Recurrent Bladder Infections
Marja Sprock, MD FACOG

Bladder infections (cystitis) that keep on recurring, even if they never progress to a kidney infection (pyelonephritis), or worse an infection of your entire body (urosepsis),  can drag you down.

One infection per year is normal for women, up to 3 when we get older, however not more than that.  Not all bladder infections are symptomatic and not all require treatment.  Also some antibiotics, like ciprofloxacin, which has been used extensively for bladder infections in the past, should not be used as a first line anymore, since the resistance to it is too high.

Urine is not sent off for culture test every time a bladder infection is diagnosed. If despite taking antibiotics, you are not getting better, it may be that the bacteria which are causing the infection are not sensitive to the antibiotic you have been taking.

Acute cystitis is an infection of the bladder (lower urinary tract); it can occur alone or together with pyelonephritis (infection of the kidney – the upper urinary tract), and all of them can be called a UTI or urinary tract infection. Most of the time when the term UTI is used, it indicates a bladder infection.

Cystitis and pyelonephritis are generally considered to be uncomplicated in otherwise healthy nonpregnant women. A complicated urinary tract infection, whether in the bladder or kidneys, is associated with an underlying condition that increases the risk of failing therapy, such as an obstruction, anatomic abnormality, urologic dysfunction, or bacteria resistant to multiple antibiotics.

Issues related to acute uncomplicated cystitis and pyelonephritis in women will be reviewed here

So one reason the infection "recurs", is if it does not really get treated. This is why you could get a call from the doctor’s office to start another antibiotic, stating that the one you were originally taking is not sensitive. That does not mean your doctor was wrong, you get coverage per local guidelines for your UTI. Once the culture comes back and you are diagnosed with a resistant bacteria or a totally different one than is regularly the case, your antibiotic may have to be changed to be effective. Years ago, you would receive antibiotics for a longer period than now, medicine has advanced. The first line recommended antibiotics will be prescribed for 3 or 5 days, but you can treat cystitis in one day if needed.

So adequate treatment is necessary for cystitis not to recur, however numerous women get reinfected.

A couple of issues can make bladder infections easier to occur, like thinner tissue in the vagina/ over the urethra in menopause, providing less resistance against the bacteria. Local estrogen may increase your resistance.

Remember: you were taught to wipe front to back.  There is a reason! Even though bacteria from the bowel are the most commonly found in an UTI, we should not "rub it in". If you have fecal incontinence, it is hard to prevent bladder infections often. Spray bottles in the toilet may help to stay clean. Remember no soap in the vagina and wipes are not great either, unless all is purely used on the anus.

The natural vaginal flora has lactobacillus and loss of these natural bacteria may make it easier for unwanted ones to enter. Soap use close to the vagina, increases the pH of the vagina, making it alkaline, and lactobacillus prefer a slightly acidic environment.

Intercourse can often cause infections, especially in thin the vaginal/ urethral tissue, as in after menopause; estrogen or prophylactic antibiotics may help.

Spermicide use and a new sex partner all increase the risk of recurrent UTI.

Recurrent infections may not have been adequately treated or recur.

Reinfection can be caused by retention/ not emptying of the bladder. The reason for not emptying the bladder can be a prolapse (the bladder has fallen down in the vagina) and has caused a bulge. The bladder often empties better at night, since it will hang down less, and may keep you from sleeping well.

Some women have no prolapse, but the bladder muscle does not contract well, sometimes a neurologic issue or prolonged overstretching of the bladder, causing retention-not emptying of the bladder, predisposing to infections.

Well if you have none of the above, some women have a genetic propensity to infection, which increases the chance that E. Coli the most common uropathogen/bacteria will bind to the cell.

Will cranberry juice help you to prevent these infections; well it has been shown to diminish the chance of adherence of some bacteria to the cell. Prophylactic antibiotics can help in some situations of retention of urine or infections after intercourse. Urinating after sex is not harmful, but not really proven to help. Abstinence may help, but I would recommend prophylactic antibiotics to take after intercourse.

Vaginal estrogen as a cream or ring will also significantly decrease the chance of recurrent infections in postmenopausal women.

Obviously if retention or not emptying of the bladder is the reason, emptying needs to be improved, either by prolapse reduction, catherization or nerve stimulation.

Recurrent bladder infections are a genetic problem for some, an anatomic problem for others or a problem that does not arise till after menopause for a lot of women. However it can be debilitating and discouraging.

There are numerous treatment options available, obviously dependent on the underlying reason. If you are bothered by recurrent bladder infections, see Dr. Sprock at Central Florida UroGynecology in Rockledge for a consultation. Call 321-806-3929 for an appointment or leave a note here.