Urinary tract infections (UTIs) are among the most common bacterial infections of all. They cover everything from mild cystitis, which passes in a few days, to pyelonephritis, which can threaten the kidney and even life.
Roughly half of all women have at least one urinary tract infection, and in men the frequency rises after the age of 50 along with prostate problems. What separates the different forms is how far the bacteria have travelled and whether there is a factor that stops the body from fighting them off – this decides whether treatment is a short course of tablets at home or a stay in hospital.
What urinary tract infections are
The urinary system includes the kidneys, the ureters, the bladder and the urethra. Depending on the level affected, urinary tract infections are divided into:
- Lower – of the bladder (cystitis) and of the urethra (urethritis). In men, inflammation of the prostate (prostatitis) is also counted among them.
- Upper – of the kidney and the renal pelvis (pyelonephritis). These are considerably more serious.
The second important division is into uncomplicated and complicated infections. An infection is uncomplicated in an otherwise healthy, non-pregnant woman with a normal urinary tract. Any infection is complicated in a man, a pregnant woman, a child, or a patient with diabetes, stones, a catheter, impaired urine drainage, a neurological condition or weakened immunity – the bacteria causing it are more varied and more resistant, and treatment takes longer.
The most severe form is urosepsis – bacteria entering the bloodstream with a life-threatening reaction of the body, most often when an infection is combined with a blockage caused by a stone.
Symptoms
The symptoms depend on the level of the infection. With a lower urinary tract infection:
- burning and pain when passing urine;
- frequent, urgent urges to pass small amounts of urine;
- heaviness low in the abdomen;
- cloudy, strong-smelling urine, sometimes with blood;
- with urethritis – a discharge from the urethra; with prostatitis – pain in the perineum.
With pyelonephritis these are joined by a temperature above 38°C, often with shivering, pain in the lower back (usually on one side), nausea, vomiting and exhaustion.
In older people the infection may not follow the usual pattern – it can show up as confusion or a decline in general health with no complaints about passing urine, while in young children the main sign is often a fever without a visible cause (see the article on urinary tract infections in children).
Urgent signs: a high temperature with shivering and lower back pain, especially if you have kidney stones; being unable to pass urine; vomiting that stops you keeping fluids down; confusion, rapid breathing or a drop in blood pressure. If you have any of these, do not wait for an appointment – go to an emergency department or call 112 (the European emergency number).
Causes and risk factors
The most common cause is the gut bacterium Escherichia coli (E. coli), followed by Klebsiella, Proteus and enterococci. Bacteria enter through the urethra and climb upwards – which is why the short female urethra explains the more frequent infections in women.
The risk increases with:
- urine stagnation – an enlarged prostate, narrowing of the urethra, stones, pelvic organ prolapse, neurogenic bladder;
- a urinary catheter or a recent urological procedure;
- diabetes and conditions that suppress immunity;
- pregnancy and the menopause;
- sexual activity and use of spermicides;
- a recent course of antibiotics, after which more resistant bacteria survive.
Diagnosis
The consultation with Dr Penev starts with a conversation about your symptoms, previous infections, antibiotics you have taken and any other illnesses. This is followed by an examination of the abdomen and the kidney areas, and in men also of the prostate.
A midstream urine test shows white blood cells, nitrites and bacteria. A microbiological culture with antibiotic sensitivity testing is essential for a complicated infection, pyelonephritis, men, children, pregnant women and recurrent infections – it identifies the bacterium and the right antibiotic. If pyelonephritis is suspected, blood is also tested for markers of inflammation and kidney function.
An ultrasound scan of the kidneys and bladder is key in complicated infections – it shows urine backing up in the kidney, a stone, residual urine after voiding or an enlarged prostate. In unclear or severe cases a CT scan is used, and with recurrent infections Dr Penev assesses whether a cystoscopy is needed.
Treatment
The basis of treatment is an antibiotic chosen according to the level of the infection, local bacterial resistance and, when available, the culture result.
Uncomplicated cystitis is treated with a short course of one to five days with a medicine that concentrates in the urine.
Pyelonephritis needs a longer course – usually between seven and fourteen days. With moderate symptoms, treatment is given as an outpatient, with tablets and a check-up after 48–72 hours. With vomiting, a severe general condition, pregnancy or a suspected blockage, the patient is admitted to hospital – at the Department of Urology at Kaspela University Hospital (UMBAL Kaspela) in Plovdiv the antibiotic is given intravenously, and a blocked kidney is drained urgently with an internal stent or a nephrostomy, because an infection behind an obstruction cannot be brought under control with medicines alone.
Complicated infections are treated for longer and always together with removing or controlling the cause: changing or removing the catheter, treating the stones, improving bladder emptying when the prostate is enlarged. Without this, the infection comes back however strong the antibiotic.
Bacteria in the urine without any symptoms (asymptomatic bacteriuria) are, as a rule, not treated – the exceptions are pregnant women and patients before urological surgery. Unnecessary antibiotics do not help; they create resistance.
When to see a urologist
Book a consultation with Dr Penev in Plovdiv or Karlovo if you are a man with a urinary tract infection, if infections come back more than twice a year, if the symptoms do not settle after three days of treatment, if there is blood in the urine, if you have diabetes, stones or a catheter, or if your child has had even one confirmed infection.
Prevention
Drink enough fluids, pass urine regularly and empty your bladder completely, empty your bladder after sex, avoid spermicides, treat constipation and keep good control of diabetes. More tips are in the article how to prevent urinary tract infections.
Most urinary tract infections are treated quickly when the level affected and any complicating factors are correctly assessed. Book an appointment with Dr Penev if you have repeated episodes, an infection with a fever, or if you are a man with urinary symptoms.
Frequently asked questions
How can I tell cystitis from pyelonephritis?
Cystitis causes burning and frequent urges to pass urine without a fever. With pyelonephritis there is a high temperature, shivering, pain in the lower back and often nausea – a condition that needs to be assessed by a doctor the same day.
Is a urine culture needed for every urinary tract infection?
For a first mild cystitis in a healthy woman, usually not. A culture is essential for men, children and pregnant women, when there is a fever, with recurrent infections and when treatment is not working, because it identifies the bacterium causing the infection and the right antibiotic.
Can a urinary tract infection go away without treatment?
Mild symptoms sometimes settle with plenty of fluids, but an infection with a fever or lower back pain should not be left to wait. Untreated pyelonephritis can damage the kidney and progress to sepsis.
Why does the infection come back after every course of antibiotics?
Most often because the cause is still there – a stone, incomplete bladder emptying, an enlarged prostate or a catheter. With recurrent infections the underlying condition is looked for and treated, not just the bacterium.
How much should I drink when I have a urinary tract infection?
Enough for your urine to be pale and for you to pass urine every three to four hours – for most adults that is about two litres a day, unless a doctor has limited your intake because of another illness.
The information on this website is for general education and does not replace an examination and consultation with a doctor. If you have urgent symptoms, seek medical help immediately or call 112.