Continuing Education Activity

Recurrent urinary tract infections (UTIs) are a common cause of morbidity, especially in young women. However, with appropriate care, they can be easily treated and further episodes prevented. This activity outlines the evaluation and management of recurrent UTIs and highlights the role of the interprofessional team in evaluating and treating patients with this condition.

Objectives:

• Describe the etiology of recurrent urinary tract infections.
• Review the presentation of a patient with recurrent urinary tract infections.
• Summarize the management considerations for patients with recurrent urinary tract infections.
• Explain the importance of improving care coordination among the interprofessional team to enhance the delivery of care for patients affected by recurrent urinary tract infections.

Introduction

Recurrent urinary tract infections (UTIs) are defined as two episodes of acute bacterial cystitis, along with associated symptoms within the last six months or three episodes within the last year.[1] Recurrent UTIs are much more common in the female population. The cost of treating urinary tract infections in the United States alone is about 3.5 billion dollars a year.[2]

A UTI has traditionally been defined as >100,000 colony forming units (CFU)/ml of urine associated with typical acute symptoms of dysuria, urgency, frequency, or suprapubic pain.[3] However, more than 100 CFU of E. coli with typical acute urinary symptoms has a positive predictive value of about 90%, suggesting that a lower CFU threshold may be more appropriate in diagnosing simple and recurrent UTIs.[4] 

Etiology

Several conditions may predispose to an increased risk of UTIs in both men and women.

• Anatomical defects that lead to stasis, obstruction, urinary reflux all result in an increased predisposition to recurrent urinary tract infections.
• Vesicoureteric reflux (VUR) is identified in up to 40% of children being investigated for a first UTI.[5] 
• Cystoceles and pelvic organ prolapse are important risk factors for recurrent UTIs in women.[6]
• Functional defects, like overactive bladder and urinary incontinence, tend to lead to recurrent infections.[7] 
• Recurrent urinary tract infections may be commonly seen in sexually active women without any identifiable structural abnormality or another predisposing condition.
• Older men can often develop urinary tract infections due to outflow obstruction or neurogenic bladder resulting in urinary stasis and an increased risk of recurrent infection.
• Several other lesions may predispose to recurrent UTIs, including intraluminal (bladder stones, neoplasms, indwelling catheters, stents, foreign bodies), intramural (ureteral stenosis/strictures), and extramural lesions (inflammatory mass, fibrosis, extrinsic mass effect, or neoplasm).[8]

Immunodeficiency typically does not lead to isolated recurrent UTIs.

Epidemiology

Approximately one in three women suffers an uncomplicated urinary tract infection (UTI) before the age of 24.[9] The lifetime prevalence of at least one symptomatic UTI in women has been estimated to be over 50%, with about 26% of women demonstrating a recurrence during six months of follow-up after treatment of initial UTI.[10] In a study in the primary care setting, 53% of women aged more than 55 years, and 36% of younger women, reported a recurrence within 1 year.[1] 

Pathophysiology

Recurrent urinary tract infections are usually new infections with different bacterial organisms. (If the organism continues to be the same, this is a relapsing infection and suggests an inadequately treated source such as an abscess, urinary stone, or prostatitis.) The source of these recurrent infections is the same as for any simple cystitis. Typically, the rectal bacterial flora contaminates the periurethral area and urethra. From there, bacteria can easily ascend and reach the bladder. Research demonstrates a complex relationship between the intestinal, vaginal, and urinary microbiome, which is not well understood.[11]

It is important to differentiate rapid reinfection (a different organism) from a relapse (the same organism which was not completely treated). A relapse is further defined as a recurrence within two weeks of completing therapy with the same organism. It is considered reinfection if the new infection is more than two weeks after completion of therapy even if the organism is the same. The vast majority of recurrent UTIs typically seen in medical offices and clinics are reinfections and do not warrant an extensive urological evaluation or imaging. Indications for imaging include persistent hematuria, history of kidney stones, repeatedly finding Proteus (often associated with urolithiasis), and relapsing infections. Risk factors for recurrent UTIs are given listed below. Of these, the most significant include the use of a diaphragm with spermicide, untreated atrophic vaginitis, and frequent sexual intercourse. Spermicides and lack of estrogen effect will disrupt the normal vaginal flora, while sexual intercourse tends to introduce vaginal bacteria into the urethra and bladder.

