29 THE KIDNEY 9. Recurrent urinary tract infections Recurrent urinary tract infections The urinary tract consists of the urethra, the bladder, the ureters, the kidneys and in men the prostate gland. An infection in any of these areas is called a urinary tract infection. Urinary tract infections are very common, particularly in females, because the female urethra is shorter than the male urethra, allowing bacteria to get into the bladder more easily. The severity of urinary tract infections varies from causing no symptoms to severe life-threatening illness. Milder infections tend to be restricted to the bladder, while more severe infections tend to spread to the kidney(s). Most often, mild discomfort on passing urine, a desire to pass urine more frequently than usual and discomfort in the lower abdomen is experienced. The urine may be cloudy or smelly. The urinary tract consists of the urethra, the bladder, the prostate gland in males, the ureters and the kidneys. An infection in any of these areas is called a urinary tract infection. In more severe cases there may be high fevers, loss of appetite, nausea, vomiting and pain in the kidney region (in the back just below the ribs). The latter symptoms usually indicate that the infection has reached one or both kidneys. Opening (meatus) of ureters Neck of bladder Prostatic utricle Prostate Bulbourethral (Cowper’s) gland Bulb of penis Abdominal aorta Scrotum Adrenal gland Inferior vena cava Urethra Corona glandis Urethral meatus Kidney Glans penis Testicular vein Testicular artery Ureters Common iliac artery Common iliac vein Internal iliac vein Internal iliac artery Bladder 30 A G U I D E F O R PAT I E N T S Urethritis (infection of the urethra) is caused by urethral inflammation, consisting of intense discomfort on passing urine and occasionally, a discharge from the urethra. Recurrent urinary tract infections continued... Certain conditions such as, being born with variations of the urinary tract, pregnancy or a disease such as diabetes mellitus, make urinary tract infections more likely. In most cases, however, urinary tract infections occur without an obvious underlying reason. Bacteria are more likely to gain access to the bladder during sexual intercourse. In addition, the bacteria is more likely to invade the bladder wall and cause symptoms if the bladder is emptied infrequently. Bacteria gain access to the bladder from the outside by passing up the tube called the urethra. Infection of the urethra is called urethritis. Once in the bladder, the bacteria multiply and invade the wall of the bladder, causing an infection (known as cystitis) and from here, they may sometimes travel up the ureter to the kidney. When this happens the infections are frequently more serious, resulting in infection of the kidney(s) called pyelonephritis. In males (usually elderly males) spread of infection to the prostate gland can occur (a condition known as prostatitis). Asymptomatic bacteriuria The term refers to the finding of a large number of bacteria in the urine in a patient without a large number of white cells (pyuria) and with no related symptoms. Studies have shown that between 1 and 15% of adolescent and adult women are affected, the figure being related to the extent of sexual activity. In sexually active Australian women, the prevalence is approximately 6%. It requires treatment only when there is a another medical condition present, making spread of infection to the kidney more likely (for example diabetes mellitus, anatomical renal tract abnormality, immune-suppressive treatment, pregnancy). If this is the case then a high fluid intake and appropriate antibiotic therapy are recommended, the choice of antibiotics is decided with the results of urine culture and depends on the sensitivities of the bacteria to antibiotics in the laboratory. Urethritis (infection of the urethra) This term refers to urethral inflammation, causing intense discomfort on passing urine and occasionally, a discharge from the urethra. Urine culture may be negative and many of the symptoms are related to the irritating effect of concentrated acid urine on an inflamed urethra. 31 The symptoms can be a real problem for the patient and may be relieved by a high fluid intake and medicines which make urine less acidic (such as Ural sachets available in pharmacies). Such treatment should only be short term. If the laboratory cultures grow bacteria in the urine then an appropriate antibiotic is recommended. If symptoms do not resolve, a sexually transmitted disease including non-specific urethritis could be responsible and this may respond to a different spectrum of antibiotics. Cystitis (infection of the bladder) Cystitis is, by far, the most common and the least serious form of urinary tract infection. It often occurs in association with infection of the urethra (urethritis). The most common features of this infection are mild discomfort Treatment of cystitis consists of drinking copious amounts of fluid, avoiding factors which may predispose to urinary tract infection and taking oral antibiotics. or a burning sensation on passing urine, a desire to pass urine more frequently than usual and discomfort and tenderness in the lower abdomen. The urine may be cloudy or be more smelly than usual. The presence of cystitis is confirmed by taking a small sample of urine (midstream urine - MSU) for examination under the microscope and culture. The laboratory can confirm the presence of abnormally high levels of bacteria in the urine, the precise type of bacteria causing the infection and the type of antibiotic likely to be effective. Treatment of cystitis consists of drinking copious amounts of fluid, avoiding Bladder factors which may predispose to urinary tract infection and taking oral antibiotics. It is very important to take these antibiotics exactly as prescribed in order for them to be fully effective. Forgetting to take some of the tablets may allow the bacteria to regain a foothold in the bladder wall. It is important to take a urine sample to your doctor a few days after completing the course of antibiotics, to allow a test to ensure the infection has gone. Any child with urinary tract infection will need more