Archives: UTI Info Accordion

This is the UTI Info Accordion post type

Common triggers

  • Baths – sometimes an unclean bath can harbour bacteria.
  • Bubble bath/bath creams and bath bombs can also cause issues.
  • Swimming pools – caustic chlorine can irritate the urethra and bladder. If the water looks cloudy, chemicals may only recently have been added
  • Public hot tubs/jacuzzis – these can be a breeding ground for bacteria as they are not regularly cleaned and sterilised
  • Condoms lubricated with spermicide – these can lead to an increase in UTIs.  Find out more about Contraception and UTI.
  • Scented toilet paper – chemicals can cause vaginal, vulval and urethral irritation
  • Douching – will upset the natural balance of vaginal secretions and can lead to bacterial vaginosis/thrush/vaginal bacterial infections
  • Underwear made of synthetic materials. Thongs are also known to cause UTI issues due to the proximity of the string to the anus (back passage) and bacterial transfer between anus and vaginal and urethral openings
  • Tight jeans – can cut blood supply to urogenital tissues and rub along the urethral entrance
  • Scented washing powders and fabric softeners – chemicals can cause vaginal, vulval and urethral irritation
  • Coffee and tea – a diuretic due to caffeine. Find out more about diet and drink
  • Cranberry juice/fruit juices – these are acidic and can cause irritation
  • Carbonated drinks – carbonic acid can be a bladder irritant and fizzy or sparkling water contains dissolved carbon dioxide which results in an acidic solution and may increase urinary urgency.  These also contain caffeine which may make any symptoms of urgency or frequency worse.
  • Chocolate – In general, chocolate with high cocoa content such as dark or bitter chocolate may lead to reactions due to the biogenic amine content. White chocolate usually is better tolerated. To produce white chocolate, the cocoa mass is deprived its cocoa powder. Only the cocoa butter is used. Milk constituents and sugar is then usually added. White chocolate contains less biogenic amines, as only the cocoa butter is used.
  • Alcohol – due to the fermentation process and in some cases high tannin levels which can cause histamine problems.  It can also increase the acidity level of your urine and irritate the bladder lining

How big a problem is there with UTI infections?

  • Urinary tract infection is one of the most common human bacterial infections with over 150 million people worldwide affected each year. (xiii)
  • The global burden of this disease is rising – 16.1% increase in age-standardised incidence between 1990 and 2013. With 58,000 years lost to disability (YLD) in 2003 alone (xiv)
  • 1.7 million women in the UK and a significant number of men and children suffer from Chronic Lower Urinary Tract symptoms (xv)
  • Around 70% of those who experience an acute UTI will find their symptoms resolve with short course antibiotic treatment. However a further 30% will not achieve symptom resolution. (xvi)
  • Approximately one in four people with a previous history of UTI will develop either recurrent or Chronic UTI (xvii)
  • In one study, 93% of women diagnosed with Interstitial Cystitis or Bladder Pain Syndrome had a previous diagnosis of UTI but were told their urine culture was negative

References

(i) Paul Little, Kate Rumsby, Rachel Jones, Greg Warner, Michael Moore, J Andrew Lowes, Helen Smith, Catherine Hawke, Geraldine Leydon and Mark Mullee Validating the prediction of lower urinary tract infection in primary care: sensitivity and specificity of urinary dipsticks and clinical scores in women
British Journal of General Practice 2010; 60 (576): 495-500. DOI: https://doi.org/10.3399/bjgp10X514747

(ii) Sathiananthamoorthy, S., et al., Reassessment of Routine Midstream Culture in Diagnosis of Urinary Tract Infection. J Clin Microbiol, 2018.

