Anasayfa » Preventing Recurrent Urinary Tract Infections (UTI)
UTIs can affect any part of the urinary tract. Most UTIs are caused by bacteria that enter the urethra and then the bladder. This can lead to infection somewhere in the urinary tract. Women are especially prone to UTIs for anatomical reasons, but men and children can also get them. Because UTIs are so common, many people are familiar with the traditional treatment for them. In young, otherwise healthy girls, recurrent infections are more likely to be linked to poor toilet and sanitary hygiene, and girls whose infections are related to constipation should be diagnosed and subsequently managed so that the constipation is also resolved.
Urinary tract infections (UTIs) are infections in any part of the urinary system. They are a common health problem that affects millions of people each year. The urinary tract is a system made up of:
Urinary tract infections (UTIs) are a common type of infection. They happen when germ-containing bacteria get into the opening of the urethra and go upwards, causing inflammation of the lower urinary tract (urethra and bladder = cystitis). There, they can cause symptoms including a strong or urgent need to urinate, pus or blood in the urine, pain or burning with urination, and pain above the pubic bone or the perineum. UTIs may extend to the upper urinary tract which consists of the ureters and the renal pelvis, potentially causing pyelonephritis, septicemia, and death. Women experience UTIs more frequently than men. In the United States, about 11 million people yearly need to see a medical doctor because of symptoms related to a lower UTI (also called “acute uncomplicated,” or reflex, cystitis; formal term: Acute Uncomplicated Cystitis in Otherwise Healthy Persons). If the treatment was partial or inappropriate, lower UTIs may recur. Frequent recurrence of cystitis or upper UTIs is distressing and costly.
Cystitis is most often the result of an ascending bacterial infection – bacteria spread from the perianal area to the vagina, and then to the urethra and bladder. If the immune system is weakened for any reason, the infection may spread directly from the perianal area to the bladder. In postmenopausal women who develop atrophic vaginitis due to estrogen deficiency, a higher pH level in the vagina encourages the growth of E. coli and other uropathogens. Incomplete urination can also cause cystitis. Some people, particularly women, do not thoroughly empty the bladder during urination. This inefficient voiding leaves a substantial quantity of urine within the bladder, providing an environment conducive to the multiplication of bacteria. Such individuals may also be unable to recognize the signs and symptoms when they need to urinate, or they may have a decreased sensation of a full bladder. Infrequent voiding normally means a large volume of urine is present. The combination of low urinary output and a high residual volume is conducive to stagnant urine. Women who are pregnant may also experience increased cystitis due to hormonal changes that relax the muscles of the ureters and the bladder, making it easier for bacteria to travel and colonize the bladder. In young, healthy women, sexual activity is a common cause of cystitis, as it can cause bacteria in the vaginal and anal areas to be pushed into the urethra. Women with diabetes or a compromised immune system are more susceptible to cystitis.
UTIs have different names depending on where they occur. The most common type, affecting the urethra and the bladder (the lower urinary tract), is called cystitis. When a UTI leads to an infection in the kidneys (the upper urinary tract), the condition is known as pyelonephritis.
Different risk factors have been identified for men and women. Women are much more likely to suffer from UTIs for several reasons. For example, the female urethra is about 4cm long, whereas a male’s can be around 20cm long. The female urethra is much shorter than that of a male, which can allow bacteria to enter the bladder more easily. Women have a short urethra and are more likely to be colonized in their lower gastrointestinal and genital tracts when compared with men. Women get UTIs more often than men and small children, and each year, more than 50% of women of reproductive age report at least 1 UTI. Two factors have been associated with recurrent cystitis with or without pyelonephritis: first, the presence of pelvic organ prolapse, and second, an increase in plasma hyaluronic acid concentration. Metabolic abnormalities such as renal calculi and hypercalciuria have a significant effect on the development of UTIs. Hypercalciuria raises the odds of UTI recurrence seven times higher than in patients without hypercalciuria.
Identifying risk factors for recurrent UTIs can help us optimize treatment for individual patients. If we understand that a patient has certain factors which raise the likelihood of developing recurrent UTIs, we can address these factors and, where possible, modify them to reduce the chances of recurrent infections. In this way, we aim to develop a personalized approach to the management of recurrent UTIs. There are various risk factors for a higher likelihood of developing recurrent UTIs. These have been well documented through decades of research. Other groups of patients will also have a higher chance of getting UTIs and will require adaptations to their antibiotic therapy.
Nulliparous women have more UTIs than parous women. It has also been suggested that the high incidence of UTIs in childhood is related to the shortness of the female urethra, and that the lengthening of the urethra in late childhood and early teenage life is related to the relative scarcity of UTI. A further reduction in the frequency of UTIs in women, as compared with children, may be due to the effects of pregnancy and childbirth. Whereas both sexes have the same number of urethral glands at birth, the number increases after 12 weeks gestation in males and after 16 weeks in females. The two stages of the process of development include production of solid cords by the glandular buds, and canalization to form a lumen. Consequently, at birth, many female glands are probably in the burst stage, and their lack of function favors UTIs in males and family in childhood.
