1 C H A P T E R 1

Painful Micturition and Increased

Frequency of Micturition
Patients may complain of a painful or burning sensation when they pass urine or
may tell you that the number of times that they pass urine each day has
increased. Both of these problems may be a sign of a urinary tract infection.
This chapter will discuss the diagnosis and management of some of these
infections which is important to prevent serious complications.
c Micturition means the passing of urine.
c Dysuria means a painful or burning sensation on passing urine.
c Frequency means an increase in the number of times urine is passed each day.
c Urinary tract infection (UTI) is an infection of the urinary tract.
It may occur anywhere from the urethra up to the kidney. A lower urinary tract
infection refers to the involvement of the bladder and urethra. An upper urinary
tract infection occurs in the ureter or kidneys. (Pyelonephritis).

This chapter will discuss:

c Cystitis - a lower urinary tract infection
c Pyelonephritis - an upper urinary tract infection
c Urinary tract infections in males
c Urinary tract infections in children
c How to take a urine sample for testing

Above is a diagram of the urogenital tract in both male and female .

Cystitis - a lower urinary tract infection
Urinary tract infections are more common in women than in men.

Petronella Manga is a 29 year old woman who complains of a

two day history of dysuria - a burning sensation on micturition.
She also needs to pass urine more frequently than usual.
Each time she passes urine, the amount is very small.
It is likely that Mrs Manga has cystitis.

What is cystitis?
Cystitis is an inflammation of the lining of the bladder - it is commonly caused
by a bacterial infection.
Signs and symptoms of c ystitis inc lude:
c Dysuria. This is a burning or painful sensation on micturition. The lining
of the urinary tract is inflamed and very sensitive in a patient with cystitis.
Urine is a little acidic, so it burns the inflamed urinary tract when urine is passed.
c Frequency. This is the need to pass urine many times a day. Only a small
amount of urine is passed each time. Often patients also need to wake up
at night to pass urine.
c Mild and vague suprapubic abdominal pain.
c The urine may smell offensive and be cloudy in colour.
A dipstix test may show blood in the urine.
Blood in the urine is called haematuria.

White blood cells may also be found in the urine. Any infection in the body
results in a sudden increase in the number of white blood cells. If the infection
is in the urinary tract, the white blood cells pass into the urine. Normally there
are about 5 - 10 white blood cells in each millilitre of urine. But you may find
hundreds or thousands of white blood cells in each millilitre of urine when a
person has a urinary tract infection. Urine white blood cells are easily assessed
using a urine dipstick. In a UTI, there may be an increase in the number of
WBC’s, elevated nitrites and possibly mild elevations in the protein level
on the dipstick
Cystitis presents with dysuria, frequency of micturition
and many white blood cells in the urine

What causes cystitis?

Cystitis is usually caused by a bacterial infection. It may develop in any
of the following ways:
c Contamination of urinary tract by faecal bacteria. Normally the urinary tract
is free of bacteria. However contamination of the urethal area may occur after
bowel movements or during sexual intercourse.
c There may be no obvious cause of the cystitis. One theory is that women
have a much shorter urethra than men do. This makes it easier for bacteria to
travel up the urethra and into the bladder. This is perhaps why females get
cystitis more commonly than males.
c Bilharzia may cause irritation of the bladder and recurring cystitis. In severe
cases, it may cause damage to the uterus and kidneys as well, which
predisposes to pyelonephritis.
c Symptoms of dysuria may also occur in the following conditions:
sexually transmitted diseases
inflammation of the vulva
drying of the mucus membranes that may occur after menopause
Contamination of the urethral tract by faecal
bacteria may cause cystitis
The management of cystitis?
There are a number of ways to treat a patient with c ystitis .
c Drinking lots of water.
Encourage the person to drink plenty of water. Water helps to flush out
the urinary tract. This makes it harder for the bacteria to survive in the
urinary tract.
c Antibiotics
An antibiotic is important to treat cystitis, in order to prevent the infection
from spreading to the kidneys.
The following antibiotics are appropriate choices:-
amoxycillin orally 250mg 8 hourly for 3 days.
trimethoprim/sulfamethoxazole (Bactrim) (80mg/400mg) orally 2 tablets
twice daily for 3 days
ciprofloxacin (Ciprobay) orally 500mg twice daily for 3 days.
c Advice on hygiene after defecation
You may also have to advise the patient to alter her hygienic practices.
This may be a sensitive subject which needs careful counselling. Instruct the
patient to clean themselves from front to back after defecation, to reduce the
introduction of bacteria to the urinary tract.

