Chronic Urinary Tract Infections (UTIs) – why they can be so hard to get diagnosed & effectively treated

This blog outlines what a UTI is, risk factors, tests used, treatment ideas and resources for more information.

Urinary Tract Infections (UTI) are common and are mainly due to bacterial infection. They are divided into lower and upper UTIs and when they become chronic, can cause much distress (for mainly women) when they aren’t correctly treated.

Lower UTIs are more common and affect mostly the bladder (cystitis). Symptoms can include painful urination, increased need to urinate, burning sensation, lower back discomfort and cloudy, smelly urine. Medical treatment usually involves oral antibiotics for 3-7 days. This short term treatment may resolve symptoms of the current infection quickly, but a significant number of women go on to develop chronic UTIs. Naturopathic treatment involves looking at ensuring water intake, alkalizing the urine with minerals, and herbs including cranberry juice or concentrate during the acute phase (if it’s caused by E.coli) , and addressing lifestyle factors such as stress, nutrient insufficiency, diet and immune function to prevent reoccurrence.

Upper UTIs are more serious and affects the kidneys and can even spread to the circulation and cause sepsis. Fever, vomiting and flank pain are the triad of symptoms, but rigors (feeling cold with shivering) and pain radiating to back can also occur. Treatment usually requires intravenous antibiotics for longer periods of time.

Ruth Kriz has specialised in helping both men and women with chronic UTI symptoms, interstitial cystitis, prostatitis and urethritis – see her videos discussing treatment considerations at: https://liveutifree.com/ruth-kriz/#preventrecurrentuti

Investigations:

Urine Tests

Dipstick: A small reagent stick is dipped into the urine and colour changes show the presence of white and red blood cells, nitrates, and protein and other parameters.

Urinalysis: The most common test is a midstream ‘Micro and Culture’ (MSU) of urine where measurements like pH, ketone, white and red blood cells are measured and the urine is cultured to see if bacteria grow, then tested for sensitivity to antibiotics. A positive test is where the bacteria are greater than 105 CFUs (colony forming units). This test is useful for common acute UTIs but does not necessary pick up chronic imbedded infections. See https://www.chronicutiaustralia.org.au/uti-testing/

MSUs are often considered by doctors to be the ‘gold standard’ of testing. If a urine shows a negative culture, the assumption is there is no infection, and antibiotics are often discouraged. However a 2019 study published in ‘Journal of Microbiology’ states that more extensive testing (i.e. DNA analysis) shows bacteria that don’t necessarily grow in the MSU culture: https://www1.racgp.org.au/newsgp/clinical/is-it-time-to-rethink-midstream-urine-culture-for?fbclid=IwAR3nvTrQ1wm3CbVTsjhHocnAHSXNZnYINLuzqRcu4KI3NrjzZTplw5utAn4

Fresh unspun urine: This test is done on first voided urine and ideally done within 15 minutes of collection. This test is recommended by Professor Malone-Lee and influences treatment recommendations. “The white cell count is the best marker of urinary infection known, if it is conducted on an immediately fresh, unspun, unstained specimen of urine examined using a microscope and a haemocytometer counting chamber” (4). The epithelial cell count (the cells that line the bladder) indicate whether there has been a response to treatment in chronic UTIs with long term antibiotic treatment. There are only a few places that offer this test but can be found in Sydney and Melbourne (see http://haemanalysis.com.au/contact/ or https://www.holistichealth.com.au)

Fresh unspun microscopy is available from a number of leading pathology labs. It requires a specific referral form your doctor. It is covered by Medicare but there is controversy as to whether the time delay will impact results and the recommendation is to do a mid-stream urine. See: https://www.labtestsonline.org.au/learning/test-index/urine-culture

Note: Referral to a urologist is indicated:

1. Failure of improvement in symptoms after antibiotics
2. Recurrent UTIs – more than 3 a year
3. Blood in urine (Haematuria)
4. Men with UTI symptoms

Blood Tests & Swabs:

-Full Blood analysis (FBE) checks if there is an increase in white cells (especially neutrophils that increase during a bacterial infection)

-CRP is an inflammatory response marker and increases during bacterial infections.

-B-HCG if pregnancy is possible as it’s important to exclude an ectopic pregnancy

-Infection screen: If there is an itch or discharge with a fishy smell a genital swab for STDs is recommended.

-I also recommend more extensive testing to check for inflammation (high sensitive CRP), nutrients like Vitamin D and zinc that are important in overall immune health, clotting risk factors (people with chronic UTIs are more likely to have biofilms which harbour the bad bugs and are more prone to clotting issues) and more recently vaginal microbiome testing to assess the bacterial and fungal makeup in the vagina (that can spread to the urinary tract)

PCR Testing:

