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Urology Resources
Urinary Tract Infection
Normal urine is sterile. When bacteria gets into the bladder via the urethra, it can infect it to cause cystitis. Left untreated, the infection can go up to the kidneys to cause a more severe infection, called pyelonephritis. Urine infection is common and can affect children and adults alike. The symptoms include frequency of urination, pelvic pain, burning sensation during urination, cloudy, smelly urine to frank blood in the urine. When the infection affects the kidneys, it will cause loin pain, shivering, fever and even septic shock.
Causes
Urine infection (UTI) is more likely to occur when there is an abnormality in the urinary tract. Women are also more prone to urine infection because their urethra is much shorter and sexual intercourse predisposes to this urine infection. Typically, women get their first cystitis when they become sexually active. Diabetic patients are also more likely to get UTI due to the excess sugar in the urine. Women are also prone to UTI after menopause because of the dry state of the vagina and urethra. Infections are also more likely to occur when there is stagnant urine in the bladder eg. from bladder or urethral diverticulum, prostate enlargement in men and weak bladder due to disease affecting the nerves, eg. diabetes, post-surgery. When the infection proves difficult to treat, an underlying cause should be suspected. This range from resistant bacteria, bladder obstruction, congenital anomaly of the urinary system, or urinary stones.
Symptoms
Urine infection can be suspected based on the history of an acute onset of frequent urination with burning pain, lower abdominal pain, and smelly/ cloudy or bloody urine.
Diagnosis
- Urine dipstick
The finding of red and white blood cells in the urine under the microscope is highly suggestive of an infection. However, the diagnosis can be also be quickly suspected from a one-minute dipstick test (combur 9) which will react positively to white blood cells and nitrites that the bacteria produce. - Urine culture
UTI can only be confirmed from culture taken from a mid-stream urine specimen. The advantage of doing a culture isolate is that it identifies which antibiotics are effective against the bacteria. The result takes 2 days. - Ultrasound
A screening ultrasound is easily done in the clinic and serves to detect bladder or kidney stones as the source. - X-rays
If ultrasound reveals a stone or an abnormal kidney, then a special X-ray of the urinary tract called intravenous urogram (IVU) is indicated. This X-ray is also done for those with recurrent infections as it is able to outline any abnormal urinary system eg. duplex ureter. If reflux of urine from the bladder up to the kidney is suspected, then another xray called a micturiting cystogram (MCU) is indicated. - Cystoscopy
Occasionally, this telescopic inspection of the bladder is indicated if there is persistent blood in the urine. It is done under local anaesthesia using a flexible scope.
Recurrent Infections
Many women suffer from frequent UTI's. Nearly 20 percent of women who have a UTI will have another episode. It is well known that some women are more prone to recurrent attacks than others. Research has shown that women with certain blood types are particularly prone to UTI's because the cells lining the vagina and urethra allow bacteria to attach more easily. Another common reason for recurrent UTI is the persistence of resistant bacteria that was not eradicated - the widespread use of antibiotics resulting in these resistant strains. Doctors often give antibiotics based on “best guess” but do not realize that the bacteria are only partially sensitive to the antibiotics, leading to incomplete eradication. Hence, the importance of doing urine culture prior to starting antibiotics.
Treatment
The mainstay of UTI treatment is an appropriate and adequate antibiotic course. Uncomplicated UTI can be cured with 3 days of treatment. The choice of drug and length of treatment depend on the patient's history and the urine tests that identify the offending bacteria. The urine culture test is especially useful in helping the doctor select the most effective drug.
Single-dose treatment is not recommended for some groups of patients, for example, those who a kidney infection, diabetics, those with structural abnormalities of the urinary system, or men with prostate infections. Longer treatment is usually needed for infections of the prostate or the testis. It is important to take the full course of treatment because symptoms may disappear before the infection is fully cleared. Pregnant women who develop UTI should be treated promptly. Only certain antibiotics are advisable during pregnancy.
Kidney infections generally require 2 - 3 weeks of antibiotics. Prostate infections usually need up to a month to clear.
