Urinary tract infection in females

1Copyright © 2014 Well Woman Clinic. All rights reserved. 1
URINARY TRACT
INFECTIONS IN
WOMEN
Dr Nupur Gupta
MBBS, MS, MICOG
Ex AIIMS
Experience 2 decades

What is Urinary Tract Infection?

 First description – 1550 BC
 Earlier treatment – herbs, rest
 Antibiotics - 1930
Introduction

 Female anatomy. A woman has a shorter urethra than a man
does, which shortens the distance that bacteria must travel to
reach the bladder.
 Sexual activity. Having a new or multiple sexual partners also
increases your risk.
 Certain types of birth control. Women who use diaphragms or
spermicidal agents for birth control may be at higher risk.
 Menopause. After menopause, a decline in circulating estrogen
causes changes in the urinary tract that make you more
vulnerable to infection.
Risk Factors: Women

 Urinary tract abnormalities
 Blockages in the urinary tract - Kidney stones
 A suppressed immune system - Diabetes and other diseases that
impair the immune system
 Catheter use (CAUTI) - People who are hospitalized, people with
neurological problems and people who are paralyzed
 A recent urinary procedure or Urinary surgery
 Neurogenic bladder, spinal cord injury
 Pregnancy & postdelivery
Other Risk Factors

 Urethritis
 Cystitis
 Ureteritis
 Pyelitis
 Pyelonephritis
Classification of UTI: Level

 Pain or burning during urination
 The urge to urinate often
 Pain in the lower abdomen, pelvic area & around pelvic bone
 Urine that is cloudy or foul-smelling
 Pelvic pressure
 Lower abdomen discomfort
 Frequent, painful urination
 Blood in urine
 Some people may have no symptoms
Symptoms of UTI: Bladder Infection

 Upper back and side (flank) pain
(costovertebral angle tenderness)
 High fever
 Shaking and chills
 Nausea, Vomiting
 Headache
Symptoms of UTI: Kidney Infection

 Burning with urination
 Discharge, dysuria & PID
Symptoms of UTI: Infection in urethra

 Rule out vaginitis, cervicitis
 Differentiate UTI from STI
Is it UTI or something else?

 It refers to persistent, actively multiplying bacteria
within the urinary tract in an asymptomatic woman
 A person may have no symptoms at all.
 Yet, a urine test shows the presence of bacteria
 Prevalence (5-6%) in pregnant & non pregnant women
 Highest incidence - African-American multi paras with
sickle-cell trait
 Lowest incidence - affluent white women of low parity
Asymptomatic Bacteriuria /Stealth UTI

 Untreated UTIs may spread from the
bladder to one or both kidneys.
 Causing damage that will permanently
reduce kidney function - can raise the
risk of kidney failure.
 A small chance that the infection may
enter the bloodstream (Urosepsis)
Complications of UTI

 Many types of bacteria live in the intestines and
genital area, but this is not true of the urinary
system.
 In fact, urine is sterile. So when E. coli is
accidentally introduced into the urinary system, it
can start a UTI
How does UTI begin?

 Not drinking enough fluids
 Taking frequent tub baths
 Holding urine in the bladder too long
 Kidney stones
What increases your risk?

 The first step in diagnosing a UTI is usually a simple urine
test called a urinalysis.
 It looks for bacteria, as well as abnormal counts of WBC,
RBC.
 Your doctor may also send urine to a lab for culture to
confirm the type of bacteria.
 Significant: 10 (3) CFU/ml in asymptomatic & 10 (5)
CFU/ml in symptomatic
Diagnosis of UTI

 E coli
 Staphylococcus
 Proteus mirabiis
 Kleibsella
 Enterococcus
Most common pathogens in Urine Culture
Chlamydia & Gonorrhoea in Urethritis (vaginal swab)

 Prescription antibiotics will almost always cure a UTI
 Your health care provider may recommend drinking
lots of fluids and emptying your bladder frequently to
help flush out the bacteria
 Kidney infections can often be treated with oral
antibiotics, too.
 But severe kidney infections may require hospital care,
including a course of intravenous antibiotics
Treating UTI

