Urinary Tract Infections (UTIs)

What is a Urinary Tract Infection (UTI)

Urinary Tract Infection (UTI) is a general term referring to infections  of the urinary system induced by microorganisms, such as bacteria, viruses and fungi. Bacteria are the most common cause of UTI. Normallly, bacteria enter the urinary tract through the urethra and are promptly removed through urination before settling and inducing symptoms. However, sometimes bacteria overcome the natural body defense and induce infection.  Urethral infection is called 'Urethritis', while bladder infection is called 'Cystitis'. Bacteria may 'travel' upwards through the ureters and infect the kidneys. Renal infection is called 'pyelonephritis'.  

What causes UTIs?

Most UTIs occur due to bacteria which normally live within the intestine. The vast majority of UTIs is caused by bacterium Escherichia coli (E. coli). Also, microbes called 'chlamydia' and 'mycoplasma' are common causes of infections of the urethra, prostate and more rarely of the bladder. They are sexually transmitted and require simultaneous treatment of both sexual partners. 

The urinary tract has various mechanisms for preventing infections:

  • At the point where the ureters meet the bladder, there are valves (ureterovesical junction) which normally allow the urine flow only from the kidney towards the bladder. 
  • Micturition  'washes out' and 'carries away' microbes trying to enter the urinary tract. 
  • In males, the prostate gland produces secretions that inhibit bacterial growth. 
  • In both males and females, the immune system plays also a defensive and protective role against infection.

However, despite the above mechanisms, UTIs may still occur. Some bacteria, have a strong capacity of adhering to the walls of the urinary tract and proliferate causing infections. 

How common are UTIs in adults?

UTIs are the second most common type of infections in humans. Particularly women are highly susceptible to developing UTIs due to anatomical reasons, since the female urethra is much smaller than in males, allowing thus bacteria to enter the bladder faster. Also, the female urethra is only a few centimeters far from the vagina and anus, where microbes normally exist. 

Women run more than 50% risk for developing at least one UTI episode during their life. UTIs in men are not as frequent as in women but, when occurring, they are usually more severe and require prolonged  therapy. 

What are the risk factors of UTIs?

Despite the fact that a UTI episode may occur in any one of us, there are still some risk factors ( factors increasing the chances for developing UTI):

  • Poor Hygiene. This refers both to absence of daily hygiene of the anogenital region and the use of inappropriate sanitary products (e.g use of aromatic bubble baths that may cause irritation, intravaginal products altering vaginal flora and destroying body defense system etc).
  • Bad urinary habits. It is a very common practice -particularly in women- to postpone urination when being out and avoid going to the restroom, no matter how intense the urge for urination may be. Also men sometimes follow the same practice mainly for vocational reasons (e.g. truck drivers). Even when women decide to go to a public toilet, they urinate in a standing position; as a result, pelvic floor muscles do not relax and, thus, the micturition mechanism is not conducted normally.  Such practices may lead to opportunistic UTIs. These have to be treated properly, combining the indicated pharmacotherapy with changes in daily habits of urination; otherwise, there will be frequent recurrences and relapses. 
  • Sexual practices.  Sexual intercourse is the most common cause of UTIs. Following sexual contact, most women have a considerable number of bacteria within their urine, which are normally discharged within 24 hours. The same applies also for men, so it is necessary for both genders to urinate after sexual contact. Also, anal intercourse increases the risk for UTIs. Another reason why sexual activity is a risk factor is the use of aromatic or non-aromatic lubricants, which irritate and alter the normal human body defense. Lastly, the increase of temperature developed in the region, due to high friction during sexual intercourse of long duration, favors microbial proliferation. 
  • Contraception: The use of a diaphragm or spermatocidal agents for contraception, favors bacterial growth. When being susceptible to UTIs, women should try other method of contraception. 
  • Urine Stagnation. In Urology, it is strongly believed that wherever there is urine stagnation, there is an infection hiding. This enhances the above mentioned arguments about the crucial role of regular voiding of the bladder. Any obstruction in the urinary tract of any origin inhibiting the flow and full release of urine -e.g. stones and prostate hypertrophy- will, sooner or later, lead to UTI. That is why post-void urine residual (PVR) is a determining factor for UTI. Also,obstruction of kidneys or ureters causes Pyelonephritis. It should be emphasized that Lithiasis is a common cause of infections, as stones cause microtraumas that actually become 'entrance gates' for bacteria and  stones themselves get contaminated; as a result, all therapies fail, for antibiotics cannot enter the stones. 
  • Νeurogenic Bladder. Patients with neurological problems, such as spinal cord injury or multiple sclerosis, have urinary problems. As a result, there is inability of full bladder voiding that results in UTIs. 
  • Urocatheter. The catheter is used in patients with inability to urinate; for example, in men with urinary urgency due to prostate hypertrophy. Being an external foreign body to human organism, the urocatheter constitutes a potential cause of infection. 
  • Diabetes Mellitus. UTIs are common in patients with diabetes mellitus. When diabetes is not well controlled, high sugar levels in the urine become "food" for bacteria. Also, the disease is often concomitant with bladder neuropathy.  
  • More rare causes of UTIs are congenital urinary tract diseases, immunosuppression in oncological patients and AIDS.

