Urinary tract infection is a common problem. There is a 50% chance of a woman getting it in her life-time. It can be very disturbing and occasionally life-threatening. Urinary tract infection is more common in females because of the short urinary passage (Urethