URINARY TRACT INFECTIONS (UTI)

Urinary tract infections are a common problem, but their causes are very different between men and women. In women infections are commonly "simple", meaning they don't have an underlying structural problem with the bladder or kidneys causing them. Their management is usually focussed therefore on prevention. In men however, as bacteria find it harder to enter the bladder up the water pipe (urethra), there is often an underlying reason why infections occur, and this is then called a "complicated" UTI. 
The investigation and treatment of men and women will therefore be described separately. Good advice for everyone is to keep a good fluid intake of at least 2 litres per day, particularly dilute fluids such as water or squash, in order to keep the bladder emptying, its best defence against infections.

UTI IN WOMEN

 

UTI IN WOMEN - CYSTITIS

Around half of women will suffer from symptoms of a urinary tract infection at some point. In about a quarter of these, the infections can become recurrent, that is 3 or more in a year or 2 or more in any 6 month period. Occasionally these can be due to a problem upstream in the kidneys, such as a stone or blockage, but this is rare unless there are symptoms such as loin pain or fever at the time.


Most infections originate from the bladder, and cause typical symptoms of "cystitis" - bladder discomfort, having to pass urine frequently and usually with stinging. Sometimes blood can be seen in the urine too. Infection should be confirmed with a urine test, particularly if blood is seen, as this can be a symptom of other more serious problems too. 


Detailed investigations such as a scan, or telescopic examination of the bladder are only required if there are reasons to suspect a problem with the kidneys, such as pain as mentioned, or if the infections become frequent and associated with other symptoms such as poor stream, or in pregnancy (due to the risk of kidney drainage problems which can occur in pregnancy and the risk to the baby if the infection becomes severe). Repeated visible blood in the urine is reason for urgent investigation, especially if it recurs after the first infection is treated, as occasionally it can be a marker of more serious problems including cancer, so speak to your GP if you experience this.

The commonest associations with UTI in women is after sex, when bacteria can get into the urethra (water pipe), and also after the menopause.  When the female hormone oestrogen level drops, as after the menopause, the normal acidity of the vagina, and its healthy normal bacteria (lactobacilli) change, so that UTI causing bacteria can grow more easily. They can also more easily enter the bladder, as the lining of the vagina and urethra can thin (atrophy), allowing bacteria to stick and be able to grow upwards towards the bladder too. There are ways of tackling both these problems, as will be discussed below.

 

SELF HELP IF YOU HAVE CYSTITIS

Many infections will need treating with antibiotics, but if the symptoms aren't too severe, and have only been present for 1 or 2 days, then you can try managing it yourself. Drink 3 litres of water per day, avoiding bladder stimulants such as caffeine and alcohol, or acidic drinks such as pure fruit juices and fizzy drinks. Over the counter agents which reduce the acidity of your urine (such as potassium citrate or sodium bicarbonate) can be helpful. So long as you can take them, anti-inflammatory painkillers are helpful, as may be paracetamol or using a hot water bottle on the tummy. You should avoid having sex until the infection has gone, and if you're unwell with high temperature, kidney pain or vomiting, seek urgent medical advice. If your symptoms don't go in 2-3 days, see your doctor.

 

PREVENTING CYSTITIS IN WOMEN

LIFESTYLE MEASURES TO PREVENT BLADDER INFECTION

General advice to prevent bladder infections include maintaining a good fluid intake of 2-3 litres per day, to keep the bladder emptying. Pass urine when you need to - don't hold on too long. Pass urine after sex to flush bacteria out of the urethra. Be careful with hygiene to avoid contamination of the vagina with bacteria from the rectum - wiping front to back. Take showers rather than bathe and avoid excessive cleaning products around the vagina - these can kill off protective bacteria and allow harmful ones to grow. Maintaining a healthy body weight and wearing loose fitting clothing with breathable fabrics e.g. cotton, may also help.

NON-ANTIBIOTIC OPTIONS

Cranberry has been frequently cited for prevention, but in reality there is not much good evidence for its use, and NICE does not recommend it. 
D-mannose is a sugar which when taken by mouth, comes out in the urine and prevents many harmful bacteria from sticking to the lingo of the bladder, thus helping to wash them out. Some studies have suggested it is as good as taking a preventative antibiotic. It can be bought from some health food shops and online, and can be used for treatment as well as prevention. 
Hiprex (methanamine hippurate) has been used for many years for prevention of UTI, as it releases bacteria killing chemicals into the urine. However, evidence for its benefit is again uncertain, and it is not routinely recommended by NICE.
Keeping the protective bacteria of the vagina healthy can be very helpful. After the menopause, using oestrogen containing creams in the vagina can help prevent UTI, and is recommended to treat post-menopausal atrophy (thinning of the lingo of the vagina), which can be uncomfortable in itself. 
Keeping the protective lactobacilli alive in the vagina can be achieved by using both oral lactobacillus containing products e.g. live yoghurts, and also lactobacillus pessaries, which can be bought at chemists and used once or twice a week.

ANTIBIOTIC PREVENTION

If infections are a frequent problem, and no distance cause can be found, probably the single most effective option is a low dose of a suitable antibiotic as a preventative. This can either be every night at bedtime, so it sits in your urine overnight, or if infections are strongly linked to sex, a single dose if and when required. Nitrofurantoin is the best antibiotic for this purpose, as it has low levels of bacterial resistance, and doesn't affect your natural protective bacteria or interrupt the oral contraceptive pill. It can very rarely cause a serious lung reaction, which in extreme cases can permanent scarring to the lungs, so it has to be used carefully especially in the elderly, and regular review undertaken. Other antibiotics can be tried, but they often produce more resistant bacteria to grow, and have other side effects. There is no benefit to routinely rotating around antibiotics unless a resistant infection develops.

OTHER OPTIONS

Some chemical treatments have been given into the bladder directly via a catheter temporarily inserted into the urethra. These agents help to reinforce the natural waterproof surface of the bladder, and are said to reduce the frequency of infections. However, these treatments are invasive, and the evidence for their benefit is unclear, meaning they are not recommended as first line treatment.
Vaccines have been trialled for a number of years, and they are used in some countries in Europe but not routinely in the UK. They work by taking tablets containing inactivated common UTI bacteria which the body then develops immunity to. Again evidence is inconclusive, hence they have not been recommended in the UK by NICE.

 

UTI IN MEN

Infections are far less common in men, as the urethra is longer and further away from the bacteria of the rectum. If a man suffers from UTIs, the symptoms are often more severe as the prostate can become infected, and urine culture is required to guide antibiotic use, which is often required for longer - 2 weeks in the first instance if prostate infection is suspected. Fever, pain in the perineum (behind the scrotum) and difficulty passing urine, occasionally with painful inability to pass urine (retention) can occur. Blood may also be seen in the urine.


If you have symptoms of an infection, make an urgent appointment to see your GP, be examined and have a urine test, with antibiotics as guided. Self help remedies are less likely to work for a man and should not be relied upon.

Further investigation to look for the cause of the infection is warranted in any man who suffers from a UTI. Often there is a cause such as incomplete bladder emptying due to an enlarged prostate or a scar in the urethra (water pipe), which need treating. Occasionally a more serious underlying problem can be detected such as bladder or prostate cancer, so men with UTIs are usually referred for specialist assessment.

Your Urologist would examine you, check your bladder emptying with a flow study, organise a scan to examine the kidneys, bladder and prostate in further detail, and possibly go on to further tests including a telescopic bladder inspection if there was any remaining concern.


Options for management and prevention could be discussed, but these are often more based on treating an underlying cause than the measures discussed above for women.