Urinary Tract Infection: Symptoms, Treatment and Preventing Recurrence

Urinary tract infection is one of the most common bacterial infections, and one of the most commonly mistreated, because antibiotics are frequently taken without confirming the diagnosis and the wrong preventive measures are widely recommended.

The anatomy of the problem

Bacteria, most often Escherichia coli from the bowel, ascend the urethra into the bladder. Women are affected far more frequently because the urethra is short and close to the anus.

Cystitis is bladder infection. Pyelonephritis is kidney infection, which is more serious. Urethritis affects the urethra alone. Asymptomatic bacteriuria means bacteria in the urine with no symptoms, and in most people it should not be treated.

Symptoms

Lower urinary tract, cystitis:

• Burning or pain on passing urine
• Frequent urination, often of small amounts
• Urgency, a sudden compelling need to go
• Lower abdominal or suprapubic discomfort
• Cloudy, strong-smelling urine
• Visible blood in the urine
• A feeling of incomplete emptying

Upper tract, pyelonephritis, needing prompt medical care:

• Fever and chills
• Pain in the flank or back, usually one-sided
• Nausea and vomiting
• Feeling systemically unwell
• Confusion, which in older adults may be the only sign

In older adults, UTI often presents atypically as confusion, falls or reduced appetite without classic urinary symptoms. However, confusion in an older person should not be assumed to be a UTI and other causes must be considered, since over-treatment of asymptomatic bacteriuria is a major driver of resistance.

In infants and young children: fever without an obvious source, irritability, poor feeding, vomiting, foul-smelling urine, or faltering growth. A first UTI in a child warrants investigation for underlying abnormalities.

Diagnosis

A urine dipstick showing nitrites and leucocyte esterase supports the diagnosis in a symptomatic woman.

A urine culture with sensitivity is important for men, children, pregnant women, recurrent infections, suspected kidney infection, treatment failure, catheterised patients and anyone recently hospitalised. Collect a midstream clean-catch sample before starting antibiotics, otherwise the culture is useless.

A urine culture is not needed for every simple cystitis in an otherwise healthy woman, but it is needed far more often than it is done.

Treatment

Antibiotic choice depends on local resistance patterns, which have shifted considerably in India, and on the site of infection. Short courses, often three to five days, are used for simple cystitis in women; men, pregnant women and kidney infection need longer courses and more careful selection.

Points that matter:

• Complete the course as prescribed
• Drink plenty of fluids
• Paracetamol for pain; urinary alkalinisers may ease burning but do not treat infection, and must not be combined with some antibiotics
• Symptoms should improve within 48 hours; if not, return for review and culture
• Never use leftover antibiotics or someone else’s prescription

Pregnancy is a special case: even asymptomatic bacteriuria is treated, because it risks pyelonephritis and preterm birth.

Seek urgent care for

Fever with flank pain, vomiting preventing oral intake, visible blood with clots, inability to pass urine, confusion, a known kidney stone or single kidney, or any UTI symptoms in pregnancy, in a man, or in a child.

Recurrent UTI

Defined as two infections in six months or three in a year. Investigation looks for stones, incomplete bladder emptying, prostate enlargement in men, diabetes, and in postmenopausal women, vaginal atrophy.

Prevention with reasonable evidence:

• Adequate fluid intake. A trial showed that increasing water intake by about 1.5 litres daily halved recurrences in women who drank little
• Do not delay passing urine
• Urinate after sex
• Vaginal oestrogen for postmenopausal women, which is one of the most effective measures available
• D-mannose, with modest but real supporting evidence
• Cranberry products, with mixed evidence; capsules standardised for proanthocyanidins perform better than juice, which is mostly sugar
• Methenamine hippurate as a non-antibiotic option
• Low-dose prophylactic antibiotics, or a single dose after intercourse, for selected patients
• Treating constipation, which contributes in children and adults
• Reviewing contraception, since spermicides and diaphragms increase risk

Of limited or no value: douching, which is harmful; antiseptic washes, which disturb normal flora; cotton versus synthetic underwear, which has little evidence; and avoiding baths.

The advice to wipe front to back is sensible hygiene but has weaker evidence than commonly assumed.

Antibiotic resistance

Resistance in urinary E. coli is now high in India, which is why culture-guided treatment matters and why antibiotics should not be taken for every episode of burning. Not all dysuria is infection: vaginal infections, sexually transmitted infections, bladder pain syndrome, stones and irritants all cause similar symptoms.

This is general information. Antibiotics for UTI should be prescribed after proper assessment, with culture where indicated, rather than bought over the counter.