CONTINENCE

Managing the symptoms of urinary

tract infection in women
Chetan Shah, Stephen Goundrey-Smith
regarding any previous UTIs and
Urinary tract infections are often seen in community settings their treatment. Aids to diagnosis
and can be debilitating for patients, involving dysuria (painful include (Mahaffey, 2006):
urination), increased urinary frequency and urgency, suprapubic Near-patient testing
pain, haematuria (blood in the urine), and polyuria (excessive urine Microbiology.
production). This article takes an in-depth look at these symptoms,
as well as the diagnosis and management of this common problem, Near-patient testing
which mostly affects female patients. Near-patient testing may include
observing the urine sample to see
if it is cloudy, or the use of urine
KEYWORDS: dipsticks. In the absence ofinfection,
Continence Urinary tract infection Antibiotic therapy a urine sample should be odour-
free and clear. Any sample that is
malodorous and cloudy is likely

U
rinary tract infections (UTIs)
are commonly seen in
general practice, accounting
for 13% of all GP consultations
each year (National Prescribing
Centre [NPC], 2009) and are the
second most common clinical
indication for antibiotic treatment
in primary and secondary care
(Scottish Intercollegiate Guidelines
Network [SIGN, 2012]).
UTIs affect women more
commonly than men around
50% of women will suffer from
a symptomatic UTI during their
lifetime, with the incidence
increasing with advancing age
(NPC, 2009) from approximately
78% for those aged 60 to 80
years of age to around 20% for
those aged 80 years and above
(Mahaffey, 2006).
Apart from being female and
increasing in age, other risk factors
for developing UTIs include
institutionalisation, being sexually
active, co-morbid diabetes and the
presence of a catheter (SIGN, 2012).
This article will focus on the
signs, symptoms, diagnosis and
management of uncomplicated
UTIs in women.
SIGNS AND SYMPTOMS
Common signs and symptoms of
UTIs include (Health Protection
Agency (now known as Public
Health England) [HPA], 2010):
Dysuria
Urinary frequency
Urinary urgency
Suprapubic pain or tenderness
Haematuria
Polyuria.
Other symptoms that may also
present are malodorous and cloudy
urine, rigors, pyrexia (fever), nausea
and an acute confusional state
(Mahaffey, 2006). The presence of
bacteria in the urine, also referred
to as bacteriuria, can often lead to
inappropriate antibiotic treatment
bacteriuria alone is rarely an
indication for antibiotic treatment
(SIGN, 2012). The diagnosis of UTI
should be primarily based on the
signs and symptoms described above
(SIGN, 2012).
to be indicative of an UTI (SIGN,
2012). However, visual inspection
of a urine sample is prone to
observer error and, therefore, may
not be a useful discriminator when
attempting to diagnose a UTI
(SIGN, 2012).
Urine dipsticks, or testing strips,
are placed into a sample of urine
for a short period of time the
urine will react with the stick,
changing colour to indicate the
presence of biochemicals and
blood cells.
Although the quality of evidence
for urine dipsticks strips is weak
(SIGN, 2012), they may have a useful
role to play in allowing treatment
to commence while awaiting
confirmation of the infection (it
may take the laboratory a while to
confirm a diagnosis, so treatment
might need to be commenced in
the meantime). The SIGN (2012)
guidance advises the use of dipstick
tests to guide treatment decisions
in otherwise healthy women aged
under 65 years whose UTI symptoms
are mild, or those who present with
less than two symptoms.

DIAGNOSIS AND TESTING Urine dipsticks test for four

Chetan Shah, Senior Lecturer in Pharmacy factors:
Practice/Public Health, University of Hertfordshire;
Stephen Goundrey-Smith, Consultant Pharmacist, A full history should be taken, Nitrites
PDC Healthcare Ltd, Leicestershire which encompasses information Leucocytes

88 JCN 2013, Vol 27, No 4

 CONTINENCE

Blood (erythrocytes) Similarly, urine dipstick testing to eradicate all contamination.

Protein.
Testing for nitrites and leucocytes
works on the rationale that bacteria
present in the urine cause urinary
nitrates to breakdown into nitrites.
Similarly, a higher concentration of
the leucocyte esterase enzyme will
be present in the urine as a result of
the increased neutrophils present
during infection (Balakrishnan and
Hill, 2011).
Urine dipstick testing for nitrites
and leucocytes is most effective
when the bacterial count is high,
however, diagnosis is more accurate
if used in combination with other
tests (BMJ Best Practice, 2013). If
the dipstick result is negative, but
the symptoms suggest a UTI, the
probability of a UTI is still relatively
high (BMJ Best Practice, 2013).
Microbiology testing
Microscopy can be used to detect
haematuria, pyuria (white cells in the
urine) or bacteriuria (Balakrishnan
and Hill, 2011), or to confirm the
organism type and guide antibiotic
selection in complicated UTI or
pyelonephritis (kidney infection)
(BMJ Best Practice, 2013). A UTI
might be considered complicated if
there are risk factors that predispose
the patient to infection (e.g. urinary
obstruction or vesico-ureteric reflux).
in general has been found to be
unreliable in the following groups
(Balakrishnan and Hill, 2011):
Pregnant women
Children under three years of age
Patients whose urinary tracts have
structural anomalies
Patients with diabetes mellitus
Patients who are
immunocompromised.
Therefore, urine dipstick testing is
of little use in these patient groups.
With mid-stream urine samples,
it may not always be possible
Severe or
3 symptoms of UTI
Patient presents with UTI symptoms
Give empirical
antibiotic treatment
Mild or 2 symptoms of UTI
Obtain urine sample
Specimens need to be either
processed promptly or refrigerated
after collection in order to minimise
bacterial multiplication (Balakrishnan
and Hill, 2011). Figure 1 illustrates a
protocol for diagnosis of UTI.
CAUSATIVE ORGANISMS
At the current time, Escherichia coli
species are the most common cause
of UTI (in 7095% of uncomplicated
cases). Other causative pathogens
in uncomplicated UTIs include
Enterobacteriae such as Proteus
mirabilis and Klebsiella species,
Urine not cloudy
Consider other
diagnosis

Urine culture and sensitivity Urine cloudy dipstick test

testing is the most specific and
sensitive test for confirmation of a
UTI. A midstream urine sample can
be sent for cultures and sensitivity Negative nitrite,
analysis to confirm the diagnosis Positive nitrite, leucocytes and blood or
and to ensure that an appropriate leucocytes and blood Negative nitrite and negative nitrite
antibiotic can be prescribed (SIGN, or positive nitrites positive leucocyte and leucocyte and
2012). A mid-stream urine sample alone positive blood
should be taken for culture to or protein
ensure that contamination of the
sample is kept to a minimum
(Mahaffey, 2006).
Could equally be UTI
There are limitations to both Probable UTI or other diagnosis.
near-patient testing and laboratory Treat if severe
Consider other
microbiology. The detection of Treat with first-line symptoms or consider
diagnosis
protein and blood in the urine by agents (follow HPA delayed antibiotic
dipstick testing is unreliable, with guidance) treatment and urine
a high rate of false positives and culture
false negatives, and is, therefore, of
comparatively little diagnostic value Figure 1.
(Balakrishnan and Hill, 2011). Protocol for diagnosis of UTI (adapted from Health Protection Agency [2010a]).