Risk Factors for Recurrent Infections include[12][13][14][15]

• Any spermicide use within the previous year, especially if used with a diaphragm
• Atrophic vaginitis
• Chronic diarrhea
• Cystocele
• First UTI when young (prior to 16 years of age)
• Genetic predisposition (usually through bacterial/vaginal mucosal adherence factors)
• Higher frequency of sexual intercourse
• Increased post-void residual urine (incomplete bladder emptying)
• Inadequate fluid intake (low urinary volumes)
• New or multiple sexual partners
• Mother with a history of frequent or multiple UTIs
• Urinary incontinence
• Use of spermicide coated condoms

Personal Hygiene Factors

• Not washing hands before wiping vaginal area after voiding
• Taking baths instead of showers
• Wiping and washing the vaginal area (incorrectly) from back to front
• Not using clean, soft washcloths to clean the vaginal area when washing
• Not cleaning bladder opening area first when washing
• Failing to use a gentle, liquid soap when washing the vaginal area
• Not using vaginal estrogen, when appropriate, in post-menopausal women

History and Physical

A complete history and physical are necessary. Acute simple cystitis presents with symptoms of urinary frequency or urgency, dysuria, and suprapubic pain. The probability of cystitis is greater than 90 percent in women with dysuria and frequency without vaginal discharge or irritation.[16] The presence of fever, chills, rigors, marked fatigue or malaise suggests that the infection has extended beyond the bladder and is now regarded as acute complicated cystitis. Clinical features of pyelonephritis include fever, chills, flank pain, costovertebral angle tenderness, nausea, and vomiting.[17] Symptoms of cystitis are often, but not universally, present in patients with pyelonephritis. Women with recurrent UTIs should have a pelvic examination to check for cystoceles, vaginitis, vaginal atrophy, and prolapse of pelvic organs.[3] 

In a study of 113 women, it was found that the presence of hematuria and urgency as symptoms of initial urinary infection were the strongest predictors of a second infection.[10] 

Men who have recurrent episodes of cystitis should undergo an evaluation for prostatitis, while elderly or debilitated patients may present with more generalized symptoms of infection (like fever and chills) or even a change in mental status without any clear localization to the urinary tract. 

To confirm a diagnosis of recurrent UTIs, there should be documentation of positive urine cultures associated with appropriate urinary symptoms.[3] If clean catch urine samples are suspicious for contamination (especially in women), consideration should be given to obtaining a catheterized specimen.[3]

In women who have very rapid recurrences of cystitis after treatment, clinical clues should be sought to attempt to classify cystitis as reinfection (i.e., new infection after the previous one was completely eradicated) or a relapse (i.e., re-emergence of the previous infection, which was incompletely eradicated previously). A recurrence is termed reinfection if the interval between two episodes is greater than 2 weeks, if a different strain of uropathogen is documented or if a sterile culture (with the patient off antibiotics) was documented between two UTI episodes. If the interval between the two episodes is less than two weeks, it is defined as a relapse. Relapsing infections often require additional evaluation with urological imaging.

Evaluation

The typical patient with recurrent UTIs does not require either cystoscopy or any urological imaging.[3][18]

In women with a history of recurrent UTI who present with typical symptoms, no further urological evaluation is necessary other than a urine culture and sensitivity, even though the diagnosis of recurrent cystitis can be made clinically. Urine cultures should be performed in the setting of a severe infection or high risk of antibiotic resistance (multidrug-resistant isolate; recent inpatient admission; recent antibiotic use; a history of travel to India, Israel, Spain, or Mexico). Urine cultures are also necessary to differentiate recurrent infections (repeat infections with different organisms) from relapsing (identical organisms on culture). Relapsing infections suggest a persistent source of bacterial inoculation, such as an abscess, chronic bacterial prostatitis, or an infected stone. The American Urological Guidelines on recurrent urinary tract infections in women recommend obtaining a urinalysis and urine culture with each episode of acute cystitis.[3]

Urological imaging is advised for only a select group of women. Indications for urological imaging include relapsing infections, persistent hematuria after treatment; a history of stone passage; or repeated isolation of Proteus from the urine, which is often associated with renal stones. Preferred imaging modalities include renal ultrasonography or, ideally, a CT scan of the abdomen and pelvis.

A variety of sampling methods have been described to establish the diagnosis of UTI in the pediatric population. However, obtaining the urine sample utilizing suprapubic aspiration or catheterization might result in lower contamination and more reliable results. Moreover, if the urine sample has been collected through a plastic bag, several more steps should be undertaken to rule out the possibility of UTI, including dipstick evaluation and microscopic analysis. The presence of leukocyte esterase and nitrite on a urinary dipstick and the possibility of pyuria and bacteriuria; both should be excluded to rule out the impression of a UTI. Utilizing a clean voided midstream urine sample for the diagnosis is limited to toilet-trained children.[19]

Performing a cystoscopy solely for the diagnosis of recurrent UTIs is rarely indicated as it might induce an ascending lower urinary tract infection. Cystoscopy is rarely helpful when utilized routinely; however, it might be useful in a few circumstances, including post-operative exclusion and management of possible ureteral injuries, to evaluate incomplete bladder emptying or to identify possibly bladder calculi. Even the optimal recommended type of irrigation fluid used during cystoscopy has been investigated. For instance, in the study conducted by Lauren N. Siff et al. during 8 months in the urogynecology departments of the joined clinics within the Cleveland health system, the authors explored the significantly higher rate of UTI in those patients who had undergone cystoscopy with 10% dextrose water in comparison with normal saline.[20] All cystoscopies were planned to exclude intraoperative ureteral injuries during complicated urogynecology procedures.

