recurrent UTI

Category	Males	Females
History	– Detailed history of urinary symptoms (frequency, urgency, dysuria, hesitancy, incomplete emptying, hematuria) – Previous episodes of UTI and treatments used. – Sexual history, frequency, new partners. – Past medical history, especially diabetes, immunosuppression, urological surgeries. – Medication history (antibiotics, medications affecting bladder function). – Lifestyle factors (hydration, hygiene practices). – Occupational exposure (dyes, benzenes, aromatic amines).	– Inquiry about urinary symptoms (frequency, urgency, dysuria, hematuria). – Detailed sexual history, contraceptive methods. – History of previous UTIs, frequency, treatments used. – Menopausal status and related symptoms. – Past medical history (diabetes, gynecological surgeries). – Medication history (antibiotics, immunosuppressive agents). – Lifestyle factors (hydration, hygiene practices, urinary habits).
Risk Factors	– Benign Prostatic Hyperplasia (BPH): Common in older males, leads to urinary retention, incomplete bladder emptying. – Prostate Infections (Prostatitis): Can cause chronic/recurrent UTIs. – Sexual Activity: Increased risk with new/multiple partners. – Chronic Diseases: Diabetes, immunosuppression. – Urinary Catheters: Indwelling catheters can be a source of infection.	– Sexual Activity: Particularly with new/multiple partners. – Contraceptive Methods: Use of spermicides, diaphragms. – Postmenopausal Status: Reduced estrogen levels increase susceptibility. – Recurrent UTIs History: Indicates predisposition to infections. < – Poor Perineal Hygiene: Contributes to recurrent infections.
Investigations	– Urinalysis and Urine Culture: Detect pyuria, bacteriuria, hematuria. – Imaging: Ultrasound (initial evaluation), CT Urogram (complicated UTIs/suspected malignancies), X-ray KUB (radio-opaque stones). – Cystoscopy: Identify bladder pathologies. – Blood Tests: Renal function tests (BUN, creatinine), CBC, PSA test for men over 50. – Specialized Tests: VCUG, urodynamic studies.	– Urinalysis and Urine Culture: Detect infections, hematuria. – Imaging: Ultrasound (initial evaluation, especially in younger patients), CT Urogram (older patients or those with risk factors for malignancy). – Cystoscopy: Diagnose bladder pathologies. – Blood Tests: Renal function tests, CBC. <br> – Specialized Tests: VCUG, urodynamic studies.
Management	– Antibiotic Therapy: – First-Line: Nitrofurantoin 100 mg twice daily for 5-7 days, Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 3 days. – Second-Line: Fosfomycin 3 g single dose, Ciprofloxacin 250-500 mg twice daily for 3 days (reserved for complicated cases). – Non-Antibiotic Measures: Increased fluid intake, proper hygiene practices. – Preventive Measures: Post-coital antibiotics for infections related to sexual activity, prophylactic low-dose antibiotics for recurrent infections. – Referral to Specialists: Urologist for structural abnormalities, recurrent UTIs, suspected malignancies; Nephrologist for renal impairment, glomerulopathies. – Surgical Interventions: For anatomical abnormalities causing recurrent UTIs.	– Antibiotic Therapy: – First-Line: Nitrofurantoin 100 mg twice daily for 5-7 days, Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 3 days. – Second-Line: Fosfomycin 3 g single dose, Ciprofloxacin 250-500 mg twice daily for 3 days (reserved for complicated cases). – Non-Antibiotic Measures: Increased fluid intake, cranberry products, probiotics. – Preventive Measures: Post-coital antibiotics for sexually active females with recurrent UTIs, topical estrogen in postmenopausal women. – Referral to Specialists: Urologist for persistent or complicated UTIs; Nephrologist for suspected glomerulopathies, renal impairment. – Surgical Interventions: For anatomical abnormalities contributing to recurrent infections.

Common Etiologies

Infectious Causes

1. Bacterial Infections:
   • Escherichia coli (E. coli): The most common cause of UTIs in both males and females. It accounts for approximately 70-95% of UTI cases​​.
   • Other Enterobacteriaceae: Such as Klebsiella, Proteus, and Enterobacter species.
   • Enterococcus faecalis: Especially in complicated UTIs and those associated with indwelling catheters​​.
   • Staphylococcus saprophyticus: Common in sexually active young women.
2. Fungal Infections:
   • Candida species: Particularly in immunocompromised individuals or those with indwelling catheters.

Anatomical and Functional Abnormalities

1. Vesicoureteral Reflux:
   • A condition where urine flows backward from the bladder to the kidneys, leading to recurrent infections.
2. Obstruction:
   • Urolithiasis (Kidney Stones): Stones can cause obstruction and recurrent infections.
   • Benign Prostatic Hyperplasia (BPH): In men, can lead to incomplete bladder emptying and recurrent UTIs​​​​.
   • Urethral Strictures: Narrowing of the urethra due to scarring or injury.
3. Neurogenic Bladder:
   • Impaired bladder function due to neurological conditions, leading to incomplete emptying and recurrent infections.

