Urinary Tract Infections

DOWNLOAD HANDOUT ON THE TREATMENT AND PREVENTION OF RECURRENT URINARY TRACT INFECTIONS IN WOMEN

 

Background

 

Infections of the urinary tract (UTI’s) are the most common bacterial infections in humans.  UTIs are particularly common in women (30% will have a UTI by age 24, 50% will have a UTI in their lifetime). Specifically, bladder infection (termed “acute bacterial cystitis”) is one of the most common reasons for a woman to seek medical attention. UTI’s are most commonly caused by bacteria normally found in the bowel and around the genital skin which ascend through the urethra into the bladder. Infections can ascend even further upstream and infect the kidneys - pyelonephritis.

 

There are many types of bacterial infection, but most start with an infection of the bladder and progress from there.

 

Lower Urinary Tract Infections usually start in the bladder, but may spread to adjacent, connected organs in males
 

Cystitis: infection of the bladder (males and females)

Urethritis: infection of the urethra; common site of sexually trasmitted infections such as Chlamydia and Gonorrhea

Prostatitis: infection of the prostate gland

Epididymitis: infection of the epididymis - a small organ behind the testis which stores sperm (males only)

Orchitis: infection of the testis, almost always associated with epididymitis (epididymoorchitis)

Upper Urinary Tract

Pyelonephritis: infection of kidney

Urosepsis: spread of infection from the kidney or other urinary organ to the blood stream and body; can be very severe if the urinary tract is not draining properly (e.g. a stone is present)

"-itis" designates that inflammation is present, however, not all inflammation is a result of microbial infection. Some types of inflammation are 'non-infectious'.

 

Causes of Urinary Tract Infection

 

Infection of the urinary tract occurs when microbes gain entry to the urinary tract and overwhelm host defenses resulting in inflammation. Except for the very end of the urethra, the urinary tract is free of bacteria (sterile). Almost all infections are caused by bacteria and almost all bacterial infections are from bacterial ascent - that is, they gain entry from the urinary tract by entering the drainage system from the outside. Infections from microbes other than bacteria are uncommon, but fungus, parasites and viruses can also cause infections.

It also is known that there is a family link. For females with urinary tract infection, if other female relaitves in your family have urinary tract infections there can be an increased propensity for infection recurrence (70% vs 40% baseline risk for females).

Women are especially prone to UTIs for a number of reasons. Contrary to popular belief, the infections are not a result of the shorter urethra in women. Nor are the infections a result of hygeine. The increased rate of infections are due to a complex interplay between the defence mechanisms of the body and bacteria which are normally found in the vagina and perianal areas (perineum). The major identifiable risk factors for recurrent infections in women are:

 

  1. Post-menopausal status (or any circumstance where there is a deficiency of vaginal estrogen)
  2. Cell surface markers (these are genetically transferred) - includes things such as blood group and Lewis antigen status.
  3. Sexual intercourse
  4. Spermicidal lubricants
  5. Alteration in the normal vaginal flora - i.e. colonization with bacteria prone to cause infectiion of the bladder
  6. Elevated post-void residual urine (i.e. urine remaining in the bladder after voiding was completed)

 

Male UTI’s are far less common and usually require assessment to rule out some anatomic abnormality, such as prostate obstruction (e.g. BPH), urethral stricture, or the like. Your urologist will discuss with you proper assessment with your best interest in mind. Bacterial prostatitis is a particular form of urinary tract infection in men and requires adequate antibiotic therapy to prevent relapse or bacterial resistance – even up to 6 weeks of treatment, or more.

 

Diagnosis

 

Your urologist will assess your situation, possibly ordering or performing further tests (e.g. urine testing, kidney (renal) ultrasound, cystoscopy, bladder function testing), and then counsel you in regards to your particular situation as to how you may be able to prevent recurrences. The diagnosis of urinary tract infection is established based on three findings:

 

UTI Diagnosis

* The urine culture results usually take 2-3 days to get back. Therefore, patients are often started on antibiotics because of presumed infection based on symptoms and pus in the urine (which can be tested in the office and results immediately available)

 

Urinary frequency, urgency, burning combined with pus and blood in the urine are most commonly due to infection. However, it is always important to keep in mind that these findings can be caused by conditions other than infection and that some of them are serious. Therefore, it is important to exclude non-infectious causes for these urinary symptoms in the appropriate circumstances - most especially if the urine culture does not show bacteria. If you are having irritative urinary symptoms that are not responding to antibiotics or the urine cultures do not show bacteria, you must be evaluated for these other causes.

 

In both men and women, certain conditions may predispose to recurring, more severe or complicated infections and may prompt evaluation or treatment by a urologist.  These conditions include diabetes mellitus, previous urinary tract surgery, neurologic diseases affecting bladder function, urinary tract obstruction, and urinary stones.  If you suffer from recurring or complicated UTI’s, your family physician may decide to refer you to a urologist for further assessment, to see if some of these underlying problems exist.

 

Prevention

 

Often times, urinary tract infection will occur for no good reason other than because of bad luck. We do not fully understand why woman develope urinary tract infections more frequently than men but it is not exclusively (or potentially at all) do to the shorter urethra in woman versus men. Contrary to popular belief, urinary tract infections are rarely do to a tight urethra (urethral stenosis) - though there are exceptions to this. It is much more likely that colonization with the vagina by bacteria which caused urinary tract infection is the major problem. The vagina is usually colonized by friendly bacteria such as lactobacillus which in fact crowd out and kill unfriendly bacteria. Loss of these friendly bacteria may occur following menopauseor following use of broad spectrum antibiotics. The other issue is that some women are inherently susceptible to infection. when bacteria ensured the bladder they are typically flushed out with urination. Some women have "sticky bladders" - bacteria which entered the bladder adhered to the bladder wall which permits then to then invade and cause infection. While we do not fully understand the reasons, there are certain genetic markers on the surface of the bladder (such as blood group markers - A, B, O) which certain types of bacteria have adapted to adhere to.

 

For patients who are developing recurrent urinary tract infections, it can be helpful to have a sense of purpose in decreasing the frequency of recurrences or trying to eliminate infections altogether. There are some safe, easy conservative things which you can try.

 

Pericoital Voiding Emptying the bladder before and after intercourse
Probiotics

Healthy vaginal flora will displace bad types of bacteria which cause bacterial vaginosis and urinary tract infection. Most supplements contain lactobacillus species - of which there are over 100 types. Loss of the healthy vaginal bacterial flora is common after broad spectrum antibiotic use and after menopause. There are many different types of lactobacillus but the common ones include acidophilus, rhamnosus and casei. Lactobacillus rhamnosus GR-1 and Lactobacillus reuteri RC-14 have been shown to reduce the frequency of recurrent infections by about 50%. Pick a supplement that has as many types as you can find from your local pharmacy or health food store.

 

Most probiotics are taken by mouth, but there may be some advantage to placing the probiotic pill directly in the vagina - those with a gel-cap may need to be cut open and placed in cream (such as KY or vagifem) before placing in the vagina since the gel cap is thick. Others come as a vaginal suppository - for example, Purfem can be placed directly in the vagina as it's thin gel cap will dissolve more easily (note that this is much more expensive than an oral probiotic). Probiotics can be taken as instructed on the bottle, but twice weekly will usually suffice. When placed in the vagina, 3 days in a row is probably effective.

 

Finding a probiotic with both rhamnosus and reuteri can be difficulty. Natures Way brand products with "Reuteri" in the label often have both. (not meant as an endorsement of this brand)

Fem Dophilus is another source of L. rhamnosus and retueri

RepHresh Pro-B contains L. rhamnosus and retueri (available at Phrmasave by special order)

Cranberry

Extract or non-sweetened juice (cranberry juice has a very low concentration of the active ingredient and is high in sugar, therefore not a good choice). These block bacteria from sticking to the bladder wall. There is evidence to show that it reduced recurrence of urinary tract infections.

The active ingredient is proanthocyanidin (PAC). An effective dose of PAC is 36 mg. Ellura is a brand of cranberry product that has 36 mg of PAC.  

D-Mannose This is a type of sugar molecule believed to interfere with adhesion of bacteria to the surface of the bladder.

Constipation

There is a association between urinary tract infections and constipation. Often treating the constipation will resolves the urinary tract infection.

 

Treatment

 

Fortunately, most infections do respond to antibiotics and these are necessary in many cases. Before the advent of antibiotics, most bladder infections would resolve over the course of a few weeks but some patients would develop kidney infections which could lead to serious complications such as scarring within the kidney, abscess formation and eventual loss of kidney function. It is important to note, however, that bladder infections in of themselves rarely lead to any sort of long term problems even if they are recurrent and treated appropriated. UTIs other than bladder infection (e.g. kidney and prostate infections) should always be treated.

 

Strategies for Patients with Frequent Infections

  1. Have thorough assessment by a urologist to exclude the presence factors that are predisposing to infedtion.
  2. Use the preventative treatments described above.
  3. Prophylactic antibiotics: routine use of antibiotics before infection develops. This is particularly helpful if the infections routinely occur after certain events such as intercourse.
  4. Self-start antibiotics: self-administration of antibiotics after infection develops. Keep a supply of antibiotics with you and start them when symptoms develop. This is useful in motivated patients who have had confirmed infections in the past combined with clear-cut symptoms (they know when the infections are starting). Patients who develop fever, flank pain, any symptoms that suggest infecdtion other than bacterial cystitis (e.g. kidney infection) or who are not responding to antibiotics after a couple of days should seek medical attention immediately.
  5. Accupuncture and pelvic floor physio have also shown to be helpful for patients with recurrent infections.