Treatment / Management

Treatment for Simple UTIs

Acute uncomplicated UTI is mostly managed in the outpatient setting. In fact, women with typical symptoms of acute cystitis can be prescribed antibiotic therapy over the telephone.[21] A urine culture is recommended when possible to optimize antibiotic therapy in cases of initial treatment failure and high-risk patients. The decision for hospitalization should be taken on a case-by-case basis. Most patients with persistent fever, pain, inability to take oral medicines, or poor medication adherence should be managed inpatient.

Management of simple cystitis is relatively straightforward. Urine cultures should be obtained before initiating therapy:

• For patients who have been treated for cystitis in the past 3 months, urine culture and susceptibility testing should be obtained to guide antibiotic therapy due to the increased risk of antibiotic resistance.
• Patients presenting with complicated cystitis or pyelonephritis should also have urine cultures prior to initiating empiric antibiotics.

The first line options for empiric antibiotic therapy for simple cystitis are:

• Nitrofurantoin 100 mg twice daily orally for 5 to 7 days. It should be avoided in suspected pyelonephritis (due to poor tissue penetration) or if creatinine clearance is <30 mL/min.
• Trimethoprim-sulfamethoxazole 160/800 mg twice daily orally for three days. It should be avoided if the local resistance rate exceeds 20%.
• Fosfomycin, as a single oral dose of 3 grams. 
• Pivmecillinam. Not available in the US, but it is available in Europe and is the agent of choice for UTIs in Nordic countries. Avoid this agent in suspected pyelonephritis due to poor tissue penetration.[22]

If the above options cannot be used, oral beta-lactams are the next best choice. Amoxicillin-clavulanate 500 mg twice daily, cefdinir (300 mg twice daily), cefadroxil (500 mg twice daily), and cefpodoxime (100 mg twice daily) are each given for five to seven days. Ampicillin or amoxicillin should be avoided due to high rates of resistance.[23][24] If the beta-lactams cannot be used, fluoroquinolones such as levofloxacin (250 to 500 mg daily), ciprofloxacin (250 to500 mg twice daily), or norfloxacin (400 mg twice daily), for three days, are good alternatives. Fluoroquinolones are contraindicated in pregnancy and should be avoided where possible to minimize the development of quinolone resistance.

For inpatient management of patients with risk factors for multi-drug resistant (MDR) pathogen infection, carbapenems (imipenem 500 mg intravenously (IV) six-hourly, or meropenem 1 gram IV eight-hourly, or doripenem 500 mg eight hourly) are used. If no risk factors for MDR are present, ceftriaxone (1 gram IV daily) or piperacillin-tazobactam (3.375 grams IV every six hours) can be used. Fluoroquinolones (ciprofloxacin or levofloxacin), both oral and parenteral, are also good alternatives. For critically ill patients, carbapenems (as above) along with vancomycin are typically used. Aminoglycosides may also be used selectively, depending on urine culture and sensitivity results as well as local antibiotic susceptibility patterns.  

Symptoms should respond to antibiotic therapy within 48 hours of initiation of therapy. If no improvement is noticed within the first 48 hours after starting therapy, a repeat urine culture should be obtained along with urologic imaging to rule out complications such as an obstructing urinary stone, hydronephrosis, urinary retention, renal abscess, or pyelonephritis.

Clinicians should not generally perform a post-treatment test of cure urinalysis or urine culture in asymptomatic patients. Repeat urine cultures should be obtained to guide further management when UTI symptoms persist following antimicrobial therapy.

Treatment for Recurrent UTIs

Recommended treatments for recurrent UTIs include maximizing personal hygiene factors, avoiding spermicides, wiping correctly, using vaginal estrogens if appropriate, etc. The effectiveness of lifestyle changes in personal hygiene in reducing recurrent UTIs has not been conclusively demonstrated.[12][25] The use of cranberry products is somewhat controversial, but so far, a benefit has not yet been definitively established.[26][27][28][29] Cranberries are thought to work by providing proanthocyanidins which decrease bacterial adherence to the urothelium. While this sounds attractive, commercially available cranberry products have limited amounts of proanthocyanidins. The bottom line is that it is suggested for whatever benefit it might provide, but advise patients that it is unclear sure how much it will ultimately help.[3] The use of probiotics is also unclear as clinical trials to date have been disappointing.[30] 

Prophylactic methenamine has been suggested, along with vitamin C, to help acidify the urine.[26] The methenamine is converted to formaldehyde in the bladder if the urinary pH remains acidic, preferably <5.5. Some studies have failed to conclusively prove a long-term benefit, but in view of increasing antibiotic resistance, further study of methenamine is certainly warranted.[31] A recent multi-institutional, clinical randomized trial study compared methenamine to trimethoprim for UTI prophylaxis and found the same rate of recurrences for both after 1 year.[32] 

