Chapter 25

Introduction

Experience has taught them, as mine has me, that one must listen to reason and agree with Hippocrates, Galen, Avicenna and many others, ancient and modern, that there is no surer way to determine the temperaments and constitutions of people of either sex than to look at the urine.

Davach de la Rivieere (18th century), The Mirror of Urines

Urinary tract infection (UTI) is a common problem affecting all ages and accounts for approximately 1% of all attendances in general practice. It is very common in sexually active women but uncommon in men and children.

Organisms causing UTI in the community are usually sensitive to most of the commonly used antibiotics. The important decision to make is whether to proceed with further investigation of the urinary tract. The morbidity of urinary infections in both children and adults is well known but it is vital to recognise the potential for progressive kidney damage, ending in chronic kidney failure. The main task in the prevention of chronic pyelonephritis is the early identification of patients with additional factors, such as reflux or obstruction, which could lead to progressive kidney damage.

UTI can be regarded as a masquerade when it presents with a constitutional problem or general symptoms, without symptoms suggestive of a urinary infection such as frequency, dysuria and loin pain. This applies particularly to infants and young children and the elderly but is not uncommon in adult women and in pregnancy. Acute UTI may occasionally present as acute abdominal pain.

In infants and children, presenting non-specific symptoms include:

• fever

• lethargy and irritability

• poor feeding

• failure to thrive

• vomiting

• abdominal pain

• diarrhoea

In the elderly:

• confusion

• behaviour disturbance

• fever of undetermined origin

Key facts and checkpoints

• Screening of asymptomatic women has shown that about 5% have bacterial UTI.1

• About 1% of neonates and 1–2% of schoolgirls have asymptomatic bacteriuria.2

• About one-third of women have been estimated to have symptoms suggestive of cystitis at some stage of their life.

• The vast majority of these women have anatomically normal kidney tracts, are at no significant risk from the UTI and respond quickly to simple therapy. The prevalence of underlying abnormalities is estimated at around 4%.3

• UTIs are largely caused by organisms from the bowel that colonise the perineum and reach the bladder via the urethra. In many young women infections are precipitated by sexual intercourse. Ascending infection accounts for 93% of UTIs.

• Haematogenous infection can occur sometimes, especially with the immunocompromised patient.

• All males and females less than 5 years old presenting with a UTI require investigation for an underlying abnormality of the urinary tract.

• In the presence of a normal urinary tract there is no evidence that UTI leads to progressive kidney damage.

• Always ...

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