Q&A: Women with recurrent UTIs need better management strategies

The pain and discomfort that women experience with recurrent UTIs are compounded by the frustration that they feel from their limited treatment options, according to a focus group study in The Journal of Urology.

The researchers noted that more than half of all women will experience a UTI at some point in their lives, and about a quarter of women will suffer from recurrent UTIs.

Also, according to the researchers, the vast majority of women with UTIs are dissatisfied with their treatment, which primarily includes repeated antibiotic therapy with little effort put into patient education and prevention strategies.

Additionally, because of the symptom overlap between UTIs and other conditions, many patients who have been diagnosed with recurrent UTIs were misdiagnosed or mistreated, the researchers found.

Victoria C.S. Scott

To help shift the paradigm in recurrent UTI treatment, the researchers recruited 29 patients from a tertiary urinary practice to take part in six focus groups. Author Victoria C.S. Scott, MD, a urologist with Cedars-Sinai Medical Center in Beverly Hills, shared her perspective about the study and its results with Healio.

Healio: What impact do recurrent UTIs have on a patient’s quality of life?

Scott: Our studies show that it’s a significant negative impact. Most health care providers wouldn’t think of a single episode of UTI as having a significant impact on a patient’s life. But when they’re recurrent and can happen at any time — and many of these women don’t have good management strategies or plans to help them obtain rapid treatment — they really have a negative impact on their social life, work, families and relationships.

Healio: What are the most common courses of treatment for these patients?

Scott: Most often when a woman develops UTI symptoms, she can progress rapidly to the point where she probably will call her primary care provider and describe her symptoms, or present to an urgent care center or ER for evaluation. Based on guidelines for simple episodes of a single UTI or an episode of acute cystitis, a lot of medical providers will prescribe antibiotics without obtaining urine culture data.

The goal is to provide more rapid treatment. But for a lot of these women, their infections get treated as single episodes rather than recognizing that they are having multiple episodes per year. So oftentimes, they don’t get the adequate evaluation or counseling with education to help them focus on prevention.

Healio: What are the biggest risks of treatment with antibiotics?

Scott: A lot of women are fearful of antibiotics if they’ve had lots of infections, and they’ve had side effects from antibiotics. In addition, many of them are aware of the risks of bacteria developing resistance to antibiotics. They also are aware of the “collateral damage” of antibiotics and disruption they can have on the normal balance of “good” and “bad” bacteria inhabiting their gastrointestinal tracts and genitourinary tracts.

Healio: Do women share similar knowledge about UTIs and their treatment?

Scott: I’m sure there was some selection bias with our focus group in terms of who wanted to participate in the study, particularly women who were very frustrated and knowledgeable about the topic. In general, I see a wide range of knowledge, but there definitely are similar levels of frustration across the board. Some women may not know quite as much, but those women are still able to come in and express significant negative impacts on their life from their recurrent UTIs.

Healio: How common was misdiagnosis among the women in your focus groups, and what complications can result from misdiagnosis?

Scott: A number of conditions have overlapping symptoms with UTI. For example, overactive bladder, interstitial cystitis and possibly even something like bladder cancer can have overlapping symptoms. If patients continue to report symptoms and don’t get a urine culture each time, then they certainly could be given antibiotics to treat a condition that’s not related to bacterial infection. We could be completely mismanaging them, giving them unnecessary treatment and overtreatment for underlying conditions we haven’t necessarily diagnosed, if we’re not working them up properly.

Healio: Is it difficult for women with UTIs to express these frustrations with their physicians?

Scott: I think a lot of them did have a hard time because — particularly if they’re only seeing their primary care provider — oftentimes these providers don’t really have time to discuss all the patient’s health concerns and issues and certainly need to focus on the ones that are probably most impactful from a health care standpoint. And so, things like recurrent urinary tract infections get brushed to the side because they’re not usually going to have a significant impact on their health.

