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Urinary Tract Infection

Normal urine is sterile. When bacteria get into the bladder via the urethra, it can cause infection (cystitis). Left untreated, the infection goes up to the kidneys to cause a more severe infection (pyelonephritis). Urine infection affects all age groups. The symptoms include frequency of urination, lower abdominal pain, burning sensation in the urine passage, cloudy and smelling urine and frank blood in the urine. When the infection affects the kidneys, loin pain, fever, chills and even septic shock can occur.

Urinary tract infection (UTI) is also more likely to occur when there is an abnormality in the urinary tract. Diabetic patients are also more likely to get UTI due to the excess sugar in their urine. UTI are also more likely to occur whenever there is stagnant urine in the bladder due to obstruction or weak bladder muscles.

Diagnosis

1. Urine dipstick

Urine dipstick. The finding of both red and white blood cells in the urine is highly suggestive of UTI. A quick dipstick test is the combur 9 which takes only a minute to do. It will react positively to white blood cells and nitrites in the presence of bacteria.

2. Urine culture

Confirmation is best done by obtaining a mid-stream urine specimen for culture to isolate the offending bacteria and identify the most appropriate antibiotic. Most laboratories can give the result within 48 hours.

3. Ultrasound

A screening ultrasound can easily be done in the clinic. This may reveal bladder or kidney stones as the underlying source [Fig 1].

4. Xrays

If ultrasound reveals a stone or an abnormal-looking kidney, then contrast X-ray of the urinary tract called intravenous urogram (IVU) is indicated [Fig 2a]. IVU is also recommended in recurrent UTI to exclude an abnormal urinary system eg. duplex ureter which allows urine to reflux up into the kidney to cause recurrent infections and ultimately, kidney damage. In addition, CT urography scan can also define such abnormal urinary systems through 3-dimensional reconstruction [Fig 2b].

5. Cystoscopy

Occasionally, endoscopic inspection of the bladder is needed to rule out anatomic bladder disease, eg. diverticulum and in elderly men, an enlarged obstructing prostate [Fig 3]. This can easily be done under local anaesthesia in the clinic.

Treatment

The mainstay of UTI treatment is an appropriate and adequate antibiotic course. Uncomplicated UTI can be cured with 5 days of treatment. The choice of drug and length of treatment depends on the patient's history and the urine tests that identify the offending bacteria. The sensitivity test is especially useful in helping the doctor select the most effective drug. The drugs most often used to treat uncomplicated UTIs are trimethoprim/sulfamethoxazole (Bactrim), nitrofurantoin, Augmentin and ciprofloxacin (Ciprobay). Longer treatment is needed by patients with infections of the prostate, epididymis, kidney infection, diabetics and cancer patients. It is important to take the full course of treatment because symptoms usuallu disappear before the infection is fully cleared. Pregnant woman who develop a UTI should be treated promptly, bearing in mind that only certain antibiotics are safe during pregnancy.

Drugs can be given to relieve the pain of urination, eg. flavoxates (Genurin, Urispas). Urine alkalinizing agents such as citrate (Urocit K, Citravescent) can also alleviate the irritative symptoms and prevent UTI.

In Females

Women are also more prone to urine infection because their urethra is much shorter. Typically, young girls get their first cystitis when they become sexually active. After menopause, women are also likely to get urine infection because the vagina and urethra becomes dry and resistance lowered. The types of bacteria that get into the bladder originate from the faeces, hence maintaining local hygiene is an important way to prevent UTI. When the infection proves difficult to treat or is recurrent, an underlying cause should always be suspected.

Recurrent Infections

Many women suffer from frequent UTIs. Nearly 20% of women who have a UTI will have another. It is well known that some women are just more prone to recurrent attacks. These women are particularly prone to infection because the cells lining the vagina and urethra lack protective mechanisms, allowing bacteria to attach more easily. Another common reason for recurrent UTI is the persistence of resistant bacteria that were not eradicated the last time round. The widespread use of antibiotics have resulted in resistant strains which remain in the lining of the urethra / bladder. Doctors often give antibiotics based on “best guess” but do not realize that if the bacteria is only partially sensitive to the antibiotics, incomplete eradication occurs. Hence, it is important to do a urine culture prior to starting antibiotics to determine if one is dealing with a resistant strain of bacteria.

