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Epsom Urogynaecology 
Clinic

Zainab Khan
 Consultant Urogynaecologist

Secretary : Jackie Huggett
Telephone: 07859896297

Recurrent UTI's

Introduction

Recurrent urinary tract infections (UTIs) pose a significant health concern, particularly for women. These infections are characterised by two episodes of acute bacterial cystitis with associated symptoms within the last six months or three episodes within the previous year. Women are more prone to recurrent UTIs compared to men, making it a prevalent issue in the female population.

Diagnosis traditionally relies on a bacterial count of >100,000 colony-forming units CFU/ml of urine, along with typical acute symptoms such as dysuria, urgency, frequency, or suprapubic pain. However, recent findings suggest that a lower CFU threshold, specifically more than 100 CFUs of E. coli with specific acute urinary symptoms, may be more appropriate for diagnosing both simple and recurrent UTIs in women.

Causes 

Epidemiology

Pathophysiology

Diagnostic Evaluation

Management of Recurrent UTI's

Recommended treatments for recurrent UTIs encompass a range of strategies, including personal hygiene practices, lifestyle changes, and non-antibiotic prophylactic therapies. It's important to note that while some approaches have demonstrated efficacy, others are still under investigation, and individual responses may vary.

1) Personal Hygiene and Lifestyle Changes:
Maximizing personal hygiene factors, avoiding spermicides, correct wiping techniques, and increased fluid intake are commonly recommended.
The effectiveness of lifestyle changes in personal hygiene has not been conclusively demonstrated, but improved hygiene is generally considered beneficial with no negative consequences.

2) Non-Antibiotic Prophylactic Therapies:
Cranberry Products:
a) Recommended as first-line prophylactic agents, but their efficacy is somewhat controversial.
b) Cranberries are thought to work by providing proanthocyanidins, reducing bacterial adherence to the urothelium.
c) Commercially available cranberry products have limited amounts of proanthocyanidins.
d) While the American Urological Association Guidelines suggest their use, patients are advised that effectiveness is uncertain.

D-mannose:
a) Proposed as an aid in recurrent cystitis due to its ability to bind to bacterial surface ligands, decreasing bacterial adherence to the urothelial mucosa.
b) Some evidence suggests a reduction in recurrent infections, but definitive studies are lacking, and optimal dosages remain undetermined (commonly suggested: 500 mg BID).

Methenamine Prophylaxis:
a) Suggested along with vitamin C to acidify urine; when urinary pH remains acidic (<5.5), methenamine converts to formaldehyde.
b) Recent systematic reviews found methenamine to be effective and well-tolerated, avoiding systemic antibiotics and their potential side effects.
c) Some studies show efficacy, indicating potential as a prophylactic antimicrobial agent, particularly in the context of increasing antibiotic resistance.
d) Not recommended if glomerular filtration rate (GFR) is <10 mL/min.

Vaginal Estrogen:
a) Shown to reduce recurrent UTIs in postmenopausal women.
b) Recommended when appropriate in addition to other prophylactic measures.

Combined Approach:
a) Combining behavioural and lifestyle modifications, probiotics, D-mannose, and cranberry products helps reduce recurrent UTI's by 76% and decreases the use of antibiotics by over 90%.

Antibiotic Prophylaxis

Antibiotic prophylaxis is a common and effective approach to controlling recurrent urinary tract infections (UTIs). However, alternative non-antibiotic means are recommended as the first line of defense. This approach helps limit the development of bacterial resistance, avoids antibiotic-related side effects, and reduces overall costs.

Methods of Antibiotic Prophylaxis for Recurrent UTIs:
1) Post-coital Prophylaxis:
a) Suitable for women with frequent episodes of cystitis associated with sexual activity.
b) Antibiotic taken after sexual activity to prevent UTI recurrence.

2) Self-Directed Therapy:
a) Patients start a short course of antibiotics at the first sign or symptom of a UTI.
b) Requires well-educated patients who reliably follow instructions.
c) Efficacy appears comparable to continuous low-dose prophylaxis with fewer gastrointestinal side effects.
d) A urine culture should still be obtained before starting treatment if possible.

3) Long-term Low-Dose Antibiotic Prophylaxis:
a) Considered the gold standard for recurrent UTI prevention but demands high patient compliance.
b) Requires a long duration of therapy (at least 6 months).
c) Carries the risk of increasing antibiotic resistance.
d) Reserved for cases where more conservative measures have failed or cannot be effectively utilized.