90 JCN 2013, Vol 27, No 4


Five-minute test
Answer the following questions
about this, either to test the new
knowledge you have gained or to
form part of your ongoing practice
development portfolio.
1 What is a urinary tract infection
(UTI)?
2 Name some of the main symptoms
of a UTI.
3 What are some of the diagnostic
testing techniques for a UTI?
4 Name some of the causes of a UTI.
5 Can you outline some of the main
treatments for UTI?
Enterococci, group B Streptococci,
Pseudomonas aeruginosa, and
Citrobacter species.
In recent years, the development
of E. coli strains with antibiotic
resistance mediated by extended
spectrum beta lactamase (ESBL)
production has been observed
(SIGN, 2012). ESBL is an enzyme
produced by some pathogens,
which breaks down beta-lactam
antibiotics (penicillins and
cephalosporins), meaning they are
no longer effective.
MANAGEMENT AND
ANTIBIOTIC THERAPY
The HPA produced a useful guidance
document for the diagnosis of UTIs
in primary care (HPA, 2010). The
guidance advises that if a patient
presents with severe symptoms
or with at least three or more of
the common signs and symptoms
described above there is a 90%
probability that a urine culture would
be positive for a UTI.
Broad spectrum antibiotics
(e.g. co-amoxiclav, quinolones and
cephalosporins) should be avoided
as first-line agents as they increase
the risk of Clostridium difficile
infection, methicillin-resistant
Staphylococcus aureus (MRSA)
and resistant UTIs. The HPA and
British Infection Association (2010)
guidance suggests considering
narrow spectrum antibiotics such as
trimethoprim or nitrofurantoin as
first-line treatments when there are
three or more symptoms of UTI.
Previous studies have
shown that trimethoprim and
nitrofurantoin are broadly
equivalent in efficacy for the
treatment of uncomplicated UTI
where there are no resistant
pathogens. However, there is now
some evidence to suggest that
resistance to trimethoprim is rising,
whereas resistance to nitrofurantoin
remains relatively low (McKinnell
et al, 2011; National Institute for
Health and Care Excellence [NICE],
2012).
The diagnosis of UTI is
particularly difficult in elderly
patients, who are more
likely to have asymptomatic
bacteriuria as they get older
If a patient presents with mild
symptoms, or at least two of the
common signs and symptoms
described earlier, a urine specimen
should be sought. If the specimen is
not cloudy, then a diagnosis other
than UTI should be considered. If
the urine is cloudy, the clinician
should perform a urine dipstick test
(in those under the age of 65 years).
Possible results and treatment
recommendations are as follows
(HPA, 2010):
A positive nitrite test, with or
without a positive leucocyte
result, indicates a probable UTI.
Based on this result the HPA
recommends antibiotic treatment
with either trimethoprim 200mg
twice-daily or nitrofurantoin
100mg modified release twice-
daily (HPA and British Infection
Association, 2010)
A negative nitrite but positive
leucocyte result indicates
that UTI or other diagnoses,
such as diabetes mellitus,
glomerulonephritis, or
coagulation disorders, are
equally likely. In such situations
the clinician should:
CONTINENCE
(i): review time of specimen
collection (morning is most
reliable)
(ii): treat if symptoms are severe
or consider delayed antibiotic
prescription, and
(iii): send for urine culture
A negative nitrite, leucocyte and
blood result, or negative nitrite
and leucocyte test but positive
blood or protein result, indicates
that an alternative diagnosis
should be considered.
Management of UTI
in elderly patients
The diagnosis of UTI is particularly
difficult in elderly patients, who are
more likely to have asymptomatic
bacteriuria as they get older. This may
be due to changes in the structure
of the urinary tract or the existence
of co-morbidities, such as type 2
diabetes.
The prevalence of bacteriuria
may be so high that urine culture
ceases to be a diagnostic test
this is particularly true for elderly
institutionalised patients because of
the close proximity of other patients/
residents and the possibility of cross-
infection (SIGN, 2012).
There is no evidence that
treatment of asymptomatic
bacteriuria in the elderly reduces
the risk of symptomatic episodes
or mortality in fact, the evidence
actually shows that antibiotic
treatment significantly increases
the risk of adverse events, such as
rashes and gastrointestinal symptoms
(SIGN, 2012).
In elderly patients, the use of
urine dipstick testing is not routinely
recommended. However, if patients
exhibit two or more of the common
signs and symptoms of UTI,
diagnosis should be guided using
urine dipstick testing, as described
above (HPA, 2010). For elderly
patients with swallowing difficulties,
or patients of any age with
dysphagia due to comorbidities such
as recent stroke, both nitrofurantoin
and trimethoprim are available in
liquid formulations.
Furthermore, there may be
high levels of antibiotic resistance
JCN 2013, Vol 27, No 4 91
 CONTINENCE
in residential facilities due to
elderly and vulnerable individuals
