Addressing Recurrent Urinary Tract Infections: Causes, Diagnosis, and Treatments

This informative episode dives into recurrent urinary tract infections (UTIs). I highlight the importance of accurate diagnosis and discuss common misconceptions. 

Many women experience symptoms that resemble UTIs but are actually due to other conditions like tight pelvic floor muscles or low estrogen levels, particularly during menopause or postpartum. 

The episode emphasizes the limitations of urgent care in managing recurrent cases and the necessity for a holistic evaluation. Various treatment options, including vaginal estrogen, prophylactic antibiotics, and physical therapy, are explored. The key takeaway is to ensure the correct diagnosis and consider broader medical evaluations for persistent symptoms.

00:28 Introduction to Recurrent Urinary Tract Infections

01:34 Prevalence and Impact of UTIs

02:32 Challenges with Urgent Care Treatment

03:04 Defining Recurrent UTIs

04:38 Exploring Non-Bacterial Causes

06:58 Holistic Evaluation and Treatment

07:34 Advanced Diagnostic Procedures

08:41 Preventative Measures and Treatments

11:05 Alternative and Emerging Treatments

12:01 Conclusion and Final Thoughts

Transcript

Hi there. I wanted to talk to you today about recurrent urinary tract infections. I was thinking about this topic because I was sitting down and reviewing our office protocol about how we treat and diagnose recurrent urinary tract infections. I see patients who have recurrent urinary tract infections or the symptoms of a urinary tract infection that is not caused by a UTI, right?

So feeling like you have a urinary tract infection, but that's not what is causing it. I see these patients all the time in the office, but I also talk to a lot of my friends who are struggling with the same thing. So, women who feel like they have a urinary tract infection every month, they're going to urgent care, they're being treated with antibiotics.

Sometimes their cultures are positive, sometimes their cultures are negative. But they're having these bladder symptoms that happen frequently that are really impacting their quality of life. And I think this makes it a really important topic for us to discuss. So urinary tract infections are common.

They're the second most common infection in the body. Most women will have at least one urinary tract infection in their lifetime. There are 8 million medical visits for urinary tract infections in the U. S. each year, and about 84 percent of these are women. If you get one urinary tract infection, 30 to 44 percent of those women will go on to have a second urinary tract infection, and then 50 percent of those women will go on to have a third infection.

So, UTIs, urinary tract infections, are common, and some women are susceptible to multiple infections. There are also times where you're more likely to get a urinary tract infection, so urinary tract infections increase when women become sexually active, and they also tend to increase at the time of menopause.

Many women get their urinary tract infections treated at urgent care. And this can be a problem over time. So urgent care does a really good job of treating acute things. So fixing problems. And if you have a urinary tract infection, they do a great job of fixing it, but they're not always thinking about all of the other things that are happening with you, your other medical problems.

What the pathophysiology might be. And so if you're someone who's getting recurrent urinary tract infections and you're going to urgent care monthly, that is a time where things need to be reassessed. You need to see a provider who can look at you more holistically rather than just trying to stamp out that urgent problem to figure out how to prevent the infections going forward.

So when I say recurrent urinary tract infection, what am I talking about? What is the definition here? There are a couple of different definitions of it, but most people agree that it is a culture proven urinary tract infection. So where there's actually been a culture, not just a urinalysis. and that you have had two infections in six months or three infections in one year.

When we see patients who are sent to the office for recurrent urinary tract infections, sometimes That person is really having recurrent infections, right? So a bacterial infection of the bladder, but frequently they are having symptoms that feel like an infection, but are not caused by a bacteria. So when we see these patients in the office, especially if we don't have the culture proven UTIs, or if someone comes in and they say, you know, I really feel like I'm having.

Urinary tract infection symptoms, but my cultures are always negative. Then we're looking for other things, right? And that doesn't mean that you're not having symptoms. It just means that those symptoms are not caused by a bacteria. So when we're assessing women who come in with these symptoms, right, and I would say commonly the symptoms are You know, burning with urination, pain with urination, pain in the pelvic floor, pain in the vagina, frequency, sometimes even more leaking. 

When we're diagnosing these people and doing the history and physical, because you always want to do a very complete history and physical, we're looking at a couple of different things that can be huge contributors. So the first is the pelvic floor muscles. And if those muscles are tight and painful, so tight pelvic floor muscles can cause symptoms that feel like a urinary tract infection.

So the symptoms feel the same and they are essentially the same, but there's no bacteria in the urine. It's caused because those muscles are too tight. And the treatment in that situation is frequently to send these patients to physical therapy to get those muscles to relax. It's almost like you have a Charlie horse. 

And in these muscles, um, we're also looking for a general urinary syndrome of menopause. So are you in perimenopause? Are you menopausal? Is there something about you that is causing your estrogen level to be low? We see this frequently in postpartum women. Some medications can cause it too. And that lack of estrogen in the vagina can cause similar symptoms.

