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Urinary Track Infections (UTI)

Urinary tract infections (UTI) are one of the most common types of infections encountered in medicine today. Countless millions of women are diagnosed with a UTI every year. It has been estimated that one half of all women will report having at least one urinary tract infection during their life1. Many of these women will experience recurrent infections. Extensive research has been done to elucidate the factors involved with a UTI. The cause, types of UTIs, diagnosis, risk factors and treatment options are much better understood today, compared to 25 years ago.

The urinary tract consists of the kidneys (the bean shaped organs found in the mid back region which are responsible for producing urine), ureters (hollow tubes that connect the kidney to the bladder), bladder (the organ that stores urine) and urethra (the tube that carries urine from the bladder out of the body). In general, urinary tract infections in women are due to bacteria gaining access to the bladder from the urethra. In females, the urethra is very short. Bacteria can adhere to the area around the urethra and multiply rapidly. Because of the shortened urethra, bacteria can enter the bladder relatively easy. Usually, the bladder environment is very hostile to the bacteria and does not allow the multiplication of bacteria. However, in the right circumstances, bacteria will multiply in the bladder. With uncontrolled growth of the bacteria, symptoms develop due to the inflammation of the bladder and urethra. These symptoms include increased frequency of urination, sensation of discomfort before, during and after voiding, and pain in the lower back and pelvis.

Types of Urinary Tract Infections:
There are many types of UTI's. Inflammation and bacterial infection of the urethra without infection of the bladder is called urethritis. Infection of the bladder is called cystitis. An infection that is spreading from the bladder and ascending into the kidneys is called pyelonephritis. This is a much more severe UTI than urethritis or cystitis. The common symptoms of increased frequency of urination, burning with urination and lower back and pelvic pain can be present with all types of UTI's. Significant infection of the urinary tract and infection with certain bacteria can lead to blood in the urine, called hemorrhagic cystitis. Approximately 30% of patients with cystitis develop hemorrhagic cystitis.2 High fever elevation is generally only seen with pyelonephritis. The most common bacteria found in UTI's is Escherichia coli (E.coli). Approximately 80% of UTI's are caused by E.coli.2 Staphylococcus saprophyticus, Klebsiella species and Enterobacter are other common bacteria that can cause a UTI.

The diagnosis of a UTI can be relatively straightforward, although occasionally it can be elusive. Recognizing the symptoms of a UTI is one of the most important clues to the diagnosis of a UTI. Often, a physician will evaluate the urine to detect markers of infection. A specimen of urine caught in the mid-stream in an aseptic manner (clean catch) is important to avoid contamination with bacteria from the skin surrounding the urethra and/or vagina. Elevated levels of white blood cells or byproducts of these cells (leukocyte esterase) are markers of infection. Byproducts of bacteria can also be detected (Nitrites) and can be helpful in the diagnosis of infection. The urine is also examined for evidence of blood, crystals (which may help in the diagnosis of kidney stones), acidity, and abnormal collections from the kidney (casts). Finally, a clean catch specimen can be sent for a culture to detect which bacteria are responsible for the infection. The physician can diagnose the infection based upon the number of bacteria present in conjunction with the symptoms present. Identifying the bacteria can also help in choosing the correct antibiotic to treat the infection.

Risk Factors:
In perimenopausal and menopausal women, certain risk factors can lead to a higher risk of infection. Pelvic prolapse with a 'dropped' bladder can lead to improper emptying of urine and higher residual amounts of urine in the bladder. This can allow bacteria to grow and cause an infection. Women with medical problems such as diabetes and multiple sclerosis are at higher risk for infection. Women at risk for sexually transmitted disease are at higher risk for infection. In fact, sexual intercourse itself is a risk factor for UTI's. There is a direct relationship between infection and frequency of intercourse.3 Spermicide and diaphragm use with spermicide for contraception is also associated with a higher rate of UTI's.4 Lastly, the menopause transition is associated with declining estrogen levels. The sensitive vaginal and urethral tissue can lose elasticity and become thin because of estrogen deficiency (urogenital atrophy). This can lead to the common symptom of burning and irritation. This thinning effect and its effect on vaginal pH does increase the rate of frequent urinary tract infections in some menopausal women.5

Treatment Options:
Antibiotics: Fortunately, there are a number of treatment options for the woman with abrupt symptoms of a urinary tract infection. The most important aspect of treatment is starting antibiotics in a timely fashion to decrease the number of bacteria present, thereby allowing inflammation to subside and symptom improvement to begin. Three to seven days of antibiotics are generally prescribed. It may take from 48 -72 hours until symptom relief is achieved. It is, however, very important to finish the entire antibiotic prescription. A physician may want to obtain a clean catch urine specimen prior to starting antibiotics. Common antibiotics used in treating UTI's include nitrofurantoin (Macrobid, Macrodantin), trimethoprin/sulfamethoxazole (Bactrim, Septra), cephalexin (Keflex), and ciprofloxacin (Cipro).

In the perimenopausal and menopausal patient with multiple UTI's, the addition of topical estrogen may decrease the risk of continued infections. Estrogen creams are available to apply to the vaginal and urethral tissues. The addition of estrogen will strengthen the sensitive tissues and lower the vaginal pH, thereby reducing recurrent infections. To cause these beneficial changes, at least 4-6 weeks of topical estrogen is necessary. Lower, less frequent doses are then necessary to prevent the recurrence of these changes. In general, commonly used dosages of topical estrogen creams will not be significantly absorbed from the vagina into the blood stream. Therefore, concerns of excessive estrogen intake should be alleviated.

Prevention of UTI's:
Certain practices can lead to a reduction in urinary tract infections. Consuming adequate amounts of water (6-8 8 ounce glasses of water per day) is beneficial to 'flush' the urinary tract system. Limiting substances that can be irritating to the bladder, such as caffeine, acidic foods (such as tomato based foods), spicy foods and carbonated beverages. Urinating after sexual relations to empty the bladder can eliminate bacteria that has migrated into the bladder during the act of intercourse. Wiping from front to back will avoid contamination with bacteria from the rectal area. Some other factors that may predispose women to a UTI include nylon underwear or panty hose, and the use of certain perfumes/lotions or bubble baths. In women with frequent infections, the use of cranberry extract or cranberry juice can lead to a decrease in the number of infections. Lastly, the topical use of estrogen is effective in preventing frequent infections in the perimenopausal and menopausal woman as discussed above.

1- Kunin LM Urinary Tract Infections. 5th ed. Baltimore, MD:Williams & Wilkins; 1997
2 - The Merck Manual. 17th ed. pg. 1884-1886. Merck Research Laboratories; 1999
3 - Remis RS, Gurwith MJ, Gurwith D, et al Risk factors for urinary tract infections. Am J Epidemiol 1987;126:685-694.
4 - Hooton TM, Scholes D, Hughes JP, et al. A prospective study of risk factors for symptomatic urinary tract infection in young women[comments]. N Engl J Med 1996;335:468-474.
5 - Harrington RD, Hooton TM Urinary tract infection risk factors and gender. J Gender-Specific Med 2000;3[8]:27-34
