Urinary tract infections (UTI) are bacterial infections which, in most cases, appear in outpatient clinic settings, globally affecting nearly 150 million people a year, especially women. Estimates show that one in three women will have at least one UTI episode in their lives, and from 30 to 50% of these women can present another case of the infection from 6 to 12 months afterwards (Grigoryan et al., 2022; Naber et al., 2022).

The likelihood of recurring infections increase with age. This growth in the incidence of recurrent UTIs is due to factors such as lower estrogen production during menopause, and a higher prevalence of urinary incontinence (Renard et al., 2015; Wagenlehner et al., 2018).

Clinically, several factors can be associated with UTI episodes, such as being female, sexual activity, diabetes, obesity, genetic susceptibility, and vaginal infections caused by different organisms that colonize the perineum and vagina, and may cause isolated or repeated infections (relapses or reinfections) at varying intervals, with higher or lower levels of severity (Flores-Mireles et al., 2015; Keren et al., 2015; Moreira et al., 2016).

Recurring urinary infections increase expenses with consultations, lab exams, medications, and hospitalizations, being thus an economic burden for the health system. Additionally, they generate social costs, as they cause absenteeism and morbidity in those affected (Flores-Mireles et al., 2015; Haddad et al., 2020; Wagenlehner et al., 2018).

Studies have shown that recurring urinary tract infections and cystitis have a strong impact on people's quality of life (Aydin et al., 2015; Izett-Kay et al., 2022; Yang, & Foley, 2018). Many women with recurring UTI experience discomfort due to its physical, psychological, emotional, and social effects, which can interfere in daily activities and quality of life, transforming these infectious frameworks into an important health problem for women, which, nonetheless, can be mitigated by the right treatment (Izett-Kay et al., 2022; Vahlensieck et al., 2016).

Prophylaxis can be a strategy to improve the quality of life of patients and avoid antibiotic overuse (Sosland, & Stewart, 2021); however, there is no consensus in Latin America about the prophylaxis or treatment of recurrent urinary infections (Haddad et al., 2020).

European studies suggest that repeated UTIs have a significant impact on the quality of life of women, representing an important problem for their physical and mental health, in addition to having relevant social impacts (Sosland, & Stewart, 2021; Wagenlehner et al., 2018). In this context, investigating the level to which recurring UTIs compromise the quality of life of women contributes to organize actions to promote health care and related activities, which may impact on the management of the services as it reduces the cost of treating these women.

Considering the above, the objective of this study was to evaluate the impact of recurring urinary infections on the quality of life of women in outpatient care.

Observational, descriptive and analytical study with 98 women attended in the outpatient clinic of a public teaching hospital in Niterói, Rio de Janeiro, Brazil. 49 of these women had recurring urinary infections, confirmed by urine culture, with no complications; 49 did not have this type of infection.

We considered an infection to be recurrent when there were three different instances of urinary tract infection with three positive urine cultures in the last 12 months, or two instances of UTI in the last six months (Malik, & Zimmern, 2018).

We selected women aged 18 or above for the study group, who had had at least two urinary tract infections in the last six months and/or three or more cases in a single year, according to clinical history as confirmed by urine culture tests (Faria et al., 2018). Women who were pregnant, were using bladder catheters, had an obstructed urinary tract, or neurogenic bladder were excluded. For the control group, we selected 49 women whose ages matched those of the case group and were undergoing some form of outpatient treatment in the same institution (outpatient service), but had no urinary tract infections.

For data collection, we used an instrument elaborated by the authors, which contained clinical variables (weight, height, hypertension, diabetes mellitus, number of pregnancies, number of childbirths, number of c-sections, active sex life, type of incontinence, contraceptive use), and the Brazilian version of the World Health Organization's quality of life questionnaire, the WHOQOL-Bref, which consists of 26 questions whose answers are scored using a five-point Likert scale in relation to four types of scales (depending on the content of the question): intensity, capacity, frequency, and evaluation (World Health Organization, 2010).

This instrument allows for a generic assessment, using a multidimensional and multicultural approach to quality of life in four domains: Physical, Psychological, Social Relations, Environment. It also includes two general questions, the first of which relates to quality of life (How would you evaluate your quality of life?), while the second is related to health (How satisfied are you with your health?). The higher the score of a domain, the better the quality of life. Values below 50.00 indicate significant quality of life impairments (Cordioli Junior et al., 2020; World Health Organization, 2010).

