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Look Up > Conditions > Urinary Tract Infection in Women
Urinary Tract Infection in Women
Overview
Definition
Etiology
Risk Factors
Signs and Symptoms
Differential Diagnosis
Diagnosis
Physical Examination
Laboratory Tests
Pathology/Pathophysiology
Imaging
Other Diagnostic Procedures
Treatment Options
Treatment Strategy
Drug Therapies
Complementary and Alternative Therapies
Patient Monitoring
Other Considerations
Prevention
Complications/Sequelae
Prognosis
Pregnancy
References

Overview
Definition

Urinary tract infection is a bacterial infection with, or causing, inflammation of urothelium. It occurs predominantly in women ages 14 to 61. Isolated UTIs occur in 25% to 30% of all women; recurrent UTIs occur in 60%, 95% of which are due to exogenous reinfection.


Etiology
  • Gram-negative bacteria causes UTIs, including Escherichia coli, Enterobacter and Klebsiella species, and Proteus mirabilis, and, less commonly, Pseudomonas aeruginosa, Serratia marcescens, and Trichomonas vaginalis protozoa.

Risk Factors
  • Changes in sexual activity: partner, frequency, intensity
  • Diabetes mellitus
  • Pregnancy
  • Use of irritant chemicals (detergents, spermicides)
  • Use of irritant contraceptive devices (e.g., diaphragm)
  • Use of oral contraceptives
  • Heavy antibiotic use, eliminating "barrier" microorganisms
  • Urinary tract abnormality or obstruction (tumor, calculi, stricture, inability to empty bladder completely)
  • Previous UTIs less than 6 months apart
  • Catheterization, hospitalization, chronic antimicrobial therapy, immunosuppressants, and corticosteroids; may trigger UTIs

Signs and Symptoms
  • Painful urination, with a burning sensation, frequency, and urgency
  • Blood or pus in urine
  • Pain or cramping in the lower abdomen
  • Chills, fever (fever may be the only symptom in infants and children)
  • Strong-smelling urine

Differential Diagnosis
  • Vaginitis
  • Pyelonephritis (up to one-third of UTI patients with mild lower UTI symptoms may have acute uncomplicated pyelonephritis.)
  • Urethritis
  • Sexually transmitted disease
  • Hematuria due to another condition, such as a tumor, calculi, TB, or, rarely, parasitic disease (malaria)
  • Intraperitoneal disease

Diagnosis
Physical Examination
  • Enlarged, tender kidney upon palpation
  • Abdominal rigidity upon palpation
  • Costovertebral tenderness upon palpation
  • Urinary symptoms: frequency, urgency, pain (only occurs in one-third of patients with lower UTI)

Laboratory Tests
  • Urinalysis with macro/micro examination
  • Suprapubic needle aspiration culture if unable to obtain clean catch: bacterial count is greater than 102 CFU/ml
  • Urine culture to differentiate urethritis (bacterial colony greatest in urethral culture) and UTI (bacterial colony greater than or equal to 105 CFU/ml)
  • Vaginal culture to differentiate vaginitis (bacterial colony greatest in vaginal culture)

Pathology/Pathophysiology

In recurrent UTIs, periurethral flora culture, indicating prolonged coliform bacterial colonization, confirm virulence over normal host defenses (urine, urine flow, urinary tract mucosa, urinary tract bacterial inhibitors)


Imaging

Recurrent or infant UTIs:

  • Plain film X ray, ultrasound, endoscopic imaging, or VCUG
  • Intravenous pyelogram (IVP)

Other Diagnostic Procedures

Urine culture (indications: pregnancy, history of UTI, diabetes mellitus, age over 65, immunosuppression, urologic abnormality, gross hematuria, unresolved or recurrent UTI symptoms, UTI symptoms for three or more days, fever, chills, flank pain, and recent—within the previous two weeks—antimicrobial therapy, hospital or nursing home stay, increase in sexual activity, or urethral catheter). Types:

  • Vaginal—swab vaginal introitus with sterile cotton applicator; place in 5 ml saline or standard transport broth
  • Urethral—void, 5 to 10 ml
  • Midstream—void, 200 ml midstream
  • Suprapubic needle aspiration of the bladder

Treatment Options
Treatment Strategy

Antibiotics eliminate bacteria and prevent progression of infection to kidneys. NSAIDs, urinary antiseptics, herbal, and homeopathic treatments are considered for symptomatic relief.


