Recurrent UTI: What It Is And What To Do About It

If you get urinary tract infections (UTIs) all the time, or even just a couple of UTIs in fairly quick succession, you’re among millions of people around the globe who suffer from recurrent UTIs. For a health issue that is so widespread, there is a surprising lack of information about it.

In this article we’ll explain what recurrent UTI is and what you can do about it. Before we dive into recurrent UTI, however, let’s start at the beginning…

What Is A UTI?

You’ve likely heard the term “UTI”, which stands for “Urinary Tract Infection”. You may also have heard a few different words and phrases relating to infections in individual parts of the urinary tract, like ‘Cystitis’ or ‘Urethritis’. In essence, these are all UTIs.

So what exactly is a UTI?

A UTI is an infection in any part of the urinary tract. This means it could be in your kidneys, bladder, ureters or urethra.

Here’s a quick brush-up on what these parts of the urinary tract do:

Your kidneys are the bean-shaped organs on either side of your spine, which play the important role of removing excess water, potassium, salt, urea and other substances from your blood as it filters through. These substances become waste products that your body expels as urine.

As the urine builds up, it’s shipped out of your kidneys to your bladder via two thin tubes (which look a bit like spaghetti) – your ureters. From your bladder, the urine leaves your body via your urethra, the final frontier of the urinary tract.

When you get a UTI, it may move through your body in stages, starting at the urethra. In this first stage, the urethra is contaminated by a pathogen. After the pathogen establishes itself, it spreads to new areas (the scientific term is to ‘colonize’), in this case upwards towards the bladder.

Stages Of A Urinary Tract Infection

The pathogen may then penetrate and colonize the bladder, causing an inflammatory response and damage to the bladder lining. If left untreated, this is the stage at which a chronic bladder infection can form.

From the bladder, the pathogen may ascend via the ureters to the kidneys, causing pyelonephritis (kidney infection).

Although less common, toxins produced by colonization of the kidneys can cause acute kidney damage. In the fifth and final stage – in severe cases – bacteria may cross the cell barrier to enter the blood, otherwise known as bacteraemia or sepsis.

At any of the stages in this process, you can begin to feel symptoms. While yours may differ from the next person, you’ll find some common themes.

Urinary Tract Infection Symptoms

Lower UTI symptoms (in the urethra and bladder) may include the following: 

• Blood in the urine (hematuria)

• Pain or burning during urination (dysuria)

• Difficulty urinating (stranguria)

• Bad-smelling urine

• Cloudy urine

• Needing to pee frequently

• Urinary incontinence

• Lower abdominal pain

• Lower back pain

• Strange sensations or pain in the pelvic region

• Pain during sex

• Irritated urethra

• Unusual discharge

Upper UTI symptoms (in the kidneys*) may include the following: 

• Upper back pain

• Side pain

• Nausea

• Vomiting

• Fever, chills or the shakes

*Note: Upper UTI infections shouldn’t be ignored, as they can be life-threatening if bacteria pass from an infected kidney into the blood. If you have symptoms of a UTI, don’t wait to see if they’ll go away on their own, as there’s always a chance they won’t and could even get much worse. See a doctor.

Chronic Urinary Tract Infection Symptoms may include the following: 

• Frequent urination

• Bloody or dark urine

• Pain or burning during urination (dysuria)

• Kidney pain

• Pain in your bladder region

• Pain radiating to genitals

• Pain radiating to legs

• A constant urge to go to the bathroom (urgency)

• Premenstrual aggravation of symptoms

• Loin pain

• Urethral pain

What Causes A Urinary Tract Infection?

Most (but not all) UTIs are caused by bacteria. So what type of bacteria cause UTI?

There’s a common misconception that all UTIs are caused by E. coli. It’s why one of the often-touted ‘tips’ for UTI is to “wipe from front-to-back”. However, while E. coli is indeed the most common culprit of UTI, it’s by no means the only one.

