Recurrent Urinary Tract Infections (UTIs) in females


30 to 50% of adult women will suffer with a UTI in their lifetime. 

Of these 25% of women will have a second infection within 6 months.~2.5% of women will have recurrent urinary infections  

Symptoms and Signs

∙ Urinary frequency (often one feels the need to go and only few drops are passed), urine (burning or stinging, foul smelling, cloudy), and lower abdominal pain 

∙ Fever, tiredness, chills and rigors 

∙ If the infection goes up to the kidney one may experience loin pain, fever and nausea 

Risk factors that lead to infection.

▪ Lack of adequate fluid intake 

▪ Poor hygiene techniques 

▪ Menopause leads to vaginal atrophy (thinning) 

▪ Antibiotics reduce the natural bacteria of the vagina that prevent colonisation by other bacteria 

▪ Weakness of the natural defences due to reduced antibody (IgA and IgG antibodies), and reduced glycosamine glycan (GAG) layer which typically acts as a barrier to bacteria in the bladder.  

▪ Incomplete bladder emptying 

▪ A weak immune system secondary to diabetes (especially uncontrolled), certain medication and. other cause

▪ Indwelling catheters

What to do if you suffer from UTI/s

Test the urine at your GP/Pharmacist/Urologist – by performing a dipstick urine test. Urine testing positive for nitrites and leukocytes must be sent for culture and sensitivity. Knowing the bacteria that are causing the infection is key to tailoring the antibiotic choice. Refrain from blind repeated antibiotic treatment as this leads to antibiotic resistance. In addition one needs to make sure that there is confirmation of a UTI as there are certain conditions like interstitial cystitis that mimic such condition. Have your urine always checked. 

What type of courses of antibiotics one can be given:

In the acute setting, the doctor will prescribe 3 to 5 day antibiotic course.  

∙ Single dose post intercourse antibiotics can be prescribed for those that UTIs are precipitated by sexual intercourse.  

∙ Urologists are refraining from the traditional prophylactic daily prescribing of antibiotics due to mounting of antibiotic resistance.

Drink plenty of fluids. Look at the colour of your urine; it should be very light  yellow if it is not you are not drinking enough. Fluid intake should be spread  throughout the day. The idea is to flush the bacteria continuously. 

Perform good hygiene practices (after emptying the bladder women should wipe  front-to-back). Empty the bladder before and after sexual intercourse) ∙ 

Avoid using products that lead to vaginal dryness such as spermicidal contraceptives, diaphragms, vaginal douching, perfumed bubble bath, soap or talcum  powder around your genitals. Use plain, unperfumed varieties, and have a shower  rather than a bath 

Attain regular bowel habits. Avoid long periods of constipation. ∙ 

Wear cotton underwear and wash underwear without fabric softener as this  damages the fibres. 

Keep an infection diary looking for patterns that are leading to recurrent infections  like stressful situations or sexual intercourse or period or long distance travelling with  period of dehydration etc) 

∙ Have regular intake with natural yogurt with live bacteria during the week. Data  is weak. 

Intravaginal application of natural yogurt with live bacteria three times a week.  Especially in post menopausal women or those that experience thinning of the vaginal  layer secondary to medications/medical conditions. This can be alternative to those  who cannot be prescribed local oestrogen treatment. Data is weak. 

D-Mannose 2g daily (either powder or tablet form). This is a non prescription item. It  may cause bloating or loose stools. If it does simply decrease the dose. It works by  binding to the finger projections of bacteria preventing them to anchor to the bladder  lining. When one empties the bladder the bacteria are flushed out.

If conservatives measures fail; your doctor may  

recommend the following: 

Methenamine hippurate (Hipprex) has antibacterial activity because the methenamine is converted to formaldehyde – an antiseptic and Hippuric acid, keeps the urine acid. Typically this is active against E. coli, enterococci and staphylococci and less effective to Enterobacter species. This is prescribed 1G twice daily on a long term basis. The evidence base for this remains poor. 

Oestrogen typically prescribed in postmenopausal females to address the thinning of the  vaginal layer to regain back the natural defences against the bacteria coming from the gut.  This can be prescribed either as oestrogen cream or pessaries. Oestrogen creams can cause  local irritation but systemic absorption and effect is minimal. These are contraindicated in  patients with a history of breast cancer and known or suspected oestrogen-dependent  malignant tumours (such as endometrial cancer). 

Additional investigations: ultrasound of your urinary tract looking for anatomical  variations, stones, incomplete bladder emptying and other factors leading to recurrent  infections. A camera test, known as flexible cystoscopy, to look at the water pipe (urethra)  and bladder inner lining to exclude anatomical reasons leading to recurrent infections. Bladder Instillations with Hyaluronic. The inner layer of the bladder has cells that are  connected tightly to each other to prevent bacterial invasion. This is referred as  glycosaminoglycan (GAG) layer. Instilling hyaluronic acid (HA) and chondroitin sulfate  (CS) aims to boosts the glycosaminoglycan (GAG) layer on the surface of the bladder,  

providing a protective layer. The instillations are typically given once a week for 4 weeks  then once monthly for 6 months. 

Mr E Calleja 

M.D., M.R.C.S.,F.E.B.U., ChM (Urology), F.R.C.S. (Urology) 

Urology Consultant with special interest in robotic pelvic surgery (UK) Prostate Cancer Clinical Champion 

GMC UK: 7487930 Med Reg MLT: 2928 





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