Symptoms and so that is another, um, primary contributor, or  I guess I would say that is another diagnosis that symptom wise acts the same, but is caused by a completely different pathophysiology. We're also looking at the vulva to see if there are any skin conditions of the vulva that could be causing some of the symptoms or discomfort.

Thank you for your time. We're looking for vaginal infections. We want to make sure that you can empty okay Um, if you're emptying poorly for some reason that can cause symptoms that feel similar And then looking for prolapse too because sometimes it could be prolapses contributing to the symptoms, right?

So once again, if you're someone who is always getting  What feels like a urinary tract infection, you're going to urgent care and you feel like you're stuck in this cycle and, and it's just not getting any better or not making sense, then you want to take a step back and you want to get a more thorough evaluation.

Urgent care does a great job, but they're really looking at, you know, infection or not infection. They're not kind of. Doing a deep dive into some of the other things that can be going on. So when we see someone in the office and they, you know, really do have recurrent urinary tract infections, right.

They're getting at least two infections in six months. And we have cultures that, that prove that. Sometimes we have to look in the bladder and do a cystoscopy. Sometimes we have to do some upper tract imaging. That is not true for everybody, but it is true for some patients. So, you know, if you have blood in your urine, the blood doesn't go away with, um, treatment of the infection.

Certain infections can cause blood in the urine. Um, but it should go away once that infection is treated, then you want to have a cystoscopy and you want to do some upper tract imaging for women who, you know, we might be concerned about a bladder stone or depending if they've had, um, some pelvic surgeries, those are reasons why we might want to do a little bit more imaging or look in the bladder, but many women don't need additional studies.

So we treat urinary tract infections according to a very specific protocol. You always want to minimize the amount of antibiotics that you're giving to women. If that particular patient has low estrogen or if they're perimenopausal or postmenopausal, we'll put them on vaginal estrogen. So vaginal estrogen has been shown to be an excellent preventative for recurrent urinary tract infections. 

So when there isn't estrogen in the vagina, you can get some of the symptoms from a decreased level and estrogen, but a low level and estrogen can also lead to urinary tract infections. And so that's 1 of the 1st things that. We give to patients vaginal estrogen is very safe If you take it as prescribed the vaginal estrogen stays in the vagina.

It's not a systemic treatment It doesn't get into the rest of your body. And so it's very safe We even have patients who have had breast cancer who are on it Although that's something that you should always talk to your medical oncologist about When you first start the estrogen and that tissue is really thin for the first couple of weeks, you can frequently feel it in the rest of your body.

So you might get a little bit of breast sensitivity, some people get a little bit irritable. But after about two weeks, all of that should go away. And then it really is a local treatment, meaning that it stays in the vagina so that it is very safe. Some patients we put on methanamine, which has also been shown to be a good preventative.

Some patients, we have to give a prophylactic antibiotic. So sometimes patients will take the antibiotic after intercourse, if their infections are correlated with intercourse. Sometimes we have to give the antibiotic for three to six months. To keep the infections from coming back and then hopefully break the cycle and give your bladder enough time to heal so that it's not as susceptible to infections in the future.

We try to minimize the amount of antibiotics that we give to people. And so putting someone on a preventative antibiotic is. Um,  you know, there's something that we don't do lightly and we definitely try to minimize, but for some patients it is warranted. Probiotics have not been shown to help to date.

There was recently a randomized controlled trial that came out with D mannose, which has shown, um, that D mannose does not help and that is a shift in the data. Um, some physicians will offer cranberry. Um, cranberry may help a little bit  and there is a vaccine that is currently only available in Europe.

It's a sublingual vaccine. So you put it under your tongue and it has inactive components of the four most common bacteria. Um, and that has shown to be an excellent preventative for women who get recurrent urinary tract infections, although it is not available in the United States right now. So I, I think the thing that is the most important when we're talking about recurrent urinary tract infections is to make sure that that's really your diagnosis and that there isn't something else going on.

When it isn't recurrent urinary tract infections, the most common thing that I see is a tight pelvic floor causing similar symptoms or a lack of estrogen causing similar symptoms. And the lack of estrogen that You know, I see that pretty commonly in perimenopausal women. And so what that means is, you know, there's someone who is in her early forties, she's super active, she's going about her life, maybe she's working, maybe she's taking care of kids. 

Um, doing whatever it is she does and then all of a sudden she feels like she's having infection after infection after infection and the decrease in estrogen may be causing symptoms that feel like an infection, but it's not really an infection or she may be getting true infections. And for those patients, vaginal estrogen almost always prevents the infections and can make a huge difference.

So it's just important to make sure that the diagnosis is correct and to think about vaginal estrogen. So if you're someone who is getting recurrent UTIs, I would say, you know, you should talk to your primary care about it. When you're not having an active infection, you could talk to your GYN about it.

You could go see a urologist or a urogynecologist. It's a very common problem that we all see very, very routinely. So I hope this help and just remember to make the right diagnosis.