Mambatta AK, Jayarajan J, Rashme VL, Harini S, Menon S, Kuppusamy J. Reliability of dipstick assay in predicting urinary tract infection. J Family Med Prim Care. 2015 Apr-Jun;4(2):265-8. doi: 10.4103/2249-4863.154672. PMID: 25949979; PMCID: PMC4408713

Gill, K., et al., A blinded observational cohort study of the microbiological ecology associated with pyuria and overactive bladder symptoms. Int Urogynecol J, 2018.
00. Khasriya and Malone-Lee. The Inadequacy of Urinary Dipstick and Microscopy as Surrogate Markers of Urinary Tract Infection in Urological Outpatients with Lower Urinary Tract Symptoms Without Acute Frequency and Dysuria. Journal of Urololgy. 2010 183(5): 1843–1847

Swamy, Gorny and Malone-Lee. Fallacies and Misconceptions in Diagnosing Urinary Tract Infection. July 2014 futuremedicine.com. https://doi.org/10.2217/fmeb2013.13.276

(iii) Khasriya R, Khan S, Lunawat R, et al. The Inadequacy of Urinary Dipstick and Microscopy as Surrogate Markers of Urinary Tract Infection in Urological Outpatients With Lower Urinary Tract Symptoms Without Acute Frequency and Dysuria. JUrol. 2010;183(5):1843-1847.  https://www.ncbi.nlm.nih.gov/pubmed/20303096

(iv) Sathiananthamoorthy, S., et al., Reassessment of Routine Midstream Culture in Diagnosis of Urinary Tract Infection. J Clin Microbiol, 2018.

Gill, K., et al., A blinded observational cohort study of the microbiological ecology associated with pyuria and overactive bladder symptoms. Int Urogynecol J, 2018.
00. Khasriya and Malone-Lee. The Inadequacy of Urinary Dipstick and Microscopy as Surrogate Markers of Urinary Tract Infection in Urological Outpatients with Lower Urinary Tract Symptoms Without Acute Frequency and Dysuria. Journal of Urololgy. 2010 183(5): 1843–1847

Swamy, Gorny and Malone-Lee. Fallacies and Misconceptions in Diagnosing Urinary Tract Infection. July 2014 futuremedicine.com. https://doi.org/10.2217/fmeb2013.13.276

(v) Gill K, Kang R, Sathiananthamoorthy S, Khasriya R, Malone-Lee J. A blinded observational cohort study of the microbiological ecology associated with pyuria and overactive bladder symptoms. Int Urogynecol J. 2018. Epub 2018/02/20. doi: 10.1007/s00192-018-3558-x. PubMed PMID: 29455238.

Khasriya R, Sathiananthamoorthy S, Ismail S, Kelsey M, Wilson M, Rohn JL, et al. Spectrum of bacterial colonization associated with urothelial cells from patients with chronic lower urinary tract symptoms. J Clin Microbiol. 2013;51(7):2054-62.

Thomas-White K, Forster SC, Kumar N, Van Kuiken M, Putonti C, Stares MD, et al. Culturing of female bladder bacteria reveals an interconnected urogenital microbiota. Nature communications. 2018;9(1):1557. Epub 2018/04/21. doi: 10.1038/s41467-018-03968-5. PubMed PMID: 29674608; PubMed Central PMCID: PMCPMC5908796.

Brubaker L, Wolfe AJ. The Female Urinary Microbiota/Microbiome: Clinical and Research Implications. Rambam Maimonides medical journal. 2017;8(2). Epub 2017/05/04. doi: 10.5041/rmmj.10292. PubMed PMID: 28467757; PubMed Central PMCID: PMCPMC5415361.

Price TK, Hilt EE, Dune TJ, Mueller ER, Wolfe AJ, Brubaker L. Urine trouble: should we think differently about UTI? Int Urogynecol J. 2017. Epub 2017/12/28. doi: 10.1007/s00192-017-3528-8. PubMed PMID: 29279968.

Price TK, Dune T, Hilt EE, Thomas-White KJ, Kliethermes S, Brincat C, et al. The Clinical Urine Culture: Enhanced Techniques Improve Detection of Clinically Relevant Microorganisms. J Clin Microbiol. 2016;54(5):1216-22. doi: 10.1128/JCM.00044-16. PubMed PMID: 26962083.