Drugs are also available to relieve the pain of UTI, eg. flavoxates (Genurin, Urispas). Urine alkalinizing agents such as citrate can be given to prevent UTI.
Women
Women who have frequent recurrences with no identifiable cause may benefit from preventive therapy. A woman who has frequent recurrences (three or more a year) should ask her doctor about one of the following treatment options:
- Take a low dose of an antibiotic daily for 3 to 6 months, eg. bactrim, nalidixic acid, amoxil
- Take a single dose of an antibiotic after sexual intercourse
Additional steps that a woman can take to avoid an infection:
- Drink plenty of water every day. Drinking cranberry juice may help inhibit the growth of some bacteria by acidifying the urine. Vitamin C supplements have the same effect
- Urinate when you feel the need. Holding the bladder for too long results in stale urine and allow bacteria to grow easily
- Pass urine immediately after sexual intercourse
Men
UTIs are unusual in men. In older men (age 50 years and beyond), it usually stems from an obstruction of the bladder, usually by an enlarged prostate (BPH). The residual urine stagnates and gets infected easily.
In younger men aged 20 to 50 years, prostate infection (prostatitis) is a common occurrence. Prostatitis can been classified into the following categories:
- Acute bacterial prostatitis
- Chronic bacterial prostatitis
- Nonbacterial prostatitis, prostatodynia and chronic pelvic pain syndrome
Symptoms
The signs and symptoms vary depending on the various types of prostatitis.
1. Acute bacterial prostatitis
The symptoms come on suddenly and may include:
- Fever and chills
- Pain in the pelvis, lower back or groin
- Urinary problems, including increased urinary urgency and frequency, difficulty or pain when urinating, sudden retention of urine, and blood in the urine
- Painful ejaculation
Acute prostatitis can be a serious condition and requires intravenous antibiotics because of the fever and severe pain.
2. Chronic bacterial prostatitis
This type of prostatitis develop more slowly and usually not as severe as acute prostatitis. In addition, the symptoms of pain tend to alternate with times when symptoms are better. These symptoms include:
- A frequent and urgent need to urinate, both day and night
- Burning sensation when urinating (dysuria)
- Pain in the pelvic area
- Pain in the lower back and scrotum
- Pain felt at the penis tip at the end of micturition
- Difficulty starting to urinate, or diminished urine flow
- Blood in semen or in urine
- Painful ejaculation
Chronic nonbacterial prostatitis
The symptoms of nonbacterial prostatitis are similar to those of chronic bacterial prostatitis. The only way to determine whether prostatitis symptoms are caused by bacterial infection or are nonbacterial is through lab tests to find out whether bacteria is present in the urine or prostate / semen fluid. Another suspect is the reflux of urine into the prostate due to a non-relaxing urinary sphincter eg. from psychological stress, excess caffeine.
Causes
Bacteria normally found in the large intestine typically cause acute prostatitis. Most commonly, acute prostatitis originates in the prostate, but occasionally the infection can spread from a bladder or urethral infection.
For chronic bacterial prostatitis, it is not entirely clear what causes this infection. It may develop after an episode of acute prostatitis when bacteria still remain in the prostate. Or it may begin as a low-grade infection due to obstruction of the prostatic ducts.
Diagnosis
Diagnosing prostatitis is by clinical means. The medical history is as outlined in the symptom list and performing a physical exam to check the pelvic area for tenderness and doing a digital rectal exam for prostate swelling and tenderness.
- Digital rectal exam
During a digital rectal exam, if the prostate gland is enlarged, indurated and tender to the touch, prostatitis is confirmed. - Urine & semen tests
These may also be done to determine the source and type of organism.
Treatment
The main treatment for acute bacterial prostatitis is antibiotics. In acute prostatitis, one may need to be hospitalized for a few days for intravenous antibiotics. For chronic nonbacterial prostatitis, a long course of oral antibiotics eg. doxycycline, bactrim, ciprobay, is given for 1 to 3 months. For chronic nonbacterial prostatitis, medications like anti-inflammatory drugs and alpha-blockers can be tried. In refractory cases, botox injections can be given into the prostate.
