This series of posts explores the treatment and prevention of urinary tract infections in women. We begin with an explanation of what exactly is and is not a urinary tract infection and how that can affect management.
Treatment for a urinary tract infection (UTI), naturally, begins with diagnosing an infection. What could be simpler? But as with many aspects of medicine, the reality can be more complicated than it seems at first. Just determining what a UTI actually means is the subject of much debate and has evolved over the last decade.
Normal Bladder Bacteria
The discussion of UTI diagnosis begins with the common idea that urine is naturally sterile, or free from living bacteria. It turns out that this is far from true. An expanding view of the normal, healthy bladder reveals that not only do many bacteria types exist in the bladder without apparent symptoms or problems, but that some of these bacteria (such as lactobacilli) may provide a benefit by reducing the growth of other bacteria that can lead to infections (we call these pathogenic bacteria). There is increasing data that destruction of the the normal bacterial colonies in the body (native microflora) may actually lead to more harm. One of these side effects may be more frequent urinary tract infections. A common disrupter of normal microflora is antibiotic use.
Further evidence of the importance of normal native bacteria are preliminary studies suggesting that some bacteria species may be harmful even if they are not causing an infection by increasing the risk of bladder cancer. All the more reason to conduct studies that try to identify both the “good” and the “bad” bacteria in the bladder. But the notion that urine is sterile appears to be a historical myth.
Another important concept to understand in association with urinary infections is that just having bacteria in the bladder does not mean that the bladder is infected. It is now understood that many people may have the types of bacteria in their bladder that should cause an infection but have no symptoms of infection. This is called asymptomatic bacteriuria and it is now understood that many times there is no need to treat these bacteria. In fact, because of the consequences of taking antibiotics including killing beneficial bacteria, treating asymptomatic bacteriuria may be quite harmful.
Because there is no real benefit from treatment but there is the potential for harm, routine urine tests looking for bacteria are not recommended if no urinary symptoms are present. If testing is done anyway, but no symptoms of infection are reported, it is not recommended to treat these bacteria.
Bladder Bacteria in Pregnancy
There are important exceptions when treatment of bacteria, even without symptoms of infection, is recommended. Pregnant women should receive treatment of asymptomatic bacteriuria (and should be screened at least once in pregnancy) due to the increase in risk for premature labor. Another frequent difference is for patients undergoing certain types of surgical procedures, particularly those on the urinary system. But for most people, bacteria in the bladder without symptoms often should not be treated with an antibiotic.
What are common symptoms of an infection? Pain with urination (dysuria) or pain located near the bladder are the most common complaints. Other patients may note frequent urination or an increased need to urinate (even to the point of urine leakage). Fever, nausea or pain that is located near the kidneys can be indications of infection but usually are associated with infections that have progressed to the kidneys. Urine color or odor are fairly poor indicators of infection by themselves as they may be caused by dietary changes or may be seen with asymptomatic bacteriuria.
If the management and prevention of UTI begins with the diagnosis, it is critical then that patients and providers understand what is and is not an infection. It is important to listen to patients and understand their symptoms (or lack of symptoms) before concluding that a UTI is present. Unfortunately, it is not as simple as sending someone’s urine off for a test. In future posts, we explore the management of simple urinary tract infections and later move on to strategies for preventing urinary tract infections when the occur recurrently.