Ambulatory and Office Urology

The Impact of Obesity on

Urinary Tract Infection Risk
Michelle J. Semins, Andrew D. Shore, Martin A. Makary, Jonathan Weiner, and
Brian R. Matlaga
OBJECTIVE To perform a study to describe the way in which an increasingly obese body mass index (BMI)
is associated with urinary tract infection (UTI). The association between UTI and obesity is not
well characterized. In fact, previous investigations of this subject have yielded conflicting
findings. UTI is increasingly being recognized as a preventable complication, and UTI rates are
used to measure quality of surgical care.
MATERIALS AND We evaluated claims over a 5-year period (2002-2006) in a national private claims database to
METHODS identify patients diagnosed with UTI or pyelonephritis by ICD-9 coding. Descriptive analyses
were performed and odds ratios were calculated.
RESULTS A total of 95,598 subjects were identified for evaluation. Gender distribution was 42.9% male
and 57.1% female. In the overall study cohort, the diagnosis of a UTI or pyelonephritis occurred
in 13% and 0.84%, respectively. Women were 4.2 times more likely to be diagnosed with a UTI
(19.3% vs 4.6%), and 3.6 times more likely to be diagnosed with pyelonephritis (1.22% vs
0.34%), than were men. At all stratifications of obesity, the obese were significantly more likely
to be diagnosed with a UTI or pyelonephritis than nonobese patients.
CONCLUSION Elevated BMI appears to be associated with an increased risk for UTI and pyelonephritis. Further
study is needed to determine whether this association may be attributed to a cause-and-effect
relationship. However, these results may serve to guide clinicians who treat obese patients,
because it may be an additional benefit of weight loss. UROLOGY 79: 266 –269, 2012. © 2012
Elsevier Inc.

T
he obesity epidemic is rapidly becoming a public
health concern; more than 30% of Americans
may be classified as obese (with a body mass index
[BMI] ⱖ30).1 Obesity is associated with multiple medical
comorbidities, including type 2 diabetes, heart disease,
hypertension, pregnancy complications, and sleep apnea.
Obesity has also been associated with urological conditions
such as male and female sexual dysfunction, infertility, in-
continence, genitourinary malignancy, and nephrolithia-
sis.2-5 A similar relationship between obesity and uri-
nary tract infection (UTI) may exist but it has not
been as well defined. Therefore, we performed a study
to characterize the association between obesity and the
incidence of UTI and pyelonephritis and stratified the
results by BMI subcategories.
Funding Support: This publication was made possible by grant number T32DK07552
from the NIH-NIDDK and its contents are solely the responsibility of the authors and
do not necessarily represent the official views of the NIH-NIDDK.
From the Departments of Urology, Surgery, and Medicine, the Johns Hopkins
University School of Medicine, and the Departments of Health Policy and Management,
Johns Hopkins School of Public Health, Baltimore, MD
Reprint requests: Brian R. Matlaga, M.D., M.P.H., James Buchanan Brady
Urological Institute, the Johns Hopkins University School of Medicine, 600 North
Wolfe Street, Baltimore, MD 21287. E-mail: bmatlaga@jhmi.edu
Submitted: June 8, 2011, accepted (with revisions): September 28, 2011
MATERIAL AND METHODS
The data and in-kind database development support and guid-
ance were provided by the Blue Cross and Blue Shield (BCBS)
Plans, BCBS of Tennessee, BCBS of Hawaii, BCBS of Michi-
gan, BCBS of North Carolina, Highmark, Inc., of Pennsylvania,
Independence Blue Cross of Pennsylvania, Wellmark BCBS of
Iowa, and Wellmark BCBS of South Dakota. All individuals
with one of these 7 plans as their primary insurer were eligible
for inclusion in the dataset. The claims data used in this study
were de-identified in accordance with the Health Insurance
Portability and Accountability Act of 1996 definition of a
limited dataset, and were used in accordance with federal stan-
dards for protecting confidentiality of the personal health in-
formation of the enrollee. The Institutional Review Board of
the Johns Hopkins University found this analysis to be exempt
from the requirement for review.
The dataset includes approximately 3.7 million insured lives
over a 5-year period (2002-2006) and includes information on
enrollee age and sex, enrollment dates, and claims for reim-
bursement for billable health care services. Included in these
data are patient diagnoses as identified by the International
Classification of Diseases, Ninth Revision (ICD-9) codes and
diagnosis-related groups (DRGs), and medical procedures clas-
sified by current procedural terminology (CPT) codes and
ICD-9 procedure codes. A subset of patients (n ⫽ 95,598) also
completed a Health Risk Assessment (HRA) that included
their body mass index (BMI); these provided the data used for