Hilt EE, McKinley K, Pearce MM, Rosenfeld AB, Zilliox MJ, Mueller ER, et al. Urine is not sterile: use of enhanced urine culture techniques to detect resident bacterial flora in the adult female bladder. J Clin Microbiol. 2014;52(3):871-6. Epub 2013/12/29. doi: 10.1128/jcm.02876-13. PubMed PMID: 24371246; PubMed Central PMCID: PMCPMC3957746.

Brubaker L, Nager CW, Richter HE, Visco A, Nygaard I, Barber MD, et al. Urinary bacteria in adult women with urgency urinary incontinence. International urogynecology journal. 2014;25(9):1179-84. doi: 10.1007/s00192-013-2325-2. PubMed PMID: PMC4128900.

Pearce MM, Hilt EE, Rosenfeld AB, Zilliox MJ, Thomas-White K, Fok C, et al. The female urinary microbiome: a comparison of women with and without urgency urinary incontinence. mBio. 2014;5(4):e01283-14. Epub 2014/07/10. doi: 10.1128/mBio.01283-14. PubMed PMID: 25006228; PubMed Central PMCID: PMCPmc4161260.

Wolfe AJ, Toh E, Shibata N, Rong R, Kenton K, Fitzgerald M, et al. Evidence of uncultivated bacteria in the adult female bladder. J Clin Microbiol. 2012;50. doi: 10.1128/jcm.05852-11.

Sathiananthamoorthy S. PhD The microbiology of chronic lower urinary tract symptoms. UCL: UCL; 2016.

(vi) Price et al. The Clinical Urine Culture: Enhanced Techniques Improve Detection of Clinically Relevant Microorganisms. Journal of Clinical Microbiology. May 2016 (54) 5

Hooton, T.M.; Roberts, P.L.; Cox, M.E.; Stapleton, A.E. Voided midstream urine culture and acute cystitis in premenopausal women. N. Engl. J. Med. 2013, 369, 1883–1891

(vii) Urinary tract infections in adults Quality standard [QS90] Published date: February 2023

(viii) https://cks.nice.org.uk/urinary-tract-infection-lower-women#!scenario:2

(ix) The Pulse 24/05/2017

(x) Price TK, Dune T, Hilt EE, Thomas-White KJ, Kliethermes S, Brincat C, et al. The clinical urine culture: enhanced techniques improve detection of clinically relevant microorganisms. J Clin Microbiol. 2016;54(5):1216–22

Ross A. Lawrenson, John W. Logie, Antibiotic failure in the treatment of urinary tract infections in young women, Journal of Antimicrobial Chemotherapy, Volume 48, Issue 6, December 2001, Pages 895–901, https://doi.org/10.1093/jac/48.6.895

(xi) Subinhibitory Antibiotic Therapy Alters Recurrent Urinary Tract Infection Pathogenesis through Modulation of Bacterial Virulence and Host Immunity Lee W Goneau, Thomas J Hannan, Roderic A MacPhee, Drew J Schwartz, Jean M Macklaim, Gregory B Gloor, Hassan Razvi, Gregor Read, Scott J Hultgren, Jeremy P Burton doi: 10.1128/mBio.00356-1531 March 2015 mBio vol. 6 no. 2 e00356-15

Sub-lethal antibiotic treatment leads to multidrug resistance via radical-induced mutagenesis: Michael A. Kohanski, Mark A. DePristo, and James J. Collins 2010 https://doi.org/10.1016/j.molcel.2010.01.003

(xii)  Diagnosis and Treatment Interstitial Cystitis/Bladder Pain Syndrome, American Urological Association Published 2011; Amended 2014

(xiii) Urinary tract infections: epidemiology, mechanisms of infection and treatment options, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4457377/

(ixv) Global Burden of Disease Study 2013 Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2015 Aug 22;386(9995):743-800. doi: 10.1016/S0140-6736(15)60692-4.

