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Uncomplicated lower urinary tract infection

Elaine Cockram
RGN BSc(Hons)
Nurse Practitioner
Lead Nurse
Edgware Walk-in Centre and Urgent Treatment Centre
E:elaine.cockram@ ntlworld.com

Lower urinary tract infection (UTI) includes cystitis (inflammation of the bladder) and urethritis (inflammation of the urethra). Uncomplicated UTI is infection by a typical pathogen in a person with a normal urinary tract and with normal renal function. Typical presentation of cystitis includes symptoms of dysuria, frequency, urgency, nocturia, haematuria and suprapubic discomfort. Typical signs are suprapubic tenderness and cloudy or foul-smelling urine. Up to 60% of women have symptomatic symptoms of UTI at some point in their life, and it affects approximately 5-10% of women each year.(1) Therefore the symptoms associated with this condition are one of the most frequent reasons for women to seek care and advice from first-contact nurses.

UTI can be caused by bacteria being transferred from the anal area to the urethra. Women are at a much greater risk of developing UTI than men. This is because the female urethra is shorter and is nearer to the anus, making it easier for perineal and perirectal flora to travel up the urethra. Unless the bacteria are voided quickly, they can infect the lining of the bladder. The most common urinary pathogen is Escherichia coli, which flourishes in environments of pH 6-7. Urine has a pH of between 4.6 and 7.5, which is an ideal environment for bacterial growth.

Cystitis may be either bacterial or nonbacterial. Nonbacterial cystitis may be caused by viruses and fungi.(2,3) Over 50% of cases of urethritis may be due to nonbacterial causes,(4) and contributory factors include:

  • Insufficient fluid intake, resulting in the urethra becoming irritated and dehydrated.
  • Wearing clothing that is too tight, which can bruise the area around the urethral meatus.
  • The use of perfumed products such as soaps and deodorants.
  • Excessive alcohol intake.
  • Sexual intercourse - the most common causative factor, either by cross-infection or mechanical trauma.(2)
  • The use of a female diaphragm or spermicide-coated ­condoms.(5)
  • Sexually transmitted diseases.

Vaginal discharge in women is highly suggestive of vaginitis, and this reduces the likelihood that UTI is present. In fact, only about 30% of women with vaginal discharge have a UTI.(6)

Pyelonephritis
Pyelonephritis is associated with more serious pathology. It occurs when infection ascends to the ureters or kidneys and is described as upper tract infection.(7)

Women who are pregnant, have persistent haematuria, a history of pyelonephritis, calculi or previous surgery, are immunosuppressed or have diabetes are considered to have "complicated" UTIs, as they have a higher risk of developing pyelonephritis.(6) These clients need to be referred to their GP for assessment.

Making a diagnosis
Dipsticking urine will determine whether symptoms are associated with bacterial infection, as indicated by the presence of leukocytes, blood, protein and nitrates. Haematuria is common in uncomplicated ­cystitis and usually resolves with treatment.

Leukocyte esterase is an enzyme found in white blood cells that appears in urine during acute infection; however, leukocytes may also be present with vaginal infections. Nitrates are not necessarily present in all UTIs as only Gram-negative bacteria such as E coli convert dietary nitrates in the urine into nitrates.(8) Nitrates are predominantly the result of meat consumption; vegetarians or those who have not recently eaten meat will have little nitrate in the urine and may have a false-negative nitrate test.(6)

Proper interpretation of urine tests requires that the urine is collected in a manner that minimises contamination by vaginal microbes or skin flora. A midstream "clean-catch" urine specimen is therefore necessary for dipstick testing.

Microscopic culture and sensitivity is not necessary unless there is evidence of suspected pyelonephritis or complicated infection. Culture results do not always accurately identify infections. Vaginal contamination and delay in processing can reduce the specificity of culture, and overly diluting urine can reduce the sensitivity of cultures.(6)

Examination
Usually only minimal examination is necessary. If there is a history of abdominal pain then an abdominal examination will be necessary to eliminate signs of peritonitis and ectopic pregnancy. HCG pregnancy testing may also be required. Vaginal examination may determine thrush, herpes or injury as a cause.

Flank (costovertebral angle) tenderness may be present. Fever and flank pain are strongly associated with pyelonephritis. Clients who are seriously ill with pyelonephritis are usually obviously septic with a temperature over 38.5°C.(3,6)

Management and treatment
Pyelonephritis is a serious, potentially life-threatening condition, which requires referral to a urologist as the client may need further investigation and intravenous antibiotics. Flank pain without pyrexia is indicative of mild pyelonephritis, which is amenable to outpatient therapy; about 20% of clients with simple cystitis may be pyrexial.(9)

Acute uncomplicated UTI usually resolves without treatment in about three days. If the symptoms are debilitating, UTI responds rapidly to antimicrobial treatment.  Three days of treatment is likely to be as effective as five or seven days. Trimethoprim or nitrofurantoin are usually the antimicrobials of choice; however, local bacterial resistance levels must be considered.(10)

Nurses that have completed the independent nurse prescribing course are able to prescribe these drugs from the Nursing Formulary. Other nurses may be able to administer by patient group direction. In all cases, instruction regarding dosage, efficiency and side-effects must be given, and the antibiotic course must be completed to prevent antibiotic resistance and recurrent infection. This is important as research has indicated that people who experience recurrent UTI may in fact have a chronic infection that has never been fully eradicated, due to bacteria burrowing deeper into the tissue of the bladder wall.(11) Recurrent UTI is defined as repeated episodes of infection - if there have been more than three episodes the patient should be referred to a urologist for investigation.

