It is estimated that approximately 50–60% of women will have at least one episode of urinary tract infection (UTI) in their lifetime. In the US, almost 10% of women receive a UTI diagnosis each year, and among these, at least 25% of women will experience a recurrence of UTI leading to chronic UTIs. If you get 2 or more UTIs in 2 months or 3 or more in a year, then it can be categorised into chronic UTIs. While acute UTIs are normally uncomplicated and easily cured, even without treatment or with a single course of antibiotics, if they progress to a chronic UTI, it can significantly impact your quality of life, leaving you in severe pain and discomfort for the long term.
Understanding Chronic UTI
If you have a chronic UTI, you may feel like after taking the full course of antibiotics, and even after clearing your infection, your symptoms do not go away. You may feel like you still have a UTI. An acute UTI becomes chronic when the antibiotics that you took fail to completely get rid of the infection-causing bacteria. This causes the bacteria present in the urine to enter the bladder lining and embed in it. As the bacteria are not present in the urine but rather hidden in your bladder lining, a urine test may not detect the bacteria and can show false negative results, making it even harder to diagnose. Moreover, this also makes it difficult for short-term antibiotics and immune cells to reach the embedded bacteria and destroy them.
Once the bacteria that cause UTI penetrate deeper into the urothelium (lining of the bladder), they go dormant (similar to hibernation) in the bladder cells. Since these dormant bacteria don't divide until they reawaken, they are resistant to antibiotics you take. The bacteria in the urothelium cause your immune system to send out distress signals. Because the bacteria are concealed inside the cells, the immune system may have difficulty identifying the infection, leading to constant pain and inflammation. Furthermore, due to the continuous inflammation, the urothelium starts thickening in order to create a barrier of defence. This thickening can cause symptoms including difficulties peeing, frequent urges to urinate, and a reduced ability to hold urine. In certain instances, the bacteria may create a biofilm–a layer of defence that renders them immune to antibiotics. These bacteria can frequently reactivate, multiply, and induce a fresh infection. Short courses of antibiotics can help treat these new infections temporarily, but they frequently don't get rid of the dormant embedded bacteria, which makes symptoms come back in no time.
Treatment for Chronic UTI
To effectively treat and cure a chronic UTI, early intervention is essential. However, in our current healthcare system, there is limited awareness regarding this chronic condition, leading to late diagnosis or misdiagnosis. The treatment of chronic UTI can be challenging since it cannot be cured with a usually prescribed short course of antibiotics. Moreover, the bacteria in many cases attains resistance to these antibiotics, making the treatment even more difficult. Below are some of the treatment approaches that could be suggested by a urologist to treat a chronic UTI.
Low-dose antibiotic treatment
While acute UTI can be treated with short-term antibiotics, chronic UTI requires long-term antibiotics treatment. A low-dose antibiotic is recommended for a minimum of six months and a maximum of two years in order to effectively cure the infection and remove the bacteria. In 2018, a 10-year observational research was conducted on 624 individuals who had been treated effectively with long-term, full-dose antibiotics for chronic UTIs. They were given first-generation, narrow-spectrum antibiotics, which meant the antibiotics only attacked the targeted bacteria and had no effect on other kinds of bacteria. The treatment prevented the deeper bladder cells from being reinfected by suppressing the bacteria as they resurfaced from the bladder lining. On average, 383 days of consistent therapy were needed for symptoms to completely disappear.
Intermittent Antibiotic Therapy
This involves taking antibiotics only when needed to prevent UTIs due to specific triggers, such as after sexual intercourse. Your doctor can prescribe a treatment plan that involves taking antibiotics following sex since having sexual intercourse is a risk factor for UTI.
Vaginal Estrogen Therapy
If you have gone through menopause, doctors may prescribe a vaginal cream containing oestrogen. This is because, after menopause, oestrogen levels drop, altering the quality of tissues in the vagina, urethra, and bladder making them more prone to UTIs.
Other strategies
D-mannose
It is a naturally occurring sugar found in many foods and functions by preventing bacteria from adhering to the bladder cells. Once D-mannose binds to the bacteria, it keeps them from adhering to the walls of the bladder. Normally, bacteria attach themselves to the cells lining the bladder by using microscopic, hair-like structures called pili, which can result in an infection. But in the presence of D-mannose, the pili will attach to D-mannose, preventing the bacteria from attaching themselves to the bladder. This makes the bacteria wash out when you urinate. Through this mechanism, concentrated D-mannose products, such as pills and sachets, have been demonstrated to potentially mitigate UTI symptoms and recurrence.