What are Recurring UTIs?

Many women frequently suffer from UTIs. Following the first episode of UTI, about 20% of young women will present recurring UTIs. Every new episode increases the risk for recurrence. Thus, there are women who have 3 or more episodes of recurring UTIs every year. If treated properly and focusing on prevention, these relapses may stop occurring within 1-2 years in some women. 

Men are less likely than women to develop UTI. Recurring UTIs usually occur in men when there are other concomitant diseases, such as prostate hypertorphy, chronic bacterial prostatitis, diabetes mellitus or neurogenic bladder (in paraplegia). 

UTIs and Gestation

Pregnant women run higher risk for developing UTI compared to other women. In addition, it is more likely for the bacteria to reach the kidneys and induce pyelonephritis. This is due to the pressure exerted by the fetus to the mother's urinary tract (mainly ureters) causing obstruction and urine stagnation. UTIs during pregnancy may cause serious problems and given that antibiotics should be avoided during this period in a woman's life, there are recommendations for periodic preventive urine testing during the gestational period. 

How severe can UTIs be?

Most UTIs are not severe. In fact, if women are treated early when the first signs and symptoms occur, UTIs may subside without even the need of pharmacotherapy -simply by consuming large amounts of water and releasing  urine. More severe are renal infections, the so-called pyelonephritis. Only in very rare cases can a UTI be life-threatening, that is when bacteria enter blood circulation and induce a generalized blood infection called 'septicemia' or 'bacteremia'.  

What are the signs and symptoms in UTI?    

UTI symptoms differ depending on age and gender. In young women, UTIs are manifested with urinary frequency, burning sensation, low abdominal pain or pain in the external genitalia when urinating, and sometimes there may be even presence of blood particularly towards the end of urination. Elderly men and women may complain about fatigue, tremor and abdominal pain, particularly when there is fever. Urine may appear cloudy, dark or bloody, very often with unpleasant odor. In patients using a catheter, the only symptom may be fever ,with or without shivering , which cannot be attributed to any other reason. Usually UTIs do not induce fever unless the bladder is infected. Fever may be a sign that infection has reached the kidneys (pyelonephritis)  or prostate (acute prostatitis) -infections that are life-threatening and require pharmacotherapy and  immediate hospitalization.

How is UTI diagnosed?

Urine testing (urinalysis) is essential any time of the day irrespective of food intake. The general urine test traces bacteria in the urine. In case of suspicion (pyospheres>2-4), your physician will recommend urine culture which takes 48 hours for bacterial proliferation in the laboratory. Once the bacterial strain is identified, the antibiogram will determine which antibiotics are indicated against the specific bacterial strain. Urine sample should be carefully collected in a special sterile container bought from the drug store, after having thoroughly washed the genital area. In case there are recurring urinary tract infections, the physician may ask for further specialized screening tests (e.g. renal and bladder ultrasound) to identify whether there is a specific problem in the urinary tract. 

How are UTIs treated?

Precaution measures is the first thing we should all have in mind: 

  • Abundant fluid intake, gradually consumed throughout the day
  • Urination at first urge, rather than postponing voiding the bladder (always in the sitting position for women)
  • Micturition essential after every sexual contact
  • Proper hygiene of the genital area

​Most bacteria-induced UTIs are treated with antibiotics. The physician will decide on the proper antibiotic and duration of the therapy, according to the patient's history, involved bacterial strain and antibiogram. In some cases, when there is comorbidity with some urinary tract disease (e.g. lithiasis or prostate hypertrophy), the UTI cause should be treated secondarily. Most patients are treated at home taking oral drugs. In severe feverish infections, there is usually need for hospitalization so that the patient receives intravenous drug administration and hydration. Particularly when there is diagnosed pyelonepritis and the urine flow towards the bladder is obstructed,  the therapist physician will recommend special therapy. 

When is there need for special therapeutic treatment?   

Besides general precautions (prevention measures), the treatment of UTIs may include some further measures per different case:

Recurring UTIs in Women

According to the female patient's history, the physician may give some instructions for reducing UTI episodes. For example:

  • Low antibiotic dose, every day for a period of 6 months or even longer
  • One antibiotic dose before or after every sexual contact

Infections during Gestation

Even if there are no symptoms, urinary infection during gestation should always be treated to avoid any potential risk either for the mother or the baby. In no case should pregnant women get drugs without the doctor's prescription, as many antibiotics are not safe to be administered during gestation. 

Infections in Men

UTIs in men often come as a result of urine flow obstruction due to stones or prostate hyperplasia. In the case of prostate infection, therapy is usually required for a long time in order to eliminate the bacterium (from 15 days up to even 6 months). 

How can Recurring UTIs be prevented?

Read carefully  General Precautions (Prevention Measures)  and follow them in your everyday life to avoid the unpleasant experience of UTI and its consequences.