Urinary Tract Infection (UTI) 2017-08-17T11:54:06+00:00

URINARY TRACT INFECTION

WHAT IS THE URINARY TRACT?

This is the excretory system of the body. The kidneys filter the blood and produce urine which is then transported by 2 tubes, one tube on each side, called the ureters. Each ureter is a 10 inch long tube that starts from the kidneys located in the upper back and goes down to the bladder which is right behind the pubic bone. The urine is deposited into the bladder from each ureter.

The bladder acts as a storage organ and holds the urine until it is time to go to the bathroom. At this stage, the bladder squeezes (contracts) and empties. The urine comes out through the urethra to the outside. Therefore, the 2 main functions of the bladder are to store and to empty.

The urethra is different in men and women. The female urethra is a short straight tube which is about 4 cm long, whereas, the male urethra passes through the prostate and is a 15 cm long tube with a couple of bends.

DEFINITION OF A UTI

This is an infection which happens in the urinary tract system. If it is a kidney infection, it is called pyelonephritis. If it is a bladder infection then it is called cystitis.

COMPLAINTS

The symptoms depend upon the age of the patient. Young women have different symptoms than older people.

  • What are the symptoms in young women who have a bladder infection?
    It is mainly dysuria where there is burning and discomfort when urinating, urgency (intense desire to urinate), frequency (going to the bathroom a lot), a sensation of going to the bathroom all the time and also a sensation of incomplete bladder emptying as the patient constantly feels the desire to go to the bathroom. Also, as this worsens, she may notice blood in the urine.

  • What about in the elderly?
    An elderly person may not have the classic symptoms of dysuria, urgency and frequency. It could be rather subtle. The patient may experience mental confusion with cloudy or malodorous urine. The mental confusion is usually picked up by a family member.

Cause: Escherichia coli is the commonest bug that causes bladder infections. It is a bacterium that is normally present in the bowel and therefore it is called a coliform. There are several other bacteria that are also responsible for a bladder infection and are collectively referred to as uropathogens.

  • Why is a bladder infection or UTI more common in women than in men?
    The female urethra is a short tube and the bacteria can ascend very easily and access the bladder causing a UTI. In a man, the urethra is a long 15 cm tube and it is very hard to get a bladder infection unless there is an intrinsic problem such as urinary retention. This could happen with an enlarged prostate. In women, a urinary tract infection can happen without any underlying cause being there.

  • Do postmenopausal women have a higher risk of bladder infections?
    In a postmenopausal woman, the vaginal pH is altered. Due to the lack of estrogen, the vaginal pH becomes more alkaline (higher pH level) and this may predispose to the colonization of bacteria that could lead to a bladder infection. Therefore, postmenopausal women may be at increased risk for bladder infection as compared to premenopausal women.

Diagnostic tests:
In most cases of simple UTI, no workup is necessary. However, if there is repeated infections or infection that is just not going away then further testing is required ( see recurrent UTI)

MANAGEMENT

In most patients with uncomplicated UTI, the best antibiotic is Macrobid or Bactrim. If the patient has an allergy to sulfa, Macrobid is the drug of choice. The antibiotic is usually prescribed for 3-5 days. In cases of complicated cystitis, the course would be extended to 7 days.

This may be cheap but the side effects could be significant.  Ciprofloxacin (Cipro) could cause tendon rupture and can cause bowel problems with C. diff enterocolitis. Therefore, it is very important to make sure that ciprofloxacin is not used as a first-line treatment unless the patient has a resistance to Bactrim/Macrobid or an allergy to these medications.

It is not a bad idea to drink water in order to flush the bacteria out, however this alone will not be adequate.

If it is very infrequent that a patient gets a bladder infection and it resolves promptly after treatment then it is not necessary. However, if the UTIs are happening very frequently or if the patient has not noticed improvement with the antibiotic, then a culture would be required to see whether the bacteria are resistant to the antibiotic.

WHAT IS RECURRENT TRACT INFECTION?

In most cases, there is no cause. There is simply an increased colonization of the uropathogens at the opening of the urethra and these get intermittently pushed into the bladder causing a urinary tract infection. The patient’s immune status allows the coliform uropathogens from the bowel to gather around the vaginal and the urethral opening in large concentrations.

If there is an obvious cause such as a stone this needs to be addressed. Once all the tests are done and there is no obvious source then it could very well be that the bacteria/uropathogens are allowed to colonize the urethral opening in large concentrations based upon the immune system. If that is the case, the goal is to decrease the concentration of the bacteria at the urethral opening

A low dose antibiotic taken on a nightly basis would help decrease the colonization of bacteria at the vaginal and urethral opening. By doing so, less bacterial numbers are available to access the bladder and cause an infection.

Recurrent UTI: workup and protocol

  • Confirm that this is truly a UTI by getting a urine culture

  • Making sure that the antibiotic is correct based upon the urine culture and sensitivity report

  • Treatment should be carried out for 7 days

  • May confirm that the urine is completely clear at the end of the treatment. Negative test of cure.

  • Evaluation of the urinary tract:
    Cystoscopy: looking inside the bladder with a telescope to make sure that there is no condition such as a stone that is causing repeated bladder infections;
    CT scan of the kidneys and ureters: to make sure that there is no anatomic problem.

  • A proper pelvic examination to make sure that there is no prolapse that could lead to urinary retention which is a risk factor for recurrent infections.