Urinary Tract Infection Symptoms Can Signal a More Complicated Disease by ROBERT A
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DIAGNOSIS Urinary tract infection (UTI) is a common diagnosis. present with sepsis, febrile infection, gross hematuria, signs of Almost all physicians and paramedical staff obstruction, urologic stones, or pregnancy must be considered have diagnosed and perhaps even treated an complicated and require a more extensive evaluation. In addition, most urologists would consider a male patient of any age with an uncomplicated UTI. infection to be complicated. However, it is likewise not uncommon for a patient to have been misdiagnosed and/or inappropriately treated for “a bladder infec- tion.” The goal of this short article is to provide a better understand- ing of how to diagnose and treat these infections. As 70 million baby boomers turn 60 years old, it will be increasingly My definition for an uncomplicated UTI is a culture-documented bac- terial or fungal infection of the bladder in the absence of an anatomi- more important to diagnose and cal abnormality. The mere presence of bacteria or yeast does not equate to infection. Symptoms of urinary urgency, frequency, dys- treat infections appropriately in uria (burning with urination), and/or suprapubic tenderness must order to minimize the impact on accompany the presence of the organisms to be considered an infection. Uncomplicated infections are common in healthy young patients as well as society. women and generally are self-limited with appropriate short-dura- tion antimicrobial therapy. The majority of patients referred to the urologist for UTIs are by nature When It Gets Complicated considered complicated. The evaluation is designed to rule out an anatomic abnormality, obstruction, or nidus for infection. Generally Patients with complicated urinary tract infections have anatomic, the investigation will incorporate upper tract imaging (visualizing metabolic, host-defense, or functional abnormalities. Patients that the kidneys) and evaluation of the bladder with cystoscopy. A Common Misdiagnosis Urinary tract infection symptoms can signal a more complicated disease BY ROBERT A. BATLER, MD 10 | THE UROLOGIST DIAGNOSIS Future Impact Frequently The diagnosis and treatment of infec- tions of the urinary tract rely on using Asked Questions proper terminology and accurate gather- ing of history and physical and available What causes UTIs? data. When a patient is diagnosed with an Most UTIs are solitary events that don’t recur infection that is considered complicated, when treated. Some patients have anatomical an investigation will often lead to the diag- and genetic predispositions that make them nosis of a reversible cause. As 70 million more susceptible to UTIs than is typical. baby boomers turn 60 years old, it will be increasingly more important to diagnose How can I avoid UTIs? and treat infections appropriately in order There are some simple steps women can take to minimize the impact on patients as to avoid UTIs, such as drinking plenty of fluids well as society. to keep well hydrated. You should not delay urinating or hold in urine without emptying Not uncommonly, a patient with incom- your bladder completely. After urinating, wipe plete bladder emptying or significant from front to back to prevent bacteria around urologic stone disease will present first the anus from entering the vagina or urethra. with the diagnosis of UTI. Unfortunately, it is also not uncommon for a patient to Urinating after sexual intercourse may also be referred for a presumed recurrent UTI decrease the risk of UTI because it can flush after several rounds of unsuccessful ther- out any bacteria that were introduced during apy for an “infection” heralded by recur- intercourse. Certain forms of birth control, rent painless gross hematuria. A patient such as spermicidal foam and diaphragms, are who presents with gross hematuria known to increase the risk of UTIs. For women must be followed carefully, particularly who have gone through menopause, estrogen when he or she is above the age of 50 replacement therapy can be a simple solution. Schematic illustration of the urinary system showing the types of pos- and/or a smoker. Painless gross hema- sible urinary tract infects in the upper tract (kidneys and ureters) and turia must always raise the suspicion When should I be concerned? in the lower tract (bladder and urethra). for malignancy. If you have symptoms of a UTI that do not improve with treatment or are accompanied As with many common diagnoses, the by nausea and vomiting, then you should danger lies in regarding the problem as seek medical attention. If you ever see blood The evaluation must be tailored appropriately to the mundane. Certainly the vast majority of uncompli- in your urine, you should contact your physi- patient. Every evaluation must include a thorough cated UTIs are mundane. However, physicians must cian immediately. physical exam, urinalysis, and, when appropriate, not be lulled by the high incidence of urinary infec- laboratory evaluation. In the pediatric population, tions. Instead, they must continue to investigate and If you are pregnant and have symptoms of a renal ultrasound and voiding cystourethrogram treat those patients who fall into the complicated UTI, then you should contact your physician (VCUG) is the rule. In the adult population, intrave- category and always consider the possibility of an immediately. UTIs during pregnancy can put nous pyelogram (IVP) or computed tomography (CT) alternate, and perhaps more serious, diagnosis. both mother and baby at risk if not addressed scan without and with contrast and cystoscopy will quickly and properly. usually be performed. An abbreviated evaluation in an elderly patient with multiple comorbidities may What should I do if I have recurring UTIs? include renal ultrasound, a KUB, and a postvoid Robert A. Batler, MD, is a graduate of When treated early, UTIs usually have no lasting residual bladder volume. Northwestern University, Evanston, Illi- influence on the urinary tract. Recurrent or undi- nois, where he received his Bachelor of agnosed UTIs could cause damage if not treated. Bacterial Colonization or UTI? Arts in psychology. He then earned his If you are having recurrent UTIs (three or more medical degree from the University of per year), then you should see your physician A special consideration is the patient whose Illinois at Chicago College of Medicine. for further testing such as a urinalysis. You may urinary tract has become colonized with bac- He completed his urology residency at also need an ultrasound or CT scan to look for teria or yeast. Most patients with a chronic in- Northwestern University. As an undergraduate, he worked any abnormalities of the urinary tract. dwelling catheter or suprapubic catheter, those as a research assistant in the Department of Biochemistry, on clean intermittent catheterization, and many Molecular Biology, and Cell Biology at Northwestern Univer- If you continue to have UTIs, you may benefit elderly women will become colonized with bac- sity. During medical school, he was a research assistant in from a longer course of low-dose antibiotics teria. These patients are particularly difficult the Department of Genetics at the University of Illinois at or by taking an antibiotic after sexual inter- to manage because they are often inappropri- Chicago College of Medicine and was awarded a National course. There are also methods of self-testing ately treated for infections in the absence of Institutes of Health intramural training grant, in which he that your urologist may help coordinate with symptoms. This practice has led to the emergence served as a research assistant in the Department of Endo- you to institute both diagnosis and treatment of highly resistant bacteria. It is my practice to crine Physiology at the National Institute of Child Health of UTIs at home. educate patients on the difference between a and Human Development, Bethesda, Maryland. Dr. Batler UTI and bacterial colonization to minimize the is a member of the American Urological Association and the Source: urologyhealth.org unnecessary therapy. Chicago Urological Society. www.urologyin.com | 11.