Available Options for Evaluation and Treatment of Urinary Tract Infections in Rural Areas – includes a free patient information PDF!

What is Urinary tract infection?

When there are more than 100,000 bacteria per ml of Urine, it is called urinary tract infection. What this means is that normally there are bacteria in the Urine.

Where do the bacteria come from and if bacteria are there why don’t we have Urinary tract infection?

The bacteria that infect the urinary tract are usually from the large intestines especially the bacteria called E. coli. They are found at the anal orifice or opening of the large intestine and are transferred to the urinary opening by contamination.

Both the openings are near each other in women and hence they are more prone to urinary infection. The bacteria could also come through the blood stream as the kidneys get almost a quarter of the output from the heart.

The kidneys do not have bacteria because a one way valve prevents the bladder urine from going up into the kidneys.

The reason we do not always have significant infection is because of the fact that when we pass urine we empty the bladder and all the urine with bacteria come out. The usual multiplication time of bacteria is about 20 minutes and we pass urine before significant amount of bacteria are there in the bladder.

Other factors unfavorable to bacterial growth include: a low pH (5.5 or less), a high concentration of urea, and the presence of organic acids derived from a diet that includes fruits and protein. Organic acids enhance acidification of the urine.

How common is Urinary tract infection?

Urinary tract infections affect 15% of women every year and about a quarter of them would experience recurrence of the infection [1]. Most women will have at least one infection in their lifetime. About 1 to 3% of all general consultations are related to urinary tract infection. One to two percent of children have urinary tract infection.

The rule of the thumb is that when anyone other than sexually active women has urinary infection it could be due to secondary causes and they need to have evaluation for these.

What are these secondary causes?

There are varieties of predisposing causes to urinary tract infection. The following is a list of them.

1. SEXUAL ACTIVITY: This is one of the reasons for more frequent infections in women. The hygiene is important. The direction of wiping or washing after passing stools is important in transmission of bacteria from the intestines.
2. INADEQUATE BLADDER EMPTYING: What this does is that each time the bladder starts with a higher bacterial count as the bladder does not become completely empty. Since the doubling time is 20 minutes eventually a time will reach when the bladder has more than 100,000 bacteria per ml. There could be several causes for incomplete emptying like:
   1. Bladder outflow obstruction due to enlargement of Prostate, valves, strictures, etc.
   2. Nuerovesical dysfunction where the bladder nerves does not function properly. It is good to remember that almost one third of the nerves of the spinal column go to the bladder for its control.
   3. Stones or anatomical obstruction can cause incomplete emptying of the bladder.
   4. If there is a diverticulum or vesico-ureteric reflux during micturation or passing urine some of the urine either go to the diverticulum or up into the ureter and kidney and come back to the bladder few minutes later.
   5. Post menopausal women could have either uterine and bladder prolapsed that prevent proper emptying of the bladder or some amount of Nuerovesical dysfunction.
3. PRESENCE OF FOREIGN BODIES: The foreign bodies form a nidus over which the bacteria can settle. The most common ones are the urinary tract stones. Presence of urinary catheters is also a predisposing factor. However the chance is less as the bladder is kept empty.
4. ANATOMICAL DEFECTS: A variety of anatomical defects can lead to frequent urinary tract infections. These should be actively ruled out in children with urinary tract infection. The most common one is the Vesico-ureteric reflux due to defective valve mechanism that allows urine to get back to the ureter.
5. PHYSIOLOGICAL CHANGES: Even normal physiological changes that occur with pregnancy [pressure on the tract and nerves] and menopause [dry tissue because of less hormones] could predispose to urinary tract infections.
6. POOR GENERAL HEALTH: Poor general health like uncontrolled diabetes, immune-suppression due to any cause, severe sepsis due to any cause, etc., could be complicated by urinary tract infections.
7. IMMOBILITY: Being bed ridden and unable to move is a cause for infection and stone formation if the intake of fluids is not adequate.

Is there anything that could be done to prevent urinary tract infection?

There are a few things that should be kept in mind to prevent urinary infections. Although these things make sense and are logical; do not have the backing of scientific studies in the very few studies that were carried out [3].

• After a bowel movement or after urinating, wipe from front to back. Earlier we learnt that the opposite is one of the predisposing factors for infection especially in women.
• Wash the skin around the anus and the genital area.
• Avoid using douches, powder, and deodorant sprays. These can act as a nidus for bacteria and also destroy the normal defense mechanisms.
• Drink plenty of fluids (including water) to flush bacteria out of your urinary system.
• Empty your bladder as soon as you feel the urge or about every 2–3 hours.
• Try to empty your bladder before and after sex.
• Wear underwear with a cotton crotch.

It is important to remember that in women the risk of urinary tract infection is about 60 times higher during the 48 hours after sexual intercourse when compared to the risk at other times.

What are the symptoms of urinary tract infection?

The following are the common symptoms of urinary tract infection:

1. Increased frequency: The normal person passes urine about six times a day. The first symptom might be increase in frequency.
2. Dysuria: Burning while passing urine is called dysuria and often this is the symptom that attracts attention.
3. Urgency: When the infection becomes severe there is urgency.
4. Strangury: The slow and painful micturation is caused by the muscular spasms of urethra and bladder.
5. Suprapubic pain: There might be constant pain in the lower abdomen over the region of the bladder. The pain may be at the back too.
6. Hematuria: The urine is blood stained with severe infection.
7. Cloudy and foul smelling urine: This occurs with severe infection.

