Urinary Tract Infection

Urinary tract infection in women, men and catheterised patients

Acute and recurrent urinary tract infection in women

Definition/diagnostic criteria Urinary tract infections (UTIs) in women are typically classified as either lower (cystitis) or upper (pyelonephritis) UTIs. Diagnosis is primarily clinical, supported by laboratory findings. Recurrent UTIs are defined as ≥2 infections in six months or ≥3 in one year.

Epidemiology UTIs are common in women due to shorter urethras facilitating bacterial entry. Approximately 50-60% of women will experience a UTI in their lifetime.

Diagnosis

Clinical features: Symptoms include dysuria, frequency, urgency, and suprapubic pain. In pyelonephritis, fever, flank pain, and systemic symptoms may occur.

Investigations: Urinalysis (dipstick testing) is first-line, detecting nitrites and leukocytes. Culture and sensitivity testing are required for complicated or recurrent cases, in pregnant women or women over the age of 65. STI testing should be considered. Other investigations such as cystoscopy or imaging in secondary care may be appropriate if an underlying cause is suspected.

Criteria for two-week wait cancer referral to urology include

  • Haematuria (non-visible and unexplained) with dysuria or raised white cell count on a blood test, age 60 years and over
  • Haematuria (visible and unexplained) either without urinary tract infection or that persists or recurs after successful treatment of urinary tract infection, age 45 years and over
  • Urinary tract infection (unexplained and recurrent or persistent), age 60 years and over 2ww urology ref

Treatment Empirical antibiotic therapy, guided by local resistance patterns, is standard. First-line options include trimethoprim or nitrofurantoin ( if egfr is 45 mL/min/1.73m2 or more). Treatment is typically for 3 days (7 days in pregnant women).

Offer an immediate antibiotic prescription to pregnant women with asymptomatic bacteriuria. (Antenatal services must be informed if group B streptococcal bacteriuria is identified)

In recurrent cases, prophylactic antibiotics or patient-initiated treatment may be considered.

Preventative measures such as behaviour and personal hygiene should be discussed — topical vaginal oestrogen and antibiotic prophylaxis may be appropriate. Referral should be made if cause is unknown or malignancy suspected.

Prognosis Most acute UTIs respond well to treatment, but recurrent UTIs may require long-term management strategies.

 

Urinary tract infection in men

Definition/diagnostic criteria UTIs in men are less common and often considered complicated. They are diagnosed based on symptoms and confirmed with urinalysis and culture.

Epidemiology The incidence is much lower than in women. UTIs in men are often associated with prostatic enlargement, instrumentation, or sexual activity.

Diagnosis

Clinical features: Similar to women, but may also include rectal pain and symptoms related to prostatitis or epididymitis.

Investigations: Urinalysis, culture, and sensitivity are essential.

Consider a prostate-specific antigen (PSA) test and digital rectal examination to assess for prostate cancer in men with any lower urinary tract symptoms, such as nocturia, urinary frequency, hesitancy, urgency or retention or visible haematuria.

Ultrasound may be indicated to rule out obstructive uropathy.

Treatment Antibiotic choices include trimethoprim or nitrofurantoin (if egfr is 45 mL/min/1.73m2 or more) but duration of therapy is typically longer than in women, often 7-14 days. Nitrofurantoin is not recommended for men with prostate involvement as it is unlikely to reach therapeutic levels in the prostate. Referral to urology is recommended for recurrent cases, if there is a suspicion of upper UTI, or possible underlying risk factor for UTI (e.g. history of renal stones or previous urological surgery).

Prognosis With appropriate treatment, the prognosis is good. However, underlying structural abnormalities must be addressed to prevent recurrence.

 

Urinary tract infection in catheterised patients

Definition/diagnostic criteria Diagnosis in catheterised patients is challenging due to frequent asymptomatic bacteriuria. Diagnosis is based on clinical signs of infection in addition to bacteriuria.

Epidemiology UTIs are the most common infection in catheterised patients. Risk increases with the duration of catheterisation.

Diagnosis

Clinical features: Localised symptoms include pain, discomfort, or purulent discharge at the catheter site. Systemic symptoms may be present.

Investigations: Urine culture from a fresh catheter specimen is recommended. Routine screening in asymptomatic patients is not advised.

Treatment Treatment is guided by culture and sensitivity results. Antibiotic choice and duration depend on severity and patient factors. Catheter position should be checked to ensure it drains correctly and is not blocked. Catheter change may be necessary.

Seek specialist advice if there is a higher risk of developing complications (for example structural or functional abnormalities or a comorbid condition such as immunosuppression), recurrent catheter associated-UTI (CAUTI) or an infection caused by atypical or resistant bacteria.

Prognosis The prognosis varies depending on patient comorbidities and response to treatment. Prevention strategies are crucial in long-term catheterised patients.

Further reading

Published: 30th July 2022 Updated: 16th February 2024

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Nursing in Practice Reference is based on the best-selling book Symptom Sorter. The experts behind Nursing in Practice Reference are Marilyn Eveleigh who is Nursing in Practice’s editorial advisor and a primary care nurse in East Sussex, Dr Keith Hopcroft who is the co-author of Symptom Sorter, a GP in Essex and Pulse editorial advisor and Dr Poppy Freeman, a GP in Camden and also a clinical advisor to Pulse.