50% of women will suffer with an acute urinary tract infection (UTI) at some point and you are more than capable of dealing with this.

Faheem Ahmed- award winning pharmacist

Such a common condition

A urinary tract infection commonly known as a UTI is a condition all of you should be able to treat with confidence. Essentially its just a bacterial infection that can either affect the lower urinary or upper urinary tract. 

Now before we get too ahead of ourselves lets start off by briefly re-capping the relevant applied anatomy- trust me it will help you in the long run.

The urinary system

Okay. Just remember this; the urinary tract consists of the urethra, urinary bladder (note the use of – urinary- to differentiate between the gall bladder) , two ureters and two kidneys- Simple stuff.

To make it easy to study the various structures within the urinary system, scientists group these structures into those that belong to the upper division and those that belong to the lower division. 

The upper urinary tract in women consists of the ureters and kidneys while the lower urinary tract consists of the urethra and bladder- on a side note, males also have something called a prostate which is also part of the lower urinary tract – just to put a spanner in the works. 

With that clear now lets clarify what is a lower and what is a upper urinary tract infection. 

Lower vs upper UTI

A lower urinary tract infection (also known as cystitis) is one that affects the lower urinary structures; magic right?, and an upper urinary tract infection (also know as pyelonephritis) affects the upper urinary structures. Please remember what the terms cystitis and pyelonephritis mean.

Now lets get to the fun stuff!

Common terminology

Getting your head around classifying UTIs can be tricky especially when there seems to be no agreed upon definitions. 

You have already learned about classifying UTIs based on the structures affected ie. upper UTI or lower UTI but, there is another classification based on the likelihood of the disease causing complications, that is; complicated UTIs and uncomplicated UTIs.

Unfortunately, as previously stated there is no set criteria that would class an individual as either having a complicated UTI or uncomplicated UTI; as such for the purpose of this article an uncomplicated UTI is:- a otherwise healthy non-pregnant female patient with symptoms of a lower UTI. 

Conversely, a patient will be classed as having a complicated UTI if they have fall within any of the following; (1) are pregnant; (2) male gender; (3) immunosuppressed (eg. advanced HIV or neutropenia); (4) suffer with renal disease; (5) individuals with risk factors that predispose them to persistent or relapsing infection (eg. calculi, indwelling catheter or other drainage devices).

How to diagnose a lower UTI?

The diagnose of a UTI is not that difficult as long as you understand the following; (1) the cause (also termed etiology) of a UTI; (2) the alterations in the bodies normal function (ie. pathophysiology); (3) the signs, symptoms (also known as the clinical manifestation) and risk factors of a UTI; (4) how to differentiate between other conditions that may mimic a UTI – also called differential diagnosis– ; (5) how patients commonly present; (6) how to manage a UTI and (7) when to refer.

Wow, now that sounds like a lot but don’t panic its really straight forward and I will break it down for you step by step. 

UTI pathophysiology in women

I want to start off by explaining the pathophysiology first – it will make more sense trust me

What you need to remember is that the opening of the anal canal is in close proximity to that of the urethra. Therefore, any bacteria lurking around the anal canal can migrate to the urethra and irritate the cells. But it doesn’t stop here. In actual fact the bacteria can then make their way up to the urinary bladder causing symptoms of a lower UTI or affect the kidneys via the ureters causing symptoms of a upper UTI. 

UTI etiology

This section is very straight forward because you just need to understand the following; (1) Escherichia coli (E-coli) is the most frequent microbial cause of lower UTIs (around 75 to 95 % of cases), with occasional infections caused by Klebsiella pneumoniae and Staphylococcus saprophyticusdon’t worry about these two for now just remember E-coli- ; (2) It is E-coli which commonly resides in the gut and can easily colonize the area around the urethra due to the close relationship between the opening of the anal canal and urethra; something I have explained earlier. 

UTI clinical manifestations & risk factors

This section will help you recognize patients who may have a UTI and help you decipher between conditions that can present with similar symptoms. So pay attention!

