Transcript: Treating Patients With Symptoms of Recurrent UTI

Liz Rohr:
Well, hey there. It's Liz Rohr from Real World NP and you are watching the Real World NP YouTube channel. We make weekly episodes to help save you time, frustration, and help you take the best care of your patients.

In this episode, I'm going to be talking about recurrent UTIs, simple cystitis that is recurrent in primary care, the definitions, risk factors, approach to evaluation and management, as well as when to refer to a specialist and to who.

One thing I want to start by saying though, is that language is really important here. So commonly in medical literature, we talk about men and women. So recurrent cystitis in women. And unfortunately, one thing that's really important to me and the company, Real World NP, is that we include all of our patients. And that is not inclusionary. And so really what I'm going to talk about is anatomy.

So what we're talking about here is recurrent cystitis in patients who have a vulva, who are assigned female at birth. And the reason for that is because when we only talk about men and women, we are excluding transgender patients, non-binary patients and whatever gender expression in between that patient's experience. So we're talking about anatomy here, anatomy-based conversations. We're talking about vulvas, and recurrence cystitis, and bladders and all that stuff.

So with that said, let's jump in.

So definition. So a recurrent UTI, simple cystitis, is defined as more than two infections in six months, or more than three infections in one year, and how common is that. So one minor thing I want to add about that is that it's a little bit of an arbitrary timeframe, but there's an idea of reinfection versus relapse. And again, this is not super strongly evidence-based, but the general thought is that if a patient has an infection and within two weeks has another infection, it's considered a relapse versus if another infection happens outside of that two-week window. And the evidence is not super strong with that, but that's like the general approach to practice and that's important. So just hold onto that thought.

So what are the risk factors for patients with recurrent cystitis? And actually I want to pause real quick. I have an episode about approach to dysuria. Definitely check that out. Even before we get to the conversation of recurrent cystitis, you need to be comfortable, first of all, that it is actually cystitis. Because dysuria can actually be a whole host of other things. So definitely check out that episode. And I believe in that episode, I put it in the updates, I think, that I did not include STI as a differential. So make sure you include that as your differential for dysuria.

But anyway, if we've already gone through that process, we've confirmed that it is a simple cystitis, not a complicated cystitis, where do we go from there? So what are the risk factors for these?

So this happens all the time. And I just want to kind of debunk some information that is really widely out there.

So one, the really evidence-based things that we know that can increase the risk for recurrent cystitis is sexual intercourse, increased frequency of sexual intercourse is associated with potentially more recurrent cystitis. We don't really have a great definition for what that means, more sexual intercourse in "spermicide use." And that includes manual spermicide, but also spermicide that is already a part of condoms. So that's, I think, really important to think about because I don't hear a lot of patients using spermicide separately, but there are a lot of condoms that include spermicide. So that is something to keep in mind. Those two things have evidence to support that that is associated with an increased risk of recurrent cystitis.

Things that do not have evidence-based associations are basically everything else that we always talk about with patients. So pre and post-coital voiding patterns. Like do they urinate before or after intercourse, not necessarily evidence-based. Frequency of urination, not necessarily evidence-based. Delayed voiding habits, wiping habits, meaning wiping front to back or not. Use of hot tubs, douching, use of pantyhose or tights, and patient's body mass index. Really, there isn't evidence to support those are actual real risk factors.

And I say that because it's like wild. I feel like we just talk about this all the time with patients. And I have some more thoughts about it to add about when we talk about management and interventions. But just know I want to say that because I think one of the things I was reading about is, and it really highlighted, we don't want to guilt patients. We don't want to put them as responsible for things that are not even evidence-based.

If we're having bias towards a patient who has a BMI of 35 who's getting recurrent UTIs, everyone's like, "Oh, well, you know what? Actually it's related to your body weight." First of all, it's not factual. Second of all, that's bias. So we want to be really mindful of these conversations of what is evidence-based and what is not, right?

So I also want to add another risk factor for patients who are postmenopausal. Things like incontinence or cystocele, especially in postmenopausal patients is more associated with cystitis. Like postmenopausal status can potentially increase that risk as well.

I also want to add that there are biologic and genetic factors, and it's just this broad non-specific thing of, you know what? Some people just get them and it's not your fault and you're doing the best you can. And I say that because so many patients that I see with this issue are really frustrated and they feel like they're doing so much. So I just want to lay that down there of the actual evidence.

So let's talk about the evaluation. It's important to have evidence that we've diagnosed an actual cystitis two to three times, in that two times in six months or three times in the course of a year. Because we don't want to dupe ourselves into thinking that somebody has cystitis when actually we haven't really investigated the cause of their dysuria in the first place. So number one, especially as a new grad, don't forget to do that.

Number two, it's helpful to have those urinalysis and culture evidence of their actual infection before we kind of continue forward with some of the more risky options for treatment and management, but definitely starting with that. And again, keeping in mind what I said about relapse infections versus recurrent. Did it just happen again within the course of that two week span or did it happen a couple weeks or months later?

But in terms of evaluation next steps, I think there might be some misinformation about there and general practices out there that are not necessarily evidence-based either. So when it comes to like, "Oh, should I talk about management and think about some of the treatment options for somebody just based on that alone, or do they need further imaging or referrals?" And so the evidence supports that you have to look at the history and the exam and think about what the reasons for referral would be. So if you have somebody who has a known cystocele, or they have urinary incontinence or other known urologic conditions, absolutely they need to see urology or urogynecology depending on the issue going on.

