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Uncomplicated female UTI: a case study

Janet Webb
BSc(Hons) RGN DipN(Lond)
Practice Nurse
Lindum Medical Practice
Lincoln

Miss Price is 73. She lives alone, is active, self-caring and generally healthy. She attended a nursing appointment at the GP surgery in an anxious and distressed state, and history taking revealed a three-day history of increasing dysuria and urinary frequency, culminating in urgency that had resulted in incontinence and an episode that morning of haematuria.

Speaking about her anxiety, Miss Price said she had dreaded becoming incontinent, assuming it would lead to her having to move to a retirement home. She had reduced her fluid intake in an attempt to address the frequency of micturition, but this had increased the dysuria and strong odour of her urine. The final deciding factor to visit the surgery had been the haematuria, which she had feared may indicate cancer.

Her medical history showed only minor illnesses apart from a cholecystectomy nearly 30 years ago, and there was no known history of carcinoma. I asked whether she had any experience of cystitis or "water infection". She had not, stressing her careful attention to personal hygiene and adding that she hardly ever used public lavatories. I reassured her that there was no implication that her personal hygiene was at fault but told her I felt she probably had a lower urinary tract infection (UTI). She provided a midstream specimen of urine, which showed presence of protein and was visibly cloudy.

Symptoms of lower UTI include lower abdominal discomfort, dysuria, frequency and urgency of micturition, cloudy or foul-smelling urine, haematuria and confusion (especially in the elderly).(1) Approximately half of women experience dysuria at some time in their lives.(2) The presence of bacteruria increases by about 1% in each decade of life in women, and after the age of 65 in women and 70 in men the prevalence increases at a much higher rate.(2) The most common bacterial cause of uncomplicated disease is Escherichia coli, which originates in bowel/faecal flora and is particularly virulent.(2)
 
Trimethoprim is the most commonly used agent for the treatment of uncomplicated UTI.  According to the British National Formulary (BNF) a short course is usually adequate for treating uncomplicated UTIs in women. Trials using trimethoprim/sulfonamide combinations have reported that the optimal treatment time is 3 days and that adverse reactions increase markedly when treatment is given for >3 days.(3) The BNF asserts that trimethoprim can be used alone and is available for use by extended nurse prescribing. It interacts with warfarin, phenytoin and digoxin, but Miss Price did not take any regular medication. She had no known drug sensitivities.

I advised her of the possible side-effects, principally gastrointestinal upset, pruritis and skin rash, adding that if these or any other symptoms developed, she should seek medical advice. She was given a prescription for trimethoprim 200mg to be taken every 12 hours for 3 days and advised to return if her symptoms persisted.

I gently advised her to wash no more than she usually did, and no more vigorously, and to rinse carefully to avoid excoriation and overdrying of her perineal skin. Sparing use of a simple barrier cream could be advised if any existing soreness was a problem.

I advised her to increase watery fluid intake to 3 litres daily to dilute her urine. To avoid future recurrence of infection I discussed the importance of not allowing her bladder to be overfull and when passing water to allow time for it to empty completely. I suggested drinking cranberry juice if she found it palatable.(1) Cranberry juice has been shown to inhibit bacterial adherence in isolates of E coli, both in vitro and in vivo,(4) although if taken in excess of a litre daily it can lead to uric acid store formation in the urine, may produce diarrhoea in people with irritable bowel syndrome, and because of its high sugar content could lead to weight gain.
 
Miss Price was relieved that her fears were probably unfounded, but was aware of the need to return if the treatment was ineffective. She did not return. Her urine sample was sent for culture and sensitivity - the laboratory reported E coli and indicated trimethoprim. If an antibiotic had been recommended that was not included in the Nurse Prescribing Extended Formulary, a care management plan would have been drawn up with Miss Price's agreement and in partnership with her GP. This would allow a nurse prescription to be written under supplementary prescribing, hence facilitating complete nursing management of the patient.

References

  1. Courtenay M, Butler M. Essential nurse prescribing. London: Greenwich Medical Media Ltd; 2002.
  2. Cowling P. Antibiotic management of urinary tract infections. Prescriber 2002;13(14).
  3. Norrby SR. Short term treatment of uncomplicated lower urinary tract infections in women. Rev Infect Dis 1990;12:458-67.
  4. Busuttil Leaver R. Cranberry juice. Prof Nurse 1996;11:525-6.