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Urinary tract infection
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Highlights
Urinary Tract Infections (UTIs)
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Urinary tract infections (UTIs) are a common type of infection caused by bacteria (most often
E. coli) that travel up the urethra to the bladder. A bladder infection is called cystitis. If
bacterial infection spreads to the kidneys and ureters, the condition is called pyelonephritis.
Cystitis is considered a lower urinary tract infection. Pyelonephritis is an upper urinary tract
infection and is much more serious.
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Women are more susceptible to UTIs than men, and their infections tend to recur. One
reason is that the urethra (the tube that carries urine away from the bladder) is shorter in
women than in men. Frequent sexual intercourse also increases a woman's risk of
developing UTIs. Contraceptive spermicides and diaphragms are additional risk factors.
When women reach menopause, the decrease in estrogen thins the lining of the urinary
tract, which increases susceptibility to bacterial infections.
Pregnancy does not increase the risk of getting a UTI, but it can increase the risk of
developing a serious infection that could potentially harm the mother and fetus. Pregnant
women should report any symptoms of UTIs to their doctors, and should get screened and
treated for asymptomatic bacteriuria (presence of significant numbers of bacteria in the urine
without symptoms).
Pregnancy
Symptoms
Seniors
Symptoms of UTIs may include:
Women
Strong urge to urinate frequently, even immediately after the bladder is emptied
Painful burning sensation when urinating
Discomfort, pressure, or bloating in the lower abdomen
Pain in the pelvic area or back
Cloudy or bloody urine, which may have a strong smell
Fever
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In This Report
• Highlights
• Introduction
• Causes
• Risk Factors
• Complications
• Symptoms
• Diagnosis
• Treatment
• Medications
• Lifestyle Changes
• Resources
• References
Related Reports
• Kidney stones
A urine test can determine if these symptoms are caused by a bacterial infection. Antibiotics are used to treat UTIs. Older people may
have a urinary tract infection but have few or no symptoms.
Treatment
Antibiotics are used to treat UTIs. Most cases of UTIs clear up after a few days of drug treatment, but more severe cases may require
several weeks of treatment.
Guidelines recommend using nitrofurantoin or trimethoprin-sulfamethoxazole as first-line antibiotic treatments for UTIs.
Fluoroquinolones (such as ciprofloxacin) are now only recommended when other antibiotics are not appropriate.
Cranberries for UTI Prevention
Cranberry juice appears to offer little benefit for preventing recurrent UTIs, according to a review by the Cochrane Collaboration. Other
studies have suggested that cranberry products may be helpful by preventing harmful bacteria from attaching and sticking to urinary
tract cells.
Male Circumcision and UTIs
Babies rarely get UTIs but when they do, these infections are much more common in boys than in girls. A recent policy statement from
the American Academy of Pediatrics (AAP), and a review of research studies in the Journal of Urology, indicate that boys who are
circumcised are far less likely to get UTIs during their first year of life than uncircumcised boys. While noting the many potential health
benefits of male circumcision (including reduced risks for acquiring sexually transmitted diseases), the AAP recommends that the
decision to circumcise should be left to parents, in consultation with their child's doctor.
Introduction
A urinary tract infection (UTI) is a condition in which one or more parts of the urinary system (the kidneys, ureters, bladder, and urethra)
become infected. UTIs are among the most common of all bacterial infections and can occur at any time of life. Nearly 95% of cases of
UTIs are caused by bacteria that typically multiply at the opening of the urethra and travel up to the bladder. Much less often, bacteria
spread to the kidney from the bloodstream.
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The male and female urinary tracts are similar except for the length of the urethra.
The Urinary System
The urinary system helps maintain proper water and salt balance throughout the body and also expels urine from the body. It is made
up of the following organs and structures:
The two kidneys, located on each side below the ribs and toward the middle of the back, play the major role in this process.
They filter waste products, water, and salts from the blood to form urine.
Urine passes from each kidney to the bladder through thin tubes called ureters.
Ureters empty the urine into the bladder, which rests on top of the pelvic floor. The pelvic floor is a muscular structure similar to
a sling running between the pubic bone in front to the base of the spine.
The bladder stores the urine. When the bladder becomes filled, the muscle in the wall of the bladder contracts, and the urine
leaves the body via another tube called the urethra. In men the urethra is enclosed in the penis. In women, it leads directly out.
Defense Systems Against Bacteria
Infection does not always occur when bacteria are introduced into the bladder. A number of defense systems protect the urinary tract
against infection-causing bacteria:
Urine functions as an antiseptic, washing potentially harmful bacteria out of the body during normal urination. (Urine is normally
sterile, that is, free of bacteria, viruses, and fungi.)
The ureters join into the bladder in a manner designed to prevent urine from backing up into the kidney when the bladder
squeezes urine out through the urethra.
The prostate gland in men secretes infection-fighting substances.
The immune system defenses and antibacterial substances in the mucous lining of the bladder eliminate many organisms.
In healthy women, the vagina is colonized by lactobacilli, beneficial microorganisms that maintain a highly acidic environment
(low pH) that is hostile to other bacteria. Lactobacilli produce hydrogen peroxide, which helps eliminate bacteria and reduces
the ability of Escherichia coli (E coli) to adhere to vaginal cells. (E coli is the major bacterial culprit in urinary tract infections.)
Types of UTIs
UTIs are generally classified as:
Uncomplicated or complicated, depending on the factors that trigger the infections
Primary or recurrent, depending on whether the infection is occurring for the first time or is a repeat event
Uncomplicated Urinary Tract Infections (UTIs)
Uncomplicated UTIs are due to a bacterial infection, most often caused by E coli. UTIs affect women much more often than men.
