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Urinary Tract infections in Women

UTI is defined as significant bacteriuria in the setting of symptoms of cystitis or pyelonephritis. These infections account for a significant number of emergency department (ED) visits, and 20% of women develop at least one UTI.

Escherichia coli causes the majority of uncomplicated cystitis cases. Among the pathogens responsible for the remainder are Staphylococcus saprophyticus, Proteus mirabilis, Klebsiella pneumonia e, or Enterococcus faecalis.

Successful emergent management includes selection of appropriate antimicrobial therapy with recommendations for follow-up care. Oral therapy with an antibiotic effective against gram-negative aerobic coliform bacteria is the principal therapeutic intervention in patients with cystitis.

The urinary tract is normally sterile. Uncomplicated UTI involves the urinary bladder in a host without underlying renal, metabolic, or neurologic diseases. Cystitis represents bladder mucosal invasion, most often by enteric coliform bacteria (eg, Escherichia coli) that inhabit the periurethral vaginal introitus and ascend into the bladder via the urethra.

In recurrent E coli UTIs, peak colonization rates of the periurethral area 2-3 days prior to the development of the symptoms of acute cystitis range from 46-90%. During this same period, asymptomatic bacteriuria rates increase from 7% to 70%.

Because sexual intercourse may promote this migration, cystitis is common in otherwise healthy young women.

Factors unfavorable to bacterial growth include a low pH (5.5 or less), a high concentration of urea, and the presence of organic acids derived from a diet that includes fruits and protein. Organic acids enhance acidification of the urine.

Frequent and complete voiding has been associated with a reduction in the incidence of UTI.

Etiology

E coli causes 70-95% of both upper and lower UTIs. Various organisms are responsible for the remainder of infections, including S saprophyticusProteusspecies, Klebsiella species, Enterococcus faecalis, other Enterobacteriaceae, and yeast. Some species are more common in certain subgroups, such as Staphylococcus saprophyticus in young women.

The most important risk factor for bacteriuria is the presence of a catheter

Sexual intercourse contributes to increased risk, as does use of a diaphragm and/or spermicide

Sexual intercourse contributes to increased risk, as does use of a diaphragm and/or spermicide

Calculi related to UTIs most commonly occur in women who experience recurrent UTIs with Proteus Pseudomonas etc

Age- and sex-related demographics

Uncomplicated UTIs are much more common in women than men when matched for age. The largest group of patients with UTI is adult women. The incidence of UTI in women tends to increase with increasing age

Rates of infection are high in postmenopausal women because of bladder or uterine prolapse causing incomplete bladder emptying; loss of estrogen with attendant changes in vaginal flora (notably, loss of lactobacilli), which allows periurethral colonization with gram-negative aerobes, such as E coli; and higher likelihood of concomitant medical illness, such as diabetes.

Although simple lower UTI (cystitis) may resolve spontaneously, effective treatment lessens the duration of symptoms and reduces the incidence of progression to upper UTI. Even with effective treatment, however, about 25% of women with cystitis will experience a recurrence.

Workout 

Urinalysis ,Dipstick testing, Urine Culture ,Ultrasound, Uroflowmetry

Risk factors

The 3 main risk factors for recurrent urinary tract infection (UTI) in women are an increased frequency of sexual intercourse, the use of a spermicide and diaphragm, and the loss of estrogen’s effect in the vagina and periurethral structures.

Women with 2 or 3 recurrent UTIs yearly may benefit from behavioral modification.

Sexually active women may attempt voiding immediately after intercourse to lessen the risk of coitus-related introduction of bacteria into the bladder

Drinking cranberry juice or taking cranberry tablets may offer some benefit in reducing recurrent UTI and does not appear to be harmful.

Approach Considerations

Appropriate antibiotic treatment leads to significantly higher symptomatic and bacteriologic cure rates and better prevention of reinfection in women with uncomplicated cystitis.

Unfortunately, treatment also selects for antibiotic resistance in uropathogens and commensal bacteria and has adverse effects on the gut and vaginal flora.

On average, women with cystitis who receive effective antibiotic treatment experience severe symptoms for somewhat longer than 3 days. Complete resolution of symptoms may require approximately 6 days. Features that have been associated with a more prolonged course include a history of somatization, previous cystitis, urinary frequency, and more severe symptoms at baseline.

Self-Initiated Antibiotic Therapy

Self-initiated antibiotic therapy may be an acceptable alternative for women with recurrent UTIs.

Women with more than 3 recurrent UTIs yearly should be considered for more aggressive prophylactic regimens in addition to behavioral modification. Women whose recurrent UTIs are associated with sexual intercourse should be offered postcoital prophylaxis. This involves taking a single dose of an effective antimicrobial after sexual intercourse.

Continuous antimicrobial prophylaxis may be required for women in whom a postcoital regimen fails; women who do not associate frequent UTIs with a modifiable cause; or those who are at risk for recurrent complicated UTIs.

Postmenopausal women who have recurrent UTIs may benefit from estrogen replacement, either systemic or local.

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