Recurrent urinary tract infection

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Chapter 35 RECURRENT URINARY TRACT INFECTION

Theodore O’Connell

In the general population, urinary tract infection (UTI) is primarily an infection of sexually active women; the prevalence of UTI in women outnumbers that in men by a ratio of 30:1. However, the prevalence of UTI increases in both sexes with advancing age, reducing the ratio to 2:1. Recurrent UTI is defined as three or more episodes of symptomatic bacteriuria within 1 year. A recurrent infection is one that occurs after documented, successful resolution of an antecedent infection.

In younger adults, recurrent infection occurs most often as a bladder infection in women and is usually related to sexual intercourse. In older persons, recurrence is primarily a lower tract disease as a result of different risk or contributing factors, which may include incomplete bladder emptying or diseases such as diabetes mellitus.

The decision to evaluate recurrent UTI radiologically, endoscopically, urodynamically, or otherwise should be based on the patient’s clinical presentation, history, findings, response to antimicrobial therapy, and pattern of recurrent UTIs. Severe UTI—defined as sepsis, fever, history of UTI lasting more than 7 days, gross hematuria, signs or symptoms of obstruction, or history of stones—warrants further evaluation. Risk factors such as diabetes mellitus, immunosuppression, debilitating disease, or pregnancy also may warrant further evaluation.

If a patient has a history of recurrent UTI, urine culture should be used to document the infection, identify the pathogen, and determine the frequency of infection. Urine culture is also used to distinguish between unresolved and recurrent infection. If the same pathogen is documented repeatedly and at close intervals, an underlying abnormality should be suspected, and an evaluation should be initiated. If the same pathogen is not found or if UTIs do not occur in a close temporal relationship, the likelihood that the infections are associated with functional, metabolic, or anatomic abnormalities is low, and the patient may be treated with low-dose antimicrobial prophylaxis.

Key Physical Findings

✓ Vital signs

✓ General examination to evaluate patient’s overall health

✓ Abdominal examination

✓ Back examination to evaluate for costovertebral angle tenderness

✓ Genitourinary examination to evaluate for urethritis or vaginitis

✓ Gynecologic examination to rule out vaginal pathologic processes

Suggested Work-Up

Urinalysis	To determine whether the urine contains infectious organisms
Urine culture	To document infection, identify the pathogen, and determine the frequency of infection
Measurement of blood urea nitrogen (BUN) and creatinine	To evaluate renal function
Quantification of postvoid residual bladder volume	To evaluate bladder emptying

One of the following tests should be considered as well:

Renal ultrasonography	To evaluate upper urinary tract architecture and establish the presence of hydronephrosis or abscess
Intravenous pyelography	To evaluate for filling defects or diagnose obstructive uropathy
Computed tomographic (CT) scan	To evaluate anatomic detail and to diagnose the presence of urinary stones

Additional Work-Up

Voiding cystography	If an anatomic abnormality is suspected
Cystoscopy	If tumor or mass is suspected
Urology consultation	For obstructive uropathy, calculi, abscess, or genitourinary abnormalities

FURTHER READING

Engel JD, Schaeffer AJ. Evaluation of and antimicrobial therapy for recurrent urinary tract infections in women. Urol Clin North Am. 1998;25:685-701.

McLaughlin SP, Carson CC. Urinary tract infections in women. Med Clin North Am. 2004;88:417-429.

Pewitt EB, Schaeffer AJ. Urinary tract infection in urology, including acute and chronic prostatitis. Infect Dis Clin North Am. 1997;11:623-646.

Yoshikawa TT, Nicolle LE, Norman DC. Management of complicated urinary tract infection in older patients. J Am Geriatr Soc. 1996;44:1235-1241.

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