Chronic, Recurrent & Embedded UTI

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A urinary tract infection, or UTI, occurs when bacteria enter the urinary tract and cause inflammation. The urinary tract consists of your kidneys, the tubes that go from the kidneys to your bladder, and the tube that carries urine to the outside when you urinate. Urine inside the urinary tract is normally free of bacteria, but if any bacteria get in, it can cause an infection.

UTIs are the second most common type of infection that people get (after the common cold), accounting for 3 million consultations every year in the UK. When a UTI occurs more than twice in six months, it is considered to be a recurrent urinary infection. About one in five women will get a recurrent UTI, and women who have more than three UTIs are more likely to continue having them. Men can also have recurrent UTIs, but this is not as common in men as in women. In many cases men with recurrent UTIs have some type of urinary obstruction.

What Causes Chronic UTI?

Bacteria can enter the urinary tract from the outside to cause a UTI to come back, or a recurrent infection can be caused by bacteria that remain in the urinary tract after a previous infection. Symptoms of recurrent UTI in men and women include the frequent urge to urinate, burning pain or pressure when passing urine, cloudy or discoloured urine, and chills and fever. Children with UTIs are more likely to have fever without the other symptoms. Common conditions that can lead to recurrent UTIs include:

  • Being in a nursing home or hospital

  • Diabetes

  • Kidney or bladder stones

  • Having a catheter

  • Previous urinary tract surgery

  • Sexual activity

  • Having an infected or enlarged prostate

  • Being born with an abnormality of the urinary tract

Embedded or Biofilm infection

When bacteria first enter the urinary tract, they are free-floating (planktonic). However, under the right circumstances, these bacteria can stick to the bladder lining, and form a networked community, shielded by a protective slimy material. This slimy material protects the bacteria from antibiotics, as well as shielding it from the body’s natural defences. This is known as biofilm and can allow bacteria to survive for long periods. Once such a biofilm develops, whenever you get a UTI, instead of recovering completely, your body can be left with an embedded infection adherent to bladder wall, that is difficult to treat.

In addition to biofilms attached to the bladder wall, bacteria can also invade bladder cells and then rapidly replicate within the cells to form intracellular bacterial communities (IBCs) with enhanced resistance to antibiotics. However, within hours of IBC development, the progeny of successfully invasive bacteria emerge from the bladder cells, again in a free-floating (planktonic) state, ready to invade neighbouring cells to start the cycle anew. This form of invasion and intracellular replication affords a survival advantage for the bacteria to persist within the bladder as it sheds it lining.

Both of these mechanisms can result in you getting acute symptoms that seem like a new UTI, then periods of minor or non-existent symptoms, before getting acute symptoms again. Then the pattern repeats. Although this may seem like recurrent UTIs, it could actually be part of a cycle caused by an ongoing infection that was never properly treated and flares up at different times. Indeed, some patients even see evidence of shed cells from bladder lining and slimy biofilm material within their urine.

Only in the last 10-15 years have biofilms and intracellular bacterial communities (IBCs) been recognised as a contributor to chronic bladder infection. Fortunately, research is now throwing further light on these mechanism and potential treatments to combat them.

How is it investigated?

If you have recurrent UTIs, then some of the ways that we investigate this are:

  • Enhanced Urine Testing – We will take a urine sample to test for bacteria and white blood cells. We may also send your urine for specialised urine tests such as broth cultures (to improve sensitivity for bacteria) and polymerase chain reaction (PCR) to look for more unusual bacteria

  • Imaging – It may be necessary to do ultrasounds to check on your kidneys and bladder emptying, special X-ray studies to see if there is an obstruction or stones in the urinary tract. We may also look into your bladder by passing a special scope through the opening into your bladder. This exam is called a cystoscopy.

  • Functional tests – We may use a test called urodynamics to check how your bladder responds when it is filling up and how well coordinated your bladder and urethra (water pipe) are when you try to pass urine. Problems in these aspects of your bladder function may contribute to bladder symptoms and / or increase your susceptibility to UTIs.

How is it treated?

If you have chronic or recurrent UTIs, then at Yorkshire Urology we can help you. Some of the ways that recurrent UTIs are treated include:

  • Extended course of antibiotics – Although a regular UTI or ‘simple cystitis’ may respond very well to antibiotics, for chronic and recurrent UTIs, antibiotics are typically needed for extended courses. We use our enhanced testing to help direct treatment in chronic and recurrent UTI.

  • Bladder instillations – a variety of therapies can be instilled into the bladder to coat the bladder and help prevent UTI symptoms including frequency, urgency, burning pain or stinging sensations when passing urine. We can also put antibiotics such as gentamicin directly into the bladder which is often the most powerful way to attack bacteria in the bladder.

  • UTI vaccines and immune boosters – Research done in a number of studies including a large Wellcome Trust study led by Mr Ali shows that some patients who get recurrent UTIs have reduced responses from their innate immune system making them more susceptible to infections. Such patient may benefit from genetic testing and specific treatments such as vaccines and immune boosters to help improve their ability to fight UTIs naturally.

  • Surgery – In some cases of prostate disease, stones, or other obstruction of the urinary system, surgery may be done to restore normal flow of urine and help clear up infections. Cauterisation / fulguration of the trigonal area of the bladder can also be used to treat symptoms and remove cells potentially infected or damaged by intracellular bacterial communities (IBCs) to promote regrowth and healing of the bladder lining. The technique is described here.

  • Antibiotics for prevention – Some strategies to prevent recurrent UTIs with antibiotics include taking low-dose antibiotics for extended periods. Other options may be include taking antibiotics on a self-initiated basis after sexual intercourse or at the first onset of symptoms (after an early warning sign – EWS) 

  • Natural remedies – We can give information based on recommendations from patient experts and representatives from Bladder Health UK on which probiotic compounds and natural dietary supplements can help with recurrent UTIs.

Recurrent UTIs are common and there are many effective treatments available. Some simple things you can do straightaway to help prevent UTIs include drinking lots of fluids, keeping the genital area clean, and wiping from front to back after a bowel movement or urination. Drinking cranberry juice and taking vitamin C supplements may also help by making your urine more acidic, which decreases the growth of bacteria. Although be careful about drinking too much juice as many contain lots of sugar.

Urinary tract infections, especially chronic and recurrent UTIs, can be a serious health problem. At Yorkshire Urology, many of our patients with long term chronic urinary tract conditions have found better treatment and are now free or recurrent and chronic UTI