The above are the symptoms of lower urinary tract infection. The upper tract infection namely the infection in the Kidney causes the following symptoms:

1. Fever: Classically this is high grade fever associated with chills and rigors.
2. Vomiting: This is another frequent feature.
3. Loin pain and tenderness: There is pain in the back at the site of the Kidney called the renal angle.
4. Fatigue and general ill feeling: This is more common in the elderly who could also have mental changes and confusion.

What are the tests that are necessary?

The following tests could be carried out in the rural areas:

1. Urine microscopy: This is a simple easily available test that would show the presence of significant number of pus cells and blood with severe infection. If plenty of epithelial cells are present it can indicate vaginal contamination and in women it is good know if she is menstruating while giving the sample.
2. Urine culture: This is important especially with upper tract infection to find out the correct antibiotic to use.
3. Ultrasound examination: This is another investigation that is available in the rural areas which can give a lot of information. It can detect swelling in the kidney and ureter, stones in the urinary tract, thickening of the bladder wall, diverticulum and other abnormalities.
4. IVU / KUB: The X - rays are used for primarily detecting urinary tract stones. While experts can detect stones from plain KUB, IVU can give the outline of the urinary tract and also gives additional information about the function.
5. Low cost Urodynamic study: This study gives a lot of information about the status of the nerve supply to the bladder and about obstruction to the urinary tract.
6. Cystoscopy: This study has a look inside the bladder with special equipment and can detect stones and other anatomical abnormalities in the urethra and bladder.

What are the differential diagnoses or other conditions presenting similarly?

The following are the differential diagnosis:

1. Vaginitis or Vulvo-vaginal infection: since the vagina is so close to the urethra there might be overlap of symptoms.
2. Sexually transmitted diseases: These can cause and also present similar to urinary tract infection.
3. Urethral syndrome: This is the name given to a complex of symptoms that indicate urinary tract infection but does not have underlying infection.
4. Dysmenorrhoea: The pain during periods could mimic urinary tract infection.

How is urinary tract infection treated?

Patient Handout

You can print copies of this PDF handout for your patients, to reinforce what you have told them.

The following are the recommendations:

For mild infection
Antibiotics taken by mouth are usually recommended because there is a risk that the infection can spread to the kidneys.

• For a simple bladder infection, you will take antibiotics for 3 days (women) or 7 - 14 days (men).
• For a bladder infection with complications such as pregnancy or diabetes, OR a mild kidney infection, you will usually take antibiotics for 7 - 14 days.
• It is important that you finish all the antibiotics, even if you feel better. People who do not finish their antibiotics may develop an infection that is harder to treat.

For recurrent infection
In postmenopausal women, topical vaginal estrogen cream decreases the risk of recurrent urinary tract infections.
In women who have three or more urinary tract infections a year the following options could be considered:

• Patient initiated short course of antibiotic therapy at the onset of symptoms suggesting urinary tract infection.
• Post-coital prophylaxis (single dose of antibiotic) if cystitis has been related to sexual intercourse.
• Continuous daily or thrice weekly prophylaxis for a longer period (six months or more).

Prophylaxis should be started after active infection has been eradicated (confirmed by a negative urine culture at least one to two weeks after treatment is stopped). Prophylaxis does not make recurrent urinary tract infections less likely to recur. When prophylaxis is discontinued, even after having been taken for extended periods, more than 50% of women will have another infection within three months.

For severe infection
For severe infection and Kidney infection admission and treatment is necessary. Appropriate injectable antibiotics help in treating the infection.

For secondary infection
The treatment is necessary for the primary cause of the infection.

AVAILABLE AT SEESHA

The standard Cystometrogram or Urodynamic studies are expensive and are available only in certain centers. SEESHA carries out these studies using a low-cost method, which is possible even in the diagnostic camps in the remote villages. These studies help to evaluate Nuerovesical dysfunction and quantify the obstruction.
At Karunya Community Hospital, at ICC hospital in Coimbatore, the Bethesda Hospital at Aizawl, Sielmat Christian Hospital at Churachandpur, Family health hospital Dimapur and other places where the SEESHA health care team provides surgical camp and diagnostic camp facilities, all the treatment modes mentioned above are available.

Dr. J. Gnanaraj MS, MCh [Urology], FICS, FARSI, FIAGES is a urologist and laparoscopic surgeon trained at CMC Vellore. He has been appointed as a Professor in the Electronics and Instrumentation Engineering Department of Karunya University and is the Director of Medical Services of the charitable organization SEESHA. He has a special interest in rural surgery and has trained many surgeons in remote rural areas while working in the mission hospitals in rural India. He has helped 21 rural hospitals start minimally invasive surgeries. He has more than 150 publications in national and international journals, most of which are related to modifications necessary for rural surgical practice. He received the Barker Memorial award from the Tropical Doctor for the work regarding surgical camps in rural areas. He is also the recipient of the Innovations award of Emmanuel Hospital Association for health insurance programs in remote areas and the Antia Finseth innovation award for Single incision Gas less laparoscopic surgeries. During the past year, he has been training surgeons in innovative gas less single incision laparoscopic surgeries.

Image: Components of the urinary system. 21 October 2006. Access the original Image information here: https://commons.wikimedia.org/wiki/File:Illu_urinary_system.jpg

Image: Vulva Illustration from Anatomy & Physiology. Author: OpenStax College. 2 May 2013. Access the original Image information here: https://commons.wikimedia.org/wiki/File:Figure_28_02_02.jpg