Acute urethral syndrome, which occurs in women, produces dysuria and pyuria (dysuria-pyuria syndrome) due to bacterial urinary pathogens like N. Gonorrhoeae, TB, or fungal disease or by trauma or inflammation of the urethra.

Patients with acute urethral syndrome have dysuria, frequency, and pyuria.

But urine culture in these patients shows colony counts that are <105/ml, which is less than the traditional criterion for bacterial urinary tract infection (UTI).

UTIs are usually referred to as simple/uncomplicated or complicated.

·         Complicated infections are caused by present when there are underlying factors that predispose to ascending bacterial infection. Its 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). They spread to other parts of the body, or are resistant to many antibiotics. They are more difficult to cure.

·         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. They do not spread to other parts of the body. They usually go away readily with treatment. 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 because of alterations in vaginal flora that allow overgrowth of Escherichia coli. In elderly women, soiling of the perineum from faecal incontinence increases risk. Patients of both sexes with diabetes have an increased incidence and severity of infections.

Causes of UTI

The culprit in at least 90% of uncomplicated infections is Escherichia coli, better known as E coli. These bacteria normally live in the bowel (colon) and around the anus.

The remaining gram-negative urinary pathogens are Klebsiella, Proteus mirabilis, and Pseudomonas aeruginosa. Enterococci (group D streptococci) and Staphylococcus saprophyticus are the most frequently implicated gram-positive organisms.

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.

Risk factors

·         Females: They have a shorter urethra, which cuts down on the distance bacteria must travel to reach the bladder.

·         Being sexually active: Sexual intercourse can irritate the urethra, allowing germs to more easily travel through the urethra into the bladder

·         Using certain types of birth control: Women who use diaphragms for birth control also may be at higher risk, as are women who use spermicidal agents.

·         After menopause

·         Kidney stones or any other urinary obstruction

·         Diabetes, HIV, steroids and immunosuppressive drugs that may impair the immune system

·         Prolonged use of tubes (catheters) in the bladder

·         Enlarged prostate

Signs and symptoms

·         Bladder infections

·         Frequent urination along with the feeling of having to urinate even though there may be very little urine to pass

·         Need to urinate during the night

·         Discomfort or pain at the urethral meatus or a burning sensation throughout the urethra with urination (dysuria)

·         Pain in the midline suprapubic region

·         Pus in the urine or discharge from the urethra

·         Blood in urine

·         Mild fever

·         Cloudy and foul-smelling urine

·         Pyelonephritis

·         All of the above symptoms

·         Vomiting is common

·         Back, side (flank) or groin pain

·         Abdominal pain or pressure

·         Chills and high spiking fever

·         Night sweats

·         Extreme fatigue

Test and diagnosis

·         Urinalysis- clean-catch, midstream-voided 5- 10 ml in a sterile container

·         Urine culture

·         Renal function test and ultrasound in pyelonephritis

·         Rarely cystoscopy

Prevention

·         Use a hot-water bottle to ease pain

·         Drink plenty of water

·         Avoid coffee, alcohol, and spicy foods, all of which irritate the bladder

·         Quit smoking-Smoking irritates the bladder and is known to increase the risk of bladder cancer

·         In women who experience ≥ 3 utis/yr, voiding immediately after sexual intercourse and avoiding use of a diaphragm may be helpful

·         Drinking cranberry juice (50 ml of concentrate or about 300 ml of juice daily) reduces pyuria and bacteriuria

Treatment

Uncomplicated UTI requires shorter duration of treatment from 5-7 days, while complicated forms of bacterial UTI require antibiotic course of 7-10 days or more. Antibiotics used are:

·         Nitrofurantoin- more use in pregnancy and prophylactic care

·         Ciprofloxacin, Levofloxacin

·         Sulfamethoxazole-trimethoprim

STD regimen for UTI- Cephalosporin III generation, Azithromycin, Doxycycline

Treatment of pyelonephritis

·         Beta lactam inhibitors like Piperacillin and Tazobactam

·         Broad spectrum cephalosporins like Imipenem and Cilastatin, Astreonam

·         Occasionally surgery (e.g, to drain abscesses, correct underlying structural abnormalities, or relieve obstruction)

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