Behavioral and Lifestyle Factors

1. Sexual Activity:
   • Increased sexual activity can introduce bacteria into the urinary tract, especially in women.
2. Poor Hygiene Practices:
   • Improper wiping techniques or infrequent urination can lead to bacterial growth and infections.
3. Use of Certain Contraceptives:
   • Diaphragms and spermicides can increase the risk of UTIs in women​​.

Medical Conditions

1. Diabetes Mellitus:
   • High blood sugar levels can lead to increased susceptibility to infections due to immune system impairment.
2. Immunosuppression:
   • Conditions like HIV/AIDS or immunosuppressive therapy (e.g., for organ transplants) increase the risk of recurrent UTIs.
3. Chronic Kidney Disease:
   • Patients with renal impairment are at higher risk of recurrent infections.
4. Postmenopausal Status:
   • Decreased estrogen levels in postmenopausal women can lead to changes in the urinary tract that increase infection risk​​.

Medical Procedures

1. Indwelling Catheters:
   • Long-term catheter use is a significant risk factor for recurrent UTIs due to bacterial colonization​​.
2. Recent Urological Procedures:
   • Procedures such as cystoscopy or catheterization can introduce bacteria into the urinary tract.

History

1. Detailed Medical History:
   • Sex and Age: Males and females have different predisposing factors, with females generally at higher risk.
   • Symptoms: Frequency, dysuria, urgency, hesitancy, incomplete emptying, and hematuria.
   • Past Medical History: Previous UTIs, urological surgeries, diabetes, immunosuppression.
   • Medications: Use of antibiotics, immunosuppressants, or medications affecting bladder function.
   • Lifestyle Factors: Sexual activity, contraceptive methods (e.g., diaphragms), hygiene practices.
   • Occupational Exposure: Contact with dyes, benzenes, or aromatic amines.
   • Family History: History of urinary tract abnormalities or urological malignancies.
2. Risk Factors:
   • Female-Specific:
     • Sexual activity.
     • Use of spermicides or diaphragms.
     • Menopause leading to decreased estrogen levels.
   • Male-Specific:
     • Benign prostatic hyperplasia (BPH).
     • Prostate infections or inflammation.
   • Common to Both:
     • History of recurrent UTIs.
     • Presence of urinary catheters.
     • Structural abnormalities in the urinary tract.
     • Chronic illnesses like diabetes.

Red Flags and Differential Diagnoses for Recurrent UTIs

Red Flags	Differential Diagnoses
Males and Females:	– Urinary Tract Infections: Common pathogens include E. coli, Klebsiella, Proteus, Enterococcus.
– Gross or persistent microscopic hematuria.	– Urolithiasis (Kidney Stones): Causes hematuria, pain, recurrent infections.
– Systemic symptoms (fever, chills, malaise, flank pain).	– Bladder Cancer: Persistent hematuria, irritative urinary symptoms.
– Weight loss, night sweats.	– Renal Cell Carcinoma: Hematuria, flank pain, palpable mass.
– Significant abdominal or flank pain.	– Prostate Cancer: Elevated PSA, hematuria, lower urinary tract symptoms in advanced stages.
– Recurrent UTIs despite treatment.	– Benign Prostatic Hyperplasia (BPH): Urinary retention, frequency, urgency.
– High-risk patient profiles (diabetes, immunosuppression).	– Interstitial Cystitis: Chronic pelvic pain, urgency, frequency.
– Men with UTIs (often indicates underlying pathology).	– Vesicoureteral Reflux: More common in children, young adults.
	– Anatomical Abnormalities: Urethral strictures, diverticula.
	– Chronic Pyelonephritis: Recurrent kidney infections, renal scarring.
	– Sexually Transmitted Infections (STIs): Gonorrhea, chlamydia causing urethritis, cystitis-like symptoms.

Hematuria: Gross or persistent microscopic hematuria can indicate underlying malignancies or severe infections.

Systemic Symptoms: Fever, chills, malaise, and flank pain suggest pyelonephritis or systemic infection.

Weight Loss and Night Sweats: Potential indicators of malignancy, such as bladder or kidney cancer.

Significant Abdominal or Flank Pain: Can indicate kidney stones or more serious conditions like renal abscess.

Recurrent UTIs Despite Treatment : May suggest anatomical abnormalities, resistant organisms, or underlying diseases.

High-Risk Patient Profiles: Patients with diabetes, immunosuppression, or known anatomical abnormalities.

Men with UTIs: UTIs are uncommon in men and often indicate an underlying pathology such as prostatitis or obstructive uropathy.

