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***Please note that due to the extraordinary frequency of patients being referred to us with a diagnosis of "recurrent UTI" without documented cultures, we are now going to enforce a policy from here on (9/13/2004) whereby patients who wish to see Dr. Casey for their "recurrent UTI" evaluation MUST have 3 documented UTIs (i.e. positive cultures) in a 1 year span prior to being appointed. If your family doctor or primary care physician is not performing cultures, or you have not had these done otherwise, you will not be appointed. Self-referrals for 'recurrent UTIs' are no longer to be accepted. We must institute this in order to continue to see patients we can treat appropriately with evidence-based medical techniques to match the standard-of-care in the community. Thanks for your understanding...DLC 9/13/2004
The diagnosis of recurrent UTI (urinary tract infection) is a common reason for referral to a urology specialist.
This diagnosis is made most often in women, though some men also have been given this diagnosis. This page is directed primarily at women with recurrent UTI.
It is important is to differentiate the types of UTIs:
How a UTI is diagnosed:
Often in a young female, the
symptoms of urgency, frequency, and dysuria
are sufficient. Generally, a urinalysis is performed to confirm.
A urinalysis can be done in one of two ways:
- Dip Urine: A dip urine is performed by placing a strip that has chemical agents into the urine. The different areas of the strip (known as a "dipstick") will react with agents in the urine that may reflect the presence of inflammatory cells (indicating possible infection), or bacteria. They may also indicate blood or blood proteins are present. A dip urine is often done by family doctors or other physicians who lack the laboratory capabilities to perform a more sophisticated urinalysis. The results of a dipstick in detecting infection are certainly not perfect. The test is generally considered "sensitive" (meaning that if there is infection, it will find it quite often), but lacks "specificity" (which means that it will often show up as a positive test despite the absence of true infection). Remember that the chief indicator a doctor may use with a dipstick urine is the presence of "leukocytes" or white blood cells, and these can be present in the absence of infections in various conditions.
Of course acute infection should be treated by antibiotics, and preferably by "culture specific" antibiotics to assure adequate eradication of bacteria. Many studies suggest 3 days of antibiotics are sufficient, though occasionally longer courses may be needed and are prescribed.
The patient with recurrent UTI (defined as more than 2-3 infections every 3 month or so) deserves to have cultures done by their family physician or internist (or gynecologist) during each symptomatic episode to determine if there truly are bacterial infections happening. Many referrals to urologists come with no culture data, and this makes it very difficult to know where to go next.
Often the "benefit of the doubt" is given the patient, and a work-up is performed as if true recurrent UTIs have been occurring.
The work-up consists basically of an upper urinary tract imaging study such as a sonogram or IVP (intravenous pyelogram) to assure there are no stones, obstruction, or other congenital (inborn) problems that make infections more likely. This upper imaging study is even more important in the patient who has been having "kidney infections" (see definition above). A sonogram is an easy test whereby sound waves are bounced off the kidneys and images are obtained that can be read by a radiologist (x-ray specialist). The IVP x-ray is done by injecting iodine contrast in a vein that is excreted in the urine allowing visualization of the kidneys on an x-ray. The bladder is seen to some degree, but usually isn't all that well visualized with this study.
Additionally, some physicians (myself included) perform a study of the lower urinary tract such as a VCUG (voiding cysto-urethrogram) that allows xray images of the bladder and urethra to be obtained. This helps to see if the bladder has a normal shape and contour, and allows visualization of the urethra. Reflux (movement of urine backwards into the ureters or kidneys) can also be detected by this study. Although this is rare in adults, we do find it occasionally, and as this is a "fixable" problem, it is good to know.
Most commonly all these x-ray studies are normal, but it is important to rule out a condition that could be surgically remediable.
The treatment of recurrent UTI is not always successful at totally eliminating infections, but can reduce them in most if precautions are followed closely.
Hygiene is key with avoidance of vaginal contamination with bowel matter being the most importance facet. Wiping after a bowel movement in the direction opposite from the vagina can help reduce vaginal colonization by bacteria (after all, it's bowel "flora" bacteria that cause UTIs). Intercourse is often cited as a precursor to infection by many ladies, so voiding before and after intercourse is recommended.
Various medical strategies are available, and I'll mention the most common strategies employed. In addition, ladies who have gone through menopause (and are candidates) should consider estrogen supplementation (female hormone) as this may help to prevent infections in some.
As mentioned, the diagnosis of "recurrent UTI" is not a rare one. However, I believe the actual presence of bacterial UTI is fairly uncommon. That leaves many patients with symptoms compatible with a UTI but without culture evidence of them. Absence of evidence does not mean evidence of absence, so the patient who is referred for evaluation and does not have culture data (i.e. the referring doctor never did cultures) must be evaluated closely so that a correct diagnosis can be made.
There are subtle clues in the history that a physician can use to try and help determine if a patient possibly has an alternative explanation for symptoms such as an inflammatory pelvic or bladder condition like IC. If no such clues can be obtained, or if there is a history of positive cultures, it may be imperative to proceed with a work-up to assure that some alternative explanation does not exist.
The references below, especially the ICA web site, are invaluable for understanding the complexity of these conditions. Again not much about IC will be discussed here due to the pre-existence of such good references.
Recurrent UTI can mean just that, but it can often mean symptoms suggestive of UTI that really are not infections at all! If you are visiting your physician with frequent symptoms of UTI, and cultures are not being done, then insist that they be done!
I hope this brief primer on Recurrent UTIs has been helpful, and as always, please notify me if you have any suggestions that may be of benefit. Dr. Casey authored this page on 4/11/2000, and the opinions expressed herein are solely his. Dr. Casey does not accept or respond to E-mail regarding any specific medical questions over the internet from patients other than his own. E-mail communication is a benefit only of Dr. Casey's established patients.*
Dr. Casey does not see patients from outside the DFW and Denton area who have chronic medical conditions such as chronic prostatitis, chronic pelvic pain syndrome, or interstitial cystitis (CPPS, CP, IC).
If Denton, Texas would not be your usual choice for a site for medical care, then you should seek care for your chronic condition locally.
Dr. Casey's practice is a full service urology practice, and he is now no longer seeing new patients with IC, as IC patients often have a complex medical history requiring a clinic setting that can address the myriad symptoms and syndrome complexes that go with this diagnosis.
Patients newly diagnosed will be referred to tertiary centers.
Thanks for your understanding.
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Click on the books above to learn more.
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