15 Urinary problems
A total of 10–15% of healthy non-pregnant women will suffer from acute uncomplicated cystitis each year1 with the highest incidence (17.5%) reported by women aged 18 to 24 years. By age 24, one-third of women will have at least one physician-diagnosed UTI that was treated with prescription medication.1 Some 12% of women with an initial infection and 48% of those with recurrent infections will have a further episode in the same year.2
Classically, women present with urinary frequency, urgency and dysuria. Dysuria without vaginal discharge or irritation has a positive predictive value of 77% for a positive urine culture.3 Affected patients may complain of pelvic discomfort pre- and post-voiding, passing small quantities of urine and sometimes of haematuria. Some may have suprapubic tenderness or pain.
In the majority of cases, infection is limited to the lower urinary tract (i.e. the bladder and urethra: cystitis) but infection can also affect the upper urinary tract causing pyelonephritis. In uncomplicated cystitis, it is rare for women to present with fever or constitutional symptoms. Pyelonephritis is more likely to be associated with back pain, fever, nausea and vomiting.
In about 50% of women who present with urinary symptoms, there is no bacteriuria. These women nevertheless present with dysuria, frequency and urgency.4 Pyuria may be present or absent. They are said to have acute urethral syndrome, or interstitial cystitis or irritable bladder.
The aetiology of urethral syndrome is unclear, but it may be due to bacteria found in low concentrations or bacteria that are difficult to culture, or to nonspecific inflammation or muscular dysfunction.
CASE STUDY: Fifth UTI in 6 months
Janey was 25 and presented to her GP with the classic symptoms of frequency and dysuria of 3 days’ duration. She had no fever but had noticed some haematuria that morning. She had a previous history of several urinary tract infections (UTIs) and had been told by another GP about the relationship between UTIs in young women and sexual activity. She tried to remember to void postcoitally and to drink lots of fluid, but this was the fourth or fifth UTI she had had in the last 6 months and she was getting sick of it. After obtaining a urine microscopy and culture (M&C) and making sure that the antibiotics Janey was prescribed were sensitive to the organism, the GP discussed with Janey the use of prophylactic antibiotics. Janey was instructed to complete her course of trimethoprim and then to try using 100 mg of trimethoprim every time she had sex to prevent a further recurrence. A couple of months later Janey returned and reported that she was asymptomatic and not having any further problems.
When providing patient education about UTIs, there are a number of predisposing factors1,5,6,7–9 that should be highlighted, the strongest of which, in young women, is recent sexual activity (the relative odds of acute cystitis increase by a factor of 60 during the 48 hours after sexual intercourse).10 It is important to inform women of the risk factors, so that they can understand how their own behaviour is related to the onset of UTIs. These factors are listed in Box 15.1. GPs should also be aware of factors that may lead to a more complicated situation, such as abnormalities of urinary tract function (for example, indwelling catheter, neuropathic bladder, vesicoureteric reflux, outflow obstruction, other anatomical abnormalities), previous urinary tract surgery and states of immunocompromise, and neurological disorders. Pregnant women are also at increased risk of pyelonephritis associated with the relative ureteral obstruction during gestation. Risk factors for UTI in postmenopausal women include recurrent UTI, bladder prolapse or cystocele, and increased post-void residual urine.11
A mid-stream specimen of urine can be tested either by a urine dipstick or by sending the sample to a laboratory for microscopy and culture. Urine microscopy and culture has long been the ‘gold standard’ for diagnosis of UTIs but it is expensive and slow to produce a result. Dipstick testing, on the other hand, can be performed on the spot by a GP or nurse. When it shows the presence of either leucocyte esterase or nitrites, it is highly predictive of a positive urine culture (whereas absence of either finding markedly reduces the likelihood of infection),13 and it has been found to be a fairly reliable way to diagnose UTIs. It is important, however, to undertake urine culture if an accurate diagnosis is needed or in order to select an effective antimicrobial (as in pregnancy, treatment failure or immunocompromise). Box 15.3 (p 286) outlines the tests commonly carried out by dipstick testing and Table 15.1 (p 286) advises how to use nitrite and leucocyte testing to guide management in symptomatic female general practice patients.
