What is a chronic UTI? Symptoms, causes, antibiotic resistance and treatments

While urinary tract infections (UTIs) are common infections, that doesn't make them any less painful or uncomfortable, especially when they become recurring or long-term.

In the UK it's estimated up to 1.7 million women suffer chronic UTIs, while many men and children also experience them, according to the Chronic Urinary Tract Infection Campaign (CUTIC).

Here, we consult the experts to understand more about UTIs and chronic UTIs, including symptoms, causes, treatments and prevention measures, as well as what we can do about them becoming increasingly resistant to antibiotics.

What is a chronic UTI?

Firstly, it's helpful to understand what typical UTIs are: common infections that affect the bladder, the kidneys and the tubes connected to them.

"A chronic UTI is when it is believed that the infection persists beyond the initial treatment and can cause pain lasting weeks or months," says Mr D C Panayi, gynaecologist and subspecialist urogynaecologist with extensive experience treating women with chronic and recurrent UTIs, bladder and vaginal pain.

UTI symptoms

As well as the above symptoms, your pee may also be dark or smell. If this is your only symptom, it might be because you've not been drinking enough water. There are other variations of symptoms for children or older people.

Infections of the bladder (cystitis) or urethra (tube that carries urine out of the body) are known as lower UTIs, and may be more likely to cause unusual pee or lower stomach symptoms as well as feeling generally unwell. Meanwhile, infections of the kidneys or ureters (tubes connecting the kidneys to the bladder) are known as upper UTIs, and can cause the same symptoms plus those associated with a high temperature, sickness, confusion and agitation or restlessness.

In some people, UTI symptoms do not go away (and can become chronic), according to the NHS, which can have a big impact on your quality of life.

UTI causes

UTIs are usually caused by bacteria from poo entering the urinary tract, according to the NHS. The bacteria enter through the tube that carries pee out of the body (urethra).

"UTIs are more common in women than men because of the close proximity of the urethra to the vagina and anus and also because the urethra is shorter in women," says Mr Panayi. They can, however, affect anyone.

Things that may increase your risk of UTIs include:

• sex

• pregnancy

• conditions that block the urinary tract like kidney stones

• conditions that make it difficult to fully empty the bladder

• urinary catheters (a tube in your bladder used to drain urine)

• having a weakened immune system

• not keeping the genital area clean and dry

"UTIs can be triggered by sex or in the menopausal woman by low oestrogen leading to vaginal dryness. But in most cases, there is no obvious cause...some women seem to be more susceptible," adds Mr Panayi.

"Use of catheters or foreign objects in the vagina or urethra can also lead to UTIs."

While these may be triggers, what about the cause of chronic UTIs? "This is not known exactly. The chronic UTI concept is really a theory that has yet to be proven."

However, the NHS describes a chronic (long-term) UTI as being caused by bacteria entering the lining of the bladder. Short-term antibiotics may not have worked and urine tests might not always pick up an infection, and symptoms can be similar to other conditions, making chronic UTIs hard to diagnose, the health service acknowledges.

Watch: Cranberry products may prevent urinary tract infections

UTI prevention

"We encourage good hygiene such as wiping from front to back and passing urine before and after sexual intercourse to help prevent UTIs," says Mr Panayi.

"Seek hygiene and fluid advice [plenty of fluids will help with regularly peeing and not feeling thirsty) and, in susceptible women, use over-the-counter treatments that help create an unfavourable environment in the urine such as cranberry supplements, red bush tea or D-mannose."

Speak to your doctor before taking any of these during pregnancy, and be aware that D-mannose and cranberry products can contain a lot of sugar. Cranberry products should be avoided if you're taking warfarin.

Mr Panayi points out that cranberry supplements are better than the drink, which is sweet. It's important to note that while cranberry extract helps prevent UTIs, it is not effective in treating UTIs, he highlights.

The NHS also advises keeping the genital area clean and dry, washing the skin around the vagina with water before and after sex, and promptly changing nappies or incontinence pads if they're soiled.

According to Mr Panayi, you also might want to try avoiding caffeine, alcohol, acidic and spicy foods and drinks. Meanwhile, the health service recommends not holding your pee if you feel the urge to go, not rushing your pee, not wearing tight synthetic underwear, not having lots of sugary food or drinks, not using scented soap, and not using condoms or a diaphragm or cap with spermicidal lube (instead try non-spermicidal lube or a different type of contraception).

And how can we ensure a UTI doesn't become chronic? "Be mindful of symptoms that persist after an initial course of antibiotics and seek medical advice if they do persist. Ideally, see a specialist in this area such as a urogynaecologist," adds Mr Panayi.

Chronic UTI treatments

If your UTI comes back after treatment, or you have two UTIs in six months, a GP may, according to the NHS:

• prescribe a different antibiotic or prescribe a low-dose antibiotic to take for up to six months

• prescribe a vaginal cream containing oestrogen, if you have gone through the menopause

• refer you to a specialist for further tests and treatments

Chronic UTIs might be treated with antibiotics that you take for a long time.

"Antibiotic strategies for treatment and prevention as well as bladder instillations to regenerate the lining of the bladder wall and symptom treatment such as pain modulators [altering messages sent along pain fibres to the brain, used in patients with long-term conditions]," may be options, suggests Mr Panayi. "There has been some success with treatments directed at histamine [a chemical your immune system releases]."

Antibiotic-resistant UTIs

Currently, 1.2 million people die from drug-resistant infections each year. And by 2040, scientists at the Ineos Oxford Institute for Antimicrobial Research (IOI) have warned this could be catastrophic as resistance to antibiotics increases, if the government doesn't invest in funding for new antibiotics now.

This is because of something called antimicrobial resistance (AMR), which occurs when bacteria develop the ability to resist the action of antibiotics that would otherwise kill them or prevent them from growing. It's the bacteria that causes our infection that can be resistant to drugs, not us ourselves.

Some 92% of bacteria that cause UTIs are resistant to at least one common antibiotic, and 80% are resistant to two, according to a previous study. For example, if you contract cystitis caused by E. coli, this could be resistant to antibiotics.

Other things like STIs are also at risk of becoming untreatable due to AMR, and everyday activities like sports and cooking could be high-risk due to injuries becoming harder to treat.

While Mr Panayi points out it is unlikely a UTI infection will be resistant to all antibiotics, chronic UTIs are on the rise, and a multidrug-resistant infection is increasingly becoming a reality.

Overcoming AMR

"Due to a lack of investment in research, we haven’t discovered a new class of antibiotics for almost 40 years. Without the development of new solutions to combat the rise of bacterial resistance to current antibiotics, we will inevitably return to a pre-antibiotic era," says Professor Timothy Walsh, research director at the IOI.

There is also increasing research into Phage therapy [recently advocated for by MPs] which predated antibiotics. This could also be a viable alternative to antibiotic treatment.

Another possible treatment pathway is being researched by scientists at Oxford University. They are using different methods of delivering drugs directly into the cells that need them, bypassing the gut and causing fewer systemic side effects. Plus, a vaccine is being developed at Duke University in the USA.

Get involved with the #NotInOurLifetime campaign and sign the petition for increased AMR funding here. You can also sign the petition asking for chronic UTIs to be considered in the government’s Women’s Health Strategy for England here.

To find out more about what a chronic UTI is like in reality, read Caroline Sampson's story here:

Living with a chronic UTI: 'My condition severely impacts my physical and mental health' (Yahoo Life UK, 8-min read)

To find out more about AMR, read more here:

Scientists warn STIs could be deadly by 2040: What is AMR and how does it threaten our health? (Yahoo Life UK, 8-min read)