Treating Patients With Symptoms Of Recurrent UTI
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Show notes:
For patients and providers, few things are more frustrating than recurrent UTIs. Patients can feel like they have done something wrong; NPs can feel like they can’t meet the needs of their patients. But really, for such a (relatively) black-and-white issue, there are some subtleties that can make all the difference in whether or not you are able to solve the issue.
This week, let’s talk about recurrent UTIs and how to get real results for your patients.
Gender - and how to approach all patients in an inclusive way
The difference between recurrent and relapsing UTI
Evidence-based versus anecdotal risk factors
Labs to order, what to look for (and how to look)
Strategies for management
Adding to the tools in your toolkit will lead to strategies for success, which will make it MUCH easier to work with the frustrated patient with recurrent UTI. Feel confident in your approach and help your patients to break the cycle of recurrent (or relapsing) UTI.
If you liked this post, also check out:
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WEBVTT
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Hey there, welcome to the Real World NP podcast. I'm Liz Rohr, family nurse practitioner, educator,
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and founder of Real World NP, an educational company for nurse practitioners in primary
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care. I'm on a mission to equip and guide new nurse practitioners so that they can
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feel confident, capable and take the best care of their patients. If you're looking for clinical
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pearls and practice tips without the fluff, you're in the right place. Make sure you subscribe and
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leave a review so you won't miss an episode. Plus you'll find links to all the episodes with
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extra goodies over at realworldnp.com slash podcast. In this episode, I'm going to be
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about recurrent UTIs, simple cystitis that is recurrent in primary care, the definitions,
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risk factors, approach to evaluation and management, as well as when to refer to a specialist
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and to who. One thing I want to start by saying though, is that language is really important
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here. So commonly in medical literature, we talk about men and women, so recurrent cystitis
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in women. And unfortunately, one thing that's really important to me and the company Real
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World NP is that we include all of our patients. And that is not inclusionary. And so really,
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what I'm going to talk about is anatomy. So what we're talking about here is recurrent
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cystitis in patients who have a vulva who are assigned female at birth. And the reason for
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that is because when we only talk about men and women, we are excluding transgender patients,
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non-binary patients and whatever gender expression in between that patients experience.
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So we're talking about anatomy here, anatomy based conversations, we're talking about
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vulvas and recurrent cystitis and bladders and all that stuff. So with that said,
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let's jump in. So definition. So a recurrent UTI simple cystitis is defined as more than two
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infections in six months, or more than three infections in one year. And how common is that
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so I want to talk about one minor thing I want to add about that is that there's it's a little
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bit of an arbitrary language, but there's something or arbitrary timeframe, but there's
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an idea of reinfection versus a relapse. And again, this is not like super strongly
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evidence based, but the general thought is that if a patient has an infection,
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and within two weeks has another infection, it's considered a relapse, versus if another
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infection happens outside of that two week window. And the evidence is not like super
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strong with that, but that's like the general approach to practice. And that's important. So
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just hold on to that thought. So what are the risk factors for patients with recurrent
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cystitis? So I'm actually, I want to pause real quick. I have an episode about approach
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to dysuria. Definitely check that out. It's a video episode and I can link to you down below
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this episode. But that is something to think about even before we get to the conversation
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of recurrent cystitis, you need to be comfortable. First of all, that it is actually cystitis,
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right? Because dysuria can actually be a whole host of other things. So definitely check out
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that episode. And I believe in that episode, I missed, I put it in the updates, I think that
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I did not include STI as a differential. So make sure you include that as your differential
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for dysuria. But anyway, if we're talking about, we've already gone through that process,
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we've confirmed that it is a simple cystitis, not a complicated cystitis. Where do we go from
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there? So what are the risk factors for these? So this happens all the time. And I just want to
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kind of debunk some information that is really widely out there. So one, the really like
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evidence based things that we know that can increase the risk for recurrent cystitis
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is sexual intercourse. Increased frequency of sexual intercourse is associated with
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potentially more recurrent cystitis. You don't really have a great definition for what that
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means, like more sexual intercourse in quotes, right? Spermicide use, and that includes like
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manual spermicide, but also spermicide that is already like a part of condoms. So that's,
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I think, really important to think about, because I don't hear a lot of patients using
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spermicide separately, but there are a lot of condoms that include spermicide. So that is
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something to keep in mind. Those two things have evidence to support that that is associated
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with increased risk of recurrent cystitis. Things that do not have evidence-based associations are
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basically everything else that we always talk about with patients. So pre and post-coital
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voiding patterns, like do they urinate before after intercourse, right? Not necessarily
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evidence-based. Frequency of urination, not necessarily evidence-based. Delayed voiding
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habits, wiping habits, meaning like wiping front to back or not. Use of hot tubs,
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douching, use of pantyhose or tights, and patient's body mass index. Really there
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isn't evidence to support that those are actual real risk factors. And I say that because it's