1. Nutripath: The option of testing the microbiome of the urinary tract providing as an important clinical assessment tool for those experiencing complicated urinary tract infections (UTI) is now available. Cost approx. $220 includes postage. See: https://nutripath.com.au/product/complicated-uti-screen-test-code-2205/
2. MicrogenX. There is an even more comprehensive test that does both PCR testing, and an even more extensive NGS (next generation sequencing – for more info see https://microgendx.com/harnessing-next-generation-dna-sequencing-a-revolution-in-urology-and-antibiotic-resistance/) that looks for over 50,000 pathogens. It also checks for bacterial resistance genes and sensitivities of the various bugs to different medications. Tests can be ordered from the USA, but specific instructions need to be followed to get the most from the results. Ideally women should initially check both the vaginal and the urinary microbiome; men the semen and urine. For more information see: https://microgendx.com/revolutionizing-urology-unraveling-the-secrets-of-infectious-diseases-with-next-generation-dna-sequencing/

Both of these tests can be ordered after a consultation with Doreen

Risk Factors for UTIs:

1. Catheters due to the introduction of bacteria
2. Hormones- e.g. use of oral contraceptives, in menopause, being female and pregnancy. In pregnancy there is relaxation of smooth muscle due to progesterone causing urinary stasis. It’s possible to have no UTI symptoms in pregnancy which is of concern as the untreated infection can harm the growing foetus. Almost all pregnant women who have catheters get UTIs.
3. Sex, IUDs, diaphragms, irritating spermicides and condom use
4. Sexually transmitted diseases (STDs)
5. Poor hygiene – it is recommended to wipe from ‘front to back’ after a bowel motion
6. Diabetes mellitus
7. Medications – Immunosuppressants e.g. corticosteroids & heavy antibiotic use
8. Use of irritant chemicals (detergents, spermicides)
9. Urinary tract abnormality or obstruction (tumour, calculi, stricture, inability to empty bladder completely)
10. Previous UTIs less than 6 months apart

Chronic UTIs

Isolated UTIs occur in 30% of all women, but recurrent UTIs occur in 60% of cases and can be difficult to treat. Chronic UTI are defined as having 3 or more UTIs in a year. Diagnosis can be tricky as bacteria imbed in the bladder lining or form ‘biofilms’ (see later) and can’t be cultured in the regular MSU nor respond to regular antibiotics

Treatment of UTIs:

• Avoid sexual activity until the acute stage of the infection is resolved.
• There is evidence the d-mannose (an amino acid) helps prevent bacterial adhesion on the bladder, particularly with E. coli infections.
• Cranberry (as this contains d-mannose) can help prevent bacterial adhesion of E. coli to the bladder wall. Options are unsweetened cranberry juice or tablets of the extract. This may be of limited effect in chronic UTIs
• Targeted probiotics: Several studies show the benefits of both oral and vaginal probiotic use. See: https://academic.oup.com/cid/advance-article-abstract/doi/10.1093/cid/ciad766/7470427?redirectedFrom=fulltext Lactobacillus crispatus shows promising results in cUTIs (5)
• Drink plenty of fluids, such as water and herbal teas for acute UTIs. With chronic UTIs, at least enough water to enable voiding every 3 hours, but not too much fluids to dilute the urine, especially during antibiotic therapy as this can dilute their effectiveness.
• Avoid sweetened fruit juices and other sweetened drinks.
• Reduce pro-inflammatory foods in the diet including refined foods, and sugar.
• Emphasise foods high in essential fatty acids such as oily fish and nuts / seeds.
• Eat a minimally processed diet rich in antioxidants, phytonutrients and bioflavonoids.
• Stress management techniques should be implemented if stress is an issue
• As with many recurrent infections, a naturopath works on correcting intestinal flora imbalances by reducing gut inflammation, improving digestion, eliminating reactive foods, chemicals and environmental stressors, and repairing damaged mucosal barriers and defective liver detoxification enzyme systems.
• Persistent, unresponsive chronic UTI may need supervision from a health professional well-versed in their treatment. Antibiotic therapy for as long as a year is a common recommendation by Professor Malone-Lee in the UK

Resources

(1) An excellent resource to explain urinary anatomy, causes, symptoms & treatment for UTIs can be found at https://www.chronicutiaustralia.org.au/

(2) Professor James Malone-Lee has treated many chronic UTIs and describes his research and the failure of current testing options.https://theconversation.com/profiles/james-malone-lee-287655

(3) The visual and description of the development of chronic UTIs

https://www.chronicutiaustralia.org.au/wp-content/uploads/2018/08/00-Chronic-urinary-infection-Picture-Commentary-August-2018.pdf

(4) Experiences of women with chronic UTIs https://www.chronicutiaustralia.org.au/accessing-chronic-uti-treatment-five-women-share-their-experience/

(5) Cochrane article on various therapies for managing recurrent UTIs in Women including cranberries, probiotics, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3784967/

(6) Article aboit impact of vaginal microbiome on chronic UTIs https://journals.asm.org/doi/10.1128/microbiolspec.UTI-0025-2016

(7) Preventative Treatments for UTI and relative effectiveness: https://www.paralogic.com.au/UTI-Preventatives

Author Doreen Schwegler is a Medical Scientist and Naturopath who does fresh urine microscopy in Mosman (Sydney).

Contact doreen@holistichealth.com.au for more information

Tania Delahoy also provides fresh urine microscopy in Wonga Park, Melbourne, Victoria: http://haemanalysis.com.au/contact/