I thought I would like to share a timely case study with you. Urinary tract infections (UTI s) are a common problem for women -14 times more likely in women than men (1.) – and are often caused by a multitude of factors.
The common ones are:
- Incomplete emptying of the bladder (following repair surgery; poor contractility of the detrusor muscle- the smooth muscle pump of the bladder; urethral stricture; anterior wall prolapse)
- Poor oestrogen (post menopause) leading to a drainpipe urethra more susceptible to allowing bacteria to enter.
- Decreased fluid intake.
- Related to very regular/vigorous sexual intercourse (sometimes known as honeymoon cystitis)
- Faecal incontinence.
- Pregnancy related (incidence of asymptomatic bacteriuria in pregnant women is 2.5-11% – in as many as 40% of these cases bacteriuria may progress to symptomatic upper UTI or pyelonephritis (2) )
I saw a patient last week who is in her late 70s and has got some memory/ occasional confusion issues (could be early dementia) and most importantly was sent to me with severe urinary incontinence. Her leakage is such that she needs to wear a full incontinence panty and within that she wears another pad and a washer. She had been referred to me by a specialist doctor who had diagnosed an overactive bladder but most importantly had suspected this patient had a UTI. The specialist collected a sample and sent it off on the day of the consultation, but also commenced her on a first line antibiotic (Keflex) and asked her to see her GP in a couple of days to check whether the test was positive and the sensitivity of the organism in the urine.
The patient followed up with the GP but he didn’t see that the sample showed the bacteria was resistant to Keflex and in fact over the course of the next few consultations, when the patient returned for check ups regarding the UTI, gave 2 repeats of the very same (non-sensitive) Keflex.
So when the patient presented to me for treatment of her urinary incontinence (which was more like flooding), my first job was to see if the incontinence severity was related to her UTI possibly still being present. The results of her urine sample showed that the bacteria was not sensitive to Keflex, so the first line of treatment for her urinary incontinence was to ask for the GP to change her antibiotics to the correct one for the bacteria present in her urine.
Fortunately the patient had all her prescriptions with her and on checking that medication list -(as we all know, many medications can be the culprit with urinary incontinence, so it’s always important to record them and check if they are contributing to urinary leakage)-the patient had an active dispensed script for 3 different anticholinergics (drugs which help treat the urge leakage associated with the overactive bladder (OAB) ) which she was taking all at the same time! Now these drugs- any one of them can contribute to confusion in the elderly, so to be taking all 3 at once – could have been worsening her confusion state.
We also covered the usual treatment strategies for OAB – but in a simpler form to make it easier for the patient with confusion to understand- and I will see in a couple of weeks how her leakage is going. Local oestrogen via vagifem pessaries twice a week can also help prevent UTIs.
So what is my point and message?
- Test urine always– don’t just keep taking antibiotics.
- Any presumed UTI must have a sample sent and if you are commenced on antibiotics please go and get the sample result checked to make sure you are on an antibiotic that is sensitive for the organism you are growing.
- If there is any dementia or memory issue then careful supervision of medications is important. There should really be a mandatory searching of all medication cupboards and throwing out of old drugs so the meds people are taking (or accidently choose to take themselves) don’t make them more confused than they already are.
- If the symptoms are not getting better then re-test the sample (this is whether it is urine, a wound or sputum: test, re-test and test again – I am an old intensive care physio and learned that a long time ago)
1.Johnson E, Urinary tract infections in pregnancy Medscape February, 2014
2. Smaill F, Asymptomatic bacteriuria in Pregnancy. Best Pract Res Clin Obstets Gynaecol Jun 2007; 21 (3): 439-50