Cystitis. Cystitis, or bladder infection, is the most common UTI. It occurs in the lower urinary tract (the bladder and urethra) and nearly
always in women. In most cases, the infection is brief and acute and only the surface of the bladder is infected. Deeper layers of the
bladder may be harmed if the infection becomes persistent, or chronic, or if the urinary tract is structurally abnormal.
Pyelonephritis (Kidney Infection). Sometimes the infection spreads to the upper urinary tract (the ureters and kidneys). This is called
pyelonephritis, or more commonly, a kidney infection.
Click the icon to see an image of the kidney.
Complicated Urinary Tract Infections
Complicated infections, which occur in men and women of any age, are also caused by bacteria but they tend to be more severe, more
difficult to treat, and more likely to recur. They are often the result of:
An anatomical or structural abnormality that impairs the ability of the urinary tract to clear out urine and therefore bacteria
Catheter use in the hospital setting or long-term indwelling catheter in the outpatient setting
Bladder and kidney dysfunction, or kidney transplant (especially in the first 3 months after transplant)
Immunocompromised patient
Recurrences can occur in people with complicated UTI if the underlying structural or anatomical abnormalities are not corrected.
Recurrent Urinary Tract Infections
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Most women who have had an uncomplicated UTI have occasional recurrences. Many of these women get another infection within a
year of the previous one. A much smaller number of women have ongoing, recurrent urinary tract infections, which follow the resolution
of a previous treated or untreated episode.
Recurrence is often categorized as either reinfection or relapse:
Reinfection. Most cases of recurring UTIs are reinfections. A reinfection occurs several weeks after antibiotic treatment has
cleared up the initial episode. It can be caused by the same bacterial strain that caused the original episode or a different one.
The infecting organism is usually introduced through fecal bacteria and moves up through the urinary tract.
Relapse. Relapse is the less common form of recurrent UTI. It is diagnosed when a UTI recurs within 2 weeks of treatment of
the first episode and is due to treatment failure. Relapse usually occurs in kidney infection (pyelonephritis) or is associated with
obstructions such as kidney stones, structural abnormalities or, in men, chronic prostatitis.
Asymptomatic Urinary Tract Infection (Asymptomatic Bacteriuria)
An asymptomatic UTI (also called asymptomatic bacteriuria) is when a person has no symptoms of infection but has a significant
number of bacteria that have colonized the urinary tract. The condition is harmless in most people and rarely persists, although it does
increase the risk for developing symptomatic UTIs.
Screening and treatment of asymptomatic bacteriuria is not usually necessary except for the following people:
Pregnant women. Pregnant women with asymptomatic bacteriuria have an increased risk of acute pyelonephritis in their
second or third trimester. Therefore, they need screening and treatment for this condition. Guidelines recommend that pregnant
women be screened for asymptomatic bacteriuria at 12 to 16 weeks gestation or at the first pre-natal visit, if later.
People undergoing urologic surgery (such as prostate surgery in men). The presence of an infection during surgery can
lead to serious consequences.
Causes
Bacteria that cause UTIs include:
Escherichia (E) coli is responsible for most uncomplicated cystitis cases in women, especially younger women. E coli is
generally a harmless microorganism originating in the intestines. It is usually found in feces (stool). If E. coli spreads to the
vaginal opening, it may invade and colonize the bladder, causing an infection. The spread of E. coli to the vaginal opening most
commonly occurs when women wipe themselves from back to front after urinating, or after sexual activity.
Staphylococcus saprophyticus accounts for 5 to 15% of UTIs, mostly in younger women.
Klebsiella species, Proteus mirabilis, and Enterococci account for most of the remaining bacterial organisms that cause UTIs.
They are generally found in UTIs in older women.
Rare bacterial causes of UTIs include Ureaplasma urealyticum and Mycoplasma hominis, which are typically harmless
organisms.
Organisms in Severe or Complicated Infections
The bacteria that cause kidney infections (pyelonephritis) are generally the same bacteria that cause cystitis. There is some
evidence that the E. coli strains causing pyelonephritis are more virulent (able to spread and cause illness).
Complicated UTIs that are related to physical or structural conditions are generally caused by a wider range of organism. E. coli
is still the most common organism, but others include Klebsiella, Citrobacter species, and P. mirabilis.
Fungal organisms, such as Candida species can cause UTIs. (Candida albicans causes the "yeast infections" that also occur in
the mouth, digestive tract, and vagina.)
Other bacteria associated with complicated or severe infection include Pseudomonas aeruginosa, Enterobacter, and Serratia
species as well as gram-positive organisms (including Enterococci species).
Bacterial Strains in Recurrent UTIs
Recurring infections are often caused by different bacteria than those that caused a previous or first infection.
Acidity and Infection Resistance
Changes in the amount or type of acid within the genital and urinary tracts contribute to lowering the resistance to infection. For
example, beneficial organisms called lactobacilli increase the acidic environment in the female urinary tract and thereby reduce the risk
of infection.
Risk Factors
UTIs are far more common among women than among men. Most women will develop a UTI at some time in their lives, and many will
have recurrences.
Specific Risk Factors in Women
Structure of the Female Urinary Tract
In general, the higher risk in women is mostly due to the shortness of the female urethra, which is 1.5 inches compared to 8 inches in
men. Bacteria from fecal matter at the anal opening can be easily transferred to the opening of the urethra.