 Phenazopyridine can help ease your pain, burning, and
irritation. It also reduces frequency and urgency.
 But it doesn't cure your infection. You still need to see your
doctor to make sure you get treatment to fight the bacteria
that's causing your UTI.
 Also, one common side effect: It turns your pee dark red or
orange while you take it.
 Flavoxate/URISPAS is a smooth muscle relaxant
Symptomatic Relief

 Alkalinises the urine
 Reduces painful urination
 Does not allow bacteria to colonise and divide in the
urinary tract
 Flushes the urinary tract
 Prevents stone formation in kidney (by reducing urates)
Role of Citralka/Disodium
potassium Citrate

Which is the best drug for you?
 Drug with high bacteriolethal concentration in all fluids of urinary
tract
 Highest efficacy (not altered by change in pH of urine or blood
 Drug with zero nephrotoxicity
 Drug broadly effective against all common bacteria causing UTI
 Drug with wide margin of safety
 Drug that is easy to administer
 Drug whose dosage schedule is simple
 Bacteria should not be able to develop resistance too early/
frequently

Only if left untreated, a urinary tract infection can have serious
consequences.
 Recurrent infections, especially in women who experience two or
more UTIs in a six-month period or four or more within a year.
 Permanent kidney damage from an acute or chronic kidney
infection (pyelonephritis) due to an untreated UTI.
 Increased risk in pregnant women of delivering low birth weight or
premature infants.
 Sepsis, a potentially life-threatening complication of an infection,
especially if the infection works its way up your urinary tract to
your kidneys.
Complications

 Perinephric or renal abscess
- Suspect in a patient not improving on antibiotics
- Diagnosis (CT or renal USG)
- May need surgical drainage
 SEPTICAEMIA
Complications of Acute Pyelonephritis

Management of Acute pyelonephritis
 Hospitalization
 Urine culture and sensitivity, blood culture
 Evaluate hemogram, serum creatinine, and Serum electrolytes
 Monitor vital signs frequently, including urinary output
(catheterization)
 Maintain UOP to 50 mL/hr with intravenous crystalloid
 Administer intravenous antibiotics
 CXR if there is dyspnea or tachypnea
 Repeat hematology and blood chemistry studies after 48 hours
 Change to oral antimicrobials when afebrile

Management of Acute pyelonephritis
 Discharge when afebrile for 24 hours, continue same antimicrobial
therapy for 7 - 10 days
 Repeat urine culture 1 to 2 weeks after antimicrobial therapy is
completed
 If there is no clinical improvement in 48 to 72 hours, then USG is
done to look for urinary tract obstruction indicated by presence of
abnormal ureteric or pyelocaliceal dilatation
 Suspect Nephrolithiasis (stones) if severe flank pain: plain X Ray or
IVP should be performed

Recurrent UTI

 Two episodes in 6 months or 3 - 4 in a year
 Diagnosed by urine culture
Recurrent UTI in women

Pathogenesis of Recurrent UTI
 The genetic background influences the individual
susceptibility to recurrent UTI
 Women with recurrent UTI are more likely to
have had their first UTI before 15 years

Prevention of Recurrent UTIs
 Antibiotic prophylaxis
- Taking a low dose of antibiotics long-term
- Taking a single antibiotic dose after sex
 Immunoactive prophylaxis
 Probiotic prophylaxis
 Cranberry prophylaxis

UTI after Menopause

 Estrogen has a protective effect
in the urinary tract
 Low estrogen levels can make it
easier for bacteria to thrive in the
vagina or urethra
UTI in Postmenopausal Women: Role of
estrogen

UTI in postmenopausal women: other
risk factors
 Atrophic vaginitis
 Incontinence, cystocoele
 Post void residual urine
 Urethral stenosis
Management: Estrogen Cream/Surgical prolapse

UTI in Pregnancy

 Kidneys become larger, VUR increases
 Dilatation of the renal calyces & ureters
 Ureteric compression (dextrorotation of uterus)
 Overt bacteriuria has been reported to be associated with
preterm or low-birth weight infants
 Bacteriuria that persists or recurs after delivery has been
associated with pyelographic evidence of chronic infection,
obstructive lesions, and congenital abnormalities.
 ACOG recommends screening for bacteriuria at the first
antenatal visit (if untreated, 25% develop infection)
Urinary Tract Changes in Pregnancy