D-mannose has been proposed as an aid in recurrent cystitis due to its ability to bind to bacterial surface ligands, which decrease the adherence of infecting organisms to the urothelial mucosa.[33] While there is some evidence of a reduction in recurrent infections from D-mannose, definitive studies have not yet been done, and optimal dosages are still undetermined.[26][33] 

Antibiotic prophylaxis has been quite successful in controlling recurrent UTIs, but using alternative means first is preferable. When other measures fail or there is evidence of multiple rapid recurrences, antibiotic prophylaxis is reasonable. Prophylaxis is never appropriate in patients who have permanent catheters or nephrostomies as this will rapidly lead to highly resistant organisms.

There are several ways antibiotic prophylaxis for recurrent UTIs can be done. Post-coital prophylaxis is appropriate for women with frequent episodes of cystitis that are clearly associated with sexual activity. Another option is the self-directed therapy approach, where patients start a short course of antibiotic treatment at their first sign or symptom of a UTI. Such an approach is reasonable if the patient is sufficiently educated about the symptoms associated with infections and will reliably follow instructions.[3] A urine culture should still be obtained prior to starting treatment, if possible. Efficacy appears to be equal to continuous low-dose prophylaxis regimens with fewer GI side effects.[34][35] If this fails, then a continuous prophylactic treatment protocol will be needed.

Surveillance urine testing and cultures in asymptomatic patients is not recommended. Asymptomatic patients, even high-risk patients in nursing homes and diabetics, do not benefit from an additional evaluation, and any bacteriuria should not be treated without symptoms.[3] (This recommendation does not apply to pregnancy or patients who are about to have urinary tract surgery.)

If a recurrent UTI patient develops an acute UTI, a urine culture should be obtained, and an alternate antibiotic agent used to treat the infection. The duration of treatment should be no longer than a week.[3] If the urine cultures show resistance to all available oral agents, then parenteral antibiotics will be required. Again, the duration of therapy should generally be no more than one week.[3] 

Long Term, Low Dose Prophylaxis

Continuous prophylaxis is typically done with a lower dose than is typically used for acute cystitis therapy. Therefore, this approach is called the long-term, low-dose therapy protocol. The selection of the antibiotic is based on culture and sensitivity results for that individual patient. Initial evaluation of the effectiveness of prophylaxis is suggested at three months. If effective, a six to twelve-month duration is typical. Unfortunately, many individuals will revert to their prior pattern of infections once prophylaxis stops.[36][37] 

Some experts will recommend continuing prophylaxis for up to two or more years in selected patients.[38][39] In such cases, nitrofurantoin, SMX-TMP, and trimethoprim alone are the preferred agents. Quinolones are not preferred for prophylaxis because of the risk of increasing bacterial resistance; however, they can be used if no other option is available. If it is determined that a quinolone antibiotic is needed for prophylaxis, norfloxacin is preferred as it has less tissue penetration outside the urinary tract than other quinolones but still maintains good urinary levels. This would typically be selected only when other first-line agents cannot be used for some reason. Some patients have continued low-dose prophylaxis for years, but this practice has not been scientifically studied or validated. Potential side effects of long-term, low-dose antibiotic usage would include gastrointestinal, hepatic, and pulmonary effects.[40]

Beta-lactams can be used but tend to rapidly change GI flora, carry a risk of pseudomembranous colitis (Clostridia), provoke bacterial resistance, and stimulate yeast overgrowth.

There is only limited data on the use of fosfomycin for UTI prophylaxis, but it may be appropriate in selected situations.[41] Prophylactic regimens are not written in stone; agents can be changed to help maintain efficacy. In patients with chronic, permanent catheters, a short course of one to three days of antibiotic prophylaxis can reduce the incidence of symptomatic UTIs. This may be appropriate in severely immunocompromised patients and possibly in those with very frequent infections after catheter changes but is not recommended routinely due to the expectation of substantially increasing antibiotic use and worsening bacterial resistance patterns.[42]

There are some negative aspects to antibiotic prophylaxis. There is the added cost and inconvenience of taking additional medication. There are possible allergies and medication cross-reactivities. Yeast superinfections and Clostridia gastrointestinal overgrowth become more likely, and continuous prophylaxis fosters the emergence of more resistant urinary pathogens.[43][44]

Overall, long-term, low dose antibiotic prophylaxis for recurrent UTIs substantially decreases recurrent urinary tract infections.[36][37][43][45][46]

Preferred Agents for Recurrent UTI Prophylaxis

• Nitrofurantoin at 50 to 100 mg daily.
• SMX-TMP at 40/200 mg daily.
• Trimethoprim at 100 mg daily.

Second Line Agents That Are Less Preferred for Prophylaxis

• Cephalexin at 125 mg or 250 mg daily
• Cefaclor at 250 mg daily
• Fosfomycin at 3 gm every 10 days
• Norfloxacin at 400 mg daily

Differential Diagnosis

• Vaginitis - the presence of vaginal discharge, odor, pruritus, dyspareunia. No frequency/urgency.
• Urethritis - Urinalysis shows pyuria but no bacteria. Common in sexually active women.
• Painful bladder syndrome - diagnosis of exclusion. Dysuria, frequency, urgency, but no evidence of infection.
• Pelvic inflammatory disorder - lower abdominal/ pelvic pain, fever, cervical discharge, with cervical motion tenderness.
• Prostatitis - consider in men. May present with pain during ejaculation and tender prostate on digital rectal examination.

Prognosis

Most recurrent UTIs have no long-term sequelae, and patients recover fully. The mortality associated with acute uncomplicated cystitis in women is negligible. However, in terms of morbidity, each episode of UTI results in a loss of 1.2 days of attendance at class/work. Younger patients without preexisting comorbidities have the best prognosis. Some factors associated with a worse prognosis may include older age, recent urinary instrumentation, recent hospitalization or antibiotic therapy, preexisting diabetes mellitus, sickle cell anemia, or chronic renal disease.[47] UTIs occurring in the setting of certain anatomical abnormalities such as renal calculi, obstruction, hydronephrosis, colovesical fistula, neurogenic bladder, renal failure, or bladder exstrophy also have a worse prognosis.

Complications

Risk factors for complications include urinary tract obstruction, recent urinary tract instrumentation, and older age and patients with diabetes mellitus (particularly for emphysematous pyelonephritis and papillary necrosis). Acute pyelonephritis can also be complicated by the infection progressing to a renal abscess, perinephric abscess, papillary necrosis, or emphysematous pyelonephritis. This may present as the failure of symptoms to improve even after 48 hours of appropriate antibiotic therapy and requires further evaluation with urological imaging. Patients with complicated UTI can present directly with bacteremia, sepsis, multiple organ system failure, or acute renal failure.

Deterrence and Patient Education

Several preventive measures can be taken to reduce further recurrences of UTI. Patients should be advised to increase fluid intake to at least 2 liters per day. In a study on 140 women, increased water intake resulted in decreased incidence of cystitis episodes by 1.5 (95% CI 1.2-1.8) (mean 1.7 versus 3.2 episodes).[48] Topical vaginal estrogen (vaginal ring/insert/cream) is recommended in postmenopausal women with vulvovaginal atrophy (genitourinary syndrome of menopause) to reduce the risk of future UTIs, provided there are no contraindications to estrogen therapy. Other behavioral modifications include wiping from front to back and early postcoital voiding.[49] There is no conclusive evidence on the beneficial role of cranberry juice in reducing episodes of recurrent UTI.[50]

Antibiotic prophylaxis should only be offered after other preventive modalities and only in women with a confirmed diagnosis of recurrent cystitis. In some situations, the toxicities and adverse effects of using antibiotic prophylaxis may outweigh the risk of recurrent UTI as cystitis rarely results in a poor outcome. The adverse effects may include direct drug toxicity, development of resistance, alteration of the microbiome, and/or Clostridioides difficile infection. In women with cystitis episodes, which are temporally associated with sexual activity, postcoital antibiotics may be advised to reduce the risk of adverse effects without compromising the drug's efficacy or promotion of antibiotic resistance.[51][52] In other cases, continuous prophylaxis may be used. The drugs used in continuous as well as postcoital prophylaxis are largely similar. The need for antibiotic prophylaxis should be reevaluated after three and six months.

Pearls and Other Issues

Experimentally, vaccines to reduce the recurrence of urinary tract infections have been developed from whole bacterial cells, but so far, they have been only marginally successful, and the beneficial effect wears off after just a few weeks.[53][54][55] Sublingual mucosal polybacterial vaccines were recently studied in immunocompromised patients with very promising results in reducing recurrent infections.[56] A bioconjugate vaccine from various E. coli genotypes seems to work better with a longer-lasting effect, and yet another promising experimental vaccine focuses on E. coli type 1 fimbrial adhesion protein.[57][58] Pilicides and mannosides are also designed to interfere with bacterial adhesion to the urothelium and may be particularly useful in patients with chronic Foley catheters.[59] Another approach uses oral immunostimulants to E. coli. This is already commercially available in Europe but not the US and has demonstrated a reduction in E. coli recurrences of 95%.[60] The use of non-steroidal anti-inflammatory agents (NSAIDS) to modify host defenses is being studied experimentally to reduce recurrent UTIs.[61][62]

In many women, recurrent UTIs may be affected by inadequate or suboptimal personal hygiene, especially in women. Controlled studies have not proven significant efficacy in reducing recurrent urinary tract infections purely from personal hygiene lifestyle modifications.[12][25] Still, it is recommended to teach optimal personal hygiene, including wiping front to back, avoiding baths, using only newly laundered soft cotton or microfiber washcloths, using very non-toxic liquid soap (such as baby soap or shampoo or something equally non-toxic with a minimum of chemicals and perfumes), washing hands first before wiping, then cleaning the private area before the rest of the body to avoid contamination of the perineum, etc. Since many ladies feel uncomfortable hearing such advice from men, even physicians, it is easier and less embarrassing for patients to have the suggestions written down in a patient guide which can then be handed out to patients to read privately at home. 

