My talk on urinary tract infections, or UTIs, at NMC Hospital was built around current guidance for doctors, and the core message for patients is straightforward: know the difference between a local infection and one that is affecting the whole body, and trust that the right treatment depends on which one you have.
Local infection or whole-body infection
Doctors now group urinary infections into two types. A localised UTI is cystitis, an infection of the bladder, with no signs of infection spreading through the body. A systemic UTI is one that causes signs of infection in the whole body. It can start from any part of the urinary tract, and it may or may not also cause the usual bladder symptoms. Both types can affect men and women.
The typical symptoms of a localised infection are dysuria (pain, burning or stinging when passing urine), urgency, frequency, incontinence, discharge of pus from the urethra, and pressure or cramping in the lower abdomen.
The signs of a systemic infection are different: fever or an abnormally low temperature, rigors (shaking chills), delirium (sudden confusion), low blood pressure, a fast heart rate, and pain or tenderness in the side of the back over the kidney. These signs may be caused by a systemic UTI, although other illnesses can produce them too.
Who is more likely to get a UTI
Risk factors include being an infant or being elderly or frail, a weakened immune system, and a bladder that does not empty fully. Abnormalities in the structure or function of the urinary tract, neurological disease, stones, and blockages in the urinary tract all raise the risk.
So do an indwelling urinary catheter, recent instruments passed into the urinary tract, previous antibiotic use, and infection with resistant bacteria. In men, prostate problems such as benign enlargement or chronic bacterial prostatitis add to the risk. In women, pregnancy and pelvic organ prolapse do.
Bacteria in the urine are not always an infection
Bacteria can grow in the urine of people who have no symptoms at all. This is called asymptomatic bacteriuria, and it is common. It usually reflects harmless colonisation, and clinical studies have shown it may even protect against a new infection.
For this reason, doctors treat it only when there is proven benefit to the patient. Treating it needlessly risks encouraging antibiotic resistance and removing a strain that may be protective. The guidance I presented advises against screening or treating it in many groups, including women without risk factors, post-menopausal women, people with well-controlled diabetes, and people with recurrent infections. The exceptions include pregnant women and people about to have a urological procedure that breaches the lining of the urinary tract.
Cystitis in women and repeated infections
Cystitis in women is an infection limited to the bladder, without fever, chills, flank pain or feeling generally unwell. In a woman without other risk factors, it can be diagnosed from her symptoms together with the absence of vaginal discharge, and a urine dipstick test helps confirm it.
A urine culture (growing the bacteria in the laboratory to identify them) is recommended when a systemic infection is suspected, when symptoms do not settle or come back within four weeks of finishing treatment, when symptoms are atypical, when resistant bacteria are likely, and in pregnancy.
Recurrent cystitis is diagnosed by urine culture. In women under 40 with no risk factors, an extensive routine workup such as cystoscopy (a camera look inside the bladder) is not needed.
The factors linked to repeat infections differ with age. In younger women they include sexual intercourse, spermicide use, a new partner, a mother with a history of cystitis, and cystitis in childhood. After menopause they include a history of cystitis before menopause, urinary incontinence, vaginal dryness from low oestrogen, a cystocele (the bladder bulging into the vagina), and urine left in the bladder after passing it.
The prevention measures doctors may discuss include drinking more fluid for premenopausal women, vaginal oestrogen for postmenopausal women, probiotics that help restore the normal vaginal bacteria, cranberry products, and bladder instillations of hyaluronic acid. Preventive antibiotics are kept for women in whom these non-antibiotic measures have failed.
Kidney infection, catheters and the prostate
Pyelonephritis is an infection of the kidney. A urine culture with testing of which antibiotics will work should be done in every case, and scans are used selectively. The treatment is then adjusted once the culture results are known, taking local resistance patterns into account.
For people with a urinary catheter, the catheter should stay in for the shortest time possible. Cloudy or smelly urine on its own does not show that a catheter-related infection is present, and routine urine cultures are not done in catheterised patients who have no symptoms.
Acute bacterial prostatitis, a sudden infection of the prostate, is treated along the same lines as a systemic urinary infection.
Men with severe, sudden pain and swelling on one side of the scrotum need urgent attention. In the pathway I presented for epididymitis (inflammation of the tube behind the testis), this pattern raises the possibility of testicular torsion, a twisted testis, which calls for urgent surgical exploration.
Using antibiotics wisely protects everyone
I closed the talk with antimicrobial stewardship, which means using antibiotics only when they help, and choosing them well. In a hospital this involves regular staff training, following local, national or international guidelines, working with infectious disease physicians and microbiologists, and auditing and feeding back on how antibiotics are used. The message on my last slide was simple: be smart and manage infections wisely.
If you have burning when passing urine, fever with urinary symptoms, or infections that keep coming back, please see a urologist.