Recurrent UTIs

“The burden of recurrent UTIs has both personal and societal aspects. The societal burden includes the clinical and economic burden of the illness, and the personal burden includes social and psychological effects which have a negative impact on quality of life. Recurrent UTIs are associated with symptoms of anxiety and depression. The sudden, rapid, and painful onset of a UTI is often a source of anxiety in patients. Feelings of guilt related to a patient’s inability to perform their usual activities, or the impact of recurrent infections on their social activities, may lead to clinical symptoms of depression. The social impact of recurrent UTIs may be particularly marked in premenopausal, working women. Treatment of a UTI alone is often not enough to improve a patient’s quality of life.” (Medina M, 2019)

The UTI Dilemma

Most of us know someone who has had frequency, urgency and burning when they urinate but when they go to the doctor, they are told they don’t have a UTI. Sometimes they get better, sometimes they just deal with it, and sometimes it progresses until they have a fever and are treated. Earlier in my career I personally looked someone in the eye, thought they had a UTI and told them that they didn’t. What is going on?

The urine culture is the gold standard (or is it?)

For years clinicians have used >100,000 colony forming units (CFU) on a standard agar-based culture as the gold standard for diagnosis. Agar based cultures have been around since the 19th century and haven’t changed much. The >100,000 CFU number came from literature looking at asymptomatic women over 60 years ago. Some studies have shown symptoms with a pathogen growing out at >1,000 CFU can be diagnostic. Two problems with this:

1) most physicians have been taught you need higher counts to mean significance

2) Most labs don’t differentiate bacteria in lower numbers.

Research has shown >50% of UTIs involve polymicrobial infection, standard culture fails to identify >80% of these. Standard cultures do not find fastidious organisms, fungi or viruses. In complex patients we need to look beyond the standard culture.

The urine should be sterile (or should it?) .

Newer techniques that use polymerase chain reaction (PCR) and next gen sequencing (NGS) show that many healthy patients without any symptoms have a complex microbial community within their bladder. Not only is this normal but it may be protective against symptomatic infections. This urinary microbiome is actively being studied and is not well understood. It may be detrimental to treat any organism found on these more sensitive studies as we risk damaging healthy bacteria.

I was diagnosed with Interstitial Cystitis (do I really have that?)

Patients with symptoms of a UTI but with a negative culture are given other diagnoses. Interstitial Cystitis, pelvic floor dysfunction and food intolerances are often given to patients with symptoms of recurrent UTI but negative cultures. New technology using PCR and NGS will often find pathologic bacteria in these patients.

I was diagnosed with recurrent UTI and now my cultures are negative (but I still hurt)

Recurrent UTI (rUTI) is diagnosed when a patient has ³ 2 UTI’s in 6 month or ³ 3 in 12 months. Treatment for rUTI may include prophylactic antibiotic, post-coital antibiotic, vaginal estrogen, or self-diagnosis and treatment (working with your doctor). Sometimes after treatment for a period of time the cultures will change. This can happen for a few reasons.

Recurrent Uti Urologist Glendale AZ
  1. Recurrent or Chronic UTI – You are clearing the bladder but have a source for reinfection. This can be a kidney stone, a urethral diverticulum, or other anatomic abnormality.
  2. Embedded UTI – When your bladder is infected it damages the lining, or urothelium. Occasionally when the body is trying to heal itself it will bury living bacteria under a new lining. This can grow and erupt into the bladder causing flares of UTI symptoms. Culture results will be variable.
  3. Biofilm – Biofilms are collaborative collections of microorganisms that work together to stay alive. They can include bacteria, fungi and viral particles and are kept together by a matrix of extracellular polymeric substances (EPS). Think of this like the slime we used to play with mixed with millions of microorganisms. Biofilms can change how they behave and become resistant to antibiotics. It is very difficult to diagnose and eradicate biofilms from the bladder.

Symptoms of Lower UTIs May Include:

First of all, find out what is going on. In patients suffering from recurrent UTI I recommend the use of either Pathnostic’s Guidance test (link https://www.pathnostics.com) or MicrogenDx’s Level 2 urine test (link https://microgendx.com/patients/). Guidance looks at the PCR of over 45 different microorganisms but then offers Pooled Antibiotic Susceptibility Testing (P-AST). This is a unique way of looking at how the group of microorganisms respond to a variety of antibiotics. All other products either look at culture resistance (which is limited to 1 organism at a time) or genetic sensitivity (genotype and phenotype of resistance will disagree 40% of the time). MicrogenDx’s test looks at a smaller group of PCR but then runs next gen sequencing (NGS). This can find pathologic bacteria and fungi who may have mutated and don’t show up on PCR. In my opinion the biggest downside of NGS is that we find the healthy bacteria too and it can be difficult to separate out what is pathologic.

Second, make sure there is nothing else going on. In patients who have not responded to standard treatments I recommend a kidney and bladder ultrasound and cystoscopy. This makes sure you don’t have something that is preventing you from getting rid of your infections. You may have kidney stones, outpouchings of the bladder or urethra, or a bladder that doesn’t empty.

Lastly, start treatment. My goal is ultimately to get patients off antibiotic but something that has taken years to build up may take months to years to treat. My philosophy is check, treat, and maintain. Make sure you are doing the simple things like drinking lots of water and urinating after intercourse. In post menopausal women without history of breast cancer I often recommend bioidentical vaginal estrogen. I’m also a fan of natural treatments, specifically proanthocyanidins (PAC) which bind to bacteria and help prevent bacterial adhesion.

The goal is to get your life back. It may take work but you are worth it!