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like wild. I feel like we just talk about this all the time with patients, and I have some
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more thoughts about it to add about when we talk about management and interventions,
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but just know I just want to say that because I think one of the things I was reading about
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and it really highlighted, we don't want to guilt patients. We don't want to put them as responsible
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for things that are not even evidence-based, right? If we're having bias towards a patient
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who has a BMI of 35 who's getting recurrent UTIs, and we're like, oh, well, you know
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it actually is related to your body weight. First of all, it's not factual. Second of all,
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that's bias, right? So we want to be really mindful of these conversations of what is
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evidence-based and what is not, right? So I also want to add another risk factor for
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patients who are post-menopausal. Things like incontinence or cysticel, especially in post-menopausal
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patients, is more associated with cystitis. Post-menopausal status can potentially increase
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that risk as well. I also want to add that there are biologic and genetic factors,
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and it's just this broad, non-specific thing of like, you know what? Some people just get
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them, and it's not your fault, and you're doing the best you can, right? And I say that
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because so many patients that I see with this issue are really frustrated, and they feel
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like they're doing so much, right? So I just want to lay that down there, of the actual evidence,
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right? So let's talk about the evaluation. It's important to have evidence that we've
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diagnosed an actual cystitis two to three times, right? In that two times in six months
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or three times in the course of a year, because we don't want to dupe ourselves into
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thinking that somebody has cystitis when actually we haven't really investigated the cause of
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their dysuria in the first place, right? So number one, especially as a new grad,
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don't forget to do that. Number two, it's helpful to have those urinalysis and culture
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evidence of their actual infection before we continue forward with some of the more risky
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options for treatment and management. But definitely starting with that. And again,
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keeping in mind what I said about relapse infections versus recurrent, right? Did it
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just happen again within the course of that two-week span, or did it happen a couple
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weeks or months later? But in terms of evaluation next steps, I think there might
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be some misinformation about there and general practices out there that are not necessarily
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evidence-based either. So when it comes to like, oh, should I really, should I talk
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about management and think about some of the treatment options for somebody just based on
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that alone, or do they need further imaging or referrals? And so the evidence supports that
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people, you have to look at the history and the exam and think about what the reasons for
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So if you have somebody who has known cysticel or they have urinary incontinence or other
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known urologic conditions, absolutely they need to see urology or urogynecology,
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depending on the issue. Some other things we want to think about is like, basically what
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you're looking to send them to a specialist for is are there any causes of like, functional
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or structural abnormalities, right? They're kidney stones that are impairing the urinary
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flow, which is causing these recurrent UTIs, right? Do you have suspicion symptom-wise like
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why you would think that? So signs that you would see something like that are relapsing
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infection, right? So they have an immediate infection within that two-week period. They
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have blood on their urinalysis after they've finished their treatment. And by the way,
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if you have trouble with interpretation of urinalysis, absolutely come join us in the
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lab interpretation crash course. We get all into that and it is absolutely magical.
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Proteus, if you have proteus on the urinalysis and culture recurrently, that's more associated
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with kidney stones. So those are potential like signs of, or if they have history of
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stones in the past, those are all potential reasons to send to urology. And that is your
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primary person that you're going to send to when you refer these patients out. But not
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needs a CT scan or a renal ultrasound or a renal and bladder ultrasound. Not everybody
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needs that imaging. Those are the risk factors though that you would consider or the symptoms
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you would consider sending to urology where they likely would do those tests versus you
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would do those tests. And then it would be incumbent upon you to interpret them.
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I've talked about that in a couple of episodes, but just make sure whenever you order a test,
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it is in alignment with the culture of your practice and is approved or you're supported
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by your collaborating providers. Okay. Let's talk about some management. So behavior changes,
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as I've said, the risk factors are a little bit shaky on the evidence. So when it comes
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to the management of behavioral interventions, it's also a little bit shaky, right? But we're
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telling all these people to do all these things. The moral of the story in terms of
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standpoint of organizations like American Urological Association and other ones like that
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is that if there are things that are not going to harm them, like cranberry pills
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or cranberry juice, right? Or pre and post-coital voiding, those are not harmful
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interventions. They may or may not be helpful, right? It's not that it's not helpful. It's
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just, we just don't have the evidence. And I think that's really important for us to
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understand, especially as newer clinicians, like it's about the evidence. What does the
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tell us? And even if we don't have the evidence, it's like, is this going to harm somebody?