Drug Therapies

General considerations: patient compliance, type of infection (isolated vs. recurrent; uncomplicated vs. complicated), cost, strength, dose, side effects, efficacy, and length (7 to 10 vs. 1 to 3 days) of treatment.

Commonly used for UTI:

  • Amoxicillin: 250 to 500 mg every eight hours
  • Fluoroquinolone (Ciprofloxacin): 250 mg every 12 hours
  • Trimethoprim-sulfamethoxazole (TMP/SMX): 160 mg trimethoprim/800 mg sulfamethoxazole every 12 hours

Also used:

  • Ampicillin: 250 to 500 mg qid
  • Cotrimoxazole: 160 to 800 mg every 12 hours
  • Nitrofurantoin: 40 to 100 mg every six hours

Used in severe UTI, with sepsis:

  • Aminoglycosides (gentamicin sulfate, kanamycin sulfate): single intramuscular dose of 5 mg/kg gentamicin, or 0.5 g gentamicin parenterally every eight hours.

Complementary and Alternative Therapies

Nutrition, herbs, and homeopathic remedies may be useful in fighting infection, relieving pain, and tonifying the urinary system.


Nutrition
  • Eliminate refined foods, fruit juices, caffeine, alcohol, and sugar which may compromise immune function. Cranberries and blueberries contain substances which inhibit adhesion of bacteria to bladder tissue.
  • Vitamin C (1,000 mg tid) acidifies urine, inhibits bacterial growth.
  • Beta-carotene (25,000 to 50,000 IU/day) is necessary for immune function and mucous membrane integrity.
  • Zinc (30 to 50 mg/day) supports immune function.

Herbs

Ascertain a diagnosis before pursuing treatment. Herbs may be used as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water. Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for roots. Drink 2 to 4 cups/day. Tinctures may be used singly or in combination as noted.

Herbal therapy should be instituted at the first sign of symptoms and continued for three days beyond resolution of symptoms. Treatment of UTIs is best accomplished through teas because of the flushing action of the additional fluid intake. Combine two herbs from each of the following categories and drink 4 to 6 cups/day.

  • Urinary antiseptics are antimicrobial: uva ursi (Arctostaphylos uva ursi), buchu (Agathosma betulina), thyme leaf (Thymus vulgaris), pipissewa (Chimaphila umbellata)
  • Urinary astringents tone and heal the urinary tract: horsetail (Equisetum arvense), plantain (Plantago major)
  • Urinary demulcents soothe the inflamed urinary tract: corn silk (Zea mays), couch grass (Agropyron repens)

Marshmallow root (Althaea officinalis) is best used alone in a cold infusion. Soak 1 heaping tbsp. of marshmallow root in 1 quart of cold water overnight. Strain and drink during the day in addition to the other tea.

For advanced or recurrent infections prepare a tincture of equal parts of goldenseal (Hydrastis canadensis) and coneflower (Echinacea purpurea). Take 30 drops four to six times/day.


Homeopathy

An experienced homeopath should assess individual constitutional types and severity of disease to select the correct remedy and potency. For acute prescribing use 3 to 5 pellets of a 12X to 30C remedy every one to four hours until acute symptoms resolve.

  • Staphysagria for UTIs associated with sexual intercourse
  • Apis mellifica for stinging pains that are exacerbated by warmth
  • Cantharis for intolerable urging with "scalding" urine
  • Sarsaparilla for burning after urination

Patient Monitoring

For chronic UTIs, perform follow-up urinalysis. For isolated UTIs, no follow-up necessary unless pain persists.


Other Considerations
Prevention
  • Drink unsweetened cranberry juice, or take cranberry juice extract.
  • Urinate before and after sexual intercourse.
  • Recheck diaphragm fit.
  • Drink plenty of fluids, such as water and herb teas. Avoid sweetened fruit juices and other sweetened drinks.
  • Avoid sexual activity until infection is resolved.