Imaging of women with an uncomplicated UTI is not warranted, as there is a low yield of positive results.14 Neither is a single episode of pyelonephritis associated with a clinically significant risk of anatomic abnormality.15 However, in cases of recurrent pyelonephritis imaging with renal ultrasound, intravenous pyelogram or voiding cystourethrogram is indicated.
Uncomplicated UTI in non-pregnant women rarely causes severe illness or has significant long-term consequences, and in 50% of patients the condition improves without antimicrobials within 3 days.16 Despite this, empiric treatment of uncomplicated UTIs has been advocated by some as the most cost-effective way to manage UTIs.17,18 Those against empiric management argue on two grounds. First, they say that the urine should be examined to ascertain the diagnosis, limit unnecessary use of antibiotics and identify those patients who may require further investigation. Second, they argue that since uncomplicated UTIs account for a substantial proportion of all prescribed antibiotics, empiric management may lead to rising levels of antibiotic resistance in the community. With regard to this latter argument, however, levels of resistance found in the laboratory may overestimate levels of resistance in general practice.19
Box 15.4 outlines the preferred antibiotics for the management of uncomplicated cystitis in non-pregnant women.
GPs have a choice of prescribing single-dose, 3- or 5-day, or the more traditional 7- to 14-day therapies for treatment of UTIs. Three-day courses of antibiotics such as trimethoprim are recommended as first-line therapy for lower, uncomplicated UTIs in young women.20,21 One-day treatments are less effective, and longer treatments are associated with increased risk of adverse effects without clinically meaningful improvement in effectiveness.22
If therapy is clinically successful, the only patients requiring a follow-up examination of the urine for bacteria are pregnant women. The reason for this is that it is only in this group of women that treatment of asymptomatic bacteriuria is justified, because of the increased risk of pyelonephritis and preterm delivery.24 Asymptomatic bacteriuria is not related to any increase in morbidity or mortality in other patient groups.
Recurrence of dysuria and frequency can either mean failure to eradicate the initial infection or reinfection. Interestingly between 12% and 16% of women receiving empiric therapy for UTI required another course of antibiotics within 4 weeks of their initial symptoms, irrespective of the type or duration of initial antibiotic therapy.25 In these women a longer course of antibiotic should be given rather than using a more sophisticated antibiotic.
While popular for treating urinary symptoms such as dysuria and frequency, urine-alkalinising agents such as potassium citrate, sodium citrate and sodium bicarbonate have yet to be proved in terms of their efficacy, over which there is some doubt.26
Case control studies6,10 have found no evidence that poor urinary hygiene predisposes women to recurrent infections, and there is no evidence to support giving women specific instructions regarding the frequency of urination, the timing of voiding (postcoital voiding), wiping patterns, douching, the use of hot tubs or the wearing of pantyhose in order to prevent the occurrence of UTIs.
If either of the last two options are put in place, prophylaxis should be started after active infection has been eradicated (confirmed by a negative urine culture at least one to two weeks after treatment is
If women have recurrent UTIs related to sexual activity, GPs can recommend 100 mg of trimethoprim to be taken after sexual intercourse, or the woman can take either 50 mg of trimethoprim or 50 mg of nitrofurantoin daily for 6 months or more.
A recent Cochrane review has found that cranberry products significantly reduced the incidence of UTIs at 12 months (RR 0.65, 95% CI 0.46 to 0.90) compared with a placebo/control. While they are more effective at reducing the incidence of UTIs in women with recurrent UTIs than in other groups, the optimum dosage or method of administration (e.g. juice, tablets or capsules) has yet to be established.32