Urinary Tract Infection

 

Welcome to <a href="Pathophysiology of Complex Patient Problems">PT 635 Pathophysiology of Complex Patient Problems</a> This is a wiki created by and for the students in the School of Physical Therapy at Bellarmine University in Louisville KY. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!

Original Editors - <a href="Pathophysiology of Complex Patient Problems">Students from Bellarmine University's Pathophysiology of Complex Patient Problems project.</a>

Top Contributors - <img class="FCK__MWTemplate" src="http://www.physio-pedia.com/extensions/FCKeditor/fckeditor/editor/images/spacer.gif" _fckfakelement="true" _fckrealelement="13" _fck_mw_template="true">  

Definition/Description

     A Urinary Tract Infection, UTI, is defined as an infection in the lining of the urinary tract caused by microbes, mainly bacteria, but also fungi and viruses<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Rose" />.  Typically, bacteria that enters the urinary tract is rapidly removed by the body before symptoms are presented, but sometimes this bacteria overcomes the natural defenses of the body resulting in an infection.  This infection may involve the lower urinary tract only or both the lower and upper urinary tracts.

Infections of the urinary tract can be subdivided into two classifications:

Upper Urinary Tract Infections:

• Renal infections
• Acute of chronic glomerulonephritis
• Renal papillary necrosis
• Renal tuberculosis
  
  

Lower Urinary Tract Infections:

• Cystitis
• Urethritis
  

Prevalence

     An estimation of 150 million UTIs occur every year world-wide, adding to $6 billion in health care costs<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Pontari" />. 

<img src="/images/thumb/9/96/Bladder.png/275px-Bladder.png" _fck_mw_filename="Bladder.png" _fck_mw_location="right" _fck_mw_width="275" _fck_mw_height="275" _fck_mw_type="border" alt="Anatomy of the male and female bladder." class="fck_mw_border fck_mw_right" />

Across all age groups, the incidence of UTI is higher in women than men, with the lifetime risk greater than 50% for women<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Rowe" />.  Women are especially prone due to anatomical reasons: uretha is shorter allowing bacteria quicker access to the bladder and the urethral opening is near bacteria sources, such as the anus and vagina<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Urinary" />. 

UTI is frequent in young and sexually active women with reported incidence rates ranging from 50-70% per person-year<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Rowe" />.  Pregnancy does not show an increased risk compared to typical women, but a UTI is more likely to travel to the kidneys in pregnant women due to hormonal and positional changes<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Urinary" />.

UTI is one of the most commonly diagnosed infections in older adults and the most frequently diagnosed infection in long-term care residents, with over 10% of women over 65 years old reported having a UTI within the past 12 months<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Rowe" />.

Characteristics/Clinical Presentation

When a patient presents with both clinical features and laboratory evidence of a urinary infection, a symptomatic UTI diagnosis can be made. Patients presenting with two of the following meet the diagnostic criteria for a symptomatic UTI<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Mody" />:

• Worsened urinary urgency or frequency
• Acute dysuria
• Suprapubic tenderness
• Costovertebral angle pain or tenderness
• Fever
  
  

Additional signs and symptoms include the following<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Goodman" /><span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Rose" />:

• Nausea and vomiting
  
• Urinary frequency
  
• Urinary urgency
  
• Flank pain
  
• Malaise
  
• Muscle aches
  
• Pelvic/lower abdominal pain
  
• Ipsilateral shoulder pain
• Pyuria
• Bacteriuria
• Low back pain
  

Associated Co-morbidities

    Conditions or diseases that can be associated with UTIs include the following<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Rose" /><span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Urinary" />:

• Diabetes Mellitus
  
• Hypertension
  
• Kidney stones
  
• Bowel incotinence
  
• Prostratic obstruction
  
• Immunological disorders
• Spinal cord injuries
• Congenitial urinary tract anomalies
     

Other risk factors include<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Rose" /><span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Goodman" />:

• Urinary catheterization
  
• Residency in a nursing home or hospitalization
  
• Immobility
  
• Previous urologic surgery
  
• Obstructive urinary tract problems
  
• Gout
  
• Hypertension
  
• Sexual Activity
  

Urinary catheterization interferes with the body's ability to clear microbes from the urinary tract, therefore, increasing the risk for bacteria; to reduce the risk of a UTI, the Infectious Diseases Society of America recommends using catheters for the shortest time possible<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Urinary" />.