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No. So it's fair for them to consider. So that also brings up that question of hygiene,
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the wiping from front to back, not necessarily evidence-based, but it's not necessarily going
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to hurt them. So it's something to try, right? But if it's not helping them and they're
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getting frustrated, it's not necessary. Like you just have that conversation with them.
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Increased fluid intake may have some more evidence. So making sure that they have
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like two liters of water a day. Again, depending on their comorbidities, someone with heart
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failure, you want to tread really lightly, right? And then just making choices about
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spermicides, right? And looking potentially into condoms with spermicide. If they are a person
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that is using condoms and sexual intercourse, that could potentially be a helpful intervention
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because we know that that's a risk factor. So if we talk about the other interventions
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we can do for management, you may or may not have seen this already, but many people take
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topical, post-menopausal patients can take topical estrogen and that is thought to return
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the vaginal flora to a more optimal state. And so that's the rationale for trying that.
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You want to think about that for post-menopausal patients if that's appropriate for their
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whole risk factor history. So don't just automatically do that. Think about is it
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safe for them to have estrogen? The other piece is using antibiotics. And I think that
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it's really easy for us to be like, you know what, let's just take some antibiotics,
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it'll be fine. One of our jobs though is to think about the risks. And unfortunately,
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medications always come with risks. So just hold that thought while I talk about the
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treatment options. So the three options are taking antibiotics preventatively at a lower
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dose on a consistent basis. Number one, continuous, post-coital. Number two is another
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option. If they find for this particular patient, they always get their cystitis after
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intercourse. That's another option. There is some evidence of self-treatment, but I don't have a
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ton of evidence for that. So I usually just do the post-coital or the continuous depending
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on the patient. And then the three options, I'm not going to give doses here on this
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channel because on the podcast and the videos is because those things change,
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but it's typically a half dose or a lower dose of medications like nitroforantoin,
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trimethoprim, sulfamethoxazole, that is quite a mouthful for the generic.
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And then of cephalexin is another kind of like third line option. And I think I just
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want you to keep in mind that none of them come without risks. So nitroforantoin, for
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example, can have some pulmonary reactions or hepatitis or neuropathy. It has been studied
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long-term use of about 12 months. But unfortunately, when you stop taking it,
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things can come back. It's not preventative for keeping it at bay forever. And then
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Bacterem, same thing, rash, nausea, vomiting, hepatitis, hyponatremia, hypoglycemia,
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those are some of the risk factors of giving Bacterem. And so you just have to keep that
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in mind when you are talking about it with patients, right? Because it's not like, oh,
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this is like an easy solution, right? We want to just think about that. So when we start
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those management options, we do want to confirm they don't have an active infection with a culture
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showing more than 100,000 colonies of bacteria because that's a different intervention than like
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the lower dose of the continuous or postcoital options. And then the other thing is if we
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decide to do that, great, if we feel comfortable. If we don't feel comfortable,
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let's send them to urology. So again, let's recap when we will send them. When the lab
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or urine tests are, they're not like what you're expecting or they're confusing or
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they have that hematuria after the infection has cleared up. If you're worried about some
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sort of functional structural urologic condition, if you feel like they might need some imaging,
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if they're having that relapsing versus recurrent type of infection, so coming back
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within that two weeks, or if you have started prophylactic treatment and it's still not
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working. I think one pearl I wanted to add in here real quick is that I had a patient
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one time who had recurrent UTIs and she had actually had sugar in her urine.
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And so what happened is that she did not have diabetes. She just had, I don't know,
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I can't remember off the top of my head the medical word for sugar in your urine,
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but that's just like she went to urology, she went to nephrology. They're like, you know
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what, you're just getting rid of a lot of sugar in your urine for no reason and you have
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so you're going to take continuous antibiotics and that was necessary for her. So again,
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really depends on the patient you're assessing, the lab results, and all of those pieces. So
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hopefully you feel more comfortable with recurrent UTIs. If you have not grabbed the ultimate
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resource guide for the new NP, head over to realworldnp.com slash guide. You get these
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episodes and straight to your inbox every week with notes from me, patient stories,
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and bonuses. I really just don't share anywhere else. Thank you so much for tuning in.
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I'll see you soon. That's our episode for today. Thank you so much for listening.
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Make sure you subscribe, leave a review and tell all your NP friends so together we can
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help as many nurse practitioners as possible give the best care to their patients.
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If you haven't gotten your copy of the ultimate resource guide for the new NP,
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