Some other things we want to think about is basically what you're looking to send them to a specialist for is are there any causes of functional or structural abnormalities? Are there kidney stones that are impairing the urinary flow which is causing these recurrent UTIs? Do you have suspicion symptom-wise why you would think that? So signs that you would see something like that are relapsing infection. So they have an immediate infection within that two week period. They have blood on their urinalysis after they've finished their treatment.

And by the way, if you have trouble with interpretation of urinalysis, absolutely come join us in the Lab Interpretation Crash Course. We get all into that. And it is absolutely magical.
 

Proteins. If you have Proteins on the urinalysis and culture recurrently, that's more associated with kidney stones, or if they have history of stones in the past. Those are all potential reasons to send to urology. And that is your primary person that you're going to send to when you refer these patients out. But not everybody needs a CT scan or a renal ultrasound or a renal and bladder ultrasound. Not everybody needs that imaging. Those are the risk factors, though, that you would consider or the symptoms you would consider sending to urology where they likely would do those tests versus you would do those tests and then it would be incumbent upon you to interpret them. I've talked about that in a couple of episodes, but just make sure whenever you order a test it is in alignment with the culture of your practice and is approved or supported by your collaborating providers.

Okay. Let's talk about some management.

So behavior changes. As I've said, the risk factors are a little bit shaky on the evidence. So when it comes to the management of behavioral interventions, it's also a little bit shaky, but we're telling all these people to do all these things. The moral of the story in terms of the standpoint of organizations like American Urological Association and other ones like that is that if there are things that are not going to harm them like cranberry pills or cranberry juice or pre and post-coital voiding, those are not harmful interventions. They may or may not be helpful. It's not that it's not helpful. It's we just don't have the evidence. And I think that's really important for us to understand, especially as newer clinicians. It's about the evidence. What does the evidence tell us? And then even if we don't have the evidence, it's like is this going to harm somebody? No. So it's fair for them to consider.

So that also brings up that question of hygiene, the wiping from front to back. Not necessarily evidence-based but is not necessarily going to hurt them. So it's something to try. But if it's not helping them and they're getting frustrated, you just have that conversation with them.

Increased fluid intake may have some more evidence. So making sure that they have adequate fluid intake, like two liters of water a day. Again, depending on their comorbidities. Someone with heart failure, you want to tread really lightly. And then just making choices about spermicides and looking potentially into condoms with spermicide. If they are a person that is using condoms in sexual intercourse, that could potentially be a helpful intervention because we know that that's a risk factor.

So if we talk about the other interventions we can do for management, you may or may not have seen this already, but postmenopausal patients can take topical estrogen. And that is thought to return the vaginal flora to a more optimal state. And so that's the rationale for trying that. You want to think about that for postmenopausal patients if that's appropriate for their whole risk factor history. So don't just automatically do that. Think about is it safe for them to have estrogen.
The other piece is using antibiotics. And I think that it's really easy for us to be like, "You know what? Let's just take some antibiotics. It'll be fine." One of our jobs, though, is to think about the risks. And unfortunately, medications always come with risks. So just hold that thought while I talk about the treatment options.

So the three options are taking antibiotics preventatively at a lower dose on a consistent basis, number one, like continuous. Post-coital, number two, is another option. If they find for this particular patient they always get their cystitis after intercourse, that's another option. There is some evidence of self-treatment, but I don't have a ton of evidence for that. So I usually just do the post-coital or the continuous, depending on the patient. And then the three options, I'm not going to give doses here on the podcast and the videos is because those things change. But it's typically a half dose or a lower dose of medications like nitrofurantoin, trimethoprim-sulfamethoxazole, that is quite a mouthful for the generic. And then cephalexin is another kind of third line option.
And I just want you to keep in mind that none of them come without risks.

So nitrofurantoin, for example, can have some pulmonary reactions or hepatitis or neuropathy. It has been studied long term use of about 12 months. But unfortunately when you stop taking it, the things can come back. It's not preventative for keeping it at bay forever. And then Bactrim, same thing, rash, nausea, vomiting, hepatitis, hyponatremia, hypoglycemia. Those are some of the risk factors of giving Bactrim. And so you just have to keep that in mind when you are talking about it with patients. Because it's not like, "Oh, this is an easy solution." We want to just think about that.

So when we start those management options, we do want to confirm they don't have an active infection with a culture showing more than a hundred thousand colonies of bacteria because that's a different intervention than the lower dose of the continuous or post-coital options. And then the other thing is if we decide to do that, great, if we feel comfortable. If we don't feel comfortable, let's send them to urology.

So again, let's recap when we will send them. When the lab or urine tests, they're not like what you're expecting, or they're confusing, or they have that hematuria after the infection has cleared up. If you're worried about some sort of functional, structural urologic condition. If you feel like they might need some imaging. If they're having that relapsing versus recurrent type of infection. So coming back within that two weeks. Or if you have started prophylactic treatment and it's still not working.

I think one pearl I wanted to add in here real quick is that I had a patient one time who had recurrent UTIs and she had actually had sugar in her urine. And so what happened is that she did not have diabetes. She just had, I don't know, I can't remember off the top of my head the medical word for sugar in your urine. But that's just like, she went to urology, she went to nephrology. They're like, "You know what? You're just getting rid of a lot of sugar in your urine for no reason. And you have no diabetes. So you're going to take continuous antibiotics." And that was necessary for her.

So again, really depends on the patient you're assessing, the lab results, and all of those pieces.

So hopefully you feel more comfortable with recurrent UTIs.

If you have not grabbed the Ultimate Resource Guide For The New NP, head over to realworldnp.com/guide. You'll get these episodes sent straight to your inbox every week with notes from me, patient stories, and bonuses I really just don't share anywhere else.

Thank you so much for tuning in. Hang in there. I'll see you soon.