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The female and male urinary tracts are similar except for the length of the urethra.
Sexual Activity
Frequent or recent sexual activity is the most important risk factor for UTIs in young women. Nearly 80% of all UTIs in premenopausal
women occur within 24 hours of intercourse. UTIs are very rare in celibate women. However, UTIs are not sexually transmitted
infections.
In general, it is the physical act of intercourse itself that produces conditions that increase susceptibility to the UTI bacteria, with some
factors increasing the risk. For example, women having sex for the first time or who have intense or frequent sex are at risk for a
condition called "honeymoon cystitis."
Click the icon to see an image of a diaphragm.
Certain types of contraceptives can also increase the risk of UTIs. In particular, women who use diaphragms tend to develop UTIs. The
spring-rim of the diaphragm can bruise the area near the bladder, making it susceptible to bacteria. Spermicidal foam or gel used with
diaphragms, and spermicidal-coated condoms, also increase susceptibility to UTIs. Most spermicides contain nonoxynol-9, a chemical
that is associated with increased UTI risk.
Pregnancy
In pregnant women, the presence of asymptomatic bacteriuria is associated with increased risk of kidney infection, which can cause
early labor and other serious pregnancy complications. For this reason, pregnant women should be screened and treated for
asymptomatic bacteriuria. Pregnant women are more susceptible to kidney infection because as the uterus enlarges it compresses the
ureters and bladder. This causes urine to back up into the kidney, increasing the risk of bacterial infection.
Menopause
The risk for UTIs, both symptomatic and asymptomatic, is highest in women after menopause. This is primarily due to decrease in
estrogen, which thins the walls of the urinary tract and reduces its ability to resist bacteria. Estrogen loss can also reduce certain
immune factors in the vagina that help block E. coli from attaching to vaginal cells. For some women, topical estrogen therapy helps
restore healthy bacteria and reduce the risk of recurrent UTIs. (Oral hormone replacement therapy is not helpful for UTIs.)
Other aging-related urinary conditions, such as urinary incontinence, can increase the risk for recurrent urinary tract infections.
Allergies
Women who have skin allergies to ingredients in soaps, vaginal creams, bubble baths, or other chemicals that are used in the genital
area are at increased risk for UTIs. In such cases, the allergies may cause small injuries that can introduce bacteria.
Antibiotic Use
Antibiotics often eliminate lactobacilli, the protective bacteria, along with harmful bacteria. This can cause an overgrowth of E. coli in the
vagina.
Specific Risk Factors in Men
Men become more susceptible to UTIs after age 50, when they begin to develop prostate problems. Benign prostatic hyperplasia
(BPH), enlargement of the prostate gland, can produce obstruction in the urinary tract and increase the risk for infection. In men,
recurrent UTIs are also associated with prostatitis, an infection of the prostate gland. Although UTIs are less common in men, they can
cause more serious problems in men than in women. Men with UTIs are more likely to require hospitalization than women.
Specific Risk Factors in Children
UTIs are rare during infancy but they are much more common in boys than in girls. Boys who are circumcised are far less likely than
uncircumcised boys to develop UTIs by the time they are 1 year old. After the age of 2 years, UTIs are more common in girls. As with
adults, E. coli is the most common cause of UTIs in children.
Vesicoureteral Reflux (VUR)
Vesicoureteral reflux (VUR) is the cause of up to half of the UTIs that occur during childhood. VUR also puts children at risk for UTI
recurrence.
VUR is a condition in which the urine backs up into the kidneys. Normally, urine travels from the kidneys through the ureters, and into
the bladder. When the bladder becomes filled, the muscle in the bladder wall contracts, and the urine leaves the body through another
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tube called the urethra. There is a valve-like mechanism at the point where the ureters join the bladder. The job of these valves is to
keep urine from flowing backward towards the kidneys when the bladder contracts. If the valves do not work well, urine may remain in
the bladder where bacteria can grow. The back flow of urine may also carry any infection from the bladder up into the kidneys.
A child may be:
Born with problems with these valves.
Born with defects in the anatomy of the lower urinary tract that cause reflects.
Have problems with nerve supply or function of the bladder, such as those with spina bifida.
Click the icon to see an image of vesicoureteral reflux.
Catheterization and UTI Risk
Most UTIs that develop in hospitalized people are due to urinary catheters. The longer any urinary catheter is in place, the higher the
risk for growth of bacteria and an infection. In most cases of catheter-induced UTIs, there are no symptoms. However, due to the risk
for wider infection, anyone requiring a catheter should be screened for infection. Catheters should be used only when necessary and
should be removed as soon as possible.
All older adults who are immobilized, catheterized, or dehydrated are at increased risk for UTIs. Nursing home residents, particularly
those who are incontinent, are at very high risk.
Medical Conditions that Increase the Risk of UTIs
Diabetes
Diabetes (type 1 and type 2) puts women at significantly higher risk for asymptomatic bacteriuria. The longer a woman has diabetes,
the higher the risk. Control of blood sugar does not affect the risk for this condition. The risk for UTI complications, and fungal-related
UTIs, is also higher in people with diabetes.
Kidney Problems
Nearly any kidney disorder, including kidney stones, increases the risk for complicated UTIs.
Neurogenic Bladder
A number of brain and nerve disorders can affect the nerves of the bladder and cause problems with the ability to empty the bladder
and control urine leakage. Multiple sclerosis, stroke, spinal cord injury, and diabetic neuropathy are common examples.
