Urinary Tract Infections (UTIs)

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UTIs consist of inflammatory infections that can affect any part of your urinary system.

The urinary system includes the upper urinary tract and lower urinary tract, which consist of the following;

• upper urinary tract ( kidneys, ureter)
• lower urinary tract (bladder, urethra).

Infections are mainly bacterial but can be fungal.

In comparison to men, women are more prone to developing UTIs because of their anatomy.

Recurrent urinary tract infections can be distressing. Finding the appropriate treatment to prevent UTIs can be challenging. One has to remember that most infections will resolve.

An in-depth understanding of the risk factors is key to building a plan to treat UTIs.

• An infection of the urethra is called urethritis
• A bladder infection is called cystitis
• A kidney infection is called pyelonephritis.
  

Escherichia, better known as E.Coli is the commonest bacteria, followed by Klebsiella and Proteus species responsible for urinary tract infections. There are other bacteria.

A urine culture helps to determine the cause of infection and directs the course of antibiotics.

They can be classified according to which part of the urinary tract is affected.

1. upper urinary tract
2. lower urinary tract

Another important distinction is if they are

1. uncomplicated UTIs
2. complicated UTIs

A urinary tract infection in patients with a weak immune system, males, and those associated with high temperature, calculi, sepsis, a blockage along the urinary tract, urinary catheters, or involving the upper urinary system are considered complicated infections

1. Females have a shorter urethra, around 4cm in length, compared to the male urethra, which is around 24 to 30 cm.
2. The female genital area, where the urethral opening lies close to the back passage.

Bacteria enter the lower urinary tract through the urethra (which carries urine), leading to a bladder infection.

30% to 50% of women will suffer from a UTI in their life. The majority are caused by E Coli bacteria.

Of these, around 25% of women will have a second infection within six months.

Around 2.5% of women will have frequent UTIs. 

If you are a male and have a UTI, you should seek medical attention, as UTIs in males are not common. This means you need further diagnostic testing.

The common symptoms of urinary tract infections are;

• urinating frequently (often one feels the need to go, and only a few drops are passed)
• constant urge
• painful urinating (burning or stinging)
• foul smelling urine
• cloudy urine
• lower abdominal pain
• fever, or chills and rigors or high temperature
• tiredness
• if one develops pyelonephritis, one may experience loin pain, fever and nausea
  

Some symptoms and signs of STIs and UTIs can be the same. To know for sure, you need to see a doctor and get tested.

• Lack of adequate fluid intake (this is the most important risk factor)
• Poor hygiene techniques (some do not wipe from front to back)
• Menopause leads to vaginal atrophy (thinning)
• Sexual activity
• Antibiotics lower the natural bacteria of the vagina that prevent other bacterial growth
• Weak natural defences due to reduced antibody (IgA and IgG antibodies) and reduced glycosamine glycan (GAG) layer, which typically acts as a barrier to bacteria in the bladder.
• Incomplete bladder emptying
• A weak immune system secondary to some medical conditions like diabetes (especially uncontrolled), certain medication and other causes
• Urinary catheter
• Spinal cord injuries that lead to functional and structural abnormalities
  

What to do if you have UTI symptoms? 

Have a urine sample checked. Visit your general practitioner (GP), pharmacist, or urologist to have your urine tested.

Urine testing positive for nitrites and white blood cells (leukocytes) must be sent for culture and sensitivity. Knowing the bacteria that are causing the infection is key for appropriate oral antibiotics. Red blood cells are a common finding when there is a urinary tract infection.

Refrain from blind repeated oral antibiotics as this leads to antibiotic resistance, and recurrent urinary tract infections will persist.

The urine test is useful to confirm the presence of bacterial infection. There are certain medical conditions like interstitial cystitis that mimic recurring UTIs.

In the acute UTI, the doctor will prescribe 3 to 5 days of antibiotic treatment.

Single-dose antibiotics after sexual activity can be prescribed for those whose infection is precipitated by sexual intercourse.

Urologists are refraining from the traditional prophylactic daily prescribing of low-dose antibiotics due to the mounting antibiotic resistance.

Ultrasound of your urinary tract looking for anatomical variations, stones, incomplete bladder emptying and other issues leading to recurrent infections.

 A camera test, known as flexible cystoscopy, looks at the water pipe (urethra) and bladder inner lining to exclude anatomical reasons leading to recurrent infections.

Drink plenty of fluids. Look at the colour of your urine; it should be very light yellow. If it is not, you are not drinking enough. Fluid intake should be spread throughout the day. The idea is to flush the bacteria continuously. One cannot emphasise enough to drink plenty.

Perform good hygiene practices (after emptying the bladder, females should wipe front-to-back). Empty the bladder before and after sexual activity.