266 © 2012 Elsevier Inc. 0090-4295/12/$36.00

All Rights Reserved doi:10.1016/j.urology.2011.09.040
Table 1. Codes used to define infection-related conditions
Indicator Type of Code Description
Cystitis ICD-9 code 595.0 acute cystitis
595.0 cystitis unspecified
595.9 unspecified cystitis
599.0 urinary tract infection
Pyelonephritis ICD-9 code 590.0 chronic pyelonephritis
590.1 acute pyelonephritis
590.8 other pyelonephritis
590.9 infection unspecified

Table 2. Analysis of subjects diagnosed with UTI

BMI n # Diagnosed with UTI (%) Odds Ratio (95% CI) P Value
Males (n ⫽ 41,026) ⬍30 26,197 959 (3.66) — —
30.0-34.9 10,544 656 (6.22) 1.59 (1.43-1.76) ⬍.0001
35.0-39.9 2936 185 (6.30) 1.72 (1.46-2.03) ⬍.0001
40.0-44.9 921 78 (8.47) 2.47 (1.94-3.16) ⬍.0001
45.0-49.9 268 18 (6.72) 2.02 (1.24-3.29) .0047
⬎50.0 160 12 (7.50) 2.35 (1.29-4.28) .0051
Females (n ⫽ 54,572) ⬍30 36,414 6718 (18.45) — —
30.0-34.9 11,116 2430 (21.86) 1.22 (1.15-1.28) ⬍.0001
35.0-39.9 4336 869 (20.04) 1.10 (1.01-1.19) .0204
40.0-44.9 1724 331 (19.32) 1.05 (0.93-1.19) .4035
45.0-49.9 603 126 (20.90) 1.16 (0.95-1.42) .1393
⬎50.0 379 83 (21.90) 1.24 (0.97-1.59) .0826

this study. A substantial proportion of patients (30.6%) com-
pleted HRAs on more than one occasion over the 5-year period.
Subjects who did not complete an HRA document were not
included in further analysis.
UTI and pyelonephritis were defined by ICD-9 coding, as
described in Table 1. These codes have been previously used by
other large-scale investigations, such as the Urologic Diseases in
America project and Agency for Healthcare Research and
Quality metrics.6-8 Specifically, for the purposes of this manu-
script, the terminology “UTI” includes diagnosis codes for both
cystitis as well as UTI, and the terminology “pyelonephritis” is
restricted to codes for acute or chronic pyelonephritis. For those
who had a diagnosis of or were treated for UTI or pyelonephri-
tis, the BMI closest in time to their diagnosis or treatment was
used. Otherwise, the highest BMI reading for a given patient
was used. Age was calculated as the date of the HRA that was
used to obtain the BMI reading. We excluded female subjects
with a code indicating pregnancy the year before, the year of, or
the year after an obese BMI value.
For statistical analysis, BMI strata were set at less than
30, 30.00-34.99, 35.00-39.99, 40.00-44.99, 45.00-49.99, and
greater ⱖ50. The main dependent variables in this study were
a diagnosis or treatment of UTI or pyelonephritis. Simple
descriptive statistics were obtained and logistic regression was
performed to model the odds of a diagnosis or procedure by age,
gender, and BMI. SAS version 9.13 was used for all analyses
(SAS Institute, Cary, NC).
RESULTS
Of the 95,598 subjects identified for evaluation, 54,572
(57.1%) were female and 41,026 (42.9%) were male. In
the overall study cohort, the diagnosis of a UTI or pye-
lonephritis occurred in 13% and 0.84%, respectively.
Women were 4.2 times more likely to be diagnosed with
a UTI (19.3% vs 4.6%) and 3.6 times more likely to be
diagnosed with pyelonephritis (1.22% vs 0.34%) than
were men. At all stratifications of obesity, the obese were
significantly more likely to be diagnosed with a UTI than
the nonobese (Table 2). With regard to pyelonephritis,
the obese were significantly more likely to be diagnosed
than the nonobese, for certain BMI ranges, but not for all
strata (Table 3). These findings were significant, as con-
firmed by logistic regression. The confidence intervals for
the odds ratios overlap among the obese cohorts, suggest-
ing that there are no significant differences among the
different strata of obesity.
COMMENT
We found that obesity is a significant risk factor for being
diagnosed with UTI as well as pyelonephritis. Within the
obese population, approximately 20% of females and 8%
of males were diagnosed with a UTI. As a group, the
obese were up to 2.5 times more likely to be diagnosed
with a UTI than were the nonobese. In particular, males
demonstrated a higher risk than females. With regard to
pyelonephritis, the obese were nearly 5 times more likely
to be diagnosed than were the nonobese; females were at
particularly higher risk.
The Urologic Diseases in America (UDA) Project has
previously reported that use of outpatient hospital and
physician office care for male subjects with UTI have
increased in the last decade, and health care expenditure
for privately insured men with UTI was twice that for
men without UTI.6 In addition, women have a reported

UROLOGY 79 (2), 2012 267

Table 3. Analysis of subjects diagnosed with pyelonephritis
BMI n # Diagnosed with Pyelonephritis (%)
Males (n ⫽ 41,026) ⬍30 26,197
30.0-34.9 10,544
35.0-39.9 2936
40.0-44.9 921
45.0-49.9 268
⬎50.0 160
Females (n ⫽ 54,572) ⬍30 36,414
30.0-34.9 11,116
35.0-39.9 4336
40.0-44.9 1724
45.0-49.9 603
⬎50.0 379
⬎50% lifetime risk of UTI.7 The UDA investigators also
explored the costly nature of UTI, because overall ex-
penditures for men with this condition in the United
States were approximately $1 billion in 2000 and for
women were $2.5 billion.7
Because the treatment of UTIs poses a significant
economic burden on society, both in terms of health care
resource usage as well as absolute economic cost, a better
epidemiologic characterization of this condition is impor-
tant. At present, however, there is a paucity of literature
defining the relationship between obesity and urinary
infection. What literature that does exist, though, is
consistent with our findings. Ribera et al evaluated risk
factors associated with UTI in a series of diabetic patients
with and without asymptomatic bacteriuria, and found
obesity to be a significant risk factor for development of
symptomatic UTI in males.9 Geerlings and associates
have also demonstrated a relationship between BMI and
asymptomatic bacteriuria although their study did not
describe any relationship between obesity and symptom-
atic UTI.10 In 2006, Olumuyiqa and associates reported a
retrospective analysis in which they evaluated postoper-
ative complications in obese vs nonobese patients, and
found that the obese had a significantly increased risk for
UTI.11
Our present work is the first study dedicated to describe
the relationship between obesity and urinary infection.
We have also subcategorized lower UTI and upper UTI
so these 2 unique conditions may be examined separately.
With all data taken together, this study provides a robust
description of the prevalence of cystitis and pyelonephri-
tis among all categories of obesity; to our knowledge,
there has been no similar report stratifying the effect of
increasing degrees of obesity, particularly among those
with extreme obesity, on urinary infection.
Our work presented herein may have implications on
future health care policies and highlight the need for
circumspection with large-scale efforts directed at reduc-
ing, or even eliminating, reimbursement for the care of
hospital-acquired UTI. Because we have demonstrated
that obesity is a significant risk factor for the diagnosis of
UTI, one might expect that hospitals providing care to a
greater proportion of obese subjects may be dispropor-
268
Odds Ratio (95% CI) P Value
71 (0.27) — —
38 (0.36) 1.21 (0.81-1.8) .3464
20 (0.68) 2.47 (1.50-4.07) .0004
6 (0.65) 2.46 (1.06-5.67) .0354
2 (0.75) 3.00 (0.73-12.33) .1275
2 (1.25) 5.05 (1.22-20.85) .0252
357 (0.98) — —
357 (0.98) 1.71 (1.42-2.05) ⬍.0001
72 (1.66) 1.75 (1.36-2.27) ⬍.0001
46 (2.67) 2.81 (2.06-3.83) ⬍.0001
10 (1.66) 1.79 (0.95-3.37) .0724
6 (1.58) 1.68 (0.74-3.78) .214
tionately affected by such policy. Risk factors such as
obesity should be accounted for as these paradigm-shift-
ing reimbursement programs are applied, so that such
negative incentives do not affect the way in which health
care is delivered to the obese—a potentially vulnerable
population. Such perverse incentives that penalize sur-
geons for caring for obese patients could disincline pro-
viders to serve this population. Metrics of performance