Immune System Problems
People with immunocompromised systems, such as those who have HIV/AIDS or who are undergoing treatment for cancer, are at
increased risk for all types of infections, including UTIs and pyelonephritis.
Urinary Tract Abnormalities
Some people have structural abnormalities of the urinary tract that cause urine to stagnate or flow backward into the upper urinary tract.
A prolapsed bladder (cystocele) can result in incomplete urination so that urine collects, creating a breeding ground for bacteria. Tiny
pockets called diverticula sometimes develop inside the urethral wall and can collect urine and debris, further increasing the risk for
infection.
Complications
In most cases, UTIs are annoyances that cause urinary discomfort. However, if left untreated, UTIs can develop into very serious and
potentially life-threatening kidney infections (pyelonephritis) that can permanently scar or damage the kidneys. The infection may also
spread into the bloodstream (called sepsis) and elsewhere in the body.
UTIs in pregnant women pose serious health risks for both mother and child. UTIs that occur during pregnancy have a higher than
average risk of developing into kidney infections. Any pregnant woman who suspects she has a UTI should immediately contact her
doctor. Many doctors recommend that women receive periodic urine testing throughout their pregnancies to check for signs of bacterial
infection.
In some adults, recurrent UTIs may cause scarring in the kidneys, which over time can lead to renal hypertension and eventual kidney
failure. Most of these adults with kidney damage have other predisposing diseases or structural abnormalities. Recurrent UTIs almost
never lead to progressive kidney damage in otherwise healthy women.
Scarring and future kidney problems are concerns for children who experience severe or multiple kidney infections.
Symptoms
Symptoms of lower UTIs usually begin suddenly and may include one or more of the following signs:
The urge to urinate frequently, which may recur immediately after the bladder is emptied.
A painful burning sensation when urinating. If this is the only symptom, then the infection is most likely urethritis, an infection
limited to the urethra.
Discomfort or pressure in the lower abdomen. The abdomen can feel bloated.
Pain in the pelvic area or back.
The urine often has a strong smell, looks cloudy, or contains blood. This is a sign of pyuria, a high white blood cell count in the
urine, and is a very reliable indicator of UTIs.
Occasionally, fever develops.
Symptoms of Severe Infection in the Kidney (Pyelonephritis)
Symptoms of kidney infections tend to affect the whole body and be more severe than those of cystitis (inflammation of the bladder and
ureters). They may include:
Symptoms of lower UTIs that persist longer than a week. Sometimes lower UTI symptoms may be the only signs of kidney
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infection. People at highest risk for such "silent" upper urinary tract infections include people with diabetes, impaired immune
systems, or a history of relapsing or recurring UTIs.
An increased need to urinate at night.
Chills and persistent fever (typically lasting more than 2 days).
Pain in the flank (pain that runs along the back at about waist level).
Vomiting and nausea.
Symptoms of UTIs in Infants and Toddlers
UTIs in infants and preschool children tend to be more serious because they are more likely to involve the kidneys. Older children are
more likely to have lower UTIs and standard symptoms. Infants and young children should always be checked for UTIs if the following
symptoms are present:
A persistent high fever of otherwise unknown cause, particularly if it is accompanied by signs of feeding problems, listlessness
and fatigue.
Painful, frequent, and foul smelling urine. (Parents are generally unable to identify a UTI just by the smell of their child's urine.
Medical tests are needed.)
Cloudy urine. (If the urine is clear, the child most likely has some other ailment, although it is not absolute proof that the child is
UTI-free.)
A recurrence of bedwetting or poor urine control during the day in a child previously had bladder control.
Abdominal and low back pain.
Vomiting and abdominal pain (usually in infants).
Symptoms of UTIs in Older People
The classic lower UTI symptoms of pain, frequency, or urgency and upper tract symptoms of flank pain, chills, and tenderness may be
absent or altered in older people with UTIs.
Symptoms of UTIs that may occur in seniors but not in younger adults include mental changes or confusion, nausea or vomiting,
abdominal pain, or cough and shortness of breath. A preexisting health condition may further confuse the picture and make diagnosis
difficult.
Diagnosis
A doctor can confirm if you have a UTI by testing a sample of your urine. For some younger women who are at low risk of
complications, the doctor may not order a urine test and may diagnose a UTI based on the description of symptoms.
Urine Tests
Urinalysis
A urinalysis is an evaluation of various components of a urine sample. It involves looking at the urine color and clarity, using a special
dipstick to do different chemical testing, and possibly inspecting some of the urine underneath a microscope. A urinalysis usually
provides enough information for a doctor or nurse to start treatment.
Urine Culture
If necessary, the doctor may order a urine culture, which involves incubating and growing the bacteria contained in the urine. A urine
culture can help identify the specific bacteria causing the infection, and determine which type of antibiotics to use for treatment. A urine
culture may be ordered if the urinalysis does not show signs of infection but the doctor still suspects a UTI is causing the symptoms. It
may also be ordered if the doctor suspects complications from the infection.
Clean-Catch Sample
To obtain an untainted urine sample, doctors usually request a so-called midstream, or clean-catch, urine sample. Here are some tips
for providing an accurate sample:
Wash your hands thoroughly, and then wash the penis or vulva and surrounding area four times, with front-to-back strokes,
using a new soapy sponge each time.
Urinate a small amount into the toilet for a few seconds and then stop. (Women should hold open with one hand the folds of the
labia while urinating.)
Position the container to catch the middle portion of the stream. Urinate until the collection cup is halfway full (about 2 ounces).
Remove the cup and urinate the remainder of your flow into the toilet.