The different treatments that have been mentioned will usually successfully
treat cystitis. However, occasionally a patient will return to you with repeated
attacks of cystitis.

Refer the patient to a doctor if she gets

recurrent attacks of cystitis
Why can cystitis occur repeatedly?
It is not always clear why cystitis recurs. However, some reasons include:
c The infection was not adequately treated and so cystitis recurs. The bacteria
may not be sensitive to your choice of antibiotic. In this case you should send
a sample of urine for bacterial culture to a laboratory. The laboratory can
often advise you as to which antibiotic is best.
c Cystitis may recur if the patient has repeated vulvo-vaginal infections.
For more information on this, refer to SEXUALLY TRANSMITTED DISEASES.
c The anatomy of the patient's urinary tract may be abnormal e.g. an abnormally
dilated ureter. This can cause repeated infection. This can only be diagnosed
with special X-rays.
Cystitis may cause serious complications
if it is not adequately treated.
Always refer the patient to a doctor if she gets recurring cystitis. The most
serious consequence of cystitis is that the infection may spread up to the kidneys
in the upper urinary tract. An infection in the upper urinary tract is called
pyelonephritis.

Pyelonephritis - an upper urinary tract infection

Pyelonephritis is a serious disease. If it becomes chronic, or is untreated it can
eventually destroy the kidney and cause permanent chronic renal failure and/or
hypertension. A patient will eventually die of chronic renal failure unless a
kidney transplant is done, or a kidney dialysis machine is used.
It is obviously very important that primary health care workers should be able
to diagnose and manage patients with pyelonephritis.
How to diagnose pyelonephritis
When pyelonephr itis occur s , the patient often complains of the
following symptoms:
c As in cystitis you will usually
find frequency and burning on
micturition.
c The patient will have a general
feeling of being ill. She will
probably have a high pyrexia
(38 - 39C) as well as hot and
cold chills. These shaking chills
are called rigors.
Note: Pyrexia and rigors are not
generally caused by simple cystitis.
c The patient may have renal angle
tenderness. This is the area of the
back, next to the spine and between Percussion of the renal angle
the bottom of the ribs and the top for tenderness.
of the pelvis. This means gently percussing the renal angles usually causes pain.
c A urine microscopy usually shows many white blood cells. There are also clumps
white blood cells in the urine. These are called white blood cell casts .
c Milder cases of pyelonephritis may be treated by a primary health care worker.
Patients with a severe attack should be referred to a doctor.

How to treat pyelonephritis

If a patient is not very ill, but you
suspect pyelonephritis, they may
receive a trial of the following
oral antibiotics:
amoxycillin 500mg 8 hourly
for 7-10 days
trimethoprim/sulfamethoxazole
(80/400mg) 2 tablets twice daily
for 7-10 days.

In severe cases, where there is high fever, severe renal angle tenderness or shock,
the patient needs intravenous antibiotics and should be referred to the doctor.
While waiting to go to hospital the patient should receive:
ampicillin 500mg IV 6 hourly or
ceftriaxone (Rocephin) 1g daily
IV fluids will also be important in these patients as bacterial infection may be
present in the blood (sepsis) and lead to shock.
Careful follow-up is very important for all patients with pyelonephritis. A patient
who has more than one attack of pyelonephritis needs to be investigated for
urinary tract abnormalities.

Remember that repeated attacks of a urinary tract

infection should be referred to a doctor.

