Urinary Tract Infection (UTI) in Females

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DESCRIPTION

  • Urinary tract infection (UTI) is the presence of pathogenic microorganisms within the urinary tract with associated symptoms such as dysuria, urinary urgency/frequency, hematuria, suprapubic pain, new or worsening incontinence
  • Uncomplicated UTI: infection in patients with an unobstructed and anatomically normal urinary tract, no predisposing risk factors and whose symptoms are confined to the lower urinary tract
  • Complicated UTI: infection in the presence of anatomical or functional abnormality, immunocompromised host, or presence of a multi-drug resistant organism (See “Risk Factors.”)
  • Recurrent UTI: symptomatic UTI that occurs following complete treatment and resolution of documented infection; two or more culture-proven infections in 6 months or three or more in 12 months
  • Asymptomatic bacteriuria (ASB): presence of bacteria in urine without causing symptoms
  • Synonym(s): cystitis

EPIDEMIOLOGY

UTIs are highly prevalent among women.

Incidence

Accounts for 10.5 million office visits and 2 to 3 million emergency room visits (with 64% of those involving female patients) and >100,000 hospital admissions with a cost of >$2 billion annually

Prevalence

  • Up to 50–70% of women have at least one UTI in their lifetime
  • About 20–40% of women with a prior UTI episode will experience another UTI.

ETIOLOGY AND PATHOPHYSIOLOGY

  • Ascension of bacteria into the bladder via the urethra is the most common etiology
  • Pathogenic organisms possess adherence factors (pili or fimbriae) and toxins that allow the initiation and propagation of UTIs.
  • Most UTIs are caused by bacteria originating from bowel flora:
    • Escherichia coli is the causative organism in 75–95% of cases of uncomplicated UTIs
    • Staphylococcus saprophyticus accounts for 5–15% of UTIs
    • Klebsiella pneumonia and Proteus mirabilis each account for approximately 4%

Genetics

Women with human leukocyte antigen 3 (HLA-3) and nonsecretor Lewis antigen have increased bacterial adherence, which may lead to an increased risk of UTI.

RISK FACTORS

  • Biologic:
    • Urinary stasis/obstruction: pelvic organ prolapse, bladder diverticula, neurogenic bladder, voiding dysfunction, urethral stricture, anatomic anomalies of the urinary tract
    • Urinary calculi
    • Immunosuppression: diabetes, HIV, malignancy, malnutrition
  • Behavioral practices that promote colonization:
    • Sexual intercourse
    • Use of spermicides or antimicrobials
    • Poor hygiene

GENERAL PREVENTION

  • Resolve urinary obstruction or stasis.
  • Adequate hydration
  • Women with frequent or intercourse-related UTI should empty bladder immediately before and following intercourse.
  • Avoid feminine hygiene sprays, diaphragms, spermicidal agents, and douches.
  • Vaginal estrogen in postmenopausal women may aid in preventing recurrent UTI.

COMMONLY ASSOCIATED CONDITIONS

See “Risk Factors.”Geriatric Considerations

  • Elderly patients are more likely to have underlying urinary tract abnormality or voiding dysfunction, or other comorbidities:
    • Poor perineal hygiene, urinary or fecal incontinence, and pelvic organ prolapse are common risk factors.
    • Decreased estrogen levels increase vaginal pH and alter microbial flora, leading to increased colonization with potentially pathogenic organisms.
  • May present with atypical symptoms such as altered mental status or urinary incontinence
  • Treatment of ASB does not improve outcomes and should be avoided

Pediatric Considerations
Bowel bladder dysfunction or congenital urinary tract abnormalities such as vesicoureteral reflux (VUR) or duplicated collecting system are risk factors.

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