Risk factors

Knowing the risk factors that predispose someone for a UTI can be extremely valuable. If you have a patient with symptoms of a UTI and the patient has the risk factors (which we will discuss below) then the probability that the patient has a UTI is more likely. 

So below are the risk factors you should be familiar with.

Risk factors for a UTI in pre-menopausal women of any age include; (1) Diabetes – because high levels of glucose in the urine creates a favorable environment for bacteria- ; (2) diaphragm use – this can kill protective bacteria in the vagina and alter pH ; (3) history of UTIs and or UTIs in childhood and ; (4) sexual intercourse. 

Risk factors for post-menopausal women and other older women include; (1) Estrogen deficiency – estrogen has protective function- ; (2) functional or mental impairment ; (3) History of UTIs before menopause ; (4) urinary catheterization – bacteria can enter the bladder easier; (5) urinary incontinence – can lead to a build up of bacteria.

Signs and symptoms

Recalling signs and symptoms for individual diseases is crucial but more important is remembering the key symptoms that are unique to a UTI.

The textbook signs and symptoms of lower UTIs consist of dysuria (fancy term for pain on urination) , urinary frequency, urinary urgency, and suprapubic pain (lower abdominal pain). 

In my experience it is also common for patients to present with hematuria (blood within the urine) which maybe detected on urinalysis (more about this later don’t worry) or it may visibly seen within the urine sample- patients usually report presence of blood in urine if they see it.

Subtle signs and symptoms

I want to point out occasionally symptoms of cystitis can be subtle and patients may not actively give this information to you – this is why your communication and consultation skills ( also referred to as history taking skills) need to be on the ball. 

The subtle symptoms tend to be more common in the elderly ie. older than 65 – but this is not a strict definition. The symptoms tend to be non-specific such as; (1) chronic dysuria; (2) urinary incontinence; (3) general sense of feeling unwell; (4) issues with gait (fancy term for observing someones walk) or falls; (5) change in mental status (eg confusion) – so be careful!

UTI mimics

Below is a list of conditions that cause symptoms similar to a UTI and I would like you to focus on those features that are only present in these conditions but not a UTI – think of the activity spot the difference!

  1. Vaginitis (=inflammation of the vagina) – Think of this if you have a patient with dysuria but also has any of the following; (1) vaginal discharge or odor – not common in UTU ; (2) vaginal pruritus (=itch) ; (3) dyspareunia (=painful sexual intercourse) ; (4) absence of urinary frequency. Cause of vaginitis include; yeast infections, trichomoniasis, and bacterial vaginosis
  1. Urethritis (=inflammation of the urethra)- You should consider this in female patients  who are sexually active and have dysuria; so sexually active female should prompt you to investigate further. Furthermore, the likelihood of urethritis is increased if on urinalysis you detect the presence of pus in urine (ie. pyuria) but no bacteria (ie bacteriuria)- we will discuss urinalysis in more depth in future articles. Causes include; chlamydia, gonorrhea, trichomoniasis, herpes simplex, noninfectious irritants such as contraceptive gels.
  1. Painful bladder syndrome- This should be considered if you have a patient who presents with ongoing discomfort of the bladder with symptoms of dysuria, frequency, and/or urgency but no evidence of infection or other cause.  
  2. Pelvic inflammatory disease– This is easy. Presence of fever with lower abdominal or pelvic pain with or without dysuria should raise suspicion- so remember fever!

Your approach to a patient

You should suspected a lower UTI in patients who present with dysuria, urinary frequency or urgency, and/or suprapubic pain in the absence of vaginal symptoms. Moreover, the probability of a lower UTI is greater than 50% in women with any of the above symptoms and if patients report dysuria combined with frequency without vaginal discharge then the likelihood is greater than 90%.

To diagnose a lower UTI you don’t usually need to undertake a physical examination- however you may find patients have some abdominal tenderness. But, I would encourage you to always document patient vital signs (which include measuring; (1) pulse, (2) oxygen saturation levels, (3) respiratory rate and (4) blood pressure) all of which should be normal. However, in women who have clinical features that are not clearly suggestive of a lower UTI, urinalysis is a useful diagnostic tool especially if there is absence of pyuria. 

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