Aymptomatic Bacteriuria in pregnancy
 Bacteriuria is typically present at the time of the first
prenatal visit in pregnancy, and if an initial positive
urine culture is treated, <1 % of women develop
urinary infection
 It may be prudent to treat in pregnancy when lower
concentrations are identified, because pyelonephritis
develops in some women with colony counts of
20,000 to 50,000 organisms/ml

UTI in Pregnancy
 Renal infection (acute pyelonephritis) is the most common
serious medical complication (septic shock) of pregnancy
 Increased risk in second trimester, nullipara and young age
 It is usually unilateral in most of cases
 Right-sided in 50% of cases
 Bilateral in 25% cases

 Nitrofurantoin
 Amoxicillin
 Amoxicillin & Clavulanate
 Cephalexin
Safe antibiotics in pregnancy

How to Prevent UTI in pregnancy
 Repeat urine culture after treatment of
bacteriuria & UTI
 Postcoital prophylaxis in women with H/o
frequent UTIs in pregnancy

UTI in Puerperium/POSTPARTUM
 Bladder sensitivity to intravesical fluid tension is
decreased as a consequence of the trauma of labor
(episiotomy, periurethral lacerations, or vaginal wall
hematomas) as well as analgesia
 Catheterization to relieve retention and distension
commonly leads to urinary infection
 Operative and instrumental delivery delays early
mobilization

Prevention of UTI

 Drink plenty of liquids, especially water allowing bacteria to be flushed
from your urinary tract before an infection can begin.
 Drink cranberry juice. Although studies are not conclusive that cranberry
juice prevents UTIs, it is likely not harmful.
 Wipe from front to back
 Empty your bladder soon after intercourse
 Avoid potentially irritating feminine products (deodorant sprays,
douches and powders) in the genital area can irritate the urethra.
 Change your birth control method. Diaphragms, or unlubricated or
spermicide-treated condoms, can all contribute to bacterial growth.
Preventing UTIs

 Some studies suggest it can prevent,
but not treat an infection, and is more
effective in young and middle-aged
women.
 Cranberries contain a substance that
prevents E. coli bacteria from sticking
to the walls of the bladder.
Is there a Cranberry Connection?

They don’t treat UTI that you already have
But they reduce the risk of UTI
? How much
? How long
Contraindicated for women with acidity & women
who are on blood thinners
Is there a Cranberry Connection?

FACTS

 Nearly 20 percent of women who have a UTI will have
another,
 and 30 percent of those will have yet another
 While they're not 100% avoidable, there are ways to help
prevent infection.
Fact 1: They are fairly common

 Most people who get UTIs will experience similar
symptoms such as pain or burning during urination and
the frequent urge to urinate
 But not everyone will have the same experience
 In fact, it is possible to have a UTI and not experience any
symptoms at all.
Fact 2: Symptoms or No Symptoms

 The main reason that the chances of infection are
increased is that the hormone progesterone, which
your body produces at an increased amount during
pregnancy, relaxes the muscle in your ureters and
bladder.
 This decrease in muscle tone, along with the pressure
that your growing uterus puts on your bladder, can
slow the flow of urine and put you at a higher risk for a
UTI.
Fact 3: Risk increases during pregnancy

 It’s true that a UTI may subside without
treatment, but
 it’s also true that the infection could spread
to your kidneys and cause serious and
permanent damage.
Fact 4: We take it lightly

LET US UNRAVEL THE MYTHS

Myth 1: Poor hygiene
 If you get one, you must have
poor hygiene
 But it can be due to hot tubs,
tight clothes, tampons etc

Myth 2: Only Women get UTIs
 Men in 60s and 70s
 More common in women (short urethra,
proximity to anus and vagina)
 Women’s lifetime risk is more than 50% (men
12%)

Myth 3: Only Sexually Active Women
 Any age
 Women who are prone: pregnant & menopausal
 Sex & spermicides can be a predisposing factor but
not always (Always pass urine)
 There can be other reasons (immunity or urinary
tract abnormalities)

Myth 4: Getting more than one UTI
is dangerous
 Look for causes
 Should be treated promptly

Thank You

Urinary tract infection in females

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