Differential Diagnoses

1. Urinary Tract Infections:
   • Common pathogens include E. coli, Klebsiella, Proteus, and Enterococcus species.
2. Urolithiasis (Kidney Stones):
   • Can cause hematuria, pain, and recurrent infections due to obstruction and irritation.
   • Symptoms include severe flank pain, nausea, and vomiting.
3. Bladder Cancer:
   • Persistent hematuria, especially in smokers or those with occupational exposure to chemicals.
   • May present with irritative urinary symptoms.
4. Renal Cell Carcinoma:
   • Hematuria, flank pain, and a palpable mass may be present.
   • Weight loss and systemic symptoms in advanced cases.
5. Prostate Cancer:
   • Elevated PSA, hematuria, and lower urinary tract symptoms in advanced stages.
   • May present with back pain or bone pain in metastatic disease.
6. Benign Prostatic Hyperplasia (BPH):
   • Common in older males, presenting with urinary retention, frequency, and urgency.
   • Can lead to recurrent infections due to incomplete bladder emptying.
7. Interstitial Cystitis:
   • Chronic pelvic pain, urgency, frequency, and discomfort in the absence of infection.
   • Often diagnosed by exclusion after ruling out other causes.
8. Vesicoureteral Reflux:
   • More common in children and young adults.
   • Recurrent UTIs due to retrograde flow of urine from the bladder to the kidneys.
9. Anatomical Abnormalities:
   • Urethral strictures, diverticula, or congenital anomalies can lead to recurrent infections.
   • Diagnosed with imaging and endoscopic evaluations.
10. Chronic Pyelonephritis:

• Often results from recurrent kidney infections.
• Associated with renal scarring and impaired kidney function.

11. Sexually Transmitted Infections (STIs):

• Gonorrhea and chlamydia can cause urethritis and cystitis-like symptoms.
• Diagnosed with specific STI testing and treated accordingly.

Investigations

1. Urinalysis and Urine Culture:
   • To detect pyuria, bacteriuria, and hematuria.
   • Urine culture to identify the causative organism and antibiotic sensitivity.
2. Imaging:
   • Ultrasound: Initial evaluation to identify structural abnormalities.
   • CT Urogram: In cases of complicated UTIs or suspected urological malignancies.
   • X-ray KUB (Kidneys, Ureters, Bladder): For detecting radio-opaque stones.
3. Cystoscopy:
   • Recommended in recurrent UTIs to identify bladder pathologies, particularly in patients with hematuria or abnormal imaging findings.
4. Blood Tests:
   • Renal Function Tests: Blood urea nitrogen (BUN) and creatinine levels.
   • Complete Blood Count (CBC): To check for anemia or signs of infection.
   • Prostate-Specific Antigen (PSA): In men over 50 years to screen for prostate cancer.
5. Specialized Tests:
   • Voiding Cystourethrogram (VCUG): To evaluate vesicoureteral reflux.
   • Urodynamic Studies: To assess bladder function, especially in patients with neurogenic bladder.

Management

1. Antibiotic Therapy:
   • Empirical Antibiotic Therapy: Initiate based on clinical guidelines and local antibiogram.
   • Specific Antibiotic Regimen:
     • First-Line:
       • Nitrofurantoin: 100 mg twice daily for 5-7 days.
       • Trimethoprim-sulfamethoxazole: 160/800 mg twice daily for 3 days.
     • Second-Line:
       • Fosfomycin: 3 g single dose.
       • Ciprofloxacin: 250-500 mg twice daily for 3 days (reserve for complicated cases).
2. Non-Antibiotic Measures:
   • Hydration: Increased fluid intake to flush out bacteria.
   • Cranberry Products: May reduce recurrence in some patients.
   • Probiotics: To restore normal vaginal flora in women.
3. Preventive Measures:
   • Post-Coital Antibiotics: Single-dose antibiotic after intercourse for sexually active females with recurrent UTIs.
   • Topical Estrogen: In postmenopausal women to reduce UTI recurrence.
4. Referral to Specialists:
   • Urologist: For patients with structural abnormalities, recurrent UTIs, or suspected urological malignancies.
   • Nephrologist: For patients with evidence of glomerulopathy or renal impairment.
5. Surgical Interventions:
   • For correcting anatomical abnormalities contributing to recurrent UTIs.
6. Lifestyle and Behavioral Modifications:
   • Emphasize proper perineal hygiene.
   • Avoid irritants such as spermicides.

Follow-Up

• Monitoring: Regular follow-up with urinalysis and culture to ensure resolution of infection.
• Long-Term Management: Address underlying causes to prevent recurrence.

For a comprehensive approach to managing hematuria and recurrent UTIs, refer to the detailed guidelines provided by the RACGP:

References

• RACGP – What to do about recurrent urinary tract infections
• RACGP – Haematuria in the general practice setting
• RACGP – Macroscopic haematuria – a urological approach