The following information covers what should be imparted to patients, so they understand their condition and its management: 

Preventing Urinary Tract Infections:

Urinary tract infections (UTIs) are extremely common, especially in women. About 50% of all women will have at least one such infection at some time. While a UTI is usually just bothersome with symptoms such as burning on urination, urinary frequency, urgency, nocturia, hematuria (blood in the urine), and odor, it is possible for a urinary tract infection to progress and affects the kidneys or other organs which can potentially be serious.

When a patient has three or more urinary tract infections within one year, it is termed a recurrent infection, and a medical review may be recommended. Much of the time, the problem can be easily corrected with some simple changes in personal hygiene. Of course, the patient doesn’t have to wait for three new infections before starting any of the following suggestions. They shouldn’t feel bad if they are not doing everything correctly, as most women will find several things they could improve. Instead, they should make the necessary changes starting right now and help reduce the future risk of urinary tract infections.

Wash Hands Before Wiping: Patients should wash their hands before using the toilet to urinate or at least before wiping. They should also wash their hands before they get into the shower to avoid passing germs from their hands back to their body near the bladder opening area.

Wipe Front to Back:  Always wipe from the front to the back after urinating. The patient should start from the front and push down and away towards the rectum. They shouldn’t try to reach from behind because their hand, wipes, or tissues will pick up bacteria from the rectum. Most urinary infections are from bacteria that normally live around the rectum and anus. Therefore, any wiping motion that starts nearer to the rectum and then approaches the bladder opening area will move potentially dangerous bacteria closer to the bladder and urinary tract. Patients should also wipe the same way, front to back, after a bowel movement. 

When Wiping, Use Toilet Paper or Baby Wipes But Only Wipe Once: It is acceptable to use toilet paper to wipe after urination, but the patient needs to wipe once, or they may actually add more bacteria to the bladder opening area. Sterile baby wipes are even cleaner than toilet paper and can be carried in their purse for use outside the home. They can also be useful if no other wipes are available. As a general rule, anything safe for babies can also be used in the delicate area around the vagina and bladder opening.

Avoid Baths: Bathwater is full of dirt and bacteria from the skin. Sitting in a tub gives the bacteria an easy way to reach the urethra and bladder opening area. Point out to the patient that they wouldn't drink that water, so it follows that they shouldn’t put their bladder opening area, since the goal is to keep it as clean as humanly possible, in the dirty water. If the patient absolutely must take a bath instead of a shower, they shouldn’t use any bubble bath or other cosmetic bath additives, which tend to be irritating to the delicate skin of the vaginal mucosa. Instruct the patient to take showers instead. Showers are preferable to baths in women who are prone to urinary tract infections. They should just let the water runoff naturally and not spray any water directly into the vagina or bladder opening area. 

Avoid Luffas and All Reusable Sponges: Luffas and other reusable sponges, including nylon, cannot be adequately cleaned or sterilized once used, so they retain bacteria that cannot be eliminated. They are also used repeatedly for days, weeks, or even months, during which they can accumulate more and more bacteria and germs. Women who are prone to infections, especially UTIs, should absolutely not use or even touch such reusable but heavily contaminated items.

Use A Gentle Liquid Soap When Washing: Bar soap will always have bacteria due to exposure to the air and bathroom environment. Also, other household members may handle it and use it. A body wash is fine for regular skin cleaning, but regular body wash is too harsh for the very gentle tissue of the vagina and bladder opening area. It is important to avoid using products with unnecessary perfumes, astringents, creams, or other possibly irritating chemicals. The recommendation is to use a gentle liquid soap with minimal additives. The patient can also use any gentle liquid baby soap or baby shampoo because it is probably acceptable for the bladder opening area if it is safe for babies. 

Use Washcloths: The best and cleanest way to apply soap is to use a very clean, soft cotton or microfiber washcloth. The washcloths can be placed into a clean, resealable plastic bag immediately after they are washed and dried as they are cleanest when they are just coming out of the dryer.  This keeps them extra clean until needed and avoids any bacterial contamination from body spray in the shower or unnecessary handling. No matter how often the patient washes their hands, they will not be as clean as these freshly laundered washcloths. The patient may want to use a second washcloth to finish their shower after properly cleaning the bladder opening area.    

