This week, I had a bumper crop of patients with urinary tract infections, or UTIs for short. I saw a lot of patients with UTIs, both in the clinic as outpatients and as inpatients admitted to the hospital. UTIs are among the most common infections seen by doctors, and proper recognition and management are essential to prevent them from becoming worse and progressing to sepsis. What exactly is a UTI? When do you have to see a doctor, and how do you avoid getting one?

Based on its name, a UTI is an infection of the urinary tract. The urinary tract is a long passage that conveys urine from the kidneys to the outside of the body. The urinary tract begins at each kidney through a tube known as a ureter. Both ureters empty into the urinary bladder. From the urinary bladder, the urine exits the body through the urethra. UTIs can occur at any level of the urinary tract. The areas that are most affected, however, are the urinary bladder and the kidneys, where larger volumes of urine can collect. The passage of urine in the ureters and urethra is transient and is less likely to cause infection unless there is a blockage, like a stone. Inflammation of the urethra, known as urethritis, is not considered a UTI and is frequently from another disease process, such as a sexually transmitted infection like gonorrhea or chlamydia.

UTIs most commonly occur in the urinary bladder since it stores the largest volume of urine. The specific medical term for a UTI affecting the urinary bladder is “cystitis,” since the Latin for bladder is "cyst," meaning a "fluid-filled body." Cystitis is usually a result of gut bacteria such as E. coli going up the urethra from the skin of the perineal area and infecting the urinary bladder lining. The perineal area (the area of the body around the anus and genitals) is easily contaminated with E. coli due to its proximity to the anus. UTIs are more common in women because the female urethra is much shorter than the male urethra, and there is a shorter distance for the bacteria to travel to get to the urinary bladder. Since urine is stored in the urinary bladder for up to several hours, the bacteria have a chance to multiply in the urine and subsequently infect the bladder lining. If the body’s defenses are unable to control the bacteria, a UTI results. Without antibiotic treatment, the infection can go up the ureters into the kidneys, a condition known as pyelonephritis. This is a much more serious infection and can lead to kidney failure, sepsis, and death. More on this later.

Symptoms of cystitis include pain on urination (dysuria), foul-smelling urine, incontinence (involuntary loss of urine), urinary urgency (the feeling of having to go right now), and urinary frequency (going very often, usually with small volumes of urine). Not all these symptoms may be present, and some women may only complain of some discomfort on urination and not actual pain. Acute uncomplicated cystitis (a urinary bladder UTI with no complicating factors) is so common among women that doctors usually go ahead and treat with antibiotics without having to do a urinalysis or other laboratory tests. This is because a further delay in treatment while waiting for the results may cause the UTI to worsen and spread. A good response to antibiotics is usually enough to confirm the presence of the UTI. Do not take antibiotics without seeing your doctor, since resistance patterns are always changing, and taking the wrong antibiotic haphazardly will not work and allow the infection to progress.

Doctors will do laboratory tests for UTIs, such as a urinalysis, urine gram stain, and culture, under specific circumstances such as failure to respond to treatment, recurrent UTIs, a history of kidney stones, or signs and symptoms of a more severe illness. This kind of UTI would then be classified as complicated cystitis. For instance, someone with UTI symptoms plus a fever may already need stronger antibiotics than what we usually use for acute uncomplicated cystitis, and may even need to be hospitalized for intravenous treatment. For my complicated cystitis inpatients, I usually also do routine blood work, like a complete blood count, a creatinine (to check the kidneys), an ultrasound to check for blockages in the urinary tract, and blood cultures if I suspect that the UTI has progressed and the bacteria may have crossed over to the blood. This is why we encourage women to see their doctor as soon as they develop dysuria, so that treatment can be given early, they stay out of the hospital, and the risk of progression is minimized.

Patients with pyelonephritis will also have dysuria, but in addition, they can have fever and flank pain. The kidneys are in the lumbar area, and an infection in one kidney will cause pain on the affected side. A physical exam tool we use is the “kidney punch” test, or a test for costovertebral angle tenderness. Don’t worry, it’s not a real punch but more of a light tap. If there is tenderness in the affected area, then the diagnosis of pyelonephritis is confirmed. Pyelonephritis is a serious, potentially life-threatening illness because it can cause kidney failure and sepsis. Pyelonephritis literally means pus in the kidneys, and a delay in treatment can cause permanent damage or death. Patients with pyelonephritis are usually treated in the hospital with intravenous antibiotics and may need longer periods of hospitalization, especially if the offending bacteria are resistant to oral antibiotics.

While many women develop UTIs even without any complicating factors other than the short female urethra, some women and men may get recurrent UTIs due to problems affecting the urinary tract. These include the presence of kidney and urinary bladder stones, abnormalities in the anatomy of the urinary tract, and other conditions, such as neurological illnesses that affect the proper flow of urine. Sometimes, the organism is difficult to eradicate due to resistance. One relatively common infection in the Philippines is tuberculosis of the kidneys, which can be diagnosed with a molecular test. These conditions may need specialized care from infectious disease experts, urologists, and nephrologists, and your doctor will make the appropriate referrals if needed.

What can you do on your own to prevent UTIs? Stay well-hydrated and practice good perineal hygiene. Avoid delaying urination once you have the urge to go. If you have comorbid conditions like diabetes, make sure you take your medications to have good sugar control, since bacteria love sugar that spills into the urine. While there is some evidence that cranberry juice may help with preventing (but not treating) UTIs, the evidence is inconsistent, and a large amount of cranberry juice can cause stomach upset. Most importantly, listen to your body. If you feel discomfort during urination, see your doctor right away. UTIs are easy to treat when diagnosed early, but if neglected, they can turn into a much bigger problem.