New and more advanced testing methods, based on molecular technology, are showing that other bacteria besides E. coli are more prominent in Urinary Tract Infections than previously thought. In fact, a recent review of 11,000 samples found E. coli in just 40% of the samples, and DNA of around 1200 individual microbial species.

There is still a lot of research to be done around UTI-causing bacteria, but the main takeaway here is this: E. coli is not the only one, and wiping front-to-back – while still the best approach – may make no difference at all!

What One Year Of UTIs In The USA Looks Like

On a practical level, this broad array of bacteria that we are only just getting to know can make treating UTI difficult. More on UTI treatment a bit later, but for now we’ll just say that unfortunately there’s no ‘one size fits all’.

It also means that if the UTI-causing bacteria isn’t detected and targeted with the correct treatment, a single UTI can become recurrent UTI.

Why Do I Keep Getting UTIs?

If you keep getting UTIs, it’s likely you’re suffering from recurrent UTI, due either to reinfection, or a persistent infection. While all these UTI terms, (recurrent infection, reinfection, persistent infection) can sound a bit similar, they are different.

Let’s start with recurrent UTI. A recurrent UTI is officially defined as three episodes of a UTI in the previous 12 months, or two episodes within the previous 6 months.

Reinfection, on the other hand, refers to an infection where the pathogen is eradicated by treatment, then the same or a different pathogen ascends the urinary tract to cause a new infection.

Finally, a persistent infection is when the pathogen that caused the UTI is not completely cleared from the bladder by treatment. The pathogen remains detectable in the urine, and after treatment returns to a level that once again causes symptoms of infection.

Another term for persistent infection that you might have heard is ‘chronic urinary tract infection’, or sometimes, ‘chronic cystitis’.

A persistent infection can repeat indefinitely, with the rise and fall of symptoms making it feel like a new infection every time. However, it’s likely to be an underlying bladder infection that was never effectively treated and so never went away.

If your UTI symptoms seem to return time and time again, no matter how much you treat them, there’s a high chance your treatment isn’t working. That’s because chronic urinary tract infections are really hard to treat. The reasons why are interesting – plus, once you understand the reasons, you’ll be empowered to seek better testing and more appropriate treatment. So let’s dive right in…

Introducing: Biofilms And Recurrent UTI

In the case of a chronic UTI, a biofilm is usually involved. A biofilm is a community of bacterial cells that stick together, and attach to the bladder wall (or in some cases, even inside the cells of the bladder wall!). This community can be fungal as well as bacterial, and there can be more than one pathogen present. Sometimes they are complex, diverse communities of multiple pathogens.

The biofilm produces a protective slime, (a sort of goop), to shield itself from antibiotics and the body’s natural defences. Think of it a bit like an invisibility cloak and a forcefield combined! The bacteria are effectively hiding in plain sight.Needless to say, this clever goopy shield makes diagnosis and treatment targeted to that community of bacteria very difficult. From time to time, bacteria are released or escape from the biofilm, which kicks off a reaction in the body. This is usually an inflammatory response, which leads to heightened UTI symptoms. You might hear people talking of ‘flare ups’ or ‘episodes’ of UTI symptoms, indicating a chronic issue that cycles through acute and symptom-free phases.

For sufferers of chronic UTI, these symptoms and pain can be really debilitating and have adverse effects on their lives, as well as their mental and physical wellbeing.

Why Your UTI Test Results May Be Negative Despite Symptoms

Now that we’ve explained a bit more about why your recurrent UTIs may in fact be one, embedded UTI, let’s take a look at UTI testing.

Have you ever had UTI symptoms, felt quite sure that you have a UTI, but your test has come back negative? This is incredibly common – not to mention frustrating. And your hunch is likely right: If you are experiencing symptoms, it’s very possible you have a UTI.