Vaginal dryness places a female at a greater risk of infection. Avoid using certain birth control method that lead to vaginal dryness, such as spermicidal contraceptives, diaphragms, or hygiene products that cause vaginal dryness, such as vaginal douching, perfumed bubble bath, soap or talcum powder around your genital area. Use plain, unperfumed varieties, and have a shower rather than a bath.

Aim for regular bowel movement. Avoid long periods of constipation. Increase fluids and fibre in your diet, and become more physically active.

Preferably wear cotton underwear. Avoid using fabric softener to wash underwear as this damages the fibres.

Keep an infection diary. This helps to identify your daily patterns that are leading to recurrent infections like stressful situations or sexual intercourse or period or long distance travelling, and more.

Have a regular intake of natural yoghurt with live bacteria during the week. Data is weak.

Intravaginal application of natural yoghurt with live bacteria three times a week. Especially in postmenopausal women or those that experience thinning of the vaginal layer secondary to medications/medical conditions. This can be an alternative for those who cannot be prescribed local oestrogen treatment. Data is weak.

Antibiotic prophylaxis has a role in specific circumstances. Prophylactic antibiotic can be given if sexual intercourse leads to recurrent uti. One takes an antibiotic 1 hour after sexual intercourse.

Many patients are stating that ' D-Mannose cured my UTI'.  D-Mannose has a role but it does not work on everyone. Take 2g daily (either in powder or tablet form). If taken as a regular dietary supplement, alongside other lifestyle changes, it can help by preventing UTIs. Some studies support its use. This is a non-prescription item. It may cause bloating or loose stools if it does simply lower the dose. It works by binding to the finger projections of bacteria that cause bladder infections preventing bacteria from anchoring to the bladder lining. In so doing, it helps to flush out bacteria.

Where can I find D-Mannose naturally?

D-mannose is a type of sugar. D-mannose occurs naturally in cranberries, black and red currants, peaches, green beans, cabbage, tomatoes, oranges, apples, aloe vera, mangos and seaweed

I am diabetic can I take D-Mannose?

D-mannose can potentially lead to higher sugar levels in diabetic patients. Rather than having higher doses, one would start at 1G daily or even 500mg.

If the sugar control is not affected, one may increase the dose; however, if it is getting out of control best to stop it and find an alternative.

Is there a role of D-Mannose in pregnant females and children?

There have not been any studies, and D-Mannose cannot be recommended.

Cranberries have a substance that can prevent bacteria from sticking to the bladder lining.

Extensive research has concluded that cranberry has no role in prevention or cure. However, many still consume cranberry juice or supplements as they feel better. Cranberry juice is a rich source of vitamin C that supports the immune system, and it counteracts oxidative stress damage from free radicals released in inflammatory situations like recurrent urinary tract infections and helps to lower bacterial growth.

What are cranberry pills made of?

Dried, powdered cranberries are the main component. Even though they are dried, the antioxidant effect remains viable. You can take them as an alternative to juice.

What happens if you regularly drink cranberry juice?

Cranberry juice is safe in healthy people if taken in moderation. Excess drinking can cause an upset stomach as it is mildly acidic, loose stools, or high blood sugars.

How fast does it take for cranberry juice to reach the urinary tract?

Some studies have shown that the time is around eight hours

What should not be taken with cranberry juice?

Warfarin, aspirin and other medications which are metabolised in the liver. If in doubt, contact your pharmacist or general practitioner (GP)

In many cases, it gets better by itself. However, if you have a tendency to suffer from frequent urinary tract infections, it is important to send a urine culture

Drinking plenty of fluids is important. This helps to flush bacteria out. Make sure to look at the colour of urine, and this has to be as close as the colour of the water.

The burning feeling or stinging of urine, discomfort, urinary frequency, fever, suprapubic pain, feeling unwell and emptying only a few drops of urine should improve day after day. 

UTIs can steal a lot of energy from one's body, and when they are recurrent UTIs, they can cause anxiety, lack of sleep and fatigue. It may take longer to recover from them.

• you think you have a bladder infection and has not gone away within 72 hours
• your symptoms have not gone away after antibiotic treatment
• frequent infections
• males that have symptoms of cystitis
• pregnant women and have symptoms of cystitis
• your child has UTI symptoms
• you have a kidney infection
  

If you have any of the above, then contact your family doctor, NHS consultant or private urologist.

Left untreated, there is an increased risk of kidney infection or sepsis (both needing hospital antibiotic therapy in the form of intravenous antibiotics), stone formation and bladder cancer.

Your NHS consultant or private urologist, or general practitioner will try to avoid long-term antibiotics. 

