A urinary tract infection (UTI) that keeps coming back or never fully resolves is called a recurrent UTI. This frustrating condition affects many women, who bear the brunt of UTIs. About 25-30% of women who have a first UTI will go on to have recurrent infections. While UTIs can happen to anyone, there are some risk factors that make women more prone to getting them. Understanding why some UTIs recur and what can be done to prevent repeat infections is helpful for women plagued by this problem.
What is a recurrent UTI?
A recurrent UTI is defined as 3 or more UTIs within a 12-month period, or 2 confirmed UTIs within 6 months. Some key features of recurrent UTIs include:
- Infections that seem to resolve but then quickly return with the same symptoms
- Repeated infections with the same bacterial strain
- Negative urine cultures between symptomatic episodes
- Infections that never fully clear with standard antibiotic treatment
While each separate infection may resolve temporarily, the culprit bacteria are never fully eradicated from the urinary tract. This allows the infection to keep returning.
What causes recurrent UTIs?
There are several possible causes of recurrent UTIs:
Anatomical abnormalities
Abnormalities in the urinary tract that prevent complete emptying of the bladder or allow urine to back up and pool can predispose women to repeat infections. Examples include:
- Blockages from kidney stones, tumors, an enlarged prostate, or bladder diverticula (small pouches that form and collect urine).
- Bladder prolapse, where loss of pelvic muscle support causes the bladder to sag and not fully empty.
- Urethral strictures that obstruct urine flow.
- Vesicoureteral reflux, where urine flows backwards from the bladder up towards the kidneys.
Treating any anatomical problems can help reduce recurrent UTI risk.
Menopause
After menopause, lower estrogen levels lead to thin bladder walls and vaginal lining. This makes it easier for bacteria to adhere and cause infections. Women may notice UTIs becoming more frequent after menopause.
Birth control methods
Use of diaphragms and spermicides can increase recurrent UTI risk. The device puts pressure on the urethra, obstructing urine flow. Chemical spermicides can also irritate the vagina and urethra, making it easier for bacteria to invade.
Urinary catheters
Indwelling Foley catheters used for urine drainage or management of urinary retention put patients at high risk for recurrent UTIs. Bacteria can gain access up the catheter and establish stubborn infections. Catheter removal is advised when feasible.
Genetic factors
There are some inherited genes that can make certain women more prone to UTIs. Researchers have identified UTI risk genes related to the immune system that make it harder for some women’s bodies to fight off infections.
Intestinal bacteria
E. coli from the intestinal tract is the primary cause of UTIs. Women prone to UTIs may have intestinal bacteria that are more adept at colonizing the urinary tract. Recurrences may be due to the virulence of their gut bacteria.
Prior antibiotic use
Previous courses of antibiotics can put women at higher risk for recurrent UTIs. This is because antibiotics kill off the normal protective bacteria in the vagina and bowel. Without these good bacteria, it’s easier for pathogens like E. coli to take over and dominate, leading to repeat infections.
Why do some UTIs keep recurring?
When UTIs recur, it’s often because the bacteria have some tricks that help them hide out in the bladder and evade antibiotics. Here are some of the ways they survive:
Forming biofilm
Bacteria that make biofilm are protected by a tough, slimy barrier. This allows them to become resistant to immune system attacks and antibiotics. Biofilms attach to the bladder wall and urinary catheters. They can’t be fully eradicated with antibiotics and provide a reservoir for repeat UTIs.
Becoming dormant
Some UTI bacteria turn dormant and avoid being killed off by antibiotics. They stop replicating until antibiotic exposure is gone. Then dormant bacteria switch back on and seed another infection. Short antibiotic courses may not be long enough to fully eliminate dormant bacteria.
Hiding within bladder cells
Intracellular bacterial communities (IBCs) form when bacteria burrow into the bladder cells lining the inside of the bladder wall. Safely inside bladder cells, bacteria can avoid antibiotics and the immune system while continuing to multiply until they burst out and cause recurrent infection.
Forming bacterial reservoirs
Bacteria can hide out long-term in tissues near the bladder. The prostate gland in men or the vaginal walls in women provide ideal bacterial reservoirs. Here they lay low until antibiotics are done before spreading and causing repeat infections.
