UTI | Urinary Tract Infection | Urinary Bladder

DEFINITION: • • UTI is a bacterial infection that affects any part of the urinary tract.

The urinary tract is the system that makes urine and carries it out of your body. It includes your bladder and kidneys and the tubes that connect them. When germs get into this system, they can cause an infection. It can affect not only the urethra and the bladder, but also ascend up into the kidneys Urinary tract infections are common sexually transmitted disease in woman. Women are more prone to because the urethra is shorter in women than in men, so bacteria have a shorter distance to travel.

CAUSE: The urine is normally sterile. An infection occurs when bacteria get into the urine and begin to grow. The infection usually starts at the opening of the urethra where the urine leaves the body and moves upward into the urinary tract.

 Escherichia coli, ( E. coli) -these bacteria normally live in the bowel (colon) and around
the anus.

 -These bacteria can move from the area around the anus to the opening of the urethra. The
two most common causes of this are poor hygiene and sexual intercourse. Usually, the act of emptying the bladder (urinating) flushes the bacteria out of the urethra. If there are too many bacteria, urinating may not stop their spread. The bacteria can travel up the urethra to the bladder, where they can grow and cause an infection. The infection can spread further as the bacteria move up from the bladder via the ureters. If they reach the kidney, they can cause a kidney infection (pyelonephritis), which can become a very serious condition if not treated promptly. Etiology

 Commensal colonic gram-negative aerobic bacteria cause most bacterial UTIs. In relatively
normal tracts, strains of E. coli with specific attachment factors for transitional epithelium of the bladder and ureters are the most frequent causes. The remaining gram-negative urinary pathogens are other enterobacteria, especially Klebsiella , Proteus mirabilis, and Pseudomonas aeruginosa. Enterococci (group D streptococci) and coagulase-negative staphylococci (eg, Staphylococcus saprophyticus) are the most frequently implicated gram-positive organisms. E. coli causes > 75% of community-acquired UTIs in all age groups; S. saprophyticus accounts for about 10%. In hospitalized patients, E. coli accounts for about 50% of cases. The gramnegative species Klebsiella , Proteus, Enterobacter, and Serratia account for about 40%, and the gram-positive bacterial cocci Enterococcus faecalis and S. saprophyticus and Staphylococcus aureus account for the remainder.

UTI risk factors include: • • • • • • • • • • • • Gender (women are more likely to have urinary tract infections than men are) Urinary tract problems (such as an enlarged prostate or kidney stones) Sexual intercourse Certain habits (such as waiting too long to pass urine) Urinary catheter Age (elderly people are more likely to develop a UTI) Medical conditions (such as diabetes, sickle cell anemia, and vesicoureteral reflux) Immunosuppressant medications Urinary tract abnormalities Diaphragms or spermicidal foam Menopause Skin allergies to soaps and cleansers used in the vaginal area.

The following people are at increased risk of urinary tract infection: • • • People with conditions that block (obstruct) the urinary tract, such as kidney stones People with medical conditions that cause incomplete bladder emptying (for example, spinal cord injury or bladder decompensation after menopause) People with suppressed immune systems: Examples of situations in which the immune system is suppressed are AIDS and diabetes. People who take immunosuppressant medications also are at increased risk. Women who are sexually active: Sexual intercourse can introduce larger numbers of bacteria into the bladder. Infection is more likely in women who have frequent intercourse. Infection attributed to frequent intercourse is nicknamed "honeymoon cystitis." Urinating after intercourse seems to decrease the likelihood of developing a urinary tract infection. Women who use a diaphragm for birth control

Men with an enlarged prostate: Prostatitis or obstruction of the urethra by an enlarged prostate can lead to incomplete bladder emptying, thus increasing the risk of infection. This is most common in older men. Males are also less likely to develop UTIs because their urethra (tube from the bladder) is longer. There is a drier environment where a man's urethra meets the outside world, and fluid produced in the prostate can fight bacteria.

The following special groups may be at increased risk of urinary tract infection: • • Very young infants: Bacteria gain entry to the urinary tract via the bloodstream from other sites in the body. Young children: Young children have trouble wiping themselves and washing their hands well after a bowel movement. Poor hygiene has been linked to an increased frequency of urinary tract infections.

Children of all ages: urinary tract infection in children can be (but is not always) a sign of an abnormality in the urinary tract, usually a partial blockage. An example is a condition in which urine moves backward from the bladder up the ureters (vesicoureteral reflux).

Hospitalized patients or nursing home residents: Many of these individuals are catheterized for long periods and are thus vulnerable to infection of the urinary tract. Catheterization means that a thin tube (catheter) is placed in the urethra to drain urine from the bladder. This is done for people who have problems urinating or cannot reach a toilet to urinate on their own. Types of Urinary Tract Infection

 Bladder Infection (Cystitis or lower tract infections)

 Bladder infections are infections that are limited to the bladder. They are much more
common than kidney infections and usually are less serious.

