Recurrent UTIs:

***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

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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.

• Bladder infection (simple cystitis)
A bladder infection is caused by an overgrowth of bacteria that make their way into the bladder via the urethra (the tube leading from the bladder to the outside.) The bacteria then grow to significant numbers and overwhelm the body's defenses producing infection.  These bacteria generally emanate from the stool or fecal matter, and make their way into the bladder via vaginal colonization.  The symptoms of cystitis (bladder infection) are typically urgency to urinate, frequent urination (frequency), and dysuria (burning or discomfort while urinating.)  These symptoms are not specific for UTI as will be discussed.
• Kidney infection (pyelonephritis)
A kidney infection, otherwise known as pyelonephritis is a UTI that has been caused by bacteria ascending to the kidney and renal pelvis (where urine is funneled down the ureter which is the tube connecting the kidney to the bladder.)  This obviously is a more serious infection, and is generally accompanied by flank (side) pain, fever, and other constitutional (systemic) symptoms.  The patient with pyelonephritis (referred to as "pyelo") often appears quite ill and may be hospitalized, though this type of UTI is rarer than cystitis.
• Vaginal infection (vaginitis)
Vaginitis or a vaginal infection is generally something different than a UTI, though the two may be simultaneous.  Oftentimes, a vaginal yeast infection can occur during antibiotic therapy for a UTI or other infection.  The symptoms may be similar with burning or a vaginal discharge.  A careful urinalysis can usually detect if there is a concomitant UTI along with a vaginal infection.
• Interstitial cystitis (IC)
Interstitial cystitis is not generally felt to be an infection at all, but its symptoms closely mimic that of a UTI in many people who have it.  IC is an entire topic in itself, and won't be covered in detail here.  See the ICA web site for more details about this condition.  There are various other IC links at the bottom of this page.  I will say that clearly more than 1/2 of all patients referred for the diagnoses of "recurrent UTI" may have IC or a related condition.  IC is a difficult, frustrating condition with no known cure or cause, and with very little in the way of successful treatment.  Patients newly diagnosed with IC by Dr. Casey will be referred to specialty centers.  A few books are listed that may help the IC sufferer through the battle.

• 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.

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• Microscopic Urinalysis:  This is a more specific way of performing a
urinalysis and entails spinning (centrifuging) the urine so that the
sediment can be examined with a microscope to look directly for the
presence of white blood cells (inflammatory cells), red blood cells, or
bacteria.  This test is very sensitive, and more specific.  It is subject to
more user interpretation at times, but is felt to be a more sophisticated
and exacting way to evaluate the urine.  Often a dip urinalysis and microscopic are combined.  In the patient with a very occasional infection, the patient's history along with a urinalysis (U/A) is generally sufficient, however when the occurrence of symptoms of infection are occurring very often, say once a month or more, it is imperative that a urine culture be performed.

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• Urine Culture:  A urine culture is a test whereby the urine is smeared
on a special laboratory "plate" that contains growth medium ("food for bacteria") and incubated for 24-48 hours to look for the presence of
bacterial growth.  This is most often done by a special laboratory, though some physicians still do these in their offices.  A urine culture is the test of choice in my opinion for anyone having frequent UTIs as it will not only tell whether there are bacteria, but will also allow the physician to know which bacteria, and to what antibiotic the bacteria. is most likely to respond to.  As mentioned above, the diagnosis of IC (interstitial cystitis) is not all that rare, and the typical scenario is a patient diagnosed with 'recurrent UTI' but with negative cultures--therefore the importance of cultures in persons with frequent symptoms of what is believed to be UTI.  It is imperative to know that a culture may be "falsely negative" (meaning that the culture shows no
growth although there may truly be bacteria there) if antibiotics have
already been administered prior to the culture being obtained.  The reason
for this is that the antibiotics that are excreted into the urine may inhibit
the growth of the bacteria on the "plate" thus fooling the physician into thinking there is no infection.  This may occur even if the bacteria in
question is not susceptible to the action of the antibiotic while in the
human body!



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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.

• Prophylactic (preventive) antibiotics:
 
 
This is a strategy occasionally employed.  The principle is to administer a small daily (or 3 time weekly) low dose of antibiotics to prevent infection.  This is effective in some ladies, and is often employed in children with reflux or some other anatomic problem.  One concern is that the long-term usage of antibiotics may lead to untoward side effects such as resistant organisms (bacteria that no longer respond to antibiotics) or other side effects of the medication.  Many ladies also get vaginal yeast infections (vaginitis) from taking antibiotics in this fashion.  Often the antibiotics are prescribed for some set period of time (3 to 6 months) and then stopped.  This is generally not my first choice line of treatment.
• Pericoital antibiotics:
 
Pericoital ("around the time of sexual intercourse") dosing of antibiotics is very useful for ladies who frequently develop infections after intercourse.  This strategy is quite simple.  After intercourse, the patient simply takes a single dose of antibiotic as she is getting up to void her bladder (see hygiene above) after intercourse.   This is quite effective, and lowers the chance of resistance and other untoward side effects greatly.  I employ this is numerous young patients who fit the pattern of having infections after sexual activity.
• Early recognition dosing:

This is a strategy that I only employ in patients who I feel can clearly recognize when they have a true infection coming on, and who I know have been documented to have bacterial infection.  The strategy is that the patient is given several courses worth of antibiotics to keep at their home, and as soon as they feel the first inkling of an infection, they initiate therapy on their own with a 3 day course of antibiotic.  The major drawback with this strategy is that self treatment often means we do not have a culture to work with if things do not get better promptly.

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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