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Urinary Tract Infection

Normal urine is sterile. When bacteria get into the urine via the urethra, it can infect the bladder to cause cystitis [Fig 1]. Left untreated, the infection goes up to the kidneys to cause a more severe infection, called pyelonephritis. Urine infection affects children and adults alike. The symptom ranges from frequency of urination, lower abdominal pain, burning sensation in the urine passage, cloudy and smelling urine to frank blood in the urine. When the infection affects the kidneys, the patient can be very ill with loin pain, chills and even shock.

Causes

Urinary tract infection (UTI) is more likely to occur when there is an abnormality in the urinary tract. Women are also more prone to urine infection because their urethra is much shorter and sexual intercourse predisposes to bacteria invasion up the urethra. Typically, young girls get their first cystitis when they become sexually active. Diabetic patients are also more likely to get urine infections due to the excess sugar in the urine. After menopause, women are also likely to get urine infection because the vagina and urethra becomes dry and resistance is lowered. UTI are also more likely to occur when there is stagnant urine in the bladder due to obstruction eg. urethral stricture associated with menopause, bladder or urethral diverticulum, prostate enlargement in men or weak bladder from nerve damage. Ultimately the types of bacteria that get into the bladder originate from the faeces and maintaining local hygiene is an important way to prevent urine infection. When the infection proves difficult to treat, an underlying cause should always be suspected.

Symptoms

The typical history is acute onset of frequent urination, burning pain, lower abdominal pain, back pain and cloudy or bloody urine.

Diagnosis

1. Urine dipstick

The finding of both red and white blood cells in the urine is highly suggestive of UTI. The diagnosis can be quickly made by using a dipstick test (combur 9) which will react positively to white blood cells and nitrites that the bacteria produce [Fig 2]. This takes only a minute to do.

2. Urine culture

Confirmation is best done by obtaining a mid-stream urine specimen for culture to isolate the offending bacteria and identify which antibiotic kills it. Most laboratories can give results of urine culture 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 3].

4. Xrays

If ultrasound reveals a stone or an abnormal kidney, then a contrast X-ray of the urinary tract called intravenous urogram (IVU) is indicated [Fig 4]. This X-ray is also recommended in those with recurrent UTI as there may be an abnormal urinary system eg. duplex ureter which allow urine to reflux up into the kidney.

5. Cystoscopy

Occasionally, this telescope inspection of the bladder is carried out to rule out associated bladder disease, particularly bladder tumours [Fig 5]. This is easily be done under local anaesthesia.

Recurrent Infections

Many women suffer from frequent UTIs. Nearly 20 percent of women who have a UTI will have another. It is well known that some women are more prone to get recurrent attacks than others. Research had shown that women with certain blood types are particularly prone to infection because the cells lining the vagina and urethra allow bacteria to attach more easily. Another common reason for recurrent UTI is the persistence of resistant bacteria that was 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.

Treatment

The mainstay of UTI treatment is an appropriate and adequate antibiotic course. An uncomplicated UTI can be cured with 3 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), amoxicillin (Amoxil), nitrofurantoin, ampicillin and newer antibiotics such as ciprofloxacin (Ciprobay). Single-dose treatment is not recommended for some groups of patients, for example, those who have delayed treatment or have signs of a kidney infection, diabetics, and men with prostate infections. Longer treatment is also needed by patients with infections that also affect the prostate or testis. It is important to take the full course of treatment because symptoms may disappear before the infection is fully cleared. Any pregnant woman who develops a UTI should be treated promptly. Only certain antibiotics are allowed during pregnancy.

Kidney infections generally require 2 weeks of antibiotic treatment. Prostate infections need up to a month. 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 mild UTI.

a) in Women

Women who have frequent recurrences with 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) should ask her doctor about one of the following treatment options:

• Take a low dose of an antibiotic daily for 3 to 6 months, eg. bactrim, nalidixic acid, amoxil.
• Take a single dose of an antibiotic after sexual intercourse and empty the bladder prior to bedtime.

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 to grow
• Passing urine immediately after sexual intercourse

b) in Men

UTI is unusual in men. In older men (age 50 years and beyond), it usually stems from an obstruction of the bladder, usually by an enlarged prostate (BPH). The residual urine stagnates and gets infected over time [Fig 6].

In younger men aged 20 to 50 years, prostate infection (prostatitis) is a common occurrence. Prostatitis can be classified into the following categories:

• acute bacterial prostatitis
• chronic bacterial prostatitis
• nonbacterial prostatitis, prostatodynia and chronic pelvic pain syndrome.

Symptoms

The signs and symptoms vary depending on the various types of prostatitis.

1) 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)
• Urinary problems, including increased urinary urgency and frequency, difficulty or pain when urinating, sudden retention of urine, and blood in the urine
• Painful ejaculation

Acute prostatitis can be a serious condition and requires intravenous antibiotics.

2) Chronic bacterial prostatitis

This type of prostatitis develop more slowly and usually not as severe as acute prostatitis. In addition, the symptoms of pain tend to alternate with times when symptoms are better. These symptoms include:

• A frequent and urgent need to urinate, both day and night
• Pain in the pelvic area, lower back and scrotum
• Pain felt at the penis tip at the end of micturition
• Difficulty with urination
• Blood in semen or in urine
• Painful ejaculation

3) Chronic nonbacterial prostatitis

The symptoms of nonbacterial prostatitis are similar to those of chronic bacterial prostatitis. The only way to determine whether the prostatitis is bacterial or not is through culturing the prostate / seminal fluid. Another cause for nonbacterial prostatitis is reflux of urine into the prostate from a non-relaxing urinary sphincter eg. from psychological stress, excess caffeine.

Diagnosis

Diagnosing prostatitis is by clinical means. The medical history is as outlined in the symptom list. A physical exam is next done to check for pelvic area tenderness and doing a digital rectal exam for prostate swelling and tenderness.

a) Digital rectal exam

The prostate gland feels enlarged, indurated and tender to the touch.

b) Urine & semen tests

These may show the type of bacteria.

Treatment

The main treatment for acute bacterial prostatitis is antibiotics. In acute prostatitis, one may need to be hospitalized to receive antibiotics intravenously. For treatment of chronic bacterial prostatitis, a long course of oral antibiotics eg. doxycycline, bactrim, ciprobay, may be needed for 1 to 3 months. For chronic nonbacterial prostatitis, anti-inflammatory drugs and alpha-blockers are the common choices. In refractory cases, botox injections can be given into the prostate.

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