should adjust for the influence of obesity in contributing
to these types of infections.
It is a cross-sectional study and thus only elucidates a
statistical association between obesity and urinary infec-
tion and one cannot infer a cause and effect relationship.
Because obesity is associated with significant medical
comorbidities, the extremely obese may have an in-
creased use of health care resources and encounters. Such
usage may lead to a detection bias, resulting in an in-
crease in incidental, asymptomatic urinary infections
that do not require treatment. In addition, the database
we examined identifies infection by ICD-9 code so they
are not necessarily culture-proven but rely on physicians
to properly code. Given the nature of an administrative
claims database, we also did not have access to certain
clinical data, including culture data, laboratory studies, or
diagnostic circumstances, and the database may contain
erroneous and incomplete coding (ie, failing to list codes
for all diagnoses relevant to a given admission, or
missing claims). That is to say, the diagnosis of UTI
was identified by coding data but was not confirmed
with clinical studies or evaluations. Although this is a
limitation, these codes have been used previously by
other large-scale investigations such as the UDA proj-
ect and Agency for Healthcare Research and Quality
metrics.6-8 Finally, the database is from a private in-
surance company and may not be representative of the
general population. Further study to confirm the asso-
ciation in other populations should be done. In addi-
tion, studies to confirm cause and effect need to be
carried out to demonstrate that weight loss among the
obese will subsequently reduce the likelihood of being
diagnosed with UTI and pyelonephritis.
Although these limitations only allow us to draw an
association between obesity and urinary infection and we
UROLOGY 79 (2), 2012
can neither conclude on cause and effect nor necessarily
apply this to the population as a whole, it introduces an
important idea that should be studied further. With both
obesity and urinary infection having a profound effect on
health care today and with the evolving reimbursement
programs, more attention should be directed toward ex-
ploring this potential relationship further.
CONCLUSIONS
Obesity (BMI ⱖ30) is associated with an increased risk
for UTI and pyelonephritis. The incidence correlates
with increasing degrees of BMI. However, the high inci-
dence of infection observed in the obese population
places a meaningful financial burden on health care re-
source use and may also lead to other medical complica-
tions. Further study to determine whether weight loss
among the obese population translates to a reduced risk
of infection should be undertaken.
Acknowledgments. We thank Chad and Nissa Richison, the
Blue Cross and Blue Shield Plans, and the many staff members
at these sites who actively contributed to this study by provid-
ing data and expert advice. These organizations included Blue
Cross Blue Shield of Tennessee, Highmark Blue Cross Blue
Shield (of Pennsylvania), Blue Cross Blue Shield of Michigan,
Blue Cross Blue Shield of North Carolina, Independence Blue
Cross (of Pennsylvania), Wellmark Blue Cross Blue Shield (of
Iowa and South Dakota), and Hawaii Medical Service Associ-
ation. We also thank Eric Bass and Jonathan Weiner for their
support of this study.
UROLOGY 79 (2), 2012
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