Urinary tract infections in males

This section will look at:
c What is prostatitis?
c What are the signs and symptoms of prostatitis?
c How would you manage prostatitis?
What is prostatitis?
Prostatitis is an inflammation of the prostate gland. It is usually caused by
infections from sexually transmitted diseases and other bacteria. It may also be
associated with an infection of the epididymis and the testis. In the diagram of
the male genital tract, note the position of the prostate gland.
Prostatitis usually presents with similar signs and symptoms as cystitis. But you
should remember that in men the prostate gland is commonly the source of
infection in cases of cystitis.
What are the signs and symptoms of prostatitis?
c Dysuria and frequency of micturition may be present.
c The urine may be offensive smelling and cloudy in colour.
c A dipstix test may show blood in the urine.
c Many white blood cells will be found if the urine is examined with a dipstick.
c There may be a mild urinary obstruction. The urethra passes through the
prostate gland. In prostatitis the prostate gland may become inflamed and put
pressure on the urethra. This causes urinary obstruction. The patient may
complain of difficulty when beginning to pass urine.
c The prostate gland will feel enlarged and tender when a rectal examination
(PR) is done. The patients discomfort will also often get worse when having a
bowel movement.
Management of prostatitis?
Prostatitis is more difficult to treat than simple cystitis, as antibiotics have
difficulty entering the prostate gland. Penicillins are not good choices for
this reason.
The following antibiotics are appropriate:
trimethoprim/sulfamethoxazole (80/400) orally 2 tablets twice daily for 14 day or
ciprofloxacin 500mg orally 1 tablet twice daily for 14 days
Urinary tract infections in children
Urinary tract infections in children are not always easy to detect, as the signs
and symptoms are not always obvious. Always consider the possibility of a
urinary tract infection if any of the following signs and symptoms are present:
c the child fails to gain weight
c the child has unexplained abdominal pains and /or vomiting
c there is a sudden onset of bed wetting
c the child has unexplained pyrexia. There will also be an increased amount of
white blood cells when a urine microscopy is done
c the parents may complain that the child’s diapers are more foul smelling
than usual
Refer any child with a urinary tract
infection to a doctor.
Referral is necessary because there is a possibility of an underlying defect in
the urinary tract. This can result in chronic renal disease if the defect is not
diagnosed early. In a confirmed case of a urinary tract infection, the doctor
should investigate the child's condition further and look for such a defect.

How to take a urine sample for testing

The following steps are involved in taking a urine sample for bacterial culture
and microscopy. It is always important to collect clean, uncontaminated
urine samples.
c Clean the external opening of the urethra with soap and water. Clean the tip
of the penis in males. Clean the opening of the urethra in females.
c In the female, spread the labia apart so that the urine stream flows freely.
c Collect the mid portion of the urine stream in a sterile container. You can do
this by waiting a second or two after the urine stream has begun, then
collecting the urine.
c Send the urine sample to the laboratory immediately if necessary or perform
a urine dipstick test. If you need to wait for transport to get the sample to
the laboratory, then keep the sample in the refrigerator.

Summary: Painful and frequent micturition

Cystitis is an infection of the lower urinary tract. It is more common in women
than in men.
The signs and symptoms of c ystitis are as follows:
c dysuria
c frequency of micturition
c cloudy urine
c blood in the urine
c suprapubic pain
c increased white blood cells in the urine
The causes of c ystitis may be as follows:
c sexually transmitted diseases
c inflammation of the vulva
c poor hygienic practices, sexual intercourse, menopause
Cystitis is treated with oral fluid and antibiotics.
Repeated attacks of cystitis should be referred to a doctor.
Pyelonephritis is an infection of the kidney i.e. an upper urinary tract infection.
The symptoms and signs of pyelonephr itis are as follows:
c high pyrexia
c rigors
c pains in the loins to percussion
c renal angle tenderness
c frequency of micturition and dysuria
c white blood cells in the urine
c white blood cell casts
Pyelonephritis can lead to chronic renal failure or hypertension.
Most cases of pyelonephritis need to be referred to a doctor.
Mild cases can be treated with antibiotics and fluids.
Careful follow up of a patient with pyelonephritis is necessary.
Males occasionally get urinary tract infections. These infections are usually
associated with prostatitis.
Prostatitis is an inflammation of the prostate gland and is treated with antibiotics.
The symptoms of prostatitis are:
c dysuria
c frequency of micturition
c cloudy urine
c blood in the urine
c increased amounts of white blood cells in the urine
c a mild urinary obstruction
c a tender, enlarged prostate on PR examination
c there may also be a spread of the infection to include the testis and
the epididymis.
Old people with dysuria and blood in the urine on microscopic examination may
have bladder cancer. They should be referred to a doctor immediately.
Urinary tract infections in children may go unnoticed as the signs and.
symptoms are not always obvious. These infections in children may present with:
c failure to gain weight
c bed wetting
c pyrexia of unknown cause
c unexplained abdominal pain and/or vomiting
Urinary tract abnormalities may be the cause of urinary tract infections in
children. You should refer all children with definite urinary tract infections
to a doctor for investigation.
When collecting urine samples for analysis, be sure that the sample is clean
and uncontaminated.