Clean the Bladder Opening Area First: The bladder is the only area of the body that can get infected if it is not cleaned properly when washing. Since it is the most important area to get clean, it should be washed first before the washcloth, or their hands have picked up any dirt, germs, or bacteria from other body parts. When surgeons perform surgery, they clean the surgical site first before moving to the surrounding area. The same principle applies to cleaning the bladder area. They need to remember only to wipe once, wiping from the front towards the back.

How to Wash - Summary: Wash the hands first, even before getting into the shower. Take a fresh, clean washcloth from the sealed plastic bag as described previously. Wet the washcloth, add some clean liquid soap, and clean the bladder opening area first with a single front to back wipe with the washcloth. Rinse well without directly spraying the bladder opening area. The washcloth used to clean the bladder opening area should probably not be used for anything else and should only be used once before being laundered.

Douches may be Acceptable but Avoid Other Personal Hygiene Products: In most cases, a vinegar and water douche or a douche with iodine or benzalkonium chloride is helpful if carried out correctly at appropriate intervals. The patient should not use any feminine hygiene sprays, cosmetics, perfumes, medicated towelettes, or similar products in the vagina or bladder opening area unless specifically approved by their clinician.

Use Tampons for Periods: Tampons are advised during menstrual periods rather than sanitary napkins or pads. A tampon will keep the bladder opening area drier and cleaner than a sanitary pad and help keep any bacterial growth and contamination away.

Avoid Long Intervals Between Urinations: The patient should try to empty their bladder at least every four hours during the daytime while awake, even if they don’t feel the specific need or urge to void. When the need to empty the bladder presents, they shouldn’t try to “hold it” until a more convenient time or place. When the bladder indicates that it is time to urinate, they need to pay attention and use the restroom as quickly as possible.

Don’t Wear Tight Clothes:  Avoid wearing pantyhose, bathing suits, or tight slacks for prolonged periods. Cotton panties for general use are suggested. They should also try to avoid habitual leg crossing. All of these will tend to press the skin folds around the vagina into the body and may introduce more bacteria into the area around the bladder opening.   

Drink More Water: Start with one extra glass with each meal. If the patient's urine appears any darker than a very pale yellow, this could mean that they are not drinking enough and should increase their fluid intake. Cranberry juice is helpful in patients with urinary tract infections, but if they don’t like cranberry juice, they can or substitute other beverages.

Take Some Extra Vitamin C and Drink Some Cranberry Juice: The clinician may recommend taking additional vitamin C. This may help increase the body’s resistance to infection. Extra vitamin C that the system cannot use immediately will be released into the urine, where it helps block bacterial growth. As noted earlier, cranberry juice may be of some extra benefit in reducing urinary tract infections. If the patient doesn’t like cranberry juice, they can get the same benefit from cranberry pills available in most drug and health food stores.

Avoid Irritating Foods Like Caffeine: Symptoms of bladder irritation may be aggravated by caffeine, regular coffee, tea, alcohol, “hot” spices, aspartame, chocolate, cola drinks, and high potassium foods like bananas and oranges.

Avoid Activities Which Increase the Risk of Bladder Infections:  Prolonged bicycling, motorcycling, horseback riding, and similar physical activities and exercises may increase the risk of bladder infections. The patient may need to limit these types of activities.  When engaging in physical activity and exercise, the patient should frequently empty their bladder and drink plenty of water and other fluids. Sexual activity may also increase the risk because it can introduce bacteria into the bladder area.

Take Special Precautions After Sexual Activity:  After intercourse, instruct the patient to empty their bladder and drink two extra glasses of water. Some patients will be advised by their clinicians to take a urinary antiseptic or antibiotic after sexual activity. They should take the medication exactly the way, and at the time their clinician recommended.

An Estrogen Vaginal Cream May Help Increase Resistance to Bladder Infections: Clinicians may suggest an estrogen cream for the vagina if the patient has had menopause, even if they are already on an oral estrogen supplement or patch. The vaginal cream will help keep the tissues around the bladder opening healthy and more resistant to infection.

Take Antibiotics Only As Prescribed by the Clinician:  If the clinician has prescribed medication or antibiotic to take as a preventive therapy, patients should follow their instructions carefully. They need to be aware that medications may be necessary for up to a year or more, depending on the nature and severity of the urinary infection problem. For some patients, a small amount of a urinary antibiotic or antiseptic taken daily at bedtime will prevent most urinary infections, give the bladder a chance to heal, and restore its natural resistance. Other patients may need to take an antibiotic only when they think they are getting an infection. The patient needs to take any prescribed medication per clinician recommendations. If they cannot remember exactly how to take the medication and there are no clear instructions on the container bottle, they should be instructed to contact their clinician or pharmacist.