There are a number of overlapping factors which place the woman at risk of further symptomatic infection. These include anatomical factors such as a short urethra, poor perineal hygiene, sexual activity, and use of diaphragms and spermicides, together with changes at the time of menopause, such as vulval, urethral, and vesical atrophy. Inadequate urine volume, protein intake, or estrogen levels will predispose to infection, coupled with the energy drained or stressed patient.
Most contraceptive methods, such as diaphragms, are associated with an increased risk of UTI. Diaphragm use is clearly associated with an increased risk of UTI. Among spermicides, nonoxynol 9 and other agents with antimicrobial properties can further increase the risk of UTIs. The use of nonoxynol was associated with an increased risk of genital tract infections in a study of indigent women in the United States, and is known to disrupt the normal vaginal flora. In a Danish study of 241 healthy, sexually active women, combined use of a diaphragm and spermicide was associated with an 8.6-fold increase in UTI risk compared to women who used no method of contraception.
It is well recognized that sexual activity increases the risk of developing a urinary tract infection for susceptible women. Some studies have estimated that sexual activity is the single most important risk factor for acute community-acquired UTI. Indeed, some women develop UTI after every instance of sexual activity. In a study of premenopausal women with a history of recurrent UTI, 81% reported that sexual intercourse was a predisposing factor for UTI. Men with no apparent signs or symptoms of urethritis are also known to expose women partners to a higher risk of developing a urinary tract infection. However, urine and midstream urine are virtually always free of bacteriuria, suggesting that upper urinary tract infections are not initiated by organisms that ascend the urethra.
If you have frequent UTIs, your provider may suggest some of the following strategies to help prevent a UTI:
– A longer course of antibiotics when you feel symptoms of a UTI, especially if you are experiencing more than two UTIs in a year. This may be in the form of a delayed prescription, which you can fill if symptoms don’t get better in a specific amount of time.
– Continuous low-dose antibiotic treatment for 6 months or longer.
– A single-dose post-intercourse antibiotic prophylaxis.
– Vaccines or immunotherapy (such as estrogen therapy).
– Probiotics, especially for people who have three or more UTIs in 1 year. These products can restore the balance of bacteria in the urinary tract. The right type of bacteria can help fight off infections.
– Tactics such as hydration, diet, wiping front to back, and bathroom habits may also help reduce recurrent UTIs. Make sure that you continue to see your healthcare provider for regular checkups. Your doctor can help determine the right course of treatment and preventive measures for your particular situation.
Considerations:
Proper handwashing can be difficult for some people with the interrelated problems of arthritis or incontinence. Options:
– Encourage the use of liquid or foam washes because a soap bar is hard to grasp and rub.
– Suggest moistened towelettes (although as a healthcare professional, this recommendation may be contraindicated, check agency policy).
– Have someone help the individual wash their hands.
– If disposable gloves are used, professionals should assess how they might be recontaminated and when they should be discarded. Caregivers must wash their hands after removing the gloves.
Practicing good hygiene is problematic due to the differing abilities of individuals. Nonetheless, some basic hygienic practices can aid in the prevention of UTI. These are especially important if an individual has urinary incontinence, is catheterized with a long-term catheter, has urinary incontinence appliances (e.g. pads or panty liners), or requires urinary catheterization. Handwashing both before and after visiting the toilet, and after bathing appear to be more important than other commonly suggested practices. Although studies show that improved personal hygiene reduces UTI, the evidence is not conclusive for some practices (e.g. perineal toileting sprays and waterless antiseptic handwashes). Continuing research should be based on a fundamental examination of their usefulness.
A diet high in fiber can also reduce UTIs. As such, it promotes bulk waste and bladder emptying. Phytoestrogens from foods such as legumes, nuts, seeds, fruit (e.g., apple), and vegetables (e.g., carrots) can help to prevent recurrent UTI. Increasing water intake is generally recommended for preventing UTI. It has not been clearly demonstrated as preventing recurrent UTI, but it may help flush unwanted bacteria and improve general health. The drinking of cranberry juice for recreational outcomes such as taste, thirst-quenching, and enjoyment and for the temporary relief of the symptoms of UTI (i.e., the alleviation of dysuria—painful or difficult urination) is commonly accepted. The evidence for ingesting cranberry juice or other cranberry products to prevent or treat UTI infections is less than compelling, but the consumption of cranberry and products is not harmful.
Dietary interventions are a long-established means of assisting people to maintain health and can play a significant and positive role in the prevention of UTI. Components of diet, such as probiotics, prebiotics, cranberries, vitamin C, and antioxidants, have been variously shown to influence risk factors for UTI. Although not definitive and with issues such as what form, how much, how long, or for whom do they work, overall dietary influences reinforce the importance of a healthful diet in promoting general health and hence reducing the risk of infection.