Medications

     The type of bacteria and patient's history play a role in the choice of medication and length of treatment determined by the health care provider.  As these infections are usually caused by bacteria, antibiotics are used to treat UTIs; Removing predisposing factors are also considered if possible- draining urine collections, removing or changing catheters<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Pontari" />.  Health care providers will sometimes perform a sensitivity test and analyze the results to select the most effective antibiotic specific to the patient based on the the site of infection and severity of illness<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Pontari" />.

Diagnostic Tests/Lab Tests/Lab Values

     Due to bacteria possibly being found in urine of healthy individuals, a UTI is diagnosed based on symptoms of the individual and a laboratory test. The health care provider will request a "midstream" urine sample and then sent on to a laboratory<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Urinary" />. In the case of recurring infections or in a hospital environment, the urine sample may be cultured to identify the bacteria growing. Sensitivity tests may also be ordered by the health care provider to interpret the most efficient medication for treatment<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Urinary" />.

<img src="/images/thumb/a/ac/UrineSample.jpg/156px-UrineSample.jpg" _fck_mw_filename="UrineSample.jpg" _fck_mw_location="right" _fck_mw_width="175" _fck_mw_height="225" _fck_mw_type="border" alt="" class="fck_mw_border fck_mw_right" />

  <img src="/images/thumb/f/ff/UTIurine.jpg/250px-UTIurine.jpg" _fck_mw_filename="UTIurine.jpg" _fck_mw_location="left" _fck_mw_width="250" _fck_mw_height="250" _fck_mw_type="border" alt="Microscopic" class="fck_mw_border fck_mw_left" />

Confirmation of a diagnosis of UTI includes a positive urine

culture (≥ 105 CFU/mL) with no more than 2 uropathogens and pyuria<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Mody" />. Dipstick tests are easy to perform in a clinic and used often when testing for UTI<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Mody" />.

Typically, symptoms of a UTI will conclude within 24-48 hours after treatment. A UTI is considered recurrent if the condition presents more than twice in a 6 months<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Rose" />.  Additional tests include the following: kidney and bladder ultrasound, voiding cystourethrogram, computerized tomography (CT) scan, MRI, radionuclide scan, urodynamics, and cystoscopy<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Urinary" />.

Etiology/Causes

    Urinary tract infections are a result from bacteria invading the urinary tract<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Rose" />.  Research confirms that most UTIs are caused by bacteria that live in the bowel, specifically the bacterium Escherichia coli (E. coli)<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Urinary" />.  The routes that bacteria take to enter the urinary tract include ascending through the urethra, bloodborne, and through the lymphatic system<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Goodman" />.

Common Causative Pathogens in Adult UTIs<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Pontari" />:

• Escherichia coli (80% of outpatient UTIs)
• Klebsiella; Enterobacter
• Proteus
• Pseudomonas
• Staphylococcus saprophyticus (5 - 15%)
• Enterococcus
• Candida
• Adenovirus type 11
  

The urinary tract encompasses several systems to prevent infection such as preventing urine from backing up toward the kidneys and urination washing removing microbes from the body.  Unfortunately, infections can still occur due to some bacteria having a strong ability to attach to the urinary tract lining<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Urinary" />.
 

Systemic Involvement

     Urinary Tract infections that are left untreated may lead to many complications, including urosepsis, systemic inflammatory response syndrome (SIRS), and chronic kidney infections. Sepsis associated with UTIs often requires hospitalization. Urosepsis spreads into the bloodstream from its origin in the urinary tract. Kidney infections also progress to the blood stream, referred to as septicemia. This complication can be life threatening. Systemic inflammatory response syndrome can also become life threatening if treatment fails. SIRS is usually the first incidence of multi-organ failure.

Medical Management (current best evidence)

    Urinary tract infections are most commonly treated by antibiotic prescription. Frequently prescribed antibiotics include:

• Nitrofurantoin<img src="/images/thumb/b/b8/Amoxicillin.jpg/200px-Amoxicillin.jpg" _fck_mw_filename="Amoxicillin.jpg" _fck_mw_location="right" _fck_mw_width="200" _fck_mw_height="200" _fck_mw_type="border" alt="Amoxicillin" class="fck_mw_border fck_mw_right" />
• Amoxicillin
• Trimethoprim
• Fluoroquinolones

Antibiotics are usually taken anywhere from 3 days to 10 days, depending on severity of symptoms, comorbidities, complications of infection, and dosage  <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Rose" />. Overutilization of antibiotics is a common issue, particularly in hospitals and long term facilities, which may cause patients to develop resistance to the medication over time<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Rowe" />.
     Alternative treatment includes the use of probiotics, ensuring proper hydration, drinking cranberry juice, and urinating frequently  <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Mody" /> <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Urinary" />. Using a heating pad on the patient’s lower back or abdomen may also help the symptoms of the UTI. Surgery may be required in the presence of an anatomical abnormality <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Rose" />.

