A Urologist’s perspective on the management of recurrent UTIs

Written by: Dr. Yana Barbalat, Lahey Health, MA

The purpose of this article is to provide a Urologist’s perspective on the management of recurrent UTI’s using antibiotics as well as cranberry PACs. Dr. Barbalat discusses the patient demographics she typically sees and how she manages their treatment. She presents a successful case study of a 70-year-old female with 4-5 recurrent UTI’s per year, followed by an explanation of the benefits of cranberry PACs for non-antibiotic recurrent UTI prevention.

Recurrent UTI’s: Common patient demographics and treatment modalities

It is estimated that over 150 million urinary tract infections (UTIs) occur annually worldwide. In women specifically, the lifetime incidence of a UTI is 50 – 60%. About 15% of those patients go on to develop recurrent UTIs, meaning having 2 or more infections in a 6-month or 3 or more infections in a 12-month period.

As a board-certified urologist who specializes in voiding dysfunction and female urology, I take care of many patients who unfortunately fall into the recurrent UTI category. My UTI patients vary in age and gender. Most commonly, I see women between the ages of 18 and 30, as well as men and women over the age of 60 with recurrent UTIs.

In younger patients, UTIs often tend to be associated with sexual activity or a new sexual partner. Most young patients do not have structural or functional abnormalities that account for their UTIs. There are usually no physical exam or ultrasound findings, although I do physical and ultrasound imaging on all these patients. Usually, there is not much I can offer as far as “lifestyle modification.” Most young people are already well hydrated and know to wipe front to back. However, young patients, as opposed to their older counterparts, tend to be more eager to start antibiotics. Their lives are busy, and they do not want to be slowed down by discomfort or pain.  So, when I see a young female with recurrent UTIs that impact her quality of life, she is often looking for antibiotic prophylaxis or an emergency antibiotic script for her next infection. The problem is that patients with recurrent urinary tract infections end up taking multiple courses of antibiotics, which leads to alterations in gut and vaginal biome, pelvic pain, yeast infections, and antibiotic resistance.

In patients over the age of 60, one or more risk factors are often involved in their recurrent urinary tract infections. Some of these risk factors include incomplete bladder emptying, dehydration, menopause, incontinence, catheter use, immunosuppression, and underlaying diseases such as diabetes and dementia. These patients also end up taking multiple courses of antibiotics. The potential for an adverse event due to antibiotic use is greater in this patient population.  These patients tend to be frailer, have insufficient renal function, and take multiple other medicines, leading to potential for drug-drug interactions. There is a greater chance for colitis, tendonitis, tendon rupture, organ toxicity, neuropathy, and electrolyte imbalances with antibiotic use in older patients.  Antibiotic resistance is also a huge issue for older patients, especially those who have polymicrobial urinary tract infections.

Case study: 70-year-old female with recurrent UTIs

Recently, I saw a 70-year-old female who presented with recurrent urinary tract infections. She reported 4-5 infections per year for the past 3 years. Cultures have been consistently positive for E.coli and she had been treated with multiple courses of antibiotics. Unfortunately, her last antibiotic course resulted in C. difficile colitis, for which she eventually needed a fecal transplant. The patient was referred to see me at that point.

First, I tried to identify modifiable lifestyle risk factors in this patient. I asked her about hydration, sexual activity, constipation, and wiping. There was nothing to modify other than to encourage her to stay well hydrated and stress the importance of having regular bowel movements. On exam, there was mild vaginal atrophy. No prolapse was seen. Bladder scan did not reveal any significant post void residual. Renal US was obtained and was normal. A cystoscopy was not indicated (no hematuria or previous pelvic surgery). The patient did not report any other significant past medical history other than hypertension.

At this point, I started her on one pill of Utiva daily. I educated the patient about the reason for cranberry use and the importance of having a “good” cranberry pill containing 36 mg of soluble PACs. We also discussed vaginal estrogen use but she wanted to hold off. I saw the patient back 3 months later, then at 6- and 12-month intervals. She has not had a recurrence of UTIs in the past 3 years and has been very happy.

Cranberry PACs for recurrent UTI prevention

In the past decade, we have seen multiple randomized controlled trials that support the use of cranberry in UTI prevention.  The American Urological Association (AUA), the Canadian Urological Association (CUA), and the Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction (SUFU) have recently published guidelines for recurrent urinary tract infection. These guidelines support the use of cranberry as the non-antibiotic option for prevention of recurrent urinary tract infections. Although there is ongoing research for other non-antibiotic alternatives, cranberry has the most robust data, and therefore got the stamp of approval from the AUA, CUA, and SUFU in 2019.

Cranberry contains proanthocyanidins (PACs) which interfere with the adhesion of bacteria to the bladder wall. Studies have shown that 36 mg of soluble PACs are needed for optimal anti-adhesion activity of cranberry. Cranberry can be consumed as a pill or a juice, however, I tend to prefer pill form to avoid the added sugar and potential for bladder and stomach irritation. Although many commercially available cranberry pills exist, very few contain 36 mg of soluble PACs. Because of this, the anti-adhesion scores of different cranberry pills vary significantly. Utiva has 36 mg of soluble PACs, with a strong anti-adhesion score.  I tell my patients to take one pill daily and then I see them back in 3 months for follow up. If they continue to get a significant number of infections, we discuss adding or substituting for other prophylactic options. If the patient is doing well, I usually have them continue the cranberry pill long term.