There are a few reasons why your UTI test result might be negative:

1. Urine is not sterile

   It has been found that the bladder has its own unique microbiome with hundreds of different bacteria. So a urine sample that may be dismissed as being ‘contaminated’ with foreign bacteria, may in fact contain bacteria that are an important part of the puzzle.

2. The pathogens causing your symptoms may not be in your sample

   Standard UTI test methods focus on free-floating pathogens. Embedded biofilm infections attached to the bladder wall are not free-floating and less likely to pass out via your urine sample. It’s also possible your urine sample is too diluted, e.g. due to over-hydrating.

3. The UTI test was never meant to be used for everyday UTIs

   The standard test that is still used today was created in the 1950s and was based on small studies on two groups of females with acute kidney infections – one group pregnant, the other not. The threshold of bacteria in a cultured urine sample that was considered to indicate a kidney infection with 80% accuracy, was never validated for use in lower UTI and has since been found to be too high.

4. UTIs can be caused by multiple pathogens

   As mentioned earlier, a UTI can be caused by multiple infection-causing pathogens. The 1950s test only looks for a single pathogen. If more than one are found, it may presume the urine sample was contaminated.

5. The standard UTI test cannot grow most bacteria

   The majority of known organisms will not grow in the standard urine culture, which generally uses a specific medium and conditions, over a short timeframe. It’s all much too fast for those bacteria that like to take their own sweet time building up in the environment of a bladder.

6. White blood cells (leukocytes) in urine are often ignored  

   The threshold for white blood cells, which, if present in your urine often indicate a UTI, is too high. Plus, white blood cells die off quickly outside the body. So lower levels of white blood cells can indicate a UTI, even if they don’t meet the threshold.

7. Epithelial cells as an immune response are overlooked

   Your urinary tract, including your bladder, is lined with delicate tissue. These are epithelial cells. Your body may shed these cells when it’s trying to fight off pathogens and biofilms. These cells were often considered urine sample contamination until recently, when researchers realized that they can actually indicate an embedded infection.

8. It’s almost impossible to collect an uncontaminated urine sample

   This one is self-explanatory to anyone who has had to provide a urine sample. It’s awkward and difficult to avoid contaminating the sample with bacteria from the surrounding skin and vagina.

Alternative Testing Options For Recurrent UTI

We’ve explained why your standard test result may be negative and hopefully you now realise that a negative test result is not the end of the road.

Remember to trust your body, if you still have symptoms, you likely still have an infection. And if conventional UTI testing methods have failed to provide answers, there are alternative UTI test methods you can try. Here are a few of them:

1. Next generation Sequencing: Used to identify bacteria, fungi and parasites in a urine sample from a large DNA database. Can also provide predictions around antibiotic resistance genes and recommendations for which antibiotics are likely to be most effective.

2. Deep Metagenomic Sequencing: Looks for all known bacteria, fungi, parasites and viruses in one single test, using an expansive DNA database. Can also provide antibiotic recommendations based on resistance genes found.

3. Pooled Antibiotic Susceptibility Testing: Considers the antibiotic sensitivity of the bacterial community as a whole, as well as individual pathogens.

4. Expanded Quantitative Urine Culture (EQUC): Uses a modified urine culture protocol that builds on the standard concept of urine culture with changes such as larger volumes of urine, and different conditions and times for incubation.

5. Fresh Sample Urine Microscopy Test: Analyzes a urine sample immediately under a microscope to look for things like bacteria, fungi, white and red blood cells, and epithelial cells.

No matter which test you opt for, you’re likely to need to provide a urine sample. Collecting a sample that has minimal contamination can be difficult, and using a specialized urine collection device to help you discard the start of the flow and only collect the midstream may help you collect a better sample

Recurrent UTI Treatment

If you have an uncomplicated UTI, there are generally three options available: Take antibiotics, try natural remedies, or drink water and wait to see if it passes.

Occasionally, a UTI is self-limiting and the infection passes out of your body in its own time. That time can be very uncomfortable. And in other cases, it doesn’t pass, but gets worse, moving into the kidneys as outlined above.

