Medscape

Andrea Hertlein

Gerry Gajadharsingh writes:

“ Urinary tract infections (UTIs) are very common, occurring mostly in women and are sometimes distressing for the patient. It is thought that an episode of acute UTI, affects 50% of women by the age of 24 yoa.  The incidence of UTI in adult males younger than 50 years of age is low. Approximately 5 to 8 per year per 10,000 population with adult women, being 30 times more likely than men to develop UTI. Incident rates are also higher in elderly women and men, particularly associated with problems of the prostate and type two diabetes.

Common symptoms include,

Dysuria — discomfort, pain, burning, tingling or stinging associated with urination.

Frequency — passing urine more often than usual.

Urgency — a strong desire to empty the bladder, which may lead to urinary incontinence.

Changes in urine appearance or consistency:

    • Urine may appear cloudy to the naked eye, or change colour or odour.
    • Haematuria may present as red/brown discolouration of urine or as frank blood.

Nocturia — passing urine more often than usual at night.

Suprapubic discomfort/tenderness.

Pyelonephritis (kidney infection) should be suspected in people with fever, loin pain or rigors.

Recurrent UTI effects, 20 to 30% of women, with an average of 2.6 infections per year. A retrospective observational study using linked health records (Clinical Practice Research Datalink [CPRD]) from almost one million patients aged ≥65 years old in England found that of 931,945 older adults, 196,358 (21%) had at least one clinically diagnosed UTI over the 10-year study period. Incidence was found to increase from 9.03 to 10.96 in women aged 65–74 years, 11.35 to 14.34 in those aged 75–84 years, and 14.65 to 19.80 in those aged over 85 years.

Sometimes women are asymptomatic, it is estimated that 4–19% of healthy elderly women — this may increase up to 50% in women in long term care facilities, will have an asymptomatic bacterial UTI. Typical features may be absent, in particular in elderly women with underlying cognitive impairment — consider UTI if the woman presents with: Generalized non-specific clinical features such as delirium, lethargy, reduced ability to carry out activities of daily living and anorexia. Alternative sources of infection and causes of delirium other than UTI must be excluded before a working diagnosis of UTI is made.

Most UTI’s tend to be because of bacterial infection with E. coli the most common bacteria found on culture, approx. 65% to 90% of cases, with Klebsiella pneumoniae in about 10% of cases.

With increasing problems of antibiotic resistance, the trend has been to try to use non-antibiotic approaches, if possible, for UTI (assuming there is no evidence of kidney infection).

D Mannose, a monosaccharide (sugar) found in fruits is often found to be very helpful and research below seems to back this up, but it does seem to be specific to E coli infection.

Drinking too much water can be as problematic as not drinking enough water, as the article suggests.

Other common over-the-counter remedies, such as cranberry juice seems to have conflicting evidence. One of the paradoxes, of course, is consuming too much sugar tends to be pro inflammatory and not supportive of the immune system. So, I’m generally not a fan of consuming regular amount of any sort of fruit juices anyway.

Having a high pH (more alkaline, urine), seems to predispose to increased UTI. Reduced oestrogen in perimenopause and menopause, allows the vaginal pH to raise (more alkaline), increasing the risk of UTI. A urine pH of 7.5 is sometimes used for a diagnosis of UTI.

In clinic the first test that’s normally performed is a Urine Dipstix, almost always, there will be signs of white cells (leucocytes) in the urine often with nitrates and sometimes blood. However, I’ve had at least one patient where leucocytes were not found on urine dipstick or on microscopy (the urine sample is sent off to a laboratory), and had a positive culture, > 100,000 cfu/ml. It’s preferable to test a first morning avoid (FMV), urine sample, midstream, but there is sometimes a problem with contamination with female patients, on collecting a midstream sample. Sending the sample off to the laboratory for microscopy and culture means that it will come back with an antibiotic sensitivity report and so the prescriber will know which type of antibiotic the patient is more likely to respond to.

The other over the counter (or prescription) medication that is increasingly used is Hiprex (methenamine Hippurate), described as a urinary antiseptic, but can also be considered as antibacterial agent or an antibiotic. It seems to work by making the urine more acidic. Long-term use is discouraged as it can cause bladder irritation.”

