5. Lifestyle Modifications
Increase fluid intake—advise to drink 2–3 L/day overall. In patients who drink less than 1.5 L/day, advise an additional 1.5 L to their usual fluid intake per day
Sexual hygiene—increased coital frequency, sexual partners, use of diaphragms and spermicide increase risk of UTI. Advise pre coital genital washing, post coital micturition, wiping front to back
Personal hygiene—advise care when shaving or using products around the genital-urinary region, regular underwear changes and avoid tight fitting undergarments
Voiding—advise techniques to reduce amount of residual urine in bladder post void, including double voiding, pelvic floor exercises and pelvic tilting
Weight loss—higher risk of UTI and pyelonephritis if BMI over 30
As with all treatments in medicine, lifestyle modifications is a vital part in preventing recurrent UTIs, yet this is the part often skimmed or skipped over in consultations.
There are many (comparatively simple) measures that can decrease the risk of UTI recurrence. However actual clinical studies on how effective these interventions are is limited in quality due to how heterogonous and multi-factorial the data is.
In real life clinical practice, the lack of side effects means there is little reason not to recommend these behavioural changes and anecdotally, a big difference can be made to rates of recurrence and healthcare utilisation when patients are appropriately counselled on these conservative measures alone.
The current 2019 EAU guidelines recommend the use of behavioural modifications to reduce the risk of recurrent UTIs.
5.2 Oral Hydration
Increasing fluid intake is one of the most common pieces of advice given to patients. The idea behind this is to increase the unidirectional flow of urine through the urinary tract, thus reducing the chance of bacterial migration backwards up into the bladder as well as “flushing away” any bacterial already present. The current British Association of Urological Surgeons (BAUS) patient advice sheet for recurrent cystitis advises 2 L of fluid a day.
A recent study in 2018 showed in 140 premenopausal women with recurrent UTIs who reportedly drank less than 1.5 L/day, increasing their fluid intake significantly improved their recurrent UTIs over the 12 months study period. The authors reported that patients who had an extra 1.5 L added to their usual fluid intake increased the number of times they voided and the volume of urine with each void, and subsequently reported almost halving the number of UTI episodes, with a longer period of time between each UTI episode .
A caveat to this is the risk of over-hydration in the more zealous patients, patients with predominately overactive lower urinary tract symptoms (increasing fluid intake in overactive bladder patients will actually worsen symptoms) or in patients requiring fluid restriction due to other underlying disease, especially renal or heart failure—whereupon advising a significant increase in fluid intake should be done with caution with specialist input.
5.3 Sexual Hygiene
Sexual intercourse and recurrent UTIs have been linked in many studies in the past, with some even suggesting which sexual positions cause the least number of UTIs! However the vast majority of these studies were done in small groups of patients and were further limited by not having a control group and the inability to control environmental/behavioural/other risk factors.
Studies show that the majority of UTIs occur within 24 hours of intercourse, with increased coital frequency (and new sexual partners) increasing the risk of UTIs. In fact a study found that university students had a 2.4 times higher risk of UTIs if they had intercourse 3 days a week compared to students who has been abstinent in the week. For those who had intercourse every day, the risk was reported to be nine times higher than the abstinent group! .
Pre and post sex voiding of urine is often advised as a way to prevent UTIs. Though the evidence for this is light, the simplicity of this suggestion and the theoretical benefits it should derive by flushing away any pathogenic contaminant from the bladder means clinicians often advise it. Furthermore before and after coitus, women should be encouraged to clean their genital areas (wiping from front to back) in order to minimise spread of uropathogens from the perianal/vaginal region to the urethra. If the male partner is uncircumcised, they should also clean under the foreskin to lower the bacterial load present, which may decrease the risk of post-coital UTI.
Finally, the use of diaphragms and spermicides has also been shown to be an independent risk factor for UTIs. The likely cause of this is either due to the diaphragm changing the bladders ability to void; therefore preventing complete bladder emptying or the insertion of the device facilitates the entry and colonisation of bacteria within the urinary tract. Furthermore the diaphragm and spermicide may alter the vaginal flora and microenvironment, weakening the commensal acidic defence against uropathogens [2–4].
5.4 Personal Hygiene
The current BAUS patient advice leaflet suggests avoiding the use of bubble baths, talcum powder or deodorants in the genital area as well as avoiding shaving and waxing close to the vaginal/urethral opening. Other studies advise avoiding douching. Similar to above, the theory is to avoid changing the protective acidic microenvironment of the vagina as well as avoid the direct introduction of uropathogens.
Needless to say, it is important to maintain good personal hygiene and change underwear daily, avoiding tight fitting garments including pantyhose and tights.
Once again, though theoretically these interventions makes sense, the actual evidence for these interventions are lacking but the lack of harm in their suggestion means they are often quoted by clinicians.
Double voiding: encouraging the patient to pass urine multiple times per trip to the toilet to fully empty bladder.
Pelvic floor exercises: Strengthening the musculature of the pelvic floor will aid in voiding. Pelvic floor exercises (either via the local continence service or physiotherapy service) may help patients void to completion. They are also especially important in patients with dysfunctional voiding such as incontinence. Furthermore, they can help patients who also have an overactive bladder, which can mimic UTI symptoms.
Pelvis tilting forwards: When sitting on the toilet, tilting the pelvis forwards can help with bladder emptying by straightening the urethra. This involves:
Ensuring knees are higher than hips when sat on toilet (a stool underfoot may help)
Leaning forwards with elbows on knees
Straighten back and bulge out abdomen
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