Antibiotics can be effective – with one important caveat: You need to take the right antibiotic for your particular infection at that particular point in time. It is not a good idea to take whatever antibiotic you have laying around – it may have no positive impact, or worse still, have negative side effects.

It makes sense then to understand how antibiotics are selected in the first place.

How Are Antibiotics For UTI Selected?

If you arrive at a clinic with a UTI, there are three things your doctor doesn’t yet know:

1. Which pathogen is causing your infection (remember there’s currently no testing method that enables your doctor to find that out instantly)

2. Which classes of antibiotic will effectively treat that bacterium

3. The resistance of that bacterium to different antibiotic classes

Your doctor may send your urine sample to a lab for testing, but if you are in a lot of discomfort in the meantime, they may prescribe according to a few common guidelines on how UTI antibiotics are selected, along with their best-educated guess.

If your antibiotics aren’t working, there are a few possible reasons why:

• It might not be the right antibiotic

• Your symptoms may be caused by more than one organism – so your antibiotic might not be treating the entire bacterial community

• Your symptoms may not be caused by bacteria

• You may have an embedded infection that requires longer term treatment.

Ineffective antibiotic treatment may in fact contribute to the recurrence of UTI by allowing bacteria to increase their resistance to that type of antibiotic.

Alternative Options For Recurrent UTI Treatment

If you have a persistent, embedded infection, a short course of antibiotics is unlikely to eradicate the issue. This kind of infection is incredibly resistant to antibiotics for a few reasons.

The biofilms that cause the chronic infection can be hard to detect in a urine sample (and therefore hard to target with the correct treatment) and further, they can be formed by multiple species. You might effectively treat one of the species in the biofilm, but even as that one decreases, others may increase in its place.

Don’t despair – treatment is possible – but it may take a little longer.

Let’s take a look at the options for recurrent UTI treatment:

1. Short course antibiotics for UTI treatment: Usually 3, 5, or 7 days of treatment, or sometimes single dose, short courses are not designed for recurrent, embedded infections.

2. Prophylactic antibiotics for recurrent UTI: This is preventative antibiotic use, taking antibiotics before you feel symptoms. While prophylactic use may decrease symptoms while the antibiotics are taken, research shows the acute episodes are likely to return when they are stopped, and studies have shown that overall they may promote the development of antibiotic-resistant forms of UTI-causing E. coli.

3. Estrogen for recurrent UTI: There appears to be a link between UTI and menopause – with lowered estrogen levels increasing the risk of UTI. In short: A healthy vaginal environment with plenty of Lactobacilli, which in turn eat glycogen found on the surface of the epithelial cells, appears to provide some protection from UTIs. When females go through menopause, the levels of estrogen are reduced, as is glycogen, and consequently the Lactobacillus population reduces too… All of which leads to higher risk of UTI. Estrogen therapy may thus possibly help reduce risk of UTI.

4. Home remedies for recurrent UTI: There is no shortage of suggested popular home remedies for UTI, but there’s a serious shortage of reliable research about them. Whether you should try them is ultimately up to you. However, it is important to separate the myths from fact and understand the science. Even an innocuous-sounding herb can upset the delicate balance in your vaginal microbiome, and may only increase your suffering.

Recurrent UTI Treatment: Mapping a Path To Success

Knowledge is power, and for health issues that are widely underrepresented and misunderstood, it is crucial. At the end of the day, you are your best advocate for your own health.

To find your way to healing take these important steps:

• Learn and understand everything you can about recurrent and chronic UTI

• Collect your very best urine sample

• Seek better UTI testing

• Seek out a specialist that can help you

• If they can’t, seek out another, it’s so important to find one that can help!

If you have any questions about recurrent UTI, you can always reach out directly to the team at Live UTI Free. They’ve connected thousands of people with specialists and share updates frequently.

Images used with permission from Live UTI Free.