In the second semester of 2018, after data collection was finished, results were analyzed using the software Statistical Package for the Social Sciences (SPSS), version 23.0. Clinical variables were used to describe the sample studied and, to evaluate the quality of life of the women analyzed, we performed statistical analyses, considering frequencies and descriptive statistical measures of the general questions about life and health of the participants; mean scores and standard deviations for the WHOQOL-Bref domains; and mean scores for the facets that form the WHOQOL-Bref domains, comparing the two groups (case and control). To compare the groups, we used a chi-squared test for general questions and the t-test for domains and facets, considering a significance level of 95% (p ≤ 0.05). To evaluate the potential impact of recurring urinary infections on quality of life, we carried out a regression analysis, adjusted for potential confounding factors (hypertension, active sex life, BMI, and use of contraceptives).

The study followed all formal requirements of national and international norms that regulate research with human beings and was approved by the Research Ethics Committee of the Universidade Federal Fluminense under Certificate of Submission for Ethical Approval No. 01655812.1.0000.5243.

Participants were aged from 18 to 87 years, with a mean of 41.6 (± 17.0); 36.7% had had from one to three pregnancies; 32.2% had given birth from one to three times; and 74.5% claimed to have an active sexual life. 37.8% had urinary incontinence (UI), caused, in 9.2% of cases, by stress, and in 14.3% by overactive bladder, with 14.3% presenting cases of mixed incontinence. Furthermore, 46.9% of the women in the control group and 18.4% of those in the study group (with recurrent urinary tract infection) were hypertensive.

When the body mass indexes (BMI) of participants were compared, 59.6% of patients in the control group and 44.2% of women with recurrent urinary tract infection were found to be overweight or had some degree of obesity, with 36.2% of the control group having grade I obesity, and 11.6% of those with recurrent urinary tract infections presenting grade III obesity. Regarding contraceptive use, 23.5% of women made continued use of contraceptives.

Table 1 Table 1 Clinical characteristics of women undergoing outpatient treatment. Niterói – Rio de Janeiro, Brazil, 2018

Clinical variables	Women with UI	Women without UI	P-value 1
Pregnancies
None	17 (34.7)	18 (36.7)	0.439
One to three	18 (36.7)	24 (49.0)
Four or more	6 (12.2)	7 (14.3)
Did not answer	8 (16.3)	-
Childbirth
None	25 (51.0)	31 (63.3)	0.800
One to three	13 (26.5)	16 (32.7)
Four or more	3 (6.1)	2 (4.1)
Did not answer	8 (16.3)	-
C-sections
None	24 (49.0)	27 (55.1)	0.491
One to three	16 (32.7)	22 (44.9)
Four or more	1 (2.0)	-
Did not answer	8 (16.3)	-
Active sex life
Yes	40 (81.6)	33(67.3)	0.105
No	9 (18.4)	16 (32.7)
Type of urinary incontinence
No	26 (53.1)	35 (71.4)	0.293
Stress incontinence	5 (10.2)	4 (8.2)
Overactive bladder	9 (18.4)	5 (10.2)
Mixed incontinence	9 (18.4)	5 (10.2)
Hypertension
Yes	9 (18.4)	23 (46.9)	0.003
No	39 (79.6)	26 (53.1)
Did not answer	1 (2.0)	-
Diabetes
Yes	2 (4.1)	5 (10.2)	0.251
No	46 (93.9)	44 (89.8)
Did not answer	1 (2.0)	-
Body mass index (BMI)
Malnutrition	1 (2.0)	-	0.002
Normal weight	23 (46.9)	19 (38.8)
Overweight	12 (24.5)	10 (20.4)
Grade I obesity	2 (4.1)	17 (34.7)
Grade II obesity	-	1 (2.0)
Grade III obesity	5 (10.2)	-
Did not answer	6 (12.2)	2 (4.1)
Contraceptive use
No	23 (46.9)	28 (57.1)	0.150
Male condom and spermicide	9 (18.4)	7 (14.3)
Continuous-use oral contraceptive	14 (28.6)	9 (18.4)
Oral cyclic contraceptive	-	4 (8.2)
Intrauterine device (IUD)	-	1 (2.0)
Did not answer	3 (6.1)	-

¹

Chi-squared test

As Table 2 shows, the percentage of women with recurring urinary infections that consider their quality of life to be bad or very bad (14.2%) is significantly higher than the percentage of women in the control group (2.0%) who evaluate their quality of life in such a way. As opposed to this result, the percentage of women with recurring urinary infections who consider their lives to be good or very good (55.1%) is significantly lower than the percentage of women in the control group (73.4%) who evaluate their lives as in this manner.

