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Urinary tract infections are common in adults but a common problem in kids as well. By the age of five, about 8% of girls and about 2% of boys have had at least one urinary tract infection or UTI.

Urinary tract infections occur when the kidneys, ureters, bladder, or urethra, as the main parts of urinary tract, become infected.

Chronic urinary tract infection is a disorder involving repeated or prolonged bacterial infection of the bladder or lower urinary tract.

Since this is a common problem, we should take a better look at what a urinary tract infection means. 

What Is a Recurrent Urinary Tract Infection?

Recurrence is common after both complicated and uncomplicated urinary tract infections. After a single uncomplicated acute urinary tract infection, recurrence occurs in approximately 27% to 48% of women, where infections usually recur a few months apart. The risk after a complicated UTI is even higher. The fact is that between 50% and 60% of individuals will have a recurrent infection 4 to 6 weeks following treatment if the underlying problem is not dealt with. We often define recurrence as either reinfection or relapse of a urinary tract infection. Reinfection is a huge problem since about 80% of recurring urinary tract infections are reinfections. [1

A reinfection occurs several weeks after antibiotic treatment has cleared up the initial episode. It is caused by a different organism from the one that caused the original episode. The infecting agent is usually introduced through the rectal region from fecal matter and moves up through the urinary tract

Relapse is a less common form of recurrent urinary tract infection, and it is diagnosed when a UTI recurs within two weeks of treatment of the first episode and is caused by the same organism. Relapse usually occurs in a kidney infection or is associated with obstructions such as kidney stones, structural abnormalities, or, in men, chronic prostatitis. [2]

Symptoms of Urinary Tract Infection

Common symptoms of urinary tract infection are [2]:

  • Pain when urinating
  • Changes in frequency of urination and the appearance and smell of urine
  • Nausea
  • Lower abdominal pain
  • Fever
  • Lower back pain or discomfort
  • Chills
  • Loss of appetite
  • Vomiting

Recurrent urinary tract infections can also cause bedwetting in children who were previously dry at night, while infants and young children may only show nonspecific signs such as fever, vomiting, or decreased appetite or activity. Some children experience urinary tract infection again and again, and that is also called recurrent UTIs. If left untreated, recurrent UTIs can cause kidney damage. It could be serious in children younger than six.

Types of Urinary Tract Infections

Common types of urinary tract infections include the following.

Cystitis is the most common type of UTI. That is a bladder infection that can occur when bacteria move up the urethra, which is the tube-like structure that allows urine to exit the body from the bladder, and into the bladder. 

Urethritis is a problem which occurs when bacteria infect the urethra. [3]

Pyelonephritis is an infection, specifically a kidney infection, that can occur when infected urine flows backward from the bladder to the kidneys, or when an infection in the bloodstream reaches the kidneys. [4]

Related Urinary Tract Conditions Associated with Recurrent UTIs

Recurrent urinary tract infections are sometimes seen in conjunction with some other conditions. Recurrent urinary tract infections could be related to vesicoureteral reflux or VUR, which is found in 30% to 50% of children diagnosed with a UTI. It is a congenital condition, which means it is present at birth. When children have this problem, their urine flows backward from the bladder to the ureters. As you already know, ureters are thin, tube-like structures that carry urine from the kidney to the bladder. If the urine in the bladder is infected with bacteria, VUR can sometimes lead to pyelonephritis. [5

Hydronephrosis is an enlargement of one or both kidneys due to backup or blockage of urine flow and is usually caused by severe VUR or a blocked ureter. Children with hydronephrosis are sometimes at risk of recurrent urinary tract infections and may need to take daily low doses of antibiotics to prevent UTIs. [6]

However, not all cases of recurrent UTIs can be traced back to these body structure-related abnormalities. For example, dysfunctional voiding, when a child does not urinate frequently enough or does not relax properly while urinating, is a common cause of urinary tract infections. Unrelated conditions that compromise the body’s natural defenses, such as diseases of the immune system, can also lead to recurrent UTIs. [7]

Using a non-sterile urinary catheter can introduce bacteria into the urinary tract and cause an infection.

Causes, Incidence, and Risk Factors for Recurrent Urinary Tract Infections

Most urinary tract infections occur in the lower urinary tract, which includes the bladder and urethra, where cystitis is caused when the normally sterile lower urinary tract is infected by bacteria and becomes inflamed. Cystitis is very common and most of the time, symptoms of cystitis disappear within 24 to 48 hours after treatment begins. Chronic or recurrent urinary tract infections include repeated episodes of cystitis, which means more than two infections in six months. It also refers to a urinary tract infection that does not respond to the usual treatment or that lasts longer than two weeks. 