(xv) UK figures based on Rand Interstitial Cystitis Epidemiology Study 2010

(xvi) Katchman, EA, Milo G, Paul M et al. Three-day vs. longer duration of antibiotic treatment for cystitis in women: systematic review and meta-analysis. Am J Med 2005; 118(11): 1196-207

(xvii) Chieng, Catherine C.Y. et al. The clinical implications of bacterial pathogenesis and mucosal immunity in chronic urinary tract infection Mucosal Immunology, Volume 16, Issue 1, 61 – 71

What affects the accuracy of the urine test?

Key factors that also affect these poor results include:

  • Research carried out in the 1950s remains the global diagnostic basis for interpreting a urine culture. Lab results must show bacterial counts of a level of more than 100,000 colony forming units of bacteria per millilitre of cultured urine to acknowledge infection. Any counts below this arbitrary, inflexible level are usually considered to indicate contamination of the sample but some studies show that a third or more of symptomatic women have counts below this level. Other studies suggest that there should be different thresholds for different bacteria, since not all grow at the same speed in the same medium.
  • This contamination will lead to the ‘mixed growth’, ‘low growth’ or ‘no significant growth’ noted on the laboratory report that people often receive via their GP surgery on return of the urine culture analysis. Indeed 1 in 4 samples in a GP setting are returned as contaminated.
  • However should these samples be rejected? – given the knowledge around the twinned vaginal and urinary microbiome and the potential for co-infections – these contaminated samples should be considered more closely. These low count bacteria are not contaminants and may well be contributors to the infection, as in some cases infections can be polymicrobial.
  • Researchers and specialist clinicians have recently found using enhanced microbial testing resources that chronic UTIs can be polymicrobial – caused by several different types of bacteria. This means the bacteria identified in your UTI may well be different to that found in others and can explain why people experience differing symptoms. However, if two or more bacteria are grown in a sample, microbiological guidelines direct that these results are noted as “mixed growth”. This is reported back to the GP with a recommendation of insufficient evidence of confirmed infection. Someone with a multi-bacterial infection can thus be denied treatment on receipt of these results from their GP.
  • Overwhelming evidence shows the tests used to detect urinary tract infections diagnose an extremely limited number of pathogens, favouring E.coli and other easy-to-grow microbes which develop quickly on laboratory culture within the window of analysis of around 18 hours. (v) This approach is effective in simple and uncomplicated UTI situations. However, this leaves a gap in identification of slow growing bacteria especially if a UTI is being caused by multiple bacteria in the urinary tract. Some bacteria can take up to 5 days to grow in laboratory culture. 80% of infections outside of a hospital environment are attributed to E-coli infections
  • The standard urine culture is selective for typical microorganisms most commonly responsible for urinary tract infections, including Escherichia coli, Staphylococcus Saprophyticus, Klebsiella pneumoniae, and Proteus mirabilis. However this laboratory culture is highly sensitive towards E.coli because of its ease of growth but detect as little as 12% of other clinically significant species (e.g., gram-positive bacteria; Enterococci and Group B streptococci). It has been demonstrated that the positive predictive value of midstream urine cultures was 93% and 99% for Escherichia coli growth of at least 102 CFU and 104 CFU, respectively, but the positive predictive value was 10% and 33% for Enterococci growth and 8 and 14% for Group B streptococci growth of at least 102 CFU and 104 CFU, respectively (vi) which leads onto the laboratory environment itself.
  • Bacterial species react differently to an oxygenated environment.  The bacteria residing in your bladder have a limited oxygen source but when a urine sample is placed on a petri dish in the laboratory, the oxygen they are exposed to increases. This means that bacteria which flourish beneficially in this type of environment will grow and those that prefer the ecosystem and oxygen levels of the bladder will grow in limited numbers and are often dismissed as contamination. Therefore, it is not an applicable test when there is a high clinical suspicion for UTI caused by atypical organisms.
  • These clinically slow-growing significant species have been less studied than E.coli over preceding years but with recent research showing that infections can be multi-bacterial, focus is now moving to these alternative bacteria and their potential role in urine infections. A study from 2013 published in The American Journal of Microbiology notes “the bacteria we isolated from our LUTS patients, while known uropathogens, were not limited to species typically found in acute UTIs”. Indeed in another study that analysed 157,000 urine samples using a different technology, E.coli was the dominant species in only 28% of cases.
  • Usage of previous antibiotics to treat a recent infection. Ideally you need to be off antibiotics for around 7-10 days to clear the medication from your system before providing another urine sample. Usage of antibiotics may inhibit bacterial growth even if you still have symptoms.
  • The standard urine culture also does not pick up on viral or fungal causes of infection, which have been proven to be the cause for certain symptomatic patients with negative culture tests, even in patients that are not immunocompromised.
  • As with dipsticks, biofilm or embedded bladder wall infections mean that the bacteria are embedded and hidden away from the urine, not floating in it. This means when you urinate, the bacteria will not transfer into the sample pot thus meaning they cannot be detected during urine analysis in the laboratory.
  • There is limited primary care knowledge around this relatively new multi bacterial science, embedded bladder wall/biofilm infections and the failings of standard mid-stream cultures to diagnose a UTI. Focus remains on the identification of one pure bacterium, usually E.coli, from the laboratory analysis to direct treatment.