 

For those affected, recurrent urinary tract infections (UTIs) are sometimes stressful. However, even an informative discussion about risk factors and the imparting of behavioural recommendations can be very helpful for many women. Antibiotic prophylaxis should only be considered once all nonantibiotic therapy options have been exhausted.

One in seven women suffers at least once a year from cystitis. Around a third of those women develop a further urinary tract infection 6-12 months after the first infection. A urinary tract infection is classified as recurrent if two symptomatic episodes have occurred within the last 6 months or if three episodes have occurred within the last 12 months.

There are many different approaches to reducing the recurrence rate of urinary tract infections, Daniel Klußmann and Florian Wagenlehner, MD, of the Department and Outpatient Clinic for Urology at the University of Giessen, Germany, wrote in DMW- Klinischer Fortschritt. Aside from general information and advice, nonantibiotic therapy options are particularly important for recurrence reduction, with the aim of preventing the development of resistance and the corresponding adverse effects of antibiotics.

Fluids and D-Mannose

An individual consultation discussion is the most important nonantibiotic strategy. Studies have shown that this strategy alone can lower the frequency of recurrent UTIs. According to the authors, special education programs on the causes and behavioural measures are especially helpful. Included in these programs is the recommendation to drink a sufficient, but not excessive, amount of fluids: approximately 1.5 litres per day. In one randomized study, this level of consumption halved UTI frequency. However, drinking an excessive amount of fluids should also be avoided, otherwise the antimicrobial peptides present in the urine become overly diluted.

The regular consumption of fruit juice, especially of that from berries, is also beneficial, according to the authors. However, study results on long-term prevention using cranberry products are inconsistent, and they are not recommended in the updated guideline. Like cranberries, D-mannose also inhibits the fimbriae of the E Coli bacteria and therefore the bacteria’s ability to bind to the bladder epithelium. The authors cite a study in which, following the intake of 2 g of D-mannose dissolved in a glass of water every day, the rate of urinary tract infections dropped significantly, compared with consumption of placebo.

Additional recommendations in the S3 guideline include various phytotherapeutic products such as bearberry leaves leaves, nasturtium herb, or horseradish root, although studies on the comparability of phytotherapeutic agents are very difficult to execute, the authors conceded.

It is already known that there is a positive correlation (by a factor of 60) between the recurrence rate of UTIs and the frequency of sexual intercourse. Even with contraceptive methods (such as vaginal suppositories, diaphragms or condoms coated with spermicide, and intrauterine devices), the risk of urinary tract infections increases by a factor of 2 to 14. Sexual abstinence, even if temporary, can be a remedy. Evidence for the recommendation to urinate immediately after coitus is contradictory in the literature, however. Excessive intimate hygiene clearly damages the local protective environment.

Estrogen Substitution Beneficial

For postmenopausal women, there is also the option of local estriol substitution (0.5 mg/day) as another nonantibiotic method of prophylaxis. This treatment serves as therapy for vaginal atrophy and reduces both vaginal colonization with uropathogens and the vaginal pH level. The authors cite Scandinavian studies that detected no increase in the risk of breast cancer from the local application of estriol.

Furthermore, the current guidelines recommend oral immunostimulation with bacterial cell wall components from uropathogenic strains of E coli (OM-89, Uro-Vaxom). The authors reported on two meta-studies in which the average recurrence rate was reduced by 39%, compared with placebo. In addition, the treatment time for breakthrough infections decreased significantly, and prevention with OM-89 could even be started during acute therapy. Also recommended is parenteral immunostimulation with inactivated pathogens (StroVac). Acupuncture as cutaneous immunostimulation has also displayed a positive protective effect.

Only when nonantibiotic therapy fails and the patient is under a high amount of psychological strain should antibiotic prophylaxis be initiated, according to the authors. A period of three to six months should be the target here. When choosing an antibiotic and before starting therapy, the corresponding pathogen should be confirmed through a urine culture, and resistance testing should be performed. On the other hand, single-use, postcoital antibiotic prevention could be an alternative, particularly for women in whom a correlation between recurrent UTIs and sexual intercourse has been suspected, the authors wrote.