The definition of a recurrent UTI is as follows: having two or more infections within six months, or three or more within a year. Yet for many, it may come as a surprise the massive burden that UTIs as a whole have on our global medical system. With more than 400 million people contracting UTIs in 2019 alone, urinary tract infections are a common and serious issue worldwide. They are the most common cause of emergency room visits worldwide. But, for women and those with female reproductive organs, UTI can often be much more than a one-and-done deal.
Recurrent UTI is tragically common among the general population. Close to 60% of women will experience a UTI within their lifetime, and about 30% of those patients will go on to have a recurrent infection within the same year. These recurrent infections have a notable impact on the patient’s quality of life and medical institutions. Despite the known effects of recurrent UTI being well-established in the literature, few guidelines exist to address it medically at the moment. This article will cover the basics of a recurrent UTI, from symptoms to how and why it develops.
Symptoms
Urinary tract infections can manifest as a lower UTI, which includes the bladder and urethra, or an upper UTI, including the ureters and kidneys. It can carry many names you might have heard before, such as cystitis, for lower urinary tract symptoms, or pyelonephritis, for upper urinary tract symptoms. Acute UTI is common, and while doctors frequently accurately diagnose acute UTI, recurrent UTI is much less understood despite its relatively high frequency. Thus, when an individual has two or more UTI flare-ups within six months or three or more within a year, they are defined as having a recurrent UTI.
Common symptoms of UTI include:
A constant urge to urinate
Pressure
Pain when urinating (or dysuria)
Waking up in the night to urinate (or nocturia)
Lower abdominal pain
Body aches
Chills
Nausea
Kidney pain (pain in the back below the ribs, or to either side of the spine)
Cloudy or strong-smelling urine.
Most symptoms can be broken down into four categories: frequency, urgency, voiding issues, and pain. One visitor to our website, Robin, wrote that: "The frequency of occurrence increased each year, by the summer I turned 60 I had back to back UTIs over the course of a 3 month period."
These symptoms are concerning, and can be triggered or increase in intensity from a myriad of things, including:
Hormonal changes
Sexual activity
Stress
Bowel movements
Exercise
Alcohol
Caffeine
Or even seemingly nothing at all
Factors that increase the risk of developing a recurrent UTI are hormonal changes, frequent sexual intercourse, contracting the first UTI at a young age, and a familial history of UTI. Notably, in menopausal women, lower estrogen levels can be associated with recurrent UTI, leading many older women to be more likely to experience recurrent UTI. Despite what many believe, recurrent UTI isn’t often caused by factors like poor hygiene and can happen to many people simply due to their genetics or anatomy.
The Science Behind Recurrence
E. coli is the most common pathogen behind urinary tract infections, with most infections being due to this bacteria. While this may be true, E. coli certainly isn’t the only bacteria that causes UTI, and if treated with the wrong antibiotic for the type of bacteria causing an infection, it likely will persist. Most literature as of now largely associates recurrent UTI either with reinfection–where a new pathogen causes an additional infection–or persistence, where the pathogen was never entirely erased from the bladder in the first place. However, new research has been indicating that recurrent UTI can also be caused by an underlying infection that was treated improperly and never resolved. In this case, recurrent UTI is usually due to a persistent infection rather than a reinfection.
At the end of the day, recurrent UTI is an unfortunately under-researched subject. This condition could have many causes, and not enough studies have been done to decisively pinpoint what makes recurrent UTI so common. We do have some theories–one theory is that UTI can be caused due to hormonal shifts. This could potentially explain why UTI is such a prevalent issue among older populations, as people during menopause experience a drop of estrogen in the body and the urobiome. Estrogen is anti-inflammatory and is believed to foster the good bacteria in the vagina and urobiome. While there is much left to discover about the complex nature of urinary tract infections, theories such as this can provide some clarity for the time being.
Treatment
It will likely come as no surprise that the traditional and most-applied treatment for any kind of UTI is antibiotics. Antibiotics are a complex and nuanced topic that can be lifesaving for some and simply beget side effects or even antimicrobial resistance for others. In most parts of the world, antibiotics are the frontline treatment for UTI despite their flaws.
The second line of defense against UTI is typically prophylactic methods, also known as preventative measures. More research needs to be done into preventative treatment for UTI, but there is burgeoning science that indicates positive results from the use of the type of sugar d-Mannose in place of antibiotics for UTI. Other prophylactic methods include hormonal treatments such as estrogen vaginal cream, the prophylactic use of antibiotics, or emerging vaccines in other parts of the world.
Lifestyle changes can also be recommended by doctors, but as covered earlier, since recurrent UTI can often be simply due to genetic or anatomical factors this might be a flawed suggestion, and puts undue responsibility on the patient. Much more research needs to be conducted on the effective treatment of recurrent UTI. As recurrent UTI is such a complex and wide-ranging condition, what constitutes an effective treatment option can be variable depending on the individual. There is no one-size-fits-all.
Future Outlook
Despite acute and recurrent UTI being the most diagnosed outpatient infection worldwide the lackluster education and research funding surrounding it is a consistent problem. While science has continued to progress further into the massive study of how to treat this condition, many healthcare professionals are not taught the latest research. Thus, doctors will be unaware of the complexities of this condition and can end up treating the infection ineffectively.
Doctors must trust that patients who come to them are the experts on their lived experience. For many people living with recurrent UTI, it can be challenging to find a doctor who will take their symptoms seriously. It is crucial that doctors acknowledge and treat the symptoms patients report. If bacteria is present in the patient, fast and quick action must be taken to prevent persistent infection. If there is a lack of evident bacteria on the standard testing but still an abundance of symptoms, doctors must be more willing to progress with advanced testing such as DNA and PCR tests that are readily available in the US. Overall, recurrent UTI is an extremely nuanced condition that has been under-researched despite how common it is. It is natural for many living with recurrent UTI to become frustrated with the state of the condition. Yet there is hope, at UTI Health Alliance we are part of an international collective working to spread awareness about recurrent and chronic UTI and to drive change. Together we can make it so.