Recurrent UTI symptoms
The symptoms of a recurrent UTI are the same as what you would feel with an initial infection. Typical UTI symptoms include:
- A strong urge to urinate frequently
- A burning sensation or pain when urinating
- Passing only small amounts of urine
- Cloudy, dark, bloody, or strange smelling urine
- Pressure or pain in the lower abdomen or pelvis
- Low back pain
Sometimes recurrent infections may produce milder symptoms than the initial UTI. But any return of these complaints warrants checking in with your doctor for evaluation. Catching recurrences quickly can help prevent complications.
Complications
Recurrent UTIs can lead to more serious problems if not treated promptly:
- Kidney infection (pyelonephritis) – Bacteria travel from the bladder up to infect one or both kidneys. Symptoms include high fever, shaking chills, flank pain, nausea and vomiting.
- Sepsis – UTIs that spread to the bloodstream can cause life-threatening sepsis. Seek emergency care for fever, rapid heart rate, rapid breathing, confusion, or extreme pain.
- Kidney damage – Recurrent kidney infections can permanently scar kidney tissues, leading to impaired function, high blood pressure, and kidney failure.
Stopping the cycle of repeat infections through preventive measures is important to avoid complications.
Who is at risk for recurrent UTIs?
While any woman can get recurrent UTIs, the following factors increase risk:
- Sexual intercourse – Additional friction and fluid exchange introduces more bacteria.
- Use of spermicides or diaphragms – Alters vaginal environment and obstructs urinary flow.
- A new sex partner – Exposure to unfamiliar bacteria.
- Menopause – Declining estrogen thins urinary tract tissues.
- History of previous UTIs – Likelihood of recurrence is greater.
- Kidney stones or other urinary obstructions.
- Urinary catheters or instrumentation like cystoscopy procedures.
- Urinary incontinence or difficulty emptying bladder completely.
- Family history – Susceptible genetic factors.
- Bowel incontinence – Bacteria from the rectum can enter the urethra.
- Anatomical defects – Example: vesicoureteral reflux.
- Spinal cord injury or neurological disease – Impaired bladder emptying.
Talk to your doctor if you have any of these UTI risk factors. Extra prevention strategies may be warranted.
When to see a doctor
You should be evaluated if:
- You have had 3 or more culture-confirmed UTIs in one year.
- You experience 2 UTIs in a 6 month period.
- Symptoms don’t improve within 48 hours of starting antibiotic treatment.
- Infections keep returning within weeks of finishing antibiotics.
- UTI symptoms recur frequently but urine cultures are negative.
- You develop a high fever, chills, nausea, vomiting, or back/side pain.
- You see blood in your urine.
Seeking prompt care rather than trying to self-treat recurrent infections is advised. Your doctor can assess for complicating factors and help get to the bottom of why UTIs keep plaguing you.
Diagnosing recurrent UTIs
To diagnose recurrent UTIs, your physician will:
- Take a medical history – Discuss your symptom patterns, sexual habits, bowel and bladder function, other medical conditions, and prior UTI treatments.
- Conduct a physical exam – Abdominal palpation to check for bladder distension, pelvic exam to assess vaginal and cervical discharge, neurological assessment of lower body.
- Order urine testing – Urinalysis and urine culture to confirm infection and identify bacteria. May require mid-stream clean catch, catheterized specimen, or straight catherization for optimal uncontaminated sample.
- Image the urinary tract – Ultrasound, CT scan or MRI to check for obstructions, stones, diverticula, or other anatomical abnormalities.
- Perform cystoscopy – Insert tubular camera into the urethra and bladder to visually inspect for lesions, masses, calculi, or strictures.
- Assess bladder function – Post-void residual urine volume checked with ultrasound to see if bladder empties completely.
- Culture urine between symptomatic episodes – Helps determine if infection is ever fully eradicated versus going dormant then flaring up again.
Identifying any structural or functional factors contributing to recurrence allows appropriate management.
Urine culture interpretation
Urine cultures are key to diagnosing recurrent UTIs. However, interpretation may be tricky when prior antibiotics have been used. It helps to understand how to make sense of culture results.
- A negative culture during symptoms suggests the previous UTI was adequately treated but something else is causing similar complaints.
- A positive culture during symptoms confirms a true recurrent infection.
- The same bacterial species repeatedly isolated indicates persistence, not recurrence. Antibiotics failed to eradicate it fully.