I think that women felt disempowered in not being able to have enough time to talk about wanting more knowledge and more options. I think those who saw specialists felt more empowered because they had more time to really dive into what was going on, undergo more extensive evaluations and come up with more individualized plans for management and prevention.

Healio: Does embarrassment play a role in whether these women feel comfortable about broaching these topics with their doctors?

Scott: Embarrassment has impaired their ability to talk about it, particularly with older women. I think this extends into their personal lives too, so they were unable to seek as much support from friends and family. Of course, that certainly exacerbated all the issues.

Healio: During the focus groups, what kind of solutions did these women suggest?

Scott: A lot of them wanted medical professionals and scientists in this area to focus on the development of more rapid diagnostics, so they could more quickly receive a diagnosis of what bacteria with antibiotic sensitivities are growing in their urine, if any. They also called for more research evaluating effective nonantibiotic preventative strategies.

Healio: What would be necessary to move treatment from a reactive model to a more preventive model?

Scott: Certainly spending more time on education with patients and providing them with options for prevention, which goes beyond simply wiping the right direction after urinating or urinating after sexual intercourse. Prevention options might include vaginal estrogen for postmenopausal women, cranberry supplements and other supplements, probiotics, drinking more than 1.5 L of water per day, preventing constipation or a low-dose antibiotic after sexual intercourse.

Again, women are asking for more rapid diagnostics, making sure that we’re identifying and not overtreating people with antibiotics and that we’re not giving them a more broad-spectrum antibiotic when we could be giving them a more narrow-spectrum antibiotic, one that’s tailored to whatever bacteria are growing.

Another important point is informing women that there is good research to suggest that some infections can be cleared without antibiotics and without major risk of development of kidney infections or hospitalizations, such as with ibuprofen and increasing fluid intake. As long as symptoms improve, they can safely try to manage mild symptoms that way. If symptoms progress, they do need to seek evaluation and treatment from a medical professional.

Healio: Some women expressed satisfaction with their care. What lessons can be learned from their responses?

Scott: I think the happiest women were those who could really sit down, express their priorities with their doctors and come up with prevention and treatment plans that were tailored to their preferences. Additionally, those women who understood that each of their UTI episodes was being properly evaluated, their providers were ruling out any underlying conditions that could be increasing their risk and those who received a lot of education about the condition from their doctor.

Healio: Based on these findings, what are the next steps for improving care?

Scott: Certainly for primary care providers to refer patients with recurrent UTIs to specialists for further evaluation and possible treatment. Also, to spend time with these patients discussing prevention options and management strategies. Technically, we define recurrent UTI as two or more infections over 6 months or three or more infections over 12 months.

Although guidelines do suggest that we can treat a simple episode of UTI just empirically with antibiotics, there is a shift for recurrent UTI patients toward always testing urine prior to initiating antibiotic therapy. This practice can really improve care for patients with recurrent infections.

On a larger scale, in terms of further research, more rapid diagnostics and nonantibiotic prevention strategies could be very helpful.

One other area I think we’re starting to learn more about is the vaginal and urinary microbiomes of women – what types of bacteria and fungi are normally present and what leads to imbalances that predispose to infections. Previously, we thought urine was sterile. But now we know that a lot of microbes do live in the bladder and in the urinary tract.

Healio: What are the next steps for research?

Scott: We are going to focus on looking at patterns of care among experts who see patients with recurrent UTIs. The American Urological Association has just come up with a set of management guidelines that are helpful, but we’re also really interested in looking at what’s happening in practice, and then comparing this to what’s going on at the primary care level as well. We’re conducting expert interviews of both sets of groups to compare practices of care for these patients and then, hopefully, helping to introduce better models, guidelines and pathways that we can present to optimize care for patients with recurrent UTIs.

References:

• Scott VCS, et al. J Urol. 2021;doi:10.1097/JU.0000000000001843.
• Anger J, et al. J Urol. 2019;doi:10.1097/JU.0000000000000296.

For more information:

Victoria C.S. Scott, MD, can be reached at victoria.scott@cshs.org.