They may recommend the following;

1. Methenamine hippurate (Hipprex)
2. Oestrogen
3. Bladder Instillations with Hyaluronic Acid
   

Has antibacterial activity because the methenamine is converted to formaldehyde – an antiseptic and Hippuric acid keeps the urine acidic.

Typically this is active against E. coli, enterococci and staphylococci and less effective against Enterobacter species. This is prescribed 1G be taken twice daily on a long-term basis.

Some studies reported that around 75 per cent of those taking Hiipprex see a benefit. The evidence base of Hipprex against urine infection remains weak.

What is the best time to take Hipprex?

It is best to take it with your breakfast and your dinner with a full glass of water.

Do you have to take Vitamin C with Hipprex?

Vitamin C makes the urine more acidic. This acidic environment helps Hipprex to form formaldehyde which is key to sterilising urine.

Burning sensation when passing urine, nausea, vomiting, loose bowel movement, abdominal pain and lack of appetite may occur.

Typically prescribed in postmenopausal females to address the thinning of the vaginal layer to regain back the natural defences against the bacteria coming from the gut. This can be prescribed either as oestrogen cream or oestrogen pessaries.

Oestrogen creams can cause local irritation, but systemic absorption and effect are minimal. These are contraindicated in patients with a history of breast cancer and known or suspected oestrogen-dependent malignant tumours (such as endometrial cancer or breast cancer).

The inner layer of the bladder has cells that are connected tightly to each other to prevent bacterial invasion. This is referred to as the glycosaminoglycan (GAG) layer. Instilling hyaluronic acid (HA) and chondroitin sulfate (CS) aims to boost the glycosaminoglycan (GAG) layer on the inner lining of the bladder, restoring the protective layer. The instillations are typically given once a week for four weeks and then once monthly for six months.

Uromune UK is an immunostimulant UTI vaccine for treating recurrent urinary infections.

The most common bacteria (Escherichia coli, Klebsiella pneumoniae, Proteus vulgaris and Enterococcus Faecalis) have been inactivated.

This self-treatment is administered daily over three months via a spray applied under the tongue each day. Once administered, it interacts with the immune system, resulting in long-term protection from UTIs in the patient. 

Data has shown around an 80% reduction in infections, giving back females a better quality of life.

At the beginning of each vial, turn the pipette horizontally and pump the spray up to 4 times to ensure the dispenser is filled properly. 

Direct the pipette under the tongue, and spray twice. Keep the dose under the tongue for around 2 minutes, and then swallow it.  Rotate the pipette back to its original position (vertically downward), and this blocks the pump action.

Meals and/or fluids should not be taken directly after the application of the spray in order to allow maximum exposure and contact of the product with the area sprayed. Brushing teeth or mouth rinsing should be avoided for at least 30 mins after taking the vaccine.

Infection of the upper urinary tract is more serious than a bladder infection. It needs to be treated promptly with adequate antibiotics. As opposed to lower urinary tract infections that require a short course of antibiotics, a kidney infection usually requires two weeks.

If untreated, a kidney infection not only leads to sepsis but as well to chronic kidney damage.

Signs and symptoms of a kidney infection?

An infection of the kidney presents with pain at the loin, fever, nausea or feeling sick. A bladder infection can precede it. Patients can as well experience pain on passing urine, frequency, urgency and foul-smelling urine.

I think I have a kidney infection. Do I need to go to the hospital?

It is a must that if you suspect that you have an upper tract infection, you need to seek medical attention. A detailed medical history is taken, and an examination followed by tests is performed.

If you are stable and the kidney infection is in its early phases, the doctor can start you on antibiotics, but if it is caught at a later stage or you are not improving on antibiotics within 24 hours, then hospitalisation for intravenous antibiotics and to rule out complicated UTI is recommended.

Who is at an increased risk of upper urinary tract infection?

• recurrent urinary tract infection
• kidney diseases (chronic kidney disease)
• uncontrolled diabetes
• weak immune system
• stones (anywhere in the urinary system)

Is it normal to feel tired after taking all the treatments?

Feeling tired is a common finding. An upper urinary system infection steals a lot of energy, and your body will need time to recuperate. Often patients take between 4 to 6 weeks to recover fully.

UTIs in males are considered complicated UTIs. This requires investigation of the urinary tract to prevent UTIs from recurring. In males, the urinary tract includes the prostate as well. The urologist needs to make sure that the urinary tract infection is not caused by problems in emptying the bladder properly from an enlarged prostate. Other common causes of UTIs in males are stones, immunosuppression, uncontrolled diabetes, and catheters.

A male with a urinary tract infection should always seek medical attention.

Written by Mr. E. Calleja

NHS Consultant, Private urologist, Robotic surgery