Securely screw the container cap in place without touching the inside of the rim and place it where directed. The sample will be
given to the doctor or sent to the laboratory for analysis.
Collection with a Catheter
Some people (small children, elderly people, or hospitalized people) cannot provide a urine sample. In such cases, a catheter may be
inserted into the bladder to collect urine. This is the best method for providing a contaminant-free sample, but it carries a risk of
introducing or spreading infection.
Other Tests
If the infection does not respond to treatment, the doctor may order other tests to determine what is causing symptoms. Imaging tests
such as ultrasound and computed tomography (CT scan) may help identify:
Serious and recurrent cases of pyelonephritis
Structural abnormalities
Obstruction (such as kidney stones) or abscess
Possible obstruction or vesicoureteral reflux in children ages 2 to 24 months
Special Types of X-Rays
Special x-rays can be used to screen for structural abnormalities, urethral narrowing, or incomplete emptying of the bladder:
Voiding cystourethrogram is an x-ray of the bladder and urethra. To obtain a cystourethrogram, a dye, called contrast
material, is injected through a catheter inserted into the urethra and passed through the bladder.
Intravenous pyelogram (IVP) is an x-ray of the kidney. For a pyelogram, the contrast matter is injected into a vein and
eliminated by the kidneys. In both cases, the dye passes through the urinary tract and reveals any obstructions or abnormalities
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on x-ray images.
Click the icon to see an image of a voiding cystourethrogram.
Click the icon to see an image of an intravenous pyelogram.
Cystoscopy
Cystoscopy is used to detect structural abnormalities, interstitial cystitis (painful bladder syndrome), or masses that might not show up
on x-rays during an IVP. The person is given a light anesthetic and the bladder is filled with water. The procedure uses a cystoscope, a
flexible, tube-like instrument that the urologist inserts through the urethra into the bladder.
Click the icon to see an image of cystoscopy.
Blood Cultures
If the person has fever or other signs of a serious infection, the doctor will order blood cultures to determine if the infection has entered
the bloodstream and is threatening other parts of the body.
Ruling Out Conditions with Similar Symptoms
About half of women with symptoms of a UTI actually have some other condition, such as irritation of the urethra, vaginitis, interstitial
cystitis, or sexually transmitted diseases (STDs). Some of these problems may also accompany or lead to UTIs.
Vaginitis
Vaginitis is inflammation of the vagina. It is commonly by a yeast infection (candidiasis) or bacterial infection (vaginosis). Occasionally,
the infection causes frequent urination, mimicking cystitis. The typical symptoms of vaginitis are itching and an abnormal discharge.
Sexually Transmitted Diseases (STDs)
Women with painful urination whose urine does not exhibit signs of bacterial growth in culture may have a STD. The most common
microorganism is Chlamydia trachomatis. Other STDs that may be responsible include gonorrhea and genital herpes.
Interstitial Cystitis
Interstitial cystitis (IC), also known as painful bladder syndrome, is an inflammation of the bladder wall that occurs almost predominantly
in women. Symptoms are very similar to cystitis, but no bacteria are present. Pain during sex is a very common complaint in these
patients, and stress may intensify symptoms.
Kidney Stones
The pain of kidney stones along with blood in the urine can resemble the symptoms of pyelonephritis. However, there are no bacteria
present with kidney stones.
Thinning Urethral and Vaginal Walls: After menopause, the vaginal and urethral walls become dry and fragile; causing pain and
irritation that can mimic a UTI.
Disorders in Children that Mimic UTIs
Problems that might cause painful urination in children include reactions to chemicals in bubble bath, diaper rashes, and infection from
the pinworm parasite.
Prostate Conditions in Men
Prostate conditions, including prostatitis (inflammation of the prostate) and BPH, can cause symptoms similar to UTIs.
Poorly-controlled Diabetes
Excess sugar in the urine can have a diuretic effect, thereby causing frequent urination.
Click the icon to see an image of benign prostatic hyperplasia.
Treatment
Antibiotics are the main treatment for UTIs. A variety of antibiotics are available, and choices depend on many factors, including
whether the infection is complicated or uncomplicated or primary or recurrent. Treatment decisions are also based on the type of
person (man or woman, a pregnant or nonpregnant woman, child, hospitalized or nonhospitalized person, or person with diabetes).
Due to the recent increase of drug-resistant bacteria, a doctor may also select an antibiotic based on the resistance rate in that
geographic area.
Treatment for Uncomplicated UTIs
UTIs can often be successfully treated with antibiotics prescribed over the phone. In such cases, a health professional provides the
people with 3-day antibiotic regimens without requiring an office urine test. This course is recommended only for women who have
typical symptoms of cystitis, who are at low risk for recurrent infection, and who do not have symptoms (such as vaginitis) suggesting
other problems.
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Antibiotic Regimen
Oral antibiotic treatment cures nearly all uncomplicated UTIs, although the rate of recurrence remains high. To prescribe the best
treatment, the doctor should be made aware of any drug allergies of the person.
The following antibiotics are commonly used for uncomplicated UTIs:
A recommended regimen is a 3-day course of trimethoprim-sulfamethoxazole, commonly called TMP-SMX (Bactrim, Septra,
and generic). TMP-SMX combines the antibiotic trimethoprim with a sulfa drug. A single dose of TMP-SMX is sometimes
prescribed in mild cases, but cure rates are generally lower than with 3-day regimens. Allergies to sulfa drugs are common and
may be serious. Therefore another antibiotic may be prescribed for a patient who is sensitive to sulfa drugs.