Similarly, the percentage of women with recurring urinary infections who consider themselves to be dissatisfied or really dissatisfied with their health (48.9%) is significantly higher than the percentage among women in the control group (14.3%) (p = 0.004). In turn, the percentage of women with recurring urinary infections who consider themselves satisfied or very satisfied with their health (34.7%) is significantly lower than the percentage of women in the control group (59.2%) who see themselves in this light.

Table 2 Table 2 Response frequency of women with and without recurring urinary infections and mean scores for general quality of life questions. Niterói – Rio de Janeiro, Brazil, 2018

Question	Answer options	With UI		Without UI
		n	%	n	%
How would you rate your quality of life? (p = 0.027) ¹	1-very bad 2-bad 3-neither bad nor good 4-good 5-very good Mean score Standard deviation	1 6 15 19 8 3.6 1.0	2.0 12.2 30.6 38.8 16.3	- 1 12 33 3 3.8 0.6	- 2.0 24.5 67.3 6.1
How satisfied are you with your health? (p = 0.004) ¹	1-very dissatisfied 2- dissatisfied 3-neither satisfied nor dissatisfied 4-satisfied 5-very satisfied Mean score Standard deviation	6 18 8 16 1 2.8 1.1	12.2 36.7 16.3 32.7 2.0	3 4 13 24 5 3.5 1.0	6.1 8.2 26.5 49.0 10.2

¹

Chi-squared test

The quality of life of women with UTIs was more compromised in the physical and psychological domains. However, these women presented a better self-assessment of quality of life when compared to the control group, as table 3 shows.

Table 3 Table 3 Quality of life assessment in the groups of women with and without recurrent urinary infections. Niterói – Rio de Janeiro, Brazil, 2018

WHOQOL-Bref domains	With UI 1	Without UI 1	p-value 2
Physical	62.81 ± 15.59	71.35 ± 14.89	0.007
Psychological	67.79 ± 14.76	73.95 ± 14.18	0.038
Social Relationships	77.76 ± 13.60	75.52 ± 15.03	0.440
Environment	67.33 ± 13.78	63.52 ± 12.05	0.148
Self-assessment of Quality of Life	72.65 ± 12.37	63.06 ± 17.10	0.002

1

Mean ± standard deviation

An evaluation of the impact of recurring UTIs on the quality of life showed that women with urinary infections had a 13.3% lower mean than those in the control group (without urinary infections), as Figure 1 shows.

After an analysis adjusted for potential confounding factors (hypertension, active sex life, BMI, and use of contraceptives), the association between recurrent urinary infections and quality of life continued to be statistically significant (β = -1.95; p = 0.014).

Figure 1 Figure 1 Impact of recurring urinary infections on the quality of life of women treated in outpatient services. Niterói – Rio de Janeiro, Brazil, 2018

Figure 2 shows the mean scores of the WHOQOL-Bref facets, according to the study groups (case x control), showing that women with recurring UTIs presented impairments in the facets Sleep and rest (48.47), Dependence on medicinal substances and medical aids (44.27), Positive feelings (46.94), and Recreation and leisure activities (44.9), while women from the control group presented impairments in the Financial resources facet (45.42).

The group of women with recurring urinary infections had significantly lower mean scores than the control group on the facets Energy and fatigue, Positive feelings, Self-esteem, Dependence on medicinal substances and medical aids, Negative feelings, and Recreation and Leisure activities.

Figure 2 Figure 2 Mean scores for the WHOQOL-bref facets, according to the groups in the study (with and without urinary infections). Niterói – Rio de Janeiro, Brazil, 2018.

This study shows that recurring urinary tract infections have a negative impact on the quality of life of women, especially in the physical and psychological domains, compromising their level of satisfaction with health. These results reiterate that these recurring infections are a public health issue that affects women, health workers, and the health system itself.

The adoption of prophylactic measures is hindered by the scarcity of studies proving their effectiveness and the lack of a consensus in this regard in Latin America. Thus, further research is necessary to expand the discussion on the risk factors associated with recurring urinary infections, its socioeconomic impact, and the efficacy of prophylactic treatments, producing knowledge that can subsidize the implementation of effective actions for the health care of this population.