living in close proximity as well as
indiscriminate antibiotic prescribing
(McClean et al, 2011). UTIs in these
patients may, therefore, be harder
to treat. Nitrofurantoin may have an
advantage over trimethoprim in these
patients in terms of its continued low
incidence of resistance.
The administration of
nitrofurantoin, formulated as
a liquid, may ensure effective
treatment of uncomplicated UTIs in
these vulnerable patient populations,
as well as ensuring the appropriate
use of antibiotics to minimise future
resistance problems (commonly
known as antibiotic stewardship).
A recent European survey of
the treatment of UTIs in residential
facilities suggests that the volume of
nitrofurantoin prescribing is indeed
increasing in the institutionalised
elderly patient population (McClean
et al, 2011).
However, as nitrofurantoin is
contraindicated in the presence
of significant renal impairment,
particular care should be taken
when prescribing to elderly
patients at increased risk of toxicity
(SIGN, 2012).
When performing urine cultures
in elderly patients, community
nurses should consider the
following:
Do not send urine for culture in
asymptomatic elderly people with
positive dipstick tests
Only send urine for culture if
there are two or more signs of
infection (especially dysuria),
fever over 38o or new episodes of
incontinence
Do not treat asymptomatic
bacteriuria in the elderly as it is
very common (SIGN, 2012).
CONCLUSION
UTIs are commonly encountered
in women in the community, with
prevalence increasing with age.
Other risk factors include sexual
activity, institutionalisation, co-
morbid disease and catheterisation
(SIGN, 2012).
92 JCN 2013, Vol 27, No 4
The diagnosis of UTIs should
always be based on the signs and
symptoms, although microbiological
testing may have a role in confirming
the diagnosis.
Guidance from the HPA (2010)
suggests considering narrow spectrum
antibiotics such as trimethoprim or
nitrofurantoin as first-line treatments in
There may be high levels
of antibiotic resistance in
residential facilities due
to elderly and vulnerable
individuals living in close
proximity.
uncomplicated UTIs. Both trimethoprim
and nitrofurantoin are available in liquid
formulations to enable treatment in a
range of patient groups, such as those
with swallowing difficulties.
Of all healthcare professionals,
community nurses are ideally placed
to advise clinicians about patients
with UTI symptoms, and the most
appropriate form of treatment for a
particular patient, as they regularly
see patients at home or in nursing/
residential homes. JCN
This paper has been funded and
reviewed by the Amdipharm Mercury
Company Ltd
REFERENCES
Balakrishnan I, Hill V (2011) Dealing with
urinary tract infections. Pharmaceutical J
287: 68790
British Medical Journal Best Practice (2013)
Urinary tract infections in women.
Available at: http://bestpractice.bmj.
com/best-practice/monograph/77.html
(accessed 22 August, 2013)
HPA (2010) Diagnosis of UTI Quick Reference
Guide for Primary Care. HPA, London
HPA/British Infection Association (2010)
Management of Infection Guidance for
Primary Care for Consultation and Local
Adaptation. HPA, London
Mahaffey W (2006) Diagnosis, treatment
and management of urinary tract
infections in primary care. Nurse
Prescribing 4(7): 28287
McClean P, Hughes C, Tunney M, Goossens
H, Jans B (2011) Antimicrobial prescribing
KEY POINTS
UTIs are common in the
community and are more
prevalent in women, the
prevalence increasing with age.
Other risk factors include sexual
activity, institutionalisation,
co-morbid disease and
catheterisation.
The diagnosis of UTIs
should be based on the signs
and symptoms, although
microbiological testing may
have a role in confirming the
diagnosis.
Guidance from the HPA (2010)
suggests considering narrow
spectrum antibiotics such as
trimethoprim or nitrofurantoin
as first-line treatments in
uncomplicated UTIs.
Both trimethoprim and
nitrofurantoin are available in
liquid formulations to enable
treatment in a range of patient
groups, such as those with
swallowing difficulties.
in European nursing homes. J
Antimicrob Chemother 66: 160916
McKinnell JA, Stollenwerk NS, Jung
CW, Miller LG (2011) Nitrofurantoin
compares favorably to recommended
agents as empirical treatment of
uncomplicated urinary tract infections
in a decision and cost analysis. Mayo
Clin Proc 86(6): 48088
NICE (2012) Urinary Tract Infection
(lower) women: evidence. Available at:
http://www.cks.nhs.uk/urinary_tract_
infection_lower_women/evidence/
supporting_evidence/antibiotic_
treatment_for_non_pregnant_women/
trimethoprim_compared_with_
nitrofurantoin (accessed 22 August
2013)
NPC (2009) Common Infections: Urinary
Tract Infection. Available at: http://www.
npc.nhs.uk/therapeutics/common_
infections/uti/resources/dfc_common_
infect_uti.pdf (accessed 22 August,
2013)
SIGN (2012) Management of suspected
bacterial urinary tract infection in
adults: a national clinical guideline.
Available at: http://www.sign.ac.uk/pdf/
sign88.pdf (accessed 22 August, 2013)
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