1. Introduction

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.

2. Methods

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.

3. Results

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.

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.

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.

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 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.

3.1 Discussion

Results show that recurring urinary tract infections in women have a significant impact on quality of life and health satisfaction. This study also shows that the quality of life of women with recurring UTI is significantly more compromised in its physical and psychological aspects than is the case for women without these infections. These findings corroborate previous studies with Asian and European women with recurring infections of this nature, which indicated that these infections had a broad negative impact on the quality of life of these women, especially affecting physical and mental dimensions (Ennis et al., 2018; Renard et al., 2015).

The fact that the physical and psychological domains of women with recurring urinary infections were the most compromised may be explained by the fact that the symptoms from these diseases are chronic, thus having the potential to affect work activities and work engagement, physical activities, family care, and other daily activities carried out by women. Furthermore, these infections lead to symptoms such as burning or pain at urination (dysuria), frequent or urgent urination, polyuria, hematuria, or lower abdomen discomfort, which can influence in daily activities and in the quality of life of women (Carvalho et al., 2023; Keren et al., 2015; McLellan, & Hunstad, 2016).

In Brazil, a study with women who had recurring urinary infections, using the WHOQOL-Bref and the King's Health Questionnaire (KHQ) as instruments, found that these infections had an effect over physical, social, and sexual activities, with loss of self-esteem and emergence of anxiety and depression (Faria et al., 2018). In addition, as these repeated infections compromise daily activities, they have an impact on the mental health of women, triggering feelings such as frustration, irritation, and fatigue (Naber et al., 2022; Scott et al., 2021; Wagenlehner et al., 2018).

A study with women from five European countries showed that, for many, recurring urinary infections are associated to the emergence of stress, and can lead to the development of depression (Wagenlehner et al., 2018). These findings are corroborated by other studies that suggest that recurring UTIs can cause negative feelings and emotional impairments (Grigoryan et al., 2022; Izett-Kay et al., 2022; Naber et al., 2022; Renard et al., 2015; Sosland, & Stewart, 2021).

The quality of life impairment in sleep and rest, positive feelings, and recreation/leisure activities that was presented by women with recurring UTIs can be related to the clinical framework originated by the infectious episodes. This hypothesis is made more credible as women with recurring urinary infections had significantly lower scores in feelings, self-esteem, and recreation/leisure activities facets, when compared to women with no infection.

The discomfort from urgent urination caused by the infection can affect the quality of sleep in women, in addition to compromising their social lives, hindering their satisfaction of enjoying life (Bermingham, & Ashe, 2012; Faria et al., 2018). There is also prejudice related with leisure activities, such as social activities in group, travels, and family activities, which may compromise self-esteem, aggravating the negative impact on the quality of life of these women (Faria et al., 2018; Seshan, & Muliira, 2014).

The recurrence of UTI episodes requires constant medication treatment, including antibiotic therapy. In addition to taking a relevant economic toll on the public health system. The inadequate use of antibiotics may favor the development of multidrug-resistant micro-organisms, making the clinical situation of the infections more severe. This may explain the fact that the score of women with recurring UTI in the facet dependence of medicinal substances or medical aids was lower than the one presented by women with no infections (Al Demour, & Ababneh, 2018; Faria et al., 2018; Medina, & Castillo-Pino, 2019; Sosland, & Stewart, 2021; Wagenlehner et al., 2018).

European data shows that recurrent urinary infections lead to an increase in absenteeism and medical consultations. According to literature, each episode of urinary infection leads, on average, to three days of sick leave. This loss of work capacity, associated to the emotional fatigue caused by the infection and its treatment, leads to a greater loss of energy and to increased fatigue among women with recurring urinary infections, favoring the emergence of negative feelings such as fear, frustration, moodiness, anxiety, and depression, in addition to having an impact on economic productivity (Bermingham, & Ashe, 2012; Medina, & Castillo-Pino, 2019; Scott et al., 2021; Wagenlehner et al., 2018).

Although literature shows an increase in the well-being of women, there are no reports of treatment-related quality of life improvements. This indicates that a successful medical treatment of an infection episode will not necessarily improve the quality of life of the patient (Sosland, & Stewart, 2021). However, studies indicate that, when there are adverse events related to treatment, the quality of life of women tends to be more compromised (Renard et al., 2015; Wagenlehner et al., 2018).

Thus, the definition and implementation of efficient strategies to prevent and treat recurring urinary tract infections requires health workers, especially physicians and nurses, to understand the real impact of these infections on the lives of these women. This requires professionals and users to make decisions together, in order to reach expectations and improve the quality of life of these women (Moskowitz, & Lee, 2018; Sosland, & Stewart, 2021; Wagenlehner et al., 2018).

Although a recent multi-centric European study pointed out that prophylaxis can reduce the number of infections and improve the quality of life of women, the lack of consensus regarding prophylaxis and how to treat recurring urinary infections in Latin America makes it harder to adopt prophylactic measures (Ennis et al., 2018; Renard et al., 2015; Wagenlehner et al., 2018). Thus, we need further studies that can evaluate the efficacy, risks and benefits that different prophylactic options bring to the quality of life of women with recurrent UTI.

This study has limitations regarding the number of women in its sample and its unicentric origin, meaning that further research on the topic is important, with larger samples from different services in different regions of the country. Nevertheless, the results found can subsidize the organization of health care actions that contribute for the quality of life of women with recurring infections, enhancing the promotion, recovery, and restoration of the health of these women undergoing outpatient care.

4. Conclusion

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.

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