In young girls, recurrent urinary tract infections may be an indication of a urinary tract abnormality, such as vesicoureteral reflux. In boys, even a single urinary tract infection should be evaluated. That is because urinary tract infections in boys are extremely uncommon in the absence of urinary tract abnormalities. 

The elderly population is at increased risk for developing cystitis. In this population, a problem occurs due to incomplete emptying of the bladder associated with such conditions as benign prostatic hyperplasia, prostatitis, and urethral strictures. Moreover, lack of enough fluids, bowel incontinence, immobility or decreased mobility, having a Foley catheter, and placement in a nursing home, all put a person at an increased risk of developing cystitis or urinary tract infections.

In addition, the following conditions also increase chances of developing a UTI [2]:

  • Diabetes
  • Advanced age and conditions that affect personal care habits (such as Alzheimer disease and delirium)
  • Problems emptying the bladder completely
  • Having a urinary catheter
  • Bowel incontinence
  • Enlarged prostate, narrowed urethra, or anything that blocks the flow of urine
  • Kidney stones
  • Staying still (immobile) for a long period of time (for example, while you are recovering from a hip fracture)
  • Pregnancy
  • Surgery or other procedure involving the urinary tract

Signs of and Tests for Recurrent Urinary Tract Infections

A chronic or recurrent urinary tract infection means that symptoms return two or more times in six months, that symptoms of a single episode last longer than two weeks, or symptoms last longer than 48 hours after treatment has begun. Tests that may be done include a urinalysis, which commonly reveals white blood cells or red blood cells. A urine culture or catheterized urine specimen may reveal bacteria in the urine. A urine culture that is positive for more than two weeks even with treatment indicates a chronic or recurrent urinary tract infection. An abdominal ultrasound or KUB, also known as an abdominal x-ray, may be needed to evaluate the status of the renal system. [8]

Treatment for Recurrent Urinary Tract Infections

Mild cases of acute cystitis may disappear on their own without treatment, but since there is a risk of the infection spreading to the kidneys or becoming a complicated UTI, treatment is usually recommended. Also, due to the high death rate in the elderly, prompt treatment is recommended for each patient. 

Antibiotics may be used to control the bacterial infection, but you must finish the entire course of prescribed antibiotics. Commonly used antibiotics include Nitrofurantoin, sulfa drugs, Amoxicillin, Cephalosporins, Trimethoprim-sulfamethoxazole, Doxycycline, or Fluoroquinolones. [9]

Chronic or recurrent urinary tract infection should be treated thoroughly and this is very important because of the chance of a kidney infection, known as pyelonephritis. Antibiotics control the bacterial infection, so they may sometimes need to be given for longer periods of time, and in some cases, stronger antibiotics may be needed. [9]

As an additional precaution, low-dose antibiotics may be recommended after acute symptoms have subsided. 

Phenazopyridine hydrochloride [10] may be used to reduce the burning and urgency associated with cystitis, and ascorbic acid (vitamin C) [11] may be recommended to decrease the concentration of bacteria in the urine. In general, surgery is not needed to treat urinary tract infections or UTIs.

Prevention of Urinary Tract Infections

Preventive measures may reduce symptoms and prevent recurrence of infection, so if you keep the genital area clean and wipe from front to back, you may prevent dragging bacteria from the rectal area to the urethra. [12]

If you're a woman, use sanitary pads during menstruation and not tampons. Do not douche, as douching interferes with the natural flora and additionally interrupts bodily mechanisms.     

Urinating immediately after sexual intercourse may help eliminate any bacteria that may have been introduced during sexual intercourse. Not urinating for long period may give bacteria time to multiply, so it is important to know that frequent urination may reduce the risk of cystitis in those who are prone to urinary tract infections. 

Increasing the intake of fluids to between 2000 and 4000 cc per day encourages frequent urination that flushes the bacteria from the bladder. You should avoid fluids that irritate the bladder, such as alcohol, citrus juices, and drinks containing caffeine. 

Follow-up urine cultures may be needed to make sure that bacteria are no longer present in the bladder after you were diagnosed with a urinary tract infection. Long-term use of prophylactics such as preventative antibiotics may be recommended for some people who are prone to chronic or recurrent urinary tract infections.

Prognosis for Urinary Tract Infection

Most cases are cured without complication after adequate treatment, although sometimes the treatment may be prolonged. Complications are pyelonephritis, a kidney abscess, and swelling of the kidneys. You should call for an appointment with your healthcare provider if symptoms of cystitis persist after treatment, or recur more than two times in six months. Call your healthcare provider if symptoms worsen, or new symptoms develop — especially persistent fever, back pain or flank pain, or vomiting.