- Different bacterial species may mean reinfection with new bacteria before old infection was cured or contamination during specimen collection.
- Low colony counts may indicate resolving infection or contamination. Higher colony counts are more indicative of true infection.
- Candida in the culture suggests recent antibiotics removed protective bacteria, allowing fungal overgrowth.
Culture confusion can be cleared up by careful scrutiny of urine collection methods and assessing the clinical scenario.
Treatments for recurrent UTIs
Several treatment strategies for recurrent UTIs may be used alone or in combination:
Prolonged antibiotic courses
Short 1-3 day antibiotic regimens often fail to fully resolve recurrent infections. Longer 7-10 day treatments are more effective.
Urinary antiseptics
Methenamine salts like hiprex form formaldehyde in urine, which prevents bacterial growth. This may be used for UTI prevention.
Suppressive antibiotics
A low dose antibiotic taken daily or post-coital can prevent recurrent infections. Nitrofurantoin, cephalexin, and trimethoprim-sulfamethoxazole are commonly used.
Topical vaginal estrogen
Estrogen cream or tablets can rebuild vaginal tissues to help fight off infections. However, systemic absorption can occur.
Probiotics
Oral lactobacillus restores protective vaginal flora imbalance caused by antibiotics. May help reduce recurrences.
Cranberry products
Some data suggests cranberry’s D-mannose blocks bacterial adhesion in urine. Shown to be mildly beneficial as a supplement.
Bladder training
Habits to fully empty the bladder and urinate at regular intervals can be helpful for chronic UTI patients. Reduces urine pooling where bacteria multiply.
Urinary catheters
If catheters are required, using silver or nitrofurazone-coated types may help reduce biofilm and encrustation.
Surgery
Correcting any anatomical defects like obstruction or reflux may be curative. Denervation surgery is sometimes done for neurogenic bladder.
| Treatment | How It Works |
| Prolonged antibiotic courses | Ensure the infection is fully eradicated, prevents dormant bacteria from persisting |
| Urinary antiseptics | Prevent bacterial growth in urine |
| Suppressive antibiotics | Prevent colonization of bacteria between infections |
| Topical vaginal estrogen | Thickens vaginal lining to impede bacterial entry |
| Probiotics | Restore normal vaginal flora to discourage pathogenic bacterial growth |
| Cranberry products | May reduce E. coli adherence to bladder wall |
| Bladder retraining | Regular voiding flushes bacteria from bladder |
| Antiseptic catheters | Reduces biofilm formation in catheterized patients |
| Surgery | Removes obstructions, repairs reflux, improves bladder emptying |
Preventing recurrent UTIs
To help avoid repeat infections:
- Drink plenty of fluids to flush out bacteria.
- Urinate before and after intercourse.
- Take showers instead of baths.
- Wipe front to back after using toilet.
- Avoid tight pants, nylons, wet bathing suits.
- Don’t use diaphragm or spermicides for birth control.
- Consider topical estrogen therapy after menopause.
- Take probiotic supplements to boost good bacteria.
- Consider daily prophylactic antibiotics if other measures fail.
- Have any urinary tract abnormalities or dysfunction corrected.
Prevention is key to breaking the cycle of recurrent UTI misery. Work with your urologist to find the optimal prevention plan for your situation.
Outlook for recurrent UTIs
For many women afflicted with repeat infections, the right combination of preventive steps and UTI treatments can significantly improve quality of life. Identifying and addressing any correctable risk factors is the first priority. Then, working with your doctor to tailor UTI prevention and management strategies to your needs offers the best chance of overcoming bothersome recurrent infections.
Conclusion
Recurrent UTIs are a common and frustrating problem for many women. These repeat infections happen when bacteria hiding out in the bladder or urinary tract repeatedly seed new infections before the prior one is fully cured. There are several theories for why UTIs can recur, including bacterial tricks that allow them to form reservoirs and avoid eradication. Diagnosis involves urine testing and exclusion of any anatomical abnormalities that may contribute to recurrence. Various therapies are employed to treat the acute infection, reduce recurrence risk, and prevent complications like kidney damage. Women plagued by recurrent UTIs can be reassured that there are many effective options to curb this problem, once the underlying causes are identified. Working closely with your healthcare provider and urologist will yield the best results for breaking the cycle of recurrence and getting back to normal urinary health.