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Experts to PCPs: Do not rush to judgment regarding UTIs
CDC data indicate the most common infection among people are UTIs, but an American Urological Association board member told Healio Family Medicine not all of these cases may be an actual UTI.
“I’ve seen numbers that indicate almost 1% of all visits to primary care doctors and ambulatory clinics are dedicated to bladder issues, those symptoms that people think are UTIs,” according to Lisa N. Hawes, MD, a urologist with Chesapeake Urology in Maryland said. “The number of people affected by UTIs runs into the millions and associated health care costs run into the billions of dollars annually that are spent on people being treated for UTIs. These infections are diagnosed and treated hundreds of times a day, but not always accurately,” Hawes said.
“A common misconception [among primary care physicians] is that all positive urinalyses indicate infection,” Priyanka Gupta, MD, an assistant professor of neurourology and pelvic reconstructive surgery, University of Michigan, said in a separate interview.
To help primary care physicians better understand UTIs, Healio Family Medicine asked Hawes and Gupta to discuss strategies for prevention, tips for diagnosis and options for managing the infection. – by Janel Miller
Q: How can a patient prevent UTIs?
Gupta: Depending on the patient, certain preventive measures can be taken, such as working to treat constipation or diarrhea in patients. Patients with bowel issues can also take probiotics which can help. There is some evidence that supplements such as cranberry tablets and D-mannose can help with prevention as well. For women who are postmenopausal, vaginal estrogen can help reduce the frequency of UTIs. If the patient has significant incontinence, treating this condition and reducing the episodes of leakage can help reduce the frequency of UTIs. Finally, if the UTI is related to intercourse, a single dose of pericoital antibiotics can be preventive as well.
Q: What is the best way to know if a patient has a UTI or some other bladder issue?
Hawes: When a patient comes in with the common symptoms of UTI — frequency, burning, urgency, pressure, blood in the urine — many clinicians will do the litmus paper dipstick test, which looks for red cells, white cells, nitrites and sugar in urine. Often, when these tests come back positive, the clinician will think the patient must have a UTI, so they prescribe an antibiotic and send them out the door. However, there are a lot of other disease processes that can create the same findings, such as passing a kidney stone, bladder cancer and interstitial cystitis. It’s much more beneficial for clinicians to take a culture that comes back with the specific bacteria so the appropriate antibiotic can be prescribed. If nitrites show up on the culture and the patient has not taken the medication Azo, which is commonly used to treat UTI symptoms, or if the patient or clinician detects a musty odor, in addition to blood in the urine, that makes it more likely the patient has a UTI.
Q: Why is identifying the specific bacteria important?
Hawes: The more we mistreat, undertreat, wrongly treat, overtreat, or partially treat these infections, the more the bacteria become resistant to antibiotics. It’s important that when you give a patient an antibiotic, you insist to the patient that he or she takes the full dose to ensure the bacteria is completely killed, even if the patient says they feel better within a couple of days. It is so important that a urine culture be taken to ensure the patient was treated properly or that if no infection were present, whatever the patient is experiencing gets treated properly.
Q: Are there certain population groups where PCPs should have a higher degree of suspicion regarding UTIs?
Hawes: Elderly women may not be as likely to experience the typical UTI symptoms in the pelvic area that younger patients have. These women often develop mental status changes instead. If a patient or their caregiver comes in describing confusion or ‘not acting right,’ the clinician should obtain a culture to ensure the urine problem is not a UTI. In some elderly women, it may be difficult to obtain a clean catch sample. Consider referring the patient to a urologist for a catheterized sample if this is a concern.
Q: What treatment options are available?
Hawes: Many patients will find that drinking lots of water, urinating frequently, controlling their constipation and getting up to urinate within a half hour of having sex can help prevent UTIs. Any food or beverage with cranberry is good, but if a patient needs to avoid sugar or is on blood thinners, cranberry pills are an option.
Q: When should a PCP recommend a patient with a UTI to a urologist?
Gupta: If UTIs are recurrent or not clearing I would recommend referral to a urologist.
Hawes: Any male with their first UTI, as well as any woman with two or more UTIs in 1 year, or who has gross hematuria and a negative culture, should be referred to a specialist.
Reference: CDC. “Urinary Tract Infection.” Available at: https://www.cdc.gov/antibiotic-use/community/for-patients/common-illnesses/uti.html. Accessed Nov. 27, 2017.
Disclosures: Neither Hawes nor Gupta report any relevant financial disclosures.