 Bladder infections may cause symptoms like lower abdominal pain(over the bladder);
pain, burning, or stinging on urination (dysuria); frequent urination (frequency), and an urgent need to pee (urgency).  Urethritis

 Urethritis is the irritation of the urethra, and is considered to be a kind of lower-tract
infection. It usually is caused by irritants such as stool, soap (especially those containing perfumes), bubble bath, or shampoo in prepubescent girls, and may be due to sexually transmitted diseases such as Chlamydia and gonorrhea in adolescent males and females.  Like cystitis, it causes pain with urination (dysuria), frequency, and urgency.

 Kidney Infection ( Pyelonephritis or uppre tract infection)  Kidney infections are infections of the ureters and the tissues of the kidney itself. These infections are less common, but usually more serious, than those of the lower tract.

 Symptoms of kidney infections are high fever and more severe disease (including
bloodstream infection-or sepsis-and even shock in some cases). They also are more likely to lead to permanent kidney scarring and other complications such as high blood pressure (hypertension).

Pathophysiology • • The urinary tract, from the kidneys to the urethral meatus, is normally sterile and resistant to bacterial colonization despite frequent contamination of the distal urethra with colonic bacteria. Mechanisms that maintain the tract's sterility include urine acidity, emptying of the bladder at micturition, ureterovesical and urethral sphincters, and various immunologic and mucosal barriers.

Complicated UTI is considered to be present when there are underlying factors that predispose to ascending bacterial infection. Predisposing factors include urinary instrumentation (eg, catheterization, cystoscopy), anatomic abnormalities, and obstruction of urine flow or poor bladder emptying. A common consequence of anatomic abnormality is vesicoureteral reflux (VUR), which is present in 30 to 45% of young children with symptomatic UTI. VUR is usually caused by a congenital defect that results in incompetence of the ureterovesical valve. It is most often due to a short intramural segment (the ureter normally transits the bladder wall at an angle; the resultant lengthy segment is more readily closed by muscular contraction than the shorter segment that occurs when the ureter passes straight through the wall). VUR can also be acquired in patients with a flaccid bladder due to spinal cord injury. Other anatomic abnormalities predisposing to UTI include urethral valves (a congenital obstructive abnormality), delayed bladder neck maturation, bladder diverticulum, and urethral duplications. Urine flow can be compromised by calculi and tumors. Bladder emptying can be impaired by neurogenic, pregnancy, uterine prolapse, cystocele, and prostatic enlargement. UTI caused by congenital factors presents most commonly in childhood. Most other factors are more common in the elderly. Uncomplicated UTI Occurs without underlying abnormality or impairment of urine flow. It is most common in young women but also somewhat common in younger men who have unprotected anal intercourse, an uncircumcised penis, unprotected intercourse with a woman whose vagina is colonized with urinary pathogens, or AIDS. Risk factors in women include sexual intercourse, diaphragm and spermicide use, antibiotic use, and a history of recurrent UTIs. Even use of spermicide-coated condoms increases risk of UTI in women. The increased risk of UTI in women using antibiotics or spermicides probably occurs because of alterations in vaginal flora that allow overgrowth of Escherichia coli. In elderly women, soiling of the perineum from fecal incontinence increases risk. Patients of both sexes with diabetes have an increased incidence and severity of infections. Diagnostic exams: Diagnosis • • Urinalysis Sometimes urine culture

Diagnosis by culture is not always necessary. If done, diagnosis by culture requires demonstration of significant bacteriuria in properly collected urine. Urine collection: If a sexually transmitted disease (STD) is suspected, a urethral swab for STD testing is obtained prior to voiding. Urine collection is then by clean-catch or catheterization.