tests. In males, an underlying structural abnormality is likely to be present and should be looked for. Cystitis Bacteria gain entry into the bladder, usually via the urethia, leading to inflammation of the bladder this is known as cystitis. Inflammation Urethra 32 A G U I D E F O R PAT I E N T S As with all urinary tract infections, spread of infection to the kidney(s), pyelonephritis, is more common in women. It usually, but not always, affects only one kidney. Recurrent urinary tract infections continued... Pyelonephritis (infection of the kidneys) As with all urinary tract infections, spread of infection to the kidney(s), pyelonephritis, is more common in women. It usually, but not always, affects only one kidney. The infection may be preceded by symptoms suggestive of cystitis. When the infection spreads up from the bladder to one or both kidneys people generally feel more unwell with high fever, loss of appetite, nausea, vomiting and pain in the kidney region (in the back just below the ribs). As with cystitis, the presence of pyelonephritis is confirmed by taking a small sample of urine (midstream urine - MSU) for examination under the microscope and culture. The laboratory can confirm the presence of abnormally high levels of bacteria in the urine, the precise type of bacteria, and the type of antibiotic likely to be effective in treating the infection. In addition, blood tests are taken to measure the function of the kidneys and in more severe cases, an ultrasound or CT scan is performed to rule out conditions such as an anatomical abnormality, or blockages such as those caused by kidney stones. People with pyelonephritis often vomit for some time before they seek medical attention. Because they are sick, they are unable to drink adequate amounts of fluid and become dehydrated, and because intravenous fluids (through a ‘drip’) and antibiotics are required, hospital admission may be necessary. Treatment is continued until the patient feels better and the temperature has returned to normal for at least 48 hours. Intravenous antibiotics are then replaced with oral antibiotics and if the patient is sufficiently well, treatment is continued at home. Following discharge from hospital it is important to maintain a high fluid intake and to avoid factors that may have made the urinary tract infection more likely. It is also very important to take the oral antibiotics exactly as prescribed in order for them to be fully effective. Forgetting to take some of the tablets can allow the bacteria to regain a foothold in the bladder wall or kidney. Oral antibiotics are usually continued for about ten days after the temperature has returned to normal. 33 It is important to arrange repeat urine tests with your doctor 1-2 weeks after completion of treatment to ensure that the infection has been completely cleared. Avoidance of future infections is of paramount importance. Following the general measures listed on pages 34 and 35 will help ensure this. Prostatitis (infection of the prostate gland) Prostatitis occurs in men and is characterised by the occurrence of severe dull deep-seated pain low in the abdomen and pelvis. It is often associated with evidence of bladder infection (cystitis), which is otherwise uncommon in men. In addition, fever and feeling generally unwell are common. Examination by the back passage if performed by your doctor would reveal Prostatitis is characterised by the occurrence of severe dull deep-seated pain low in the abdomen and pelvis. tenderness of the prostate gland. This condition is treated in the same way as cystitis, with high fluid intake and appropriate antibiotic therapy for several weeks. Inflamed renal cortex Renal papilla Renal pelvis Pyelonephritis Ureter This condition can be the result of a bacterial or viral infection of the renal pelvis and kidney. If untreated, severe kidney damage may occur. The main symptoms are high fever, intense pain, vomiting, diarrhoea and blood in urine. 34 A G U I D E F O R PAT I E N T S Maintaining a high fluid intake greater than 2 litres per day, will help prevent recurrent urinary tract infections. Recurrent urinary tract infections continued... General measures to help prevent recurrent urinary tract infections: > Maintain a high fluid intake - greater than 2 litres per day. > Frequent passing of urine - never delay going to the toilet after experiencing the urge to do so. > Always empty your bladder before going to sleep at night. > Always empty your bladder soon after sexual intercourse - bacteria often gain access to the female bladder during sexual intercourse. > Relax when passing urine to ensure complete bladder emptying - do not force or strain. Take time to ensure the bladder is completely empty. > Wipe your bottom from ‘front to back’ - most urinary tract infections are caused by bacteria moving forward from around the area of the anus. 35 > Maintain good hygiene - ensure that your ‘bottom’ area is clean and all irritants such as soap are thoroughly washed away. > Shower in preference to taking baths. > Always shower after vigorous exercise to maintain hygiene. > Avoid bubble baths - these can irritate the skin and wash away natural substances that protect against bacteria. > Avoid skin irritants such as sprays. > Always shower after spas or ‘Jacuzzis’. > Avoid underwear that causes excessive perspiration - use cotton rather than nylon underwear. > Cranberry tablets or juice taken twice a day may prevent bacteria binding to the bladder wall. > Consult your local doctor and have a urine culture performed if any symptoms suggestive of urinary tract infection occur - treating a mild infection early may avoid more serious infection and possible hospitalisation later. > Arrange a repeat urine test with your doctor a week to ten days after completing a course of antibiotics for treatment of a urinary tract infection to ensure the infection is completely eradicated. > Treat any vaginal thrush infections promptly - thrush infections predispose to urinary tract infection. Arrange a repeat urine test with your doctor a week to ten days after completing a course of antibiotics for treatment of a urinary tract infection to ensure the infection is completely eradicated.