If Patients Follow All These Suggestions And Get An Infection Anyway: The guidelines and suggestions listed here will help most women avoid bladder infections most of the time. If they get an infection despite these precautions, they need to seek medical help promptly. A urine specimen for the examination should be given to the clinician if requested. Patients should seek prompt help for excessive vaginal discharge or other signs of vaginal inflammation and infection. Patients may be started on an antibiotic at this time, and compliance is crucial. In some cases, the clinician may request additional tests such as kidney X-rays or a direct examination of the bladder with a telescope (cystoscopy). Sterilization of washcloths may be the next reasonable step for those where simpler measures have not been adequate.

Sterilizing Washcloths for Home Use

The clinician may recommend sterilizing washcloths for washing and personal hygiene to help prevent recurrent urinary tract infections. This extra step is probably unnecessary for most patients with recurrent infections, but it can be beneficial for the more severe or resistant cases. Patients should use only those washcloths purchased for this purpose and remember to wipe correctly from front to back.

Home Sterilization of Washcloths

1. Wash the washcloths with hot water and soap or detergent as one normally would in a clothes washer. If the patient doesn’t have a washer, they can use soap and hot water in a sink.
2. Boil the washcloths in water for at least 20 minutes.
3. Take the washcloths out of the water and allow them to dry or use the clothes dryer.
4. When dry, place each washcloth in a separate, sealable microwave-safe plastic bag such as a ziplock bag.
5. The bags should be left open and not sealed yet.
6. Place the bags in the microwave. In the center of the microwave, put a large glass of cold water. The washcloths should not be placed in the water.
7. Put the microwave on high for five minutes and turn it on. Replace the glass of cold water (now very hot) with a new glass of cold water and microwave on high for an additional five minutes. 
8. Let the bags cool, then close them. The washcloths are now sterile inside a sterile bag.

This technique will kill the germs and bacteria on the washcloths by using microwave radiation for sterilization. Without the glass of cold water to absorb the heat, the bags would melt, and the washcloths would catch fire.

Summary of Tip for Preventing Infections

• Wipe in the correct direction, from front to back.
• Wash hands before using washcloths, tissues, or toilet paper for wiping or washing.
• Use a clean, gentle liquid soap because it tends to be much cleaner than bar soap.
• Only wipe once with each washcloth or tissue. If more cleaning is needed, use another washcloth.
• Clean the bladder area first when washing to prevent contamination with bacteria from other parts of the body.
• Don’t use these washcloths for any other purpose except to clean the area around the bladder opening.
• Drink extra water and take some extra vitamin C. Drink cranberry juice or take cranberry pills. 
• The patient can consider using an estrogen cream twice a week (or as prescribed by the clinician) if they are past menopause.

Enhancing Healthcare Team Outcomes

Recurrent UTIs often have a typical presentation of dysuria, urinary frequency or urgency, and suprapubic pain with/without fever, chills, flank pain, costovertebral angle tenderness, and nausea/vomiting. The diagnosis is often not in question. But, according to the literature, there exists a gap in the perception of the symptom severity between the clinician and the patient, which may be attributed to misinformation, misconceptions, or miscommunication.[63]

Recurrent UTIs require management from an interprofessional healthcare team that includes clinicians (MDs, DOs, PAs, NPs), nurses, and pharmacists, all coordinating their efforts and sharing case information to achieve optimal outcomes with the fewest adverse events. [Level 5] The primary care clinician is often the point of first medical contact in the care of a patient with a UTI. A proper history and physical exam should be conducted in a patient with recurrent UTIs. In several situations, it may be imperative to involve the nephrologist, as deemed necessary, according to the severity or the persistent nature of the disease. In cases of suspected urinary tract obstruction, the radiologist has an important role in helping to determine the cause using the necessary imaging. The nurses are also vital members of the interprofessional group as they will monitor the patient's vital signs and assist with the education of the patient and family.[64] The pharmacist should ensure that the right antibiotics are chosen on a case-by-case basis. The clinical presentation may be more complicated in a pregnant woman as the widespread inflammation may present as abdominal pain and might be falsely interpreted to be of obstetrical etiology. In such cases, the first point of contact may be an obstetrician. A unique aspect of managing recurrent UTIs is the self-diagnosis and self-treatment of UTI by the patient. This can be done if the patient is motivated, has a good relationship with the clinician, and has clearly documented recurrent UTIs. It has been demonstrated to have similar efficacy as conventional therapy.[35] [Level 1]

The American Urological Association (AUA) Guidelines are evidence-based guidelines for recurrent UTIs reviewed by an interprofessional expert committee. The current guidelines, published in 2019, have been developed after an exhaustive review of current medical literature from peer-reviewed journals.[3] The only non-antibiotic-based therapies for recurrent UTIs currently recommended by the AUA Guidelines are cranberry prophylaxis and vaginal estrogen.

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Disclosure: Nishant Aggarwal declares no relevant financial relationships with ineligible companies.

Disclosure: Saran Lotfollahzadeh declares no relevant financial relationships with ineligible companies.