Another first-line option is nitrofurantoin (Furadantin, Macrobid, Macrodantin, and generic). It is usually taken daily for 5 days.
Fosfomycin (Monurol) is not as effective as other antibiotics but may be used during pregnancy. Resistance rates to this drug
are very low.
Fluoroquinolone antibiotics, also called quinolones, are only recommended for UTIs when other antibiotics cannot be used.
Ciprofloxacin (Cipro, generic) is the quinolone antibiotic most commonly prescribed. Quinolones are usually given over a 3-day
period. Pregnant women should not take these drugs.
Other antibiotics may also be used, including amoxicillin-clavulanate cefdinir, cefaclor, and cefpodoxime-proxetil. These drugs
may be prescribed when other antibiotics are not appropriate. They are usually given in 3 to 7 day regimens.
After a week of antibiotic treatment, most people are free of infection. If the symptoms do not clear up within the first few days of
therapy, doctors generally suggest that women discontinue their antibiotic and provide a urine sample for culturing in order to identify
the specific organism causing the condition.
It should be noted that resistance to many of the commonly used antibiotics is growing.
Treatment for Relapsing Infection
A relapsing infection (caused by treatment failure) occurs within 3 weeks in about 10% of women. Relapse is treated similarly to a first
infection, but the antibiotics are usually continued for 7 to 14 days. Relapsing infections may be due to structural abnormalities,
abscesses, or other problems that may require surgery. Such conditions should be ruled out.
Treatment for Recurrent Infections
Women who have 2 or more symptomatic UTIs within a 6-month period, or 3 or more episodes over the course of a year, may need
preventive antibiotics. All women should use lifestyle measures to prevent recurrences.
Intermittent Self Treatment
Many, if not most, women with recurrent UTIs can effectively self-treat recurrent UTIs without going to a doctor. In general, this requires
the following steps:
As soon as the person develops symptoms, she takes the antibiotic. Infections that occur less than twice a year are usually
treated as if they were an initial attack, with single-dose or 3-day antibiotic regimens.
In some cases, she also performs a clean-catch urine test before starting antibiotics and sends it to the doctor for culturing to
confirm the infection.
A woman should consult a doctor under the following circumstances:
If symptoms have not gone away within 48 hours
If there is a change in symptoms
If the person suspects that she is pregnant
If the person has more than 4 infections a year
Women who are not good candidates for self-treatment are those with impaired immune systems, previous kidney infections, structural
abnormalities of the urinary tract, or a history of infection with antibiotic-resistant bacteria.
Postcoital Antibiotics
If recurrent infections are clearly related to sexual activity and episodes recur more than two times within a 6-month period, a single
preventive dose taken immediately after intercourse is effective. Antibiotics for such cases include TMP-SMX, nitrofurantoin,
cephalexin, or a fluoroquinolone (such as ciprofloxacin). (Fluoroquinolones are not appropriate during pregnancy.)
Continuous Preventive Antibiotics (Prophylaxis)
Continuous preventive (prophylactic) antibiotics are an option for some women who do not respond to other measures. With this
approach, low-dose antibiotics are taken continuously for 6 months or longer.
Treatment for Kidney Infections (Pyelonephritis)
People with uncomplicated kidney infections (pyelonephritis) may be treated at home with oral antibiotics. Ciprofloxacin (Cipro, generic)
or another fluoroquinolone is typically given but other antibiotics, such as trimethoprim-sulfamethoxazole (TMP-SMX), may be used.
People with moderate-to-severe acute kidney infection and those with severe symptoms or other complications may need to be
hospitalized. In such cases, antibiotics are usually given intravenously for several days. Chronic pyelonephritis may require long-term
antibiotic treatment.
Treatments for Specific Populations
Treating Pregnant Women
Pregnant women should be screened for UTIs, since they are at high risk for UTIs and their complications. Antibiotics used for treating
pregnant women with UTIs include amoxicillin, ampicillin, nitrofurantoin, and cephalosporins. Fosfomycin (Monurol) is not as effective
as other antibiotics but is sometimes prescribed for pregnant women. In general, there is no consensus on which antibiotic is best for
pregnant women although some types of antibiotics, such as fluoroquinolones and tetracyclines, should not be taken as they can cause
harm to the fetus.
Pregnant women with asymptomatic bacteriuria (evidence of infection but no symptoms) have an increased risk for acute pyelonephritis
in their second or third trimester. They need screening and treatment for this condition. In such cases, they should be treated with a
short course of antibiotics (3 to 5 days). For an uncomplicated UTI, pregnant women may need longer-term antibiotics (7 to 10 days).
Treating Children with UTIs
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Children with UTIs are generally treated with TMP-SMX, cephalexin (Keflex, generic) and other cephalosporins, or
amoxicillin/clavulanic acid (Augmentin, generic). These drugs are usually taken by mouth in either liquid or pill form. Doctors sometimes
give them as a shot or IV. Children usually respond to treatment within a few days. Prompt treatment with antibiotics may help prevent
renal scarring.
Vesicoureteral reflux (VUR) is a concern for children with UTIs. (See Risk Factors section in this report.) VUR can lead to kidney
infection (pyelonephritis), which can cause kidney damage. If the reflux of urine is not severe, the child has a good chance of growing
out of this problem without any damage to the kidneys. The two treatment options for children with VUR that is more severe or has
caused infections are long-term antibiotics to prevent infections or surgery to correct the condition. However, there is debate as to the
benefit of these approaches. Current guidelines advise that antibiotics do not really help prevent recurrent UTIs in children, and that
VUR itself may not substantially increase the risk for recurrent UTI.
