Female Recurrent Urinary Tract Infection - My Doctor Online The ...

Female
Kaiser Oakland Urology

First Some Basics
“UTI”means urinary tract infection
UTIs are almost ALWAYs caused by one bacteria
species growing in the bladder
“Cystitis" means bladder inflammation
Usually from a bladder infection

Bladder Infection
Most UTIs are really bladder infections
Typical Bladder UTI symptoms:
Frequent and urgent urination
Burning or discomfort during urination
Pressure over the bladder
Blood in urination

Female Anatomy
The Big Picture

Female Anatomy
Near the bladder

How is a UTI diagnosed?
Urinalysis (“UA”):
Preliminary test – same day results
Based on properly collected “midstream”
urine specimen
UTI preliminary diagnosis made on basis of:
White blood cells (wbcs)
a sign of inflammation

UA False Positive Tests

Urine Culture
Confirms the UA result
Takes 24‐48 hrs for results
Added Information
Bacteria type
Bacterial antibiotic sensitivities
Expected response to particular antibiotics
Many bacteria are resistant to common
antibiotics

Urine Culture
False Positives
Common Problem!
Many women have great difficulty collecting a
clean catch urine specimen due to their
anatomy
Poor collection technique
Vaginal skin bacteria contaminate the urine
specimen
Many urine cultures result in indeterminate
“mixed genital flora” culture results

The Typical TRUE UTI test
Results
UA:
10‐25 wbc
Rare epithelial cell
Urine Culture:
E. Coli Bacteria
50,000‐100, 000 CFU

The Typical False Positive UTI
test Results
UA:
0‐5 wbc
Many epithelial cells
implies poor collection
Urine Culture:
Mixed Genital Flora ( lots of different bacteria)
10,000‐25, 000 CFU

Potential result of
Indeterminate Urine tests
Uncertainty about the diagnosis
Other conditions may be the cause of UTI‐
like symptoms or abnormal urine tests!
Unnecessary use of antibiotics
Treatments with ineffective antibiotics
Side‐effects of antibiotics
Acquiring resistant bacteria

Getting to the Right Diagnosis
Indeterminate urine tests are a fact of life!
Most indeterminate urine tests result from collection
problems

Solving the Problem
Straight Catheterization
Sterile collection
Reliable results
Takes 2 minutes
Minimal or no pain

Straight Catheterized Urine
Tests
Correctly identifies real UTIs
Selection of the best antibiotic
Sometimes suggest possible cause
Identifies patients who do not have UTIs!
These patients are often VERY frustrated
Continued symptoms
Multiple treatments with unhelpful antibiotics
Leads to appropriate treatment of the their
true problem

UTI Bacteria
Bacteria live on and in our bodies
Very clean people still have bacteria!
Common location for lots of bacteria:
Genital and anal areas
Colon
Mouth
Hands

Bacteria that cause UTIs
Come from ourselves –not others!
Sources of bacteria:
Our colon –the ultimate reservoir!
Our anal area
Our genital areas
UTIs result when these bacteria:
Enter our bladders through the urethra
Survive our defense mechanisms
Grow and thrive

Antibiotics Resistance
Repeated use of antibiotics can leads to bacterial
resistance.
Women don’t become resistant, their bacteria do!

Antibiotics Resistance
When bacteria in the vagina and colon are repeatedly
exposed to antibiotics, resistant bacteria are selected
and promoted.
Survival of the fittest!
Resistant bacteria survive, sensitive bacteria don’t!

Antibiotics Resistance is
Dangerous
Antibiotic resistant bacteria:
May not respond to standard treatments when we are
seriously ill from infection!
Colonize our skin, nose, mouth, colon, genital areas and
homes
They create a potential danger to people we live with too.

Our Plan to Prevent
Antibiotic Resistance
Use antibiotics only when we really need them.
Use the right antibiotic that kills the specific bacteria
involved in infection.
Use the shortest course necessary.
Avoid the use of multiple antibiotics.
Use good hygiene to prevent spreading resistant
bacteria
Hand washing!

Why Do Some Women Get Lots
of UTIs?
Failure of defense mechanisms

Defense Against UTIs
Urethra “door way”
Length
Men have longer urethra’s
They have fewer UTIs
Closure
An open urethra lets bacteria in
Immune system
Mechanical flushing during urination
Complete bladder emptying
Frequent bladder emptying

What is the most common cause of
UTIs for Healthy Women?
It is in the genes!

Genetic Susceptibility
Our genes determine which proteins line our urinary
tract
Certain proteins on our urinary tract act as “handles”
for bacterial adherence
Adherence proteins allow bacteria to avoid the usual
mechanical washing defenses that are important for
resistance to infection

Other common causes of UTIs
Poor bladder emptying
Stagnant urine promotes bacteria growth
Impaired immune system
Diabetes
Steroids ( Prednisone)
Immune suppression medications
Impaired urethral gate‐keeper mechanisms

Causes of poor bladder
emptying
Neuropathy
Diabetes
Parkinson’s
M.S.
Poor bladder contractility
Common among elderly women
Chronic bladder over‐distension
Urine holding
Teachers!
Poor bladder habits

Common causes of Poor
Bladder emptying
Dysfunctional voiding
Pelvic floor dysfunction
Anxiety and stress!!!
Cystocoele/ Pessaries
Unknown causes

Poor Urethra Gate‐keeper
Shortened Urethral length
Anatomic changes w/ aging
Shortens the functional urethra length
Poor Urethral closure
Stress incontinence
Post Menopause
Poor Hygiene
Foreign body
Pessary
Catheters
Urinary incontinence
chronic wetness

Rare Causes of UTIs
Infection kidney stones
Specific bacteria form stone
Routine calcium stones due not harbor bacteria!
Urethral Diverticula
Colovesical fistula
Connection between bladder and colon
Vesico‐vaginal fistula
Connection between bladder and vagina
Radiation, GYN cancers

Signs that Serious Causes
of UTIs May Be Present
Fever >101 degrees
Visible blood in urine despite appropriate
antibiotic treatment
Childhood UTIs or congenital urinary tract
problems
Passing air during voiding
Chronic bladder issues when UTI is NOT present
Unexplained weight loss
Unexplained chronic illness

When Women are MOST susceptible
Sexual activity‐
Bacteria enter the bladder
VERY common for young women
“Honeymoon cystitis”
Women 18‐30
After menopause

Practical Solutions
Prevention!
Suppressive antibiotics
Short course of “as needed” antibiotics

UTI Prevention
Reduce risk factors
Improve bladder emptying
Increase fluid intake
2L daily
Frequent voiding
Timed every 2 hrs during the day
Void immediately after sexual activity
Manage incontinence
Manage stress and anxiety

Suppressive Antibiotics
Level the playing field!
Many risk factors can’t be changed.
Genetic susceptibility
Makes sense if 6+ UTIs every year
These women likely have genetic
susceptibility!
Suppressive Treatment:
Minimize the development of antibiotic
resistant bacteria
Small antibiotic dose ( urinary cleansing)
After or before sex
Daily or every other day

As Needed Antibiotics
For women with a few UTIs every year
Treat when symptoms arise
Suppressive treatment is over exposure to
antibiotics
As Needed Treatment:
Refillable, open prescriptions
3‐5 day antibiotic treatment
Urine tests should be performed before starting
Confirm UTI is present
Confirm antibiotic will be effective
Lab slips ready at home

Need More Information?
American Urological Association
www.urologyhealth.org/
National Institute of Health
www.kidney.niddk.nih.gov/
Your Kaiser Urologist’s Website