Complications/Sequelae
  • Pyelonephritis
  • Renal abscess
  • Gram-negative sepsis

Prognosis

Antibiotics stop symptoms of uncomplicated, isolated UTIs within 24 to 48 hours and destroy bacteria with indicated duration of treatment. Herbal remedies treat UTIs while homeopathic remedies relieve the symptoms.


Pregnancy

Risk factors for complications include the following.

  • Untreated bacteriuria (develops into pyelonephritis 20% to 40% of the time)
  • Undetected UTI

Treatment during pregnancy includes the following.

  • Routine urinalysis during first trimester
  • Antibiotics for positive cultures
  • Prophylaxis if recurrrent UTIs during pregnancy
  • Hospitalization for acute pyelonephritis

References

Avorn J, Monane M, Gurwitz JH, Glynn RJ, Choodnovskiy I, Lipsitz LA. Reduction of bacteriuria and pyuria after ingestion of cranberry juice. JAMA. 1994;271:751-754.

Berkow R, ed. The Merck Manual. 16th ed. Rahway, NJ: Merck and Company Inc; 1992.

Blumenthal M, ed. The Complete Commission E Monographs: Therapeutic Guide to Herbal Medicines. Boston, Mass: Integrative Medicine Communications; 1998:432.

Engel JD, Schaeffer AJ. Evaluation of and antimicrobial therapy for recurrent urinary tract infections in women. Urol Clin North Am. 1998;25:685-701.

Goodman-Gilman A, Rall T, Nies A, Palmer T. The Pharmacological Basis of Therapeutics. 8th ed. New York, NY: Pergamon Press; 1990.

Howell A, Vorsa N, Der Marderosian A, Foo Lai Yeap. Inhibition of the adherence of P-fimbriated Escherichia coli to uroepithelial-cell surfaces by proanthocyanidin extracts from cranberries. N Engl J Med. 1998;339:1085-1086. Letter.

Kruzel T. The Homeopathic Emergency Guide. Berkeley, Calif: North Atlantic Books; 1992:98-102.

Murray M, Pizzorno J. Encyclopedia of Natural Medicine. 2nd ed. Rocklin, Calif: Prima Publishing; 1998.

Ofek I, Goldhar J, Zafriri D, Lis H, Adar R, Sharon N. Anti-Escherichia coli adhesion activity of cranberry and blueberry juices. N Engl J Med. 1991;324:1599. Letter.

Schmidt DR, Sobota AE. An examination of the anti-adherence activity of cranberry juice on urinary and nonurinary bacterial isolates. Microbios. 1988;55:173-181.

Schulz V, Hänsel R, Tyler VE. Rational Phytotherapy: A Physicians' Guide to Herbal Medicine. New York, NY: Springer; 1997.

Sobel JD. Pathogenesis of urinary tract infection: role of host defenses. Infect Dis Clin of North Am. 1997;11:531-549.

Sobota AE. Inhibition of bacterial adherence by cranberry juice: potential use for the treatment of urinary tract infections. J Urol. 1984;131:1013-1016.

Ullman D. The Consumer's Guide to Homeopathy. Tarcher/Putnam; 1996.

Werbach M, Murray M. Botanical Influences on Illness: A Sourcebook of Clinical Research. Tarzania, Calif: Third Line Press; 1994.

Zafriri D, Ofek I, Adar R, Pocino M, Sharon N. Inhibitory activity of cranberry juice on adherence of type 1 and type P fimbriated Escherichia coli to eucaryotic cells. Antimicrob Agents Chemother. 1989;33:92-98.


Copyright © 2000 Integrative Medicine Communications

This publication contains information relating to general principles of medical care that should not in any event be construed as specific instructions for individual patients. The publisher does not accept any responsibility for the accuracy of the information or the consequences arising from the application, use, or misuse of any of the information contained herein, including any injury and/or damage to any person or property as a matter of product liability, negligence, or otherwise. No warranty, expressed or implied, is made in regard to the contents of this material. No claims or endorsements are made for any drugs or compounds currently marketed or in investigative use. The reader is advised to check product information (including package inserts) for changes and new information regarding dosage, precautions, warnings, interactions, and contraindications before administering any drug, herb, or supplement discussed herein.