Recurrent UTIs can have a profound effect on quality of life, but they aren’t that well understood, Urogynaecologist, Obstetrician and Gynaecologist Dr James Alexander said in a recent Healthed podcast.

Women are most often affected says the Sydney-based practitioner. He says he sees women of all ages, who are often in ‘constant discomfort’, and may be experiencing overactive bladder symptoms as a result—which of course can be very socially debilitating.

But he says it’s not something they always want to talk about.

Lingering infections may play a role

Recurrent UTIs are defined as two laboratory confirmed UTIs in six months or three in one year. The most predictive symptom of a UTI is “terminal dysuria.

Dr Alexander says we don’t always know why some people get recurrent UTIs. For some “it’s a result of how the bacteria colonises the bladder, but it’s also about how the host responds to that colonisation. And if you have a difficulty with either part, you can end up having someone who’s susceptible to urine infections,” he says.

Antibiotics can kill protective bacteria

“The vagina produces lactobacilli and this is protective against urinary tract infections. So, when people go through menopause (which produces a less hospitable environment for lactobacilli), or take antibiotics that kills their lactobacilli, they can be more susceptible to acquiring a urinary tract infection.”

Dehydration and changes in antimicrobial factors due to the urinary pH level or high osmolality can also increase susceptibility. Changes in protective barriers to the urothelium which make it easier for bacteria to become pathogenic may also be a factor, he says.

Antibiotic use plays a role too.

“The destruction of normal vaginal flora from antibiotics can lead to candida infections, due to a reduced lactobacilli population, and this can make them more likely to have a repeat urinary tract infection. There are also impacts on gut health with ongoing antibiotic use,” Dr Alexander says.

The culture matters

When we analyse urine cultures, Dr Alexander says it’s vital that “we look at their microscopy, the level of leukocytes and red blood cells, The results of the culture and the type of bacteria that is reported.” This, he says, gives us “the sensitivities and resistance of the different antibiotics, which is incredibly important in treating UTI’s effectively.”

Another investigation that can be useful is a post void residual.

“A high post void residual makes it more likely to contract a urinary tract infection due to urinary stasis. Additionally, if there’s persistent negative symptoms or gross haematuria in the urine specimens, this may be a sign of bladder cancer and at that stage a cystoscopy and urine cytology would be warranted,” he says.

Dr Alexander says symptomatic UTIs need to be treated with antibiotics, but prevention is crucial.

“When we’re thinking about preventing urinary tract infections, ideally, we’re thinking to be probiotic, rather than antibiotic. There are many non-antibiotic treatment regimens that can be employed and some of these will also help improve the normal flora of the vagina, which is protective against urinary tract infections.”

Prevention is better than cure

One of these is topical or local oestrogen – specifically oestradiol cream. He says this is particularly useful in postmenopausal women as it helps reduce the vaginal pH which in turn promotes lactobacillus growth within the vagina.

He says studies show the cream performs better than the pessaries in this regard.

Probiotic supplements may be helpful, but he says Hiprex with Vitamin C which converts to formaldehyde can work well as a preventative.

Another option is D-Mannose. “Two grams of this in 200 ml of water has also been shown to be preventative against urinary tract infections,” Dr Alexander says.

Cranberry juice may have a role, but the strength is important. “I’d say with cranberry the jury’s still out. The most recent Cochrane Review suggested that there wasn’t enough evidence to promote the use of cranberry for the prevention of urinary tract infections. There have been a few randomised control trials since that Cochrane review which have shown a benefit in postmenopausal women, and women who have undergone an operation recently may benefit. There’s also been some studies which have shown high dose cranberry is more beneficial to low dose cranberry.”

He says look for products with at least 36 milligrams of proanthocyanidins, a type of polyphenol found in cranberries.

When it comes to picking the best antibiotic to start with to reduce the risk of antibiotic resistance, Dr Alexander says his preference is nitrofurantoin.

“One study showed that with trimethoprim and sulfamethoxazole, resistance built up to a level of about 90%,” he says.

There are some exciting developments coming though that may be game changers, and one is a vaccine against E. coli. It’s available in New Zealand (but not Australia currently), he says, and is a tablet you take daily for three months.

“It’s a moving area of research. We’re getting a better understanding of what works and what doesn’t and which has less side effects and more side effects. So, watch this space.”

Listen to Dr Alexander discuss this topic in more detail here.

Recommended resources:

• Chronic UTI Australia