UTI - chronic or recurrent

Alternative names
Urinary tract infection - chronic or recurrent

Definition
This is a disorder involving repeated or prolonged bacterial infection of the bladder or lower urinary tract (urethra).

Causes, incidence, and risk factors

Most urinary tract infections (UTI) occur in the lower urinary tract, which includes the bladder and urethra. Cystitis (lower urinary tract infection) is caused when the normally sterile lower urinary tract is infected by bacteria and becomes inflamed. Cystitis is very common.

Most of the time, symptoms of cystitis disappear within 24 to 48 hours after treatment begins. Chronic or recurrent urinary tract infection includes repeated episodes of cystitis (more than 2 in 6 months), or urinary tract infection that does not respond to the usual treatment or that lasts longer than 2 weeks.

In young girls, recurrent urinary tract infections may be an indication of a urinary tract abnormality, such as vesicoureteral reflux, and should be evaluated by a medical care provider. (In boys, even a single urinary tract infection indicates the necessity for evaluation, because urinary tract infections in boys are extremely uncommon in the absence of urinary tract abnormalities.)

The elderly population are at increased risk for developing cystitis due to incomplete emptying of the bladder associated with such conditions as benign prostatic hyperplasia (BPH), prostatitis, and urethral strictures.

Also, lack of adequate fluids, bowel incontinence, immobility or decreased mobility, having a Foley catheter, and placement in a nursing home, all place the person at increased risk for developing cystitis.

Symptoms

     
  • pressure in the lower pelvis  
  • urination, painful (dysuria)  
  • frequent need to urinate (frequency)  
  • urgent need to urinate (urgency)  
  • need to urinate at night  
  • abnormal urine color - cloudy  
  • blood in the urine (hematuria)  
  • foul or strong urine odor

Additional symptoms that may be associated with this disease:

     
  • nausea and vomiting  
  • fever  
  • fatigue  
  • fever  
  • chills  
  • mental changes or confusion (Note: In elderly people, mental changes or confusion often are the only signs of a possible urinary tract infection.)

Signs and tests

Chronic or recurrent urinary tract infection means one of the following is true:

     
  • Symptoms return two or more times in 6 months  
  • Symptoms of a single episode last longer than two weeks  
  • Symptoms last longer than 48 hours after treatment has begun

Tests that may be done include:

     
  • A urinalysis - commonly reveals white blood cells (WBC) and/or red blood cells (RBC).  
  • A urine culture (clean catch) or catheterized urine specimen - may reveal bacteria in the urine. A urine culture that is positive for more than 2 weeks even with treatment indicates chronic or recurrent UTI.  
  • An abdominal ultrasound or KUB (abdominal X-ray) - may be needed to evaluate the status of the renal system (kidneys, ureters, and bladder).

Treatment
Mild cases of acute cystitis may disappear spontaneously without treatment. However, because of the risk of the infection spreading to the kidneys (complicated UTI), treatment is usually recommended. Also, due to the high mortality rate in the elderly population, prompt treatment is recommended.

MEDICATIONS:
Antibiotics may be used to control the bacterial infection. It is imperative that you finish the entire course of prescribed antibiotics. Commonly used antibiotics include:

     
  • nitrofurantoin  
  • sulfa drugs (sulfonamides)  
  • amoxicillin  
  • cephalosporins  
  • trimethoprim-sulfamethoxazole  
  • doxycycline

Chronic or recurrent urinary tract infection should be treated thoroughly because of the chance of kidney infection (pyelonephritis). Antibiotics control the bacterial infection. They may need to be given for long periods of time (as long as 6 months to 2 years), or stronger antibiotics may be needed than for single, acute episodes of cystitis. Prophylactic low-dose antibiotics may be recommended after acute symptoms have subsided.

Phenazopyridine hydrochloride (pyridium) may be used to reduce the burning and urgency associated with cystitis. In addition, acidifying medications, such a ascorbic acid may be recommended to decrease the concentration of bacteria in the urine.

SURGERY:
Surgery is generally not needed to treat urinary tract infections.

OTHER THERAPY:
Preventive measures may reduce symptoms and prevent recurrence of infection. Keeping the genital area clean and remembering to wipe from front to back may reduce the chance of dragging bacteria from the rectal area to the urethra.

Urinating immediately after sexual intercourse may help eliminate any bacteria that may have been introduced during intercourse. Refraining from urinating for a long period of time may allow bacteria time to multiply, so frequent urination may reduce the risk of cystitis in those who are prone to urinary tract infections.

DIET:
Increasing the intake of fluids (2000 to 4000 cc per day) encourages frequent urination that flushes the bacteria from the bladder. Avoid fluids that irritate the bladder, such as alcohol, citrus juices, and those containing caffeine.

MONITORING:
Follow-up urine cultures may be necessary to ensure that bacteria are no longer present in the bladder.

Expectations (prognosis)
Most cases are cured without complication after adequate treatment. The treatment may be prolonged.

Complications

     
  • pyelonephritis  
  • kidney abscess  
  • swelling of the kidneys (hydronephrosis)

Calling your health care provider
Call for an appointment with your health care provider if symptoms of cystitis persist after treatment, or recur more than 2 times in 6 months.

Call your health care provider if symptoms worsen or new symptoms develop, especially persistent fever, back pain or flank pain, and vomiting.

Prevention
Cleanliness of the genital area may help reduce the chances of introducing bacteria through the urethra. The genitals should be cleaned and wiped from front to back to reduce the chance of “dragging” bacteria from the rectal area to the urethra.

Increasing the intake of fluids may allow urination to “flush out” the bacteria from the bladder.

Refraining from urinating for long periods of time can give bacteria time to multiply, so those prone to urinary tract infections, should urinate frequently to help reduce the risk of developing cystitis.

Long-term use of prophylactic (preventative) antibiotics may be recommended for some people who are prone to chronic or recurrent urinary tract infections.

Johns Hopkins patient information

Last revised: December 3, 2012
by Gevorg A. Poghosian, Ph.D.

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