What affects the accuracy of the dipstick test?

Factors affecting the accuracy of dipsticks and thus diagnosis of a UTI based on the guidelines above may include:

  • Dilution of the sample by drinking too much liquid (the first urination of the day when you wake up or acidic, concentrated urine is best for analysis). GPs fail to advise patients to wait at least four hours before providing a sample.
  • Usage of previous antibiotics to treat a recent infection. Ideally you need to be off antibiotics for around 7-10 days to clear the medication from your system before providing another urine sample. This is because the continuation of the medication in your system may inhibit bacterial growth even if you still have symptoms.
  • Certain bacterial strains not producing nitrate reductase which converts urinary nitrates to nitrite – as noted above this is a key part of the dipstick analysis to determine a UTI.
  • Various chemicals may also interfere with urine dipstick analysis producing a false negative result. These include ascorbic acid (such as vitamin C) and oxalic acid (an organic compound found in many plants including leafy greens, vegetables, fruits, cocoa, nuts and seeds).
  • Biofilm or embedded bladder wall infections mean that the bacteria are hidden away from the urine, not floating in it. Thus when you urinate, the bacteria will not transfer into the sample pot meaning they cannot be detected on a dipstick.

Other Lower Urinary Tract Symptom Causes

Other causes of lower urinary tract symptoms can include:

Upper UTI Symptoms

Some or all of these symptoms may occur:

  • upper back and side (flank) pain
  • high fever
  • shaking and chills
  • nausea
  • vomiting
  • blood or pus in the urine

Lower UTI Symptoms

Some or all of these symptoms may occur:

  • A frequent and pressing urge to pass urine, while only being able to void small amounts of urine
  • A hesitant or intermittent flow of urine
  • A need to pass urine many times a day – this can rise to 4-6 times an hour on bad days
  • Pain, usually burning or stinging, when passing urine (known as dysuria) in the bladder or urethra
  • Having to get up several times in the night to go to the toilet
  • Cloudy urine or blood in the urine (haematuria)
  • A strong, sweet or “fishy” smell to the urine – bacteria can change the odour of urine
  • For women, pain and inflammation across the pubic bone, pelvic floor and lower abdomen. Pain may radiate into the vagina or along the vulva.
  • For men, pain and inflammation radiating into the rectum. Pain may travel down the legs as well.
  • A pressure sensation in the lower abdomen and pelvis – due to the inflammation of the bladder pressing against the other pelvic organs.
  • Fever, feeling generally unwell, a dull ache in the lower abdomen and back. These symptoms may mean the infection has spread to the kidneys
  • Emotional distress and brain fog/confusion. This can particularly affect the elderly.
  • Discharge may accompany the above symptoms in the case of urethritis

