Urinary Tract infection; Causes and Solutions!

I have been asked many times to talk about urinary tract infections, shortly known as UTIs. They have been commonly confused by some ladies with vaginal or even sexually transmitted infections. But the question is: what are UTI? How can you tell if you have one? And what are the behavioral changes that can allow you to decrease the chance of their occurrence?
Well, before talking about the infections of the urinary tract, you should become more familiar with your anatomy. The urinary tract is a group of organs that handle your urine; starting from the kidneys (the two bean shaped organs that filter your blood from many toxins), to the ureters (the tubes that take urine from the kidneys to the bladder), the bladder (the urine reservoir) ending with the urethra (the tube that takes urine from your bladder to the outside during the process of urination). Infection of any of the previously mentioned organs falls under the definition of a urinary tract infection.

If the infection is located to the urinary bladder, we call it “Cystitis”, however, when the infection involves the kidneys it becomes much more serious and we refer to it as “Pyelonephritis”. These infections are very common, especially among women because of their short distance between the urethral opening (above the vaginal opening) and the anus. Actually, according to one study, the woman’s lifetime risk for developing a urinary tract infection is around 40-50%, whereas the man’s lifetime risk is only 12%! The incidence of urinary tract infections is expected to increase with advancing age, however there are 2 general peaks in that incidence; the first occurring between 18-30 years of age, as it coincides with the initiation of penetrative sexual intercourse (this is called “Honeymoon Cystitis"), and the second occurring after menopause (the stage of loss of period for 12 consecutive months).

Symptoms

The classic reported symptoms of urinary tract infections are: burning upon urination, frequent urination, a sensation of incomplete voiding, blood in urine, lower abdominal and pelvic pain, painful sexual intercourse, urine incontinence (involuntary leak of urine), and urinary urgency (a sudden feeling for a need to go).
If the infection is spread to the kidneys (less common that the bladder infection), then symptoms become much worse and patients can develop fever, chills, nausea/vomiting and back pain in addition to other systemic symptoms of infection.
Keep in mind that elderly women can exhibit unusual symptoms of UTI, such as altered mental status, a generalized feeling of unease and change in their functional status, with or without the previously mentioned urinary symptoms.  

Risk factors

Now what about the risk factors for developing a urinary tract infection?

Being a woman is unfortunately an important risk factor just because of the anatomy of women. As you known by now, women tend to have a much higher chance than men to develop all kinds of urinary infections, and this is secondary to the close proximity of the urethra to the anus. Another important risk is sexual intercourse, as studies have always linked a recent coital activity to a new urinary tract infection, this entity is coined as “honeymoon cystitis”.
Also, a history of a UTI will predispose you to develop another in the future (such as a history of bladder or kidney infection in the past 12 months).
Also, the use of spermicide-coated condoms (to kill sperms and protect you further from unwanted pregnancies), and diaphragms (a condom-like structure inserted in the vagina as a contraceptive method) can also increase your risk for Cystitis (bladder infection).
Moreover, if you have medical problems such as diabetes (especially if it is poorly controlled), or structural problems in your urinary tract, you can have a higher chance for developing UTIs.
Other risks for urinary tract infection include, pregnancy, low immunity state (due to medical conditions or medications), menopause, kidney stones and the long-term use of urinary catheters.
Finally, one can never forget the genetic factors, as there is increasing evidence that some people might be more likely to have urinary tract infections regardless of their behavioral or health conditions.

How can you know if you have it?

As I always tell you, you know yourself the most, hence you should be keen on investigating any changes in your urinary habits. If you suffer from any new onset urinary symptom, whether it is a new burning sensation upon urination, a sensation of incomplete voiding or frequent urination, you should seek medical advice.
I recommend against the use of over the counter medicines before seeing a health care provider, as the initiation of an antibiotic can obscure the diagnosis of your UTI, and sometimes your symptoms can be secondary to another pathology (such as a vaginal infection. You can check my article on Vaginal Infections on https://onlinewomenhealth1.blogspot.com/2020/07/how-can-i-know-if-i-have-vaginal.html) and thus treatment can differ. If you have typical symptoms of urinary infections without any existing vaginal infection, your doctor might prescribe you an antibiotic without doing any further tests. However, sometimes the diagnosis is not clear cut and thus your doctor might request some urine studies (urine analysis and/or urine culture) in order to tailor the therapy accordingly.
Nevertheless, if you have a history of recurrent urinary tract infection, then your doctor might prescribe you a medicine over the phone (based on your history). The point is, always contact your health care provider and let him/her tell you what to do.