Women with frequent UTI and no identifiable cause may benefit from preventive therapy. About 4 out of 5 women who have a UTI get another in 18 months. A woman who has frequent recurrences (three or more a year) can consider the following treatment options:

• Low dose antibiotic daily for 3 to 6 months, eg. bactrim, nitofurantoin
• Single dose antibiotic immediately after sexual intercourse

Additional steps that a woman can take to avoid an infection are:

• Drinking plenty of water every day. Drinking cranberry juice may also help because it inhibits the growth of some bacteria by acidifying the urine. Vitamin C supplements have the same effect
• Not holding the bladder for too long because stale urine is a good medium for bacteria
• Passing urine immediately after sexual intercourse

In Males

UTI is unusual in men. In older men (above 50 years), it usually stems from obstruction of the bladder, usually by an enlarged prostate (BPH) as the stagnant residual urine allows bacteria to flourish easily [Fig 4].

Young men (20 to 50 years) are also prone to prostate infection (prostatitis). Many of them are assumed to have simple UTI and given a short course of antibiotics which is not sufficient in eradicating the bacteria within the prostate and they subsequently get a re-infection.

Diagnosis

Prostatitis is a clinical diagnosis. The medical history is as outlined in the symptom list. A physical exam is done to check for pelvic area tenderness and a digital rectal exam will reveal a swollen (boggy) prostate with tenderness [Fig 5].

In suspected cases of sexually transmitted disease, swab and blood tests can be done to look for the offending organism.

Types

Prostatitis can be classified into the following categories:

a)acute bacterial prostatitis
b)chronic bacterial prostatitis
c) nonbacterial prostatitis, prostatodynia and chronic pelvic pain syndrome.

a) Acute bacterial prostatitis

The symptoms come on suddenly and may include:

• Fever and chills
• Pain in the pelvis, lower back or groin
• Burning pain during urination (dysuria)
• Frequent urination
• Bloody urine
• Difficulty emptying the bladder and even sudden painful retention of urine

Acute prostatitis can be a serious condition and requires intravenous antibiotics until the fever subsides, followed by oral antibiotics for at least 3 weeks.

b) Chronic bacterial prostatitis

Chronic bacterial prostatitis develops more slowly and usually not associated with high fever. The symptoms of pain tend to wax and wane and include:

• Frequent and urgent need to urinate, both day and night
• Dull ache in the pelvic area, lower back and scrotum
• Pain referred to the penis tip at the end of micturition
• Hesitancy when initiating a urine stream
• Blood in urine or semen
• Pain after ejaculation

c) Chronic non-bacterial prostatitis

Chronic non-bacterial prostatitis is due to persistent non-infective inflammation of the prostate. The symptoms are similar to those of chronic bacterial prostatitis. A man is assumed to have non-bacterial prostatitis only after an adequate course of antibiotics has been given. The only way to prove whether the prostatitis is bacterial or not is from direct culture of the prostate / seminal fluid. Nonbacterial prostatitis may also be chemical in nature, eg. from reflux of urine into the prostate as a result of non-relaxing urinary sphincter eg. psychological stress, excess caffeine.

Treatment

Any new case of prostatitis is always assumed to be bacterial in origin. Quinolone antibiotics eg. ciprofloxacin and levofloxacin are initially given for at least 3 to 4 weeks. For chronic bacterial prostatitis, a longer course of antibiotics eg. up to 3 months may even be needed. For chronic non-bacterial prostatitis, non-steroidal anti-inflammatory drugs (to reduce the inflammation) and alpha-blockers (to relax the muscle surrounding the prostate and urinary sphincter) are the common choices.

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