Symptomatic, recurrent lower urinary tract infections (rUTI) in women are a common condition for which best practice guidelines related to treatment and prevention have not been well established. rUTi aﬀects women of all ages and is defined as 2 or more symptomatic episodes in 6 months or 3 episodes in 1 year. Between 20% to 30% of women who have one UTI will have a rUTI, and approximately 25% of these women will have more recurrent episodes.
Symptoms of rUTI may typically include burning with urination, foul smelling urine, urinary urgency, and frequency. Treatment strategies should focus on relieving symptoms while at the same time preventing the overuse of antibiotics, which can cause increased side effects as well as the development of antibiotic resistance.
Who is at risk or rUTI?
- For premenopausal women, sexual activity can be associated with rUTI.
- Birth control products such as nonoxynol-9 spermicide can be a risk factor as well.
- Lack of estrogen in postmenopausal women can lead to vaginal atrophy, acidic PH changes, and overgrowth of bacteria leading to UTI
What type of work up is needed to treat rUTI?
A urine culture prior to treatment with antibiotics is important to document infection and help determine optimal antibiotic treatment. More complex cases may require renal imaging or cystoscopy.
How is rUTI best treated?
Short course treatment of 3-5 days is recommended. Preferred first line antibiotics are Nitrofurantoin, Trimethoprim-Sulfa, and Fosfomycin. Fluoroquinilones such as Cipro are discouraged.
rUTI prevention strategies:
Some prevention strategies include lifestyle and behavioral modifications:
- controlling blood glucose in diabetics is important
- Sexually active women should avoid spermicide gel use. It is unclear whether voiding after intercourse is useful
- Avoid unnecessary or prolonged antibiotic use (more than 5 days)
- maintain adequate hydration
There are also therapeutic interventions, such as antibiotic treatments:
- The use of antibiotic prophylaxis may sometimes be indicated and can be done in several ways.
- The use of a single low dose antibiotic immediately after intercourse can be very effective in preventing.
- Once daily low dose antibiotics for 6-12 months may be required at times and is effective.
- A patient self start 3 day course of antibiotics can be a convenient way to treat intermittent It is best to get a urine culture prior to starting treatment.
While commonly used to prevent rUTI, there is little data to support the use of Cranberry products or D-mannose. The value of oral and vaginal probiotics is questionable.
Vaginal estrogen therapy reduces vaginal PH, reduces bacterial colonization, restores lactobacillus, and reduces rUTI in postmenopausal women. There is no documentation of increased breast cancer risk or rise in serum Estrogen levels. Oral estrogens do not reduce UTI risk.
Methenamine Hippurate :
This is a bacteriostatic agent that increases urinary levels of formaldehyde. It does not promote antibiotic resistance. There is some evidence that using methenamine as prophylaxis may help prevent rUTI and reduce need for prophylactic antibiotics.
OM-89 (Uro-Vaxom) is an oral vaccine only available in Europe. It appears to be safe and eﬀective in reducing rUTI. Hopefully, this will available in the U.S. soon
rUTI’s are frustrating for women and can significantly impact quality of life, and daily activities. Identifying underlying risk factors is important. There are potentially preventive measures worth discussing with your doctor.
If you have any more questions about the treatment and prevention of rUTIs in women, click here to schedule an appointment with a Georgia Urology expert today.