How can you treat your UTI?

As I just mentioned, your UTI needs to be properly diagnosed by a professional. When the diagnosis is made, then most cases can be managed with oral pills (antibiotics).
If you have a simple bladder infection (no kidney involvement), you will probably need to take the antibiotic for 3 to 7 days.
In case of a diagnosed kidney infection, you will need to take your antibiotics for a longer duration (up to 14 days). In some instances, a kidney infection needs to be managed in hospital with intravenous antibiotics for 24-72 hours before you can be discharged home on oral pills (such as during pregnancy, or if you have high grade fever and chills or severe nausea and vomiting and cannot tolerate oral medicines).
Finish the full course of prescribed antibiotic! Even though you might feel a tremendous improvement within two days of initiating the antibiotic, you should still continue the full course so that your infection won’t come back.
Sometimes you may be prescribed a “pain killer” that specifically acts on the bladder and urethral walls (i.e. phenazopyridine) in order to alleviate your burning sensation and bothersome symptoms that come along your infection.

Follow-up

Usually after you finish your antimicrobial course and you notice full improvement in your symptoms, there is no need to follow up with your physician. However, if you have blood in urine (known as "hematuria") on initial assessment, then a repeat urine study is recommended after 1 to 2 weeks of your therapy to make sure you cleared the "hematuria" (in other words, in order to make sure that the blood in your urine was secondary to your bacterial infection and not to any other urinary tract pathology).
Make sure not to perform your hematuria-check urine analysis while you are on your period, as the menstrual blood can contaminate the urine specimen and lead to a false positive result!

Moreover, if you do not improve (or if you worsen) after 48 to 72 hours of oral antimicrobial therapy, or if your symptoms recur within few weeks of treatment, then you should seek immediate medical advice to evaluate for factors that might be compromising your clinical response.
In the setting of pregnancy, a follow up is always indicated (check Pregnancy section below)

Pregnancy

Pregnancy is an independent risk factor for developing urinary tract infections, and pregnant ladies belong to a special population as they may be at an increased risk of a complicated urinary tract infection if they seek no medical attention.
During pregnancy regular urine studies are performed in order to check for any urinary bacterial infection even in the absence of symptoms.
This is crucial because studies have shown that pregnant ladies with a urinary bacterial infection (even without symptoms) are more likely to have a progressive kidney infection, to deliver prematurely and to have a more complicated pregnancy course.
Also, because up to 30% of pregnant ladies fail to clear their infections following a short course of therapy, they are advised to repeat their urine studies 1 to 2 weeks after the termination of their antimicrobial therapy. This test is medically known as “The Test of Cure”, so keep it in the back of your minds.
In the setting of a kidney infection (pyelonephritis) during pregnancy, the mainstay of therapy is in-hospital intravenous antibiotics for at least 1 to 2 days until the lady becomes afebrile (no more fever), and clinically more stable. By that time the culture results are expected to be out and the patient would be discharged on oral therapy to complete a 10-14 days course. Pregnant ladies with recurrent urinary tract infections or with only 1 episode of pyelonephritis during pregnancy, should be maintained on suppressive antimicrobial therapy throughout their pregnancy course.

Recurrent Urinary Tract Infection

Recurrent urinary tract infection is defined as having 3 or more episodes of UTI in a 12 months period, or 2 or more episodes in a 6 months period. However, this diagnosis should only be made by your physician, because as you know, there are some vaginal infections that can mimic a UTI (such as vaginal fungal infections) ( check my article about Vaginal Infections on https://onlinewomenhealth1.blogspot.com/2020/07/how-can-i-know-if-i-have-vaginal.html).
In case you were diagnosed to have repeated infections then there are some behavioral habits that can keep you from getting more infections such as:

• Avoiding spermicides (in condoms or vaginal creams)
  
  
• Wipe front to back. This may be basic but it was shown to reduce the risks of UTIs, so I would always encourage you to teach you daughters to always practice this basic hygienic method in order to decrease their risk of UTI.
  