Children with acute kidney infection are treated with various antibiotics including oral cefixime (Suprax) or a short course (2 to 4 days)
of an intravenous (IV) antibiotic (typically gentamicin, given in one daily dose). An oral antibiotic then follows the IV.
Management of Catheter-Induced Urinary Tract Infections
Catheter-induced UTIs are very common, and preventive measures are extremely important. In-dwelling catheters should not be used
unless absolutely necessary and they should be removed as soon as possible. Long-term catheter use is associated with increased risk
for infections. For men, condom catheters may be an alternative to indwelling catheters.
Daily Hygiene
A typical catheter comes pre-connected and sealed, and uses a drainage bag system. To prevent infection, some of the following tips
may be helpful:
Drink plenty of fluids.
Make sure the catheter tube is free of any knots or kinks.
Clean the catheter and the area around the urethra with soap and water daily and after each bowel movement. (Women should
be sure to clean front to back.)
Wash hands before touching the catheter or surrounding area.
Never disconnect the catheter from the drainage bag without careful instructions from a health professional on strict methods for
preventing infection.
Keep the drainage bag off the floor.
Stabilize the bag against the leg using tape or some other system.
Antibiotics for Catheter-Induced Infections
People using catheters who develop UTIs with symptoms should be treated for each episode with antibiotics and the catheter should be
removed, if possible, or changed. A major problem in treating catheter-related UTIs is that the organisms involved are constantly
changing. Because there are likely to be multiple species of bacteria, doctors generally recommend an antibiotic that is effective against
a wide variety of microorganisms.
Although high bacteria counts in the urine (bacteriuria) occur in most catheterized people, administering antibiotics to prevent a UTI is
rarely recommended. Many catheterized people do not develop symptomatic UTIs even with high bacteria counts. If bacteriuria occurs
without symptoms, antibiotic therapy has little benefit if the catheter is to remain in place for a long period.
Catheterization is accomplished by inserting a catheter (a hollow tube, often with an inflatable balloon tip) into the urinary bladder. This
procedure is performed for urinary obstruction, following surgical procedures to the urethra, in unconscious people (due to surgical
anesthesia or coma), or for any other problem in which the bladder needs to be kept empty (decompressed) and urinary flow ensured.
Medications
Although antibiotics are the first treatment choice for UTIs, antibiotic-resistant strains of E. coli, the most common cause of UTIs, are
increasing worldwide. As more bacteria have become resistant to the standard UTI treatment TMP-SMX, the antibiotics nitrofurantoin
and fosfomycin have become alternative first-line choices for drug therapy.
Below are some of the antibiotic classes used most commonly to treat UTIs.
Trimethoprim-Sulfamethoxazole (TMP-SMX)
The typical treatment for an uncomplicated UTI is a 3-day course of the combination drug trimethoprim-sulfamethoxazole, commonly
called TMP-SMX (Bactrim, Septra, and generic). A 1-day course is somewhat less effective but poses a lower risk for side effects.
Longer courses (7 to 10 days) work no better than the 3-day course and have a higher rate of side effects.
TMP-SMX should not be used in people who are allergic to sulfa drugs. Allergic reactions can be very serious. Trimethoprim (Proloprim
or Trimpex) is sometimes used alone in those allergic to sulfa drugs. TMP-SMX can interfere with the effectiveness of oral
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contraceptives. High rates of bacterial resistance to TMP-SMX exist in many parts of the United States.
Nitrofurantoin
Nitrofurantoin (Furadantin, Macrodantin, Macrobid, and generic) is an antibiotic that is used specifically for UTIs as an alternative to
TMP-SMX. It is usually taken twice a day for 5 days. It is not useful for treating kidney infections. Nitrofurantoin frequently causes
stomach upset and interacts with many drugs. Other chronic or serious medical conditions may also affect its use. It should not be used
in pregnant women within 1 to 2 weeks of delivery, in nursing mothers, or in those with kidney disease.
Fosfomycin
The antibiotic fosfomycin (Monurol) may be prescribed as a 1-dose treatment for women who are pregnant or for other select people. In
general, it is less effective for treating UTIs than TMP-SMX or nitrofurantoin.
Beta-Lactams
Beta-lactam antibiotics share common chemical features and include penicillin, cephalosporins, and some newer drugs.
Penicillin
Until recent years, the standard treatment for a UTI was 10 days of amoxicillin, a penicillin antibiotic, but it is now ineffective against E.
coli bacteria in many cases. A combination of amoxicillin-clavulanate (Augmentin) is sometimes given for drug-resistant infections.
Cephalosporins
Antibiotics known as cephalosporins are alternatives for infections that do not respond to standard treatments or for special
populations. They are often classed as first, second, or third generation. Cephalosporins used for treatment of UTIs include cephalexin
(Keflex, generic), cefadroxil (Duricef, generic), cefuroxime (Ceftin, generic), loracarbef (Lorabid), and cefixime (Suprax), among others.
Other Beta-Lactam Drugs
Other beta-lactam antibiotics have been developed. For example, pivmecillinam (a form of mecillinam), is commonly used in Europe for
UTIs. It is not available in the United States.
Fluoroquinolones (Quinolones)
Fluoroquinolones (also simply called quinolones) were formerly used as alternatives to TMP-SMX but they are now recommended for
UTIs only when other antibiotics are not appropriate. Fluoroquinolones are effective for treating acute kidney infections (pyelonephritis).