The following are some of the ways in which recurrent infections can be treated.
Continuous antibiotics are effective in decreasing the frequency of recurrent urinary tract infections (UTI). In one study, trimethoprim was found to be 95% effective in preventing UTI. Additionally, research in women with recurrent urinary tract infection (RUTI) found that either postcoital use or self-treatment helped prevent recurrences, but that they were less effective than continuous antibiotics. However, they were associated with less frequent or severe side effects. In postcoital use, women who noted blood and/or discomfort arising from sexual activity would take a single antibiotic immediately after sex. In self-treatment, women self-medicated without a doctor’s supervision. All three antibiotics reduced symptom duration during attacks and lessened the severity of the illness.
2. Vaginal estrogens
Topical vaginal estrogens may be effective in preventing RUTI. However, in one study, it was found that they did not significantly decrease the risk of recurrence compared to no treatment. Additionally, some women may suffer from side effects such as endometrial hyperplasia. These women should be watched more closely due to their revised risk of endometrial and breast cancer.
Antibiotic prophylaxis is commonly utilized in clinical practice and has been effective in preventing rUTI in numerous observational studies. The appropriateness of UTI prophylaxis can impact prescribing practice, susceptibility patterns, and patient outcomes. However, there are concerns about antibiotic use, including the potential risk of toxicity, the direct and indirect costs of the medications, and the possible development of antibacterial resistance. The risk factors of resistance should be taken into consideration. Therefore, given the wide range of risk factors and individual variations, routine antibiotic prophylaxis should only be considered for individuals with three or more well-documented rUTIs within the previous 12 months. Any significant factors related to rUTI, such as pregnancy, surgery, bleeding, or fecal infection, can be considered for use in the treatment or prevention process. It is advocated to comprehensively evaluate the patient’s past history and discuss the pros and cons of using continuous/intermittent antibiotic prophylaxis with the patient.
It is estimated that in women with recurrent urinary tract infections (rUTI), 25% of antibiotics consumed are used as prophylaxis, which is associated with significant cost, patient burden, and antibiotic resistance. It is difficult to measure the use of prolonged/intermittent regimens of antibiotics for self-directed treatment in response to the onset of urinary symptoms. While the optimal pharmacologic regimen for treating and preventing rUTIs is not known, there are a variety of commonly utilized approaches to rUTI prevention. These include consumption of prophylactic antibiotics, antibiotics taken at the first onset of symptoms, use of vaginal or oral probiotics, non-antibiotic therapy strategies to reduce rUTIs, and prophylactic methods.
Prevention of recurrent UTI using the urinary immunostimulant (OM-89 = Uro-Vaxom) has been extensively studied in human medicine and found to be equally effective as long-term antibiotic prophylaxis. Intravesical administration of oral mast E. coli extract was found to induce mast Th1 response, down-regulating the serum proinflammatory cytokines and antibody response. It is not currently known if the Uro-Poxom is effective in bitches. If it is as efficient as mast E. coli extract, it is a promising non-antibiotic approach to be used to prevent recurrent UTI in dogs.
Several studies have recently examined the use of urinary immunostimulants in dogs for the prevention of recurrent urinary tract infections. The use of intravesical E. coli and S. simiae extracts as immunostimulants, following primary infection, has successfully reduced the incidence of recurrent UTI in bitches, even though intravesical administration is shown to be as effective as the short-term parenteral antibiotic administration approach.
Future research is likely to lead to the development of new strategies to prevent microbial colonization and invasion of the urinary tract. Current research leaders, including the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), recognize the importance of developing newer, more effective strategies for prevention of not only UTI but also other microbial colonization-based diseases. These sponsors welcome research ranging from basic host-pathogen interaction studies focusing on innate and adaptive immune responses as well as analyses using state-of-the-art molecular biology, biochemistry, microbiome methodologies, and microbiology to clinical trials. A greater understanding of the genetic and other host factors that contribute to an individual’s risk for colonization and invasion of the urothelium and other urinary tract tissues by uropathogens is likely to lead to the development of more personalized preventive strategies for recurrent UTI.
Clinical episodes of UTI occur sporadically in healthy individuals but can be recurrent in some. Such recurrences cause symptomatic distress and discomfort in many individuals. Over the past two decades, both basic microbiology studies and clinical observations have increased our understanding of the pathogenesis of recurrent UTI. E. coli is the most common cause of community-acquired recurrent clinical infection. Distinguishing between reinfection and relapse has often been difficult but is important for choosing the appropriate treatment. The most well-documented host risk factors for recurrent E. coli UTI include prior UTIs with the same isolate, a postmenopausal state, a history of voiding dysfunction, and urogenital atrophy. Studies also suggest that genetic and immunological host factors contribute to individual susceptibility.