To obtain a clean-catch, midstream-voided specimen, the urethral opening is washed with a mild, nonfoaming disinfectant and air dried. Contact of the urinary stream with the mucosa should be minimized by spreading the labia in women and by pulling back the foreskin in uncircumcised men. The first 5 mL of urine is not captured; the next 5 to 10 mL is collected in a sterile container. A specimen obtained by catheterization is preferable in older women (who typically have difficulty performing a clean-catch) and in women with vaginal bleeding or discharge. Many clinicians also use catheterization to obtain a specimen if evaluation includes a pelvic examination. Diagnosis in patients with indwelling catheters is discussed elsewhere Urine testing: Microscopic examination of urine is useful but not definitive. Pyuria is defined as ≥ 8 WBCs/μL of uncentrifuged urine, which corresponds to 2 to 5 WBCs/high-power field in spun sediment. Most truly infected patients have > 10 WBCs/μL. The presence of bacteria in the absence of pyuria, especially when several strains are found, is usually due to contamination during sampling. Microscopic hematuria occurs in up to 50% of patients, but gross hematuria is uncommon. WBC casts, which require special stains to differentiate from renal tubular casts, indicate only an inflammatory reaction; they can be present in pyelonephritis, glomerulonephritis, and noninfective tubulointerstitial nephritis. Dipstick tests also are commonly used. A positive nitrite test on a freshly voided specimen (bacterial replication in the container renders results unreliable if the specimen is not tested rapidly) is highly specific for UTI, but the test is not very sensitive. The leukocyte esterase test is very specific for the presence of > 10 WBCs/μL and is fairly sensitive. In adult women with uncomplicated UTI with typical symptoms, most clinicians consider positive microscopic and dipstick tests sufficient; in these cases, given the likely pathogens, cultures are unlikely to change treatment but add significant expense. Cultures are recommended when symptoms are suggestive but urinalysis is nondiagnostic; for complicated UTI, including UTI in patients with diabetes, immunosuppression, recent hospitalization or urethral instrumentation, or recurrent UTI; for patients > 65 yr; and perhaps for patients with symptoms of pyelonephritis. All prepubertal children should have a urine culture when a UTI is suspected. Urine should be cultured as soon as possible or stored at 4° C if a delay of > 10 min is expected. Samples contaminated with large numbers of epithelial cells are unlikely to be helpful. An uncontaminated specimen should be obtained for culture. Criteria, based on the guidelines of the Infectious Diseases Society of America, for bacteriuria are: • • • • Among women with suspected asymptomatic bacteriuria, 2 consecutive clean-catch voided specimens from which the same bacterial strain is isolated in colony counts of > 105/mL Among women with suspected acute urethral syndrome, a clean-catch voided specimen from which a single bacterial species is isolated in colony counts from 102 to 104/mL Among men, a clean-catch voided specimen from which a single bacterial species is isolated in colony counts > 105/mL Among women or men, a catheter-obtained specimen from which a single bacterial species is isolated in colony counts of > 102/mL

Occasionally, UTI is present despite lower colony counts, possibly because of prior antibiotic therapy, very dilute urine (sp gr < 1.003), or obstruction to the flow of grossly infected urine. Repeating the culture improves the diagnostic accuracy of a positive result, ie, may differentiate between a contaminant and a true positive result. Infection localization: Clinical differentiation between upper and lower UTI is impossible in many patients, and testing is not usually advisable. When the patient has high fever, costovertebral angle tenderness, and gross pyuria with casts, pyelonephritis is highly likely. The best noninvasive technique for differentiating bladder from kidney infection appears to be the response to a short course of antibiotic therapy. If the urine has not cleared after 3 days of treatment, pyelonephritis should be checked for.

Symptoms similar to those of cystitis and urethritis can occur with vaginitis, which may cause dysuria from the passage of urine across inflamed labia. Vaginitis can often be distinguished by the presence of vaginal discharge, vaginal odor, and dyspareunia. Other testing: Seriously ill patients require evaluation for sepsis, typically with CBC, electrolytes, BUN, creatinine, and blood cultures. Patients with abdominal pain or tenderness are evaluated for other causes of an acute abdomen. Pyuria without bacteriuria can be present with appendicitis, inflammatory bowel disease, and other extrarenal disorders. UTI: MEDICAL MANAGEMENT  Inhibit Bacterial Growth To promote comfort and decrease complications, broad-spectrum antibiotics typically begin before the culture and sensitivity results are known.  Modify Diet Certain foods are known to irritate the bladder, such as caffeine, alcohol, tomatoes, spicy food, chocolate, and some berries. Client should be encouraged to avoid bladder irritants during the acute phase of UTI. Cranberry juice and ascorbic acid (vitamin C) have been used to acidify the urine and help for prevention of symptomatic UTIs.  Increased fluid intake To treat and prevent UTI, encourage increased fluid intake, especially water, if the client is not required to restrict fluids. The desired amount is 3-4L/day. Increased fluids flush the urinary system and are important in preventing urolithiasis (urinary calculi, or stones).  Prevent Complications Broad spectrum antibiotic therapy may destroy normal flora in the body and allow an overgrowth of opportunistic organisms. On occasion, diarrhea, associated bowel problems, and vaginal candidiasis may develop. Some antibiotics may reduce the effectiveness of oral contraceptives and estrogen, whereas sulfa drugs increase sensitivity to the effects of the sun. Complications can also occur if the infection is not completely eradicated. UTI: Surgical Management  The need for surgery is rare; operations are performed only to address structural anomalies that cause repeated infections.  UTI: Nursing Management  Administer prescribed medications, give adequate instructions to client regarding antibiotic therapy  Provide information about dietary changes needed to keep the urine acidic and to reduce bladder irritation





Sign up to vote on this title
UsefulNot useful