  
• Avoid the use of diaphragms and switch to other contraceptive methods. 
  
  
• Drink more fluids, as a diluted urine is less likely to harbor infections (however there is no need to drink more than 3 liters of water per day as excessive consumption can negatively affect your blood sodium levels and cause water intoxication)
  
  
• Avoid holding your urine. Urine flushing is a good way to wash off bacteria in the urinary tract.
  
  
• Urinate right after SEX! This might help in flushing the bacteria that are pushed from the vagina into the urethra and bladder during your sexual intercourse. However, this was not supported to be beneficial by robust data, but I would still encourage it as it has no harms or risks.
  
  
• Vaginal estrogen application should be limited to women with vaginal dryness (mainly post-menopausal women, and those with premature ovarian failure or other forms of a low estrogen state). Vaginal estrogen can come in the form of a cream or vaginal pill and it was proven to reduce the risk of recurrent urinary tract infections in the right population.
  
  
• If you have proven recurrent UTIs and the above-mentioned methods do not help, your doctor might prescribe you an antibiotic to take after sex, with any new urinary symptom or routinely with a certain time interval. Nevertheless, always remember that antibiotics have their own risks, so this should be your last option in managing recurrent UTIs.
  
  
• Cranberry juice or extract; there are different studies with varying support to cranberry in the prevention of urinary tract infections. Most studies did not show an improved outcome on UTI risk in cranberry consumers. However, I would still advocate its use as it has no harm. I would recommend the cranberry pills instead of the juice as the latter can disturb your blood sugars.
  
  

Finally, let’s have some fun in debunking few misconceptions about urinary tract infections

Myth 1: “My urinary tract infection is a sexually transmitted infection”

Fact 1: UTIs are not sexually transmitted infections. However frequent sexual intercourse increases the chances of developing UTI.

Myth 2: “UTIs are very rare infections”

Fact 2: UTIs are the most common infections we seen in our clinics and emergency settings. The woman’s lifetime risk for developing a UTI is around 40-50%.

Myth 3: “If I have a UTI, my partner should receive antibiotics too”

Fact 3: No. Since UTIs are not sexually transmitted infections, then your partners should not receive therapy

Myth 4: “UTI is a sign of poor hygiene”

Fact 4: UTIs are not linked to a bad hygiene, as women with normal hygienic practices can still have recurrent UTIs. My only advise in that regard is for you to wipe front to back and not the other way around.

Myth 5: “UTIs only occur in women”

Fact 5: Even though a man’s lifetime risk for developing UTI is 12%, however this can still occur in men too.

Myth 6: “Contraceptive methods do not increase the risk of UTIs”

Fact 6: As it was previously mentioned in the article, some contraceptive methods (such as spermicides and diaphragms) were associated with an increased UTI risk. So, women with recurrent UTIs are advised to choose alternative birth control methods.

Myth 7: “UTIs are not a big deal!”

Fact 7: Even though most healthy ladies are expected to clear their urinary infection with time, however sometimes this simple infection can get complicated and spread to the kidneys. So, I always encourage everyone (old/young, healthy/sick...) to seek medical attention in the setting of any suspected urinary tract infection

Myth 8: “Tight clothes can cause UTIs”

Fact 8: Tight clothes have been linked to vaginal fungal infections, especially during humidity, however, they were not linked to the development of urinary infections.

Myth 9: “Probiotics are enough to protect me from recurrent UTIs”

Fact 9: Probiotics are truly effective in fixing the vaginal and bowel bacterial flora (the good bacteria), however studies are inconclusive about the value of probiotics alone in the prevention of recurrent urinary tract infections. I would recommend the use of probiotics in addition to other preventive strategies to best prevent UTIs. (probiotics include Yogurt, supplements, Kefir and fermented food) 

Myth 10: “I will not catch UTI from oral sex”

Fact 10: Urinary tract infections can still be acquired after oral sex, as the oral bacteria can contaminate the urethra and spread to the bladder (although this is not very common, however still possible).

 

In conclusion, urinary tract infections are commonly seen, especially in women. The symptoms can vary from one patient to another, so you should always seek professional health whenever you suspect changes in your urinary habits.
Drink your water, avoid holding your urine, void in a timely fashion and try to limit the use of spermicides if you have experienced UTIs before.

Karam