There are certain features of the urinary tract anatomy that could be the culprit.
- Short urethra: female urethras are shorter than male urethras and this is normal. However, this leads to easier movement of bacteria from the outside environment into the bladder.
- Duplicated ureter: this is a rare congenital defect where two ureters flow from a single kidney. The “extra” ureter can sometime insert in abnormal locations increasing the risk of bacterial contamination.
- Fistula: an abnormal connection between two organs or vessels such as the bladder and vagina.
Underlying conditions
It’s important for your doctor to understand your full medical history in order to know how they might play a role in your chronic UTI. If it is thought that an underlying condition may be the root cause of your symptoms, the best treatment may be to gain better control of the underlying condition.
- History of urinary tract surgery or trauma
- Diabetes
- Immunocompromised state: this can be due to a number of reasons such as chronic steroid use, taking of immunosuppressant medications, or infections such as HIV/AIDS
- Menopause: menopause throws off the natural balance of the bacteria in the vagina due to lower pH resulting in less Lactobacillus, or “good bacteria” in the vagina, and allowing for bad bacteria, like the bacteria that causes UTIs, to move in
- Radiation cystitis: resulting from radiation treatment to the vagina or pelvis which causes alterations to the bladder and other parts of the urinary tract
- Urinary tract obstruction: blockage to the urinary tract kidneys, ureters, bladder, and urethra) by tumors, blood clots, urinary stones, and pelvic organ prolapse.
- Voiding dysfunction: if there is inability to fully empty the bladder, urinary retention can serve as a “broth” in which bacteria can grow
Diagnosis
Diagnosis of a UTI is pretty simple, Your doctor will take a urine sample to perform a diagnostic test. The most common tests include:
- Urinalysis: a point-of-care test that looks at certain markers of infection in the urine
- Urine culture: the gold-standard test that attempts to grow out bacteria or other infection organisms in the urine. If enough growth of a pathogenic organism is identified, then a UTI can be diagnosed. This test takes several days to result and may not always be performed if other strong indicators of UTI such as patient symptoms are present.
Women are often very accurate in identifying a UTI simply through their symptoms, especially if they’ve previously had confirmed UTIs. For these patients with a documented history of UTIs, we are usually happy to begin treatment without performing additional urine testing.
While the tests mentioned above are good at identifying the presence of infection, your doctor may choose to perform additional tests to determine the root cause of these infections. These tests can help to diagnose or rule out anatomical abnormalities and obstructions, and include:
- Cystoscopy: a procedure that looks inside the urethra and bladder with a small camera
- Urodynamic Testing: a functional test of the bladder that checks if the bladder is filling and emptying correctly
- Abdominal imaging: ultrasound and x-rays of the kidneys and ureters can identify potential urinary tract obstructions, anatomical abnormalities, tumors, and other causes of chronic UTI
It may feel daunting to get to the bottom of this recurrent infection, but there are doctors who specialize in doing just that. I want you to feel empowered to ask questions and seek help so you don’t have to experience the bitter symptoms and stigma around recurrent UTIs. Let’s talk about treatment options.
Recurrent UTI Treatment Options
When an acute case of UTI is identified, the treatment is with antibiotics that the bacteria causing the infection is susceptible to. However, the goal of treating recurrent UTI is to try and prevent the next one from ever happening. There are several approaches that we can take to achieve this:
Prophylactic Antibiotic Therapy
This treatment method entails taking a low-dose antibiotic either daily, or after specific events that result in UTI such as sexual intercrouse. Your doctor will take your allergies, medical history, medication list, and type of bacteria causing infections from prior cultures into account to choose the right prescription for you.
Non-Antibiotic Prophylaxis
These therapies are usually oral pills and they work in several different ways. One medication acidifies the urine to prevent bacterial growth. Another medication can help to prevent bacteria from sticking to the bladder wall. Probiotic supplements can help to restore the bladder microbiome to avoid the colonization of pathogenic bacteria in the bladder.
Vaginal Estrogen Therapy
This treatment is specific to postmenopausal women and has proven effective in preventing recurrent UTIs by rebalancing the vaginal flora and reducing the risk of vaginal wall thinning. This hormone therapy comes in the form of a ring or cream that is inserted into the vagina. Unlike oral hormone replacement therapy which is taken as a pill, vaginal estrogen therapy is not significantly absorbed into the bloodstream so it has minimal risk of causing the serious adverse side effects that oral systemic hormone therapy can cause such as stroke, heart attack, blood clots, breast cancer, and uterine cancer.
Behavioral Modifications
These therapies are usually presented in tandem with use of a prophylactic strategy to help prevent a recurrence. These therapies include drinking plenty of water, wearing cotton underwear and loose clothing, peeing after sexual intercourse, wiping front to back after going to the bathroom, using forms of birth control other than spermicide and diaphragms, and avoiding products with fragrance. Although the research on whether or not these behaviors actually help to prevent UTI is conflicting, they are low-risk changes that can be made that would only help with treating recurrent UTIs.
Surgery
If the root cause of your recurrent UTIs is determined to be a urinary tract abnormality or obstruction, your doctor may opt to surgically repair the urinary tract, or remove the obstructions.
Risks of Untreated UTIs
UTIs can go away on their own, but when a person has symptoms of UTI and testing to prove that an infection exists, it isn’t recommended to forego antibiotic treatment, especially if you’re experiencing recurrent infections. There are some serious potential consequences of leaving a UTI untreated.
Pyelonephritis
Also known as a kidney infection, pyelonephritis can cause permanent damage to the kidney or even become life threatening if the infection spreads to your bloodstream. This occurs when the UTI-causing bacteria moves up into your kidneys.
Urosepsis
This occurs when the infection spreads from the urinary tract into the bloodstream. Sepsis can be life-threatening or lead to multiple-organ failure, chronic pain, and even amputations.
Conclusion
UTIs are common, but if you’ve been experiencing a chronic UTI that just keeps on coming back, there is hope. I wanted to show you that there are diagnosable causes with evidence-based treatment plans out there for you. Your next best step is to contact your primary care provider or gynecologist who can help you with next steps. They may refer you to a urologist or urogynecologist (like me!) to discuss the need for further diagnostic testing or treatment options. Don’t be afraid to ask questions and advocate for yourself now that you know all about chronic UTIs!