Examples of quinolones include ofloxacin (Floxacin, generic), ciprofloxacin (Cipro, generic), and levofloxacin (Levaquin, generic).
These drugs can have severe side effects that the person should discuss with the doctor.
Pregnant women should not take fluoroquinolone antibiotics. They also have more adverse effects in children than other antibiotics and
should not be the first-line option in most pediatric situations.
Other Antibiotics Used for UTIs
Doripenem
Doripenem (Doribax) is a newer carbapenem antibiotic, which is used to treat complicated UTIs. It is given by injection.
Tetracyclines
Tetracyclines include doxycycline, tetracycline, and minocycline. They may be used for UTIs caused by Mycoplasma or Chlamydia.
Side effects include skin reactions to sunlight and tooth discoloration. Tetracyclines cannot be taken by children or pregnant women.
Aminoglycosides
Aminoglycosides include gentamicin, tobramycin, and amikacin. They are given by injection for very serious bacterial infections. They
can be given only in combination with other antibiotics. Gentamicin is the most commonly used aminoglycoside for severe UTIs. They
can have very serious side effects, including damage to hearing, sense of balance, and kidneys.
Medications for Treating Symptoms
Although antibiotics can cure most UTIs, severe symptoms can persist for several days until the drug eliminates the bacteria. Other
medications may be used for relieving symptoms until the antibiotics take action.
Phenazopyridine
Phenazopyridine (Pyridium, Uristat, AZO Standard, Urodol, and generic) relieves pain and burning caused by the infection. People
should not take this medicine for more than 2 days.
Side effects include headache and upset stomach. The drug turns urine a red or orange color, which can stain fabric and be difficult to
remove. Rarely, it can cause serious side effects, including shortness of breath, a bluish skin, a sudden reduction in urine output,
shortness of breath, and confusion. In such cases, people should immediately call the doctor.
Antispasm Drugs
Methenamine (Urised, Cystex, and generic) or flavoxate (Urispas, generic) reduce bladder spasms, which may occur with some UTIs.
However, these drugs can have severe side effects, which the person should discuss with the doctor.
Lifestyle Changes
Although there is no evidence that good hygiene makes a real difference in preventing UTIs, it is always a wise practice. The following
are some hygiene tips for women:
Clean the genital and urinary areas from front to back with soap and water after each bowel movement.
Avoid tight-fitting pants.
Wear cotton-crotch underwear and panty hose, changing both at least once a day. (Mild detergents are best for washing
underwear.)
Take showers rather than baths.
Avoid bath oils, feminine hygiene sprays, douches, and powders. As a general rule, do not use any product containing perfumes
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or other possible allergens near the genital area. Douching is never recommended as it may irritate the vagina and urethra and
increase the risk of sexually transmitted diseases (STDs).
Choose sanitary napkins instead of tampons (which some doctors believe encourage infection). Napkins and tampons, in any
case, should be changed after each urination.
Drink plenty of fluids and urinate frequently.
Appropriate hygiene and cleanliness of the genital area may help reduce the chances of introducing bacteria through the urethra.
Females are especially vulnerable to this, because the urethra is in close proximity to the rectum. The genitals should be cleaned and
wiped from front to back to reduce the chance of dragging E. coli from the rectal area to the urethra.
Sexual Precautions
Sexual intercourse is one of the most common risk factors for uncomplicated UTIs in women. In addition to abstaining from sex while
you have a UTI, the following recommendations may reduce the risks from sexual activity:
Keep the genital and anal areas clean before and after sex. Urinate before and after intercourse to empty the bladder and
cleanse the urethra of bacteria.
Discuss with your doctor contraceptive alternatives to the spermicides used with condoms and diaphragms.
Avoid sex with multiple partners. This can cause many health problems, including STDs.
Cranberries, Blueberries, and Lignonberries
Cranberries, blueberries, and lignonberry (European relative of the cranberry), are three fruits that appear to have protective properties
against urinary tract infections. These fruits contain compounds called tannins (or proanthocyanadins). Tannins may prevent E. coli
from adhering to cells in the urinary tract, thereby inhibiting infection.
Cranberry juice is the best-studied home remedy for UTIs. Many studies have indicated that cranberry juice may help decrease the
number of symptomatic UTIs, especially for women with recurrent urinary tract infections. However, other studies and reviews suggest
that cranberries provide little benefit.
It is not clear what the optimum dosage is for cranberries, or whether it is best to use juice or tablet form although some studies suggest
that drinking juice is more effective than taking tablets. Some research recommends drinking at least 1 to 2 cups of cranberry juice daily
or taking at least 300 to 400 mg in tablet form twice daily.
Probiotics and Lactobacilli
Probiotics are beneficial microorganisms that may protect against infections in the genital and urinary tracts. The best-known probiotics
are the lactobacilli strains, such as Lactobacillus acidophilus, which is found in yogurt and other fermented milk products (kefir), as well
as in dietary supplement capsules. The probiotics bifidobacteria and GG lactobacilli may also be helpful. Studies do not conclusively
show a benefit for probiotics in preventing UTIs. More research is needed.
Resources
www.kidney.niddk.nih.gov -- National Kidney and Urologic Diseases Clearinghouse
www.urologyhealth.org -- Urology Care Foundation
www.acog.org -- American College of Obstetricians and Gynecologists
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Review Date: 3/28/2016
Reviewed By: Scott Miller, MD, urologist in private practice in Atlanta, GA. Also reviewed by David Zieve, MD, MHA, Isla Ogilvie, PhD, and the A.D.A.M. Editorial team.
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