Cranberry Extract
Proanthocyanidins found in cranberries have the ability to inhibit bacteria, especially E. coli, from adhering to bladder walls. When these bacteria are unable to attach to the bladder lining, they are more easily flushed out through urine. Cranberry extract is available as unsweetened juice and supplements like capsules or tablets. However, even though cranberries can aid in the prevention of UTIs, they are ineffective in treating an existing UTI.
Probiotics
Your urinary tract harbours many beneficial bacteria collectively known as the urinary microbiota. These include bacteria like Lactobacillus and Streptococcus, which help protect against urinary infections. In women with UTIs, these bacteria are often depleted, but probiotics can help restore a healthy urinary microbiota, improving defence against UTI-causing bacteria.
Some personal hygiene and self-care tips
There is a popular misconception that UTIs are caused only by poor personal hygiene. However, it is crucial to follow hygiene practices to lower the risk of chronic UTIs. Some of these best practices include wiping from front to back, wearing breathable and loose-fitting cotton underwear, avoiding scented soaps and spermicidal condoms, as well as maintaining a dry and clean genital region. It is important to drink plenty of water (at least 8 glasses per day) so that you urinate more frequently, which lessens the possibility for bacteria to attach and multiply in the bladder. When you feel the need to urinate, immediately empty your bladder. Moreover, try to make an effort to completely empty your bladder. It is also important to urinate both before and after intercourse. Some other tips include limiting sugar-filled foods and drinks, as these might encourage the growth of UTI-causing bacteria, as well as refraining from drinking a lot of alcohol since it could irritate your bladder. You could also take paracetamol or NSAIDs to ease the pain and discomfort.
If you are experiencing chronic UTIs, it is important to consult your doctor to determine the best treatment plan for you. Treatment of chronic UTIs requires a more tailored approach like specific medications, lifestyle changes, or additional testing to identify underlying causes. Therefore, depending on your symptoms and problems, your doctor can help direct you toward the best ways to treat chronic UTIs.
Sources
Aggarwal, N., Leslie, S. W., & Lotfollahzadeh, S. (2024). Recurrent urinary tract infections. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK557479/
Akgül, T., & Karakan, T. (2018). The role of probiotics in women with recurrent urinary tract infections. Turkish Journal of Urology, 44(5), 377–383. https://doi.org/10.5152/tud.2018.48742
Ala-Jaakkola, R., Laitila, A., Ouwehand, A. C., & Lehtoranta, L. (2022). Role of D-mannose in urinary tract infections – a narrative review. Nutrition Journal, 21(1), 18. https://doi.org/10.1186/s12937-022-00769-x
Ferrante, K. L., Wasenda, E. J., Jung, C. E., Adams-Piper, E. R., & Lukacz, E. S. (2021). Vaginal estrogen for the prevention of recurrent urinary tract infection in postmenopausal women: A randomized clinical trial. Female Pelvic Medicine & Reconstructive Surgery, 27(2), 112–117. https://doi.org/10.1097/SPV.0000000000000749
Jent, P., Berger, J., Kuhn, A., Trautner, B. W., Atkinson, A., & Marschall, J. (2022). Antibiotics for preventing recurrent urinary tract infection: Systematic review and meta-analysis. Open Forum Infectious Diseases, 9(7), ofac327. https://doi.org/10.1093/ofid/ofac327
Medina, M., & Castillo-Pino, E. (2019). An introduction to the epidemiology and burden of urinary tract infections. Therapeutic Advances in Urology, 11. https://doi.org/10.1177/1756287219832172
Papp, S. B., Christie, A. L., & Zimmern, P. E. (2023). Characteristics of nationwide urinary tract infection (UTI) visits by age and type II diabetes status in women. Cureus, 15(9), e46000. https://doi.org/10.7759/cureus.46000
Prevention of Urinary Tract Infection (UTI) in Women. (2023). Diseases & Conditions, Medscape. https://emedicine.medscape.com/article/1958794-overview
Swamy, S., Barcella, W., De Iorio, M., Gill, K., Khasriya, R., Kupelian, A. S., Rohn, J. L., & Malone-Lee, J. (2018). Recalcitrant chronic bladder pain and recurrent cystitis but negative urinalysis: What should we do? International Urogynecology Journal, 29(7), 1035–1043. https://doi.org/10.1007/s00192-018-3569-7
Urinary tract infections (UTIs). (2017). nhs.uk. https://www.nhs.uk/conditions/urinary-tract-infections-utis/
What is chronic UTI. (2023). CUTIC. https://cutic.co.uk/what-is-chronic-uti/
Williams, G., Hahn, D., Stephens, J. H., Craig, J. C., & Hodson, E. M. (2023). Cranberries for preventing urinary tract infections. The Cochrane Database of Systematic Reviews, 2023(4), CD001321. https://doi.org/10.1002/14651858.CD001321.pub6\
Assessed and Endorsed by the MedReport Medical Review Board