Physical Therapy Management (current best evidence)

     Physical therapists that are trained in pelvic floor dysfunction can greatly improve a UTI patient’s quality of life. A typical approach includes training pelvic floor musculature, manipulative techniques, local heat, breathing and relaxation techniques, postural education, muscle coordination reeducation, and behavioral therapy. Therapists are also encouraged to educate the patient on drinking and voiding schedules to ensure consistency. Treatments and patient education have been found to improve efficiency of emptying the bladder, create better bowel habits, and promote full relaxation of the pelvic-floor when voiding<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Souza" />. All of these factors may lead to a decreased incidence and reoccurrence of UTIs.
     For those patients in the hospital, recent studies have shown that mobilization of patients with a catheter is safe and is not associated with urinary-related adverse effects, including urinary tract infections.

<img src="/images/thumb/0/02/Pelvic_Floor_Muscles.jpg/502px-Pelvic_Floor_Muscles.jpg" _fck_mw_filename="Pelvic Floor Muscles.jpg" _fck_mw_location="center" _fck_mw_width="540" _fck_mw_height="366" _fck_mw_type="border" alt="PelvicFloorMuscles" class="fck_mw_border fck_mw_center" />

Differential Diagnosis

The American Urological Association has identified conditions that can cause symptoms similar to UTI, including:

</dd>

• STDs: Genital Herpes, Gonorrhea, Chlamydia, Trichomonas
• Inflammatory disorders: Vaginitis, Prostatitis, Urethritis
• Nephrolithiasis (Kidney Stones)
• Trauma
• Genitourinary Tuberculosis
• Genitourinary Neoplasm
• Intra-abdominal Abscess
• Yeast Infection

<img src="/images/thumb/9/95/JaundiceKid.jpg/152px-JaundiceKid.jpg" _fck_mw_filename="JaundiceKid.jpg" _fck_mw_location="left" _fck_mw_width="152" _fck_mw_height="188" _fck_mw_type="border" alt="" class="fck_mw_border fck_mw_left" />

Variation in symptom presentation:

Post-menopausal women present with constitutional symptoms, such as abdominal pain, back pain, chills, and constipation<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Rowe" />.

Nursing home patients present with nonspecific symptoms, such as confusion and a decline in functional status. 

Children are usually the hardest to diagnose due to the their vagueness of symptoms. The typical adult symptoms of frequency, urgency, and dysuria are usually absent in children. Young children sometimes present with irritability, poor feeding, vomiting, or jaundice.  UTI should be considered in any child between two months and two years of age with fever that doesn't have an identifiable source of infection.<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Beck" /> Young children with incontinence and abdominal pain should be checked for UTI. <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Beck" />

Case Reports/ Case Studies

 1. Physiotherapy For Women With Recurrent Urinary Tract Infection: A Promising Approach

• http://www.ics.org/Abstracts/Publish/218/000223_poster.pdf

2. Pelvic floor therapy in girls with recurrent UTIs

• http://www.ncbi.nlm.nih.gov/pubmed/9634033

Resources

American Urological Association
http://www.auanet.org/education/adult-uti.cfm

NYU School of Medicine Department of Urology
http://www.med.nyu.edu/urology/patient-care-information/conditions-we-treat/recurrent-urinary-tract-infections#diagnosis

European Association of Neurology
http://uroweb.org/wp-content/uploads/19-Urological-infections_LR2.pdf

Choices in Health
http://choicespc.net/physical-therapy-for-urinary-problems-and-pelvic-floor-dysfunction/

Recent Related Research (from <a href="http://www.ncbi.nlm.nih.gov/pubmed/">Pubmed</a>)

http://www.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1twh4oYFmCRxDnF-K12oI-0b51xUbejqtqL6fa9t8hKbLt8sKl%7Ccharset=UTF-8%7Cshort%7Cmax=10

References

<span class="fck_mw_references" _fck_mw_customtag="true" _fck_mw_tagname="references" />

<a _fcknotitle="true" href="Category:Bellarmine_Student_Project">Bellarmine_Student_Project</a>