Advice
There are a number of host defences that provide natural protection against UTIs. These include normal voiding, which mechanically flushes bacteria out of the bladder, and the acidic pH of urine, which suppresses growth of bacteria, and the intrinsic immunological functions of the bladder mucosa.(6) To encourage these natural defence mechanisms, the following advice should be given(13):

  • Increase fluid intake to about two litres (four pints) of fluid a day (not including alcohol or drinks with a high caffeine intake, such as coffee and tea).
  • Drink cranberry juice, as this helps prevent ­bacteria from adhering to the walls of mucosal cells in the bladder.(4) A small study has shown that 50ml of cranberry juice daily can prevent ­recurrences of UTI.(12)
  • Use mild analgesia such as paracetamol and/or ibuprofen to soothe the pain. Pain may lead to incomplete voiding, thereby allowing bacteria to multiply in the bladder.(14)
  • Maintain perineal hygiene by washing regularly, but avoiding soaps and deodorants, and wiping from front to back to avoid introducing bacteria to the genital area.
  • Avoid wearing tight trousers or synthetic materials that do not let the skin "breathe".
  • Encourage pre- and postcoital washing of genitals and voiding.
  • Ensure complete bladder emptying and frequent voiding to prevent stagnation of urine.
  • Reassess if symptoms of systemic illness such as back/loin pain, pyrexia, vomiting and frank ­haematuria develop.
  • If symptoms persist beyond three days of treatment, the patient may have antibiotic-resistant infection or undiagnosed risk factors for complications.

Conclusion
Uncomplicated UTIs are common, and most can be diagnosed by a first-contact nurse. Particular care is needed not to miss complications such as pyelonephritis and pregnancy. It is also important to be aware of causative reasons and give relevant advice to prevent recurrent infection.

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References

  1. Foxman B, Barlow R, D'Arcy H, Gillespie B, Sobel JD. Urinary tract infection: self-reported incidence and associated costs. Ann Epidemiol 2000;10:509-15.
  2. Remis RS, Gurwith MJ, Gurwith D, Hargett-Bean NT, Layde PM. Risk factors for urinary tract infection (abstract). Am J Epidemiol 1987;126:685-94.
  3. Mead M. Cystitis and UTI. Practice Nurse 1996;9:402-3.
  4. Beachey EH. Bacterial adherence: adhesin receptor interactions mediating the attachment of bacteria to mucosal surface. J Infect Dis 1981;143:325-45.
  5. Fihn SD, Boyko EJ, Chen CL. Use of spermicide-coated condoms and other risk factors for urinary tract infection caused by Staphylococcus saprophyticus. Arch Int Med 1998;158:281-7.
  6. Ebell MH, Barry HC. Urinary tract infection. In: Weiss D, editor. 20 common problems in primary care. New York: McGraw-Hill; 1998.
  7. Fisher P. Urinary tract infections. Practice Nursing 1997;8(19):37-40.
  8. Allen A. The management of UTI in general practice. Audit Gen Practice 1996;4(5):20-1.
  9. Baerheim A. Empirical treatment of uncomplicated cystitis. BMJ 2000;323:1197-8.
  10. Urinary tract infection (lower) women. Available from URL:http://www.prodigy.nhs.uk/guidance.asp?gt=uti%20(lower)%20-%20women
  11. Berger A. Burrowing bacteria may explain recurrent urinary tract ­infections. BMJ News 1998;317(1437).
  12. Kontiokari T, Sundquist K, Nuutinen M, et al. Randomised trial of cranberry-lingonberry juice and Lactobacillus GG drink for the ­prevention of urinary tract infections in women. BMJ 2001;322:1571.
  13. Brooks D. Acute dysuria and frequency in women. Update 1995;4:269-74.
  14. O'Dowd T. Cystitis. In: McPherson A, editor. Women's problems in general practice. Oxford: Medical Publishing; 1993. p. 284-94.

Resources
Cystitis HEBS
W:www.hebs.scot.nhs.uk

University College London Urology and Nephrology Institute
W:www.ucl.ac.uk/uro-neph

Infections in ­pregnancy
W:www.ukparents.co.uk/archives/infections-preg.shtml

Urinary tract ­infection in adults
W:www.niddk.nih.gov/health/urolog/pubs/utiadult/utiadult.htm