UTI Causes

There are many causes from which a UTI can develop, these can include:

  • After sexual intercourse (anal or vaginal), through a new sexual partner (size matters sometimes), poor post sex hygiene or using sex toys that have not been previously thoroughly cleaned or sterilised
  • Misshapen bladder or structural/physical anomalies within the urinary tract
  • Urinary tract obstructions or blockages, such as an enlarged prostate or kidney stones
  • Investigative surgery of urinary tract including cystoscopy/bladder or urethral stretch /hydrodistension of the bladder or bladder biopsy
  • Childbirth
  • Diabetes particularly those diagnosed with type 2 diabetes
  • Injury or paralysis to the spinal cord reducing/stopping signals from the urinary tract to the brain to empty the bladder. This condition is known as neuropathic or neurogenic bladder and those affected need to self catheterise or have an indwelling catheter to empty the bladder.
  • Vaginal/bowel prolapse preventing complete emptying of the bladder
  • After being catheterized or where an indwelling catheter is in place
  • Sexually transmitted diseases (for urethritis)
  • Pelvic surgery including mesh implant or hysterectomy
  • Menopause/Peri-Menopause/Premature Menopause
  • Being on certain birth control pills, using an IUD, diaphragm and spermicide usage
  • Personal hygiene including not wiping from front to back after bowel movements. This can particularly affect children and the elderly

Issues with D Mannose:

  • Controlled trials and studies are often limited in complementary and alternative medicine and involve small numbers of participants. They are often conducted under less rigorous controls, guidelines and environments than those undertaken for the development of new pharmaceutical medications such as antibiotics. Do your research, there should be clear, peer reviewed, empiric evidence as to the efficacy of D Mannose rather than theorisation about how it may be beneficial in the treatment of a chronic UTI.
  • There are very limited patient research trial studies. More are needed and several are currently in trial publishing in 2020.
  • Length of study and size of participant groups. Current studies available have shown trials of under one year and in small patient trial groups.  This studypublished in the World Journal of Urology in 2013 noted that in their patient cohort of 399 women those taking D-mannose powder alone showed effectiveness in preventing UTI. However it fared no better than those women taking a daily prophylactic dose of nitrofurantoin and the recurrence rate did not differ between patients who took standard Nitrofurantoin prophylaxis and those who took D-mannose powder. This lack of scientific and clinical rigor applied to study design and outcomes is common with alternative therapies.
  • In Vitro vs In Vivo. Most studies undertaken are either in laboratory known as “test tube conditions” or with the use of mice rather than human participants. Human behavioural, genetic, and environmental differences in comparison to those of mice mean it is difficult to compare like with like.
  • Different strains of bacteria. Infections are now recognised to be polymicrobial (comprised of more than one bacteria). Not all bacterial strains have these Pili (grappling hooks) and thus D-Mannose molecules in the urine won’t be effective in binding these bacteria to them and expelling them through urination. Instead the bacteria will bind to the urothelium and form bacterial colonies. Indeed certain strains of UPEC do not create Pili.
  • Once bacteria have attached to the cells of the bladder wall and started to reproduce, D-Mannose will not prevent the infection developing further.
  • There has been insufficient research into the optimum dosage for the prevention of recurrent infections.
  • For those with gastric issues such as Crohns or colitis, D-mannose may not be absorbed. Additionally, pathogenic e coli in the intestines may bind to most D-mannose available preventing sufficient molecules being filtered through the kidneys and into the bladder. Different people will react differently to the same D-mannose dose due to their age, weight, and overall health.
  • Commercial D-Mannose powder is often made from corn, particularly the less expensive versions. For those with allergies, a reaction to D-Mannose derived from corn may include a mild rash headaches and stomach aches.
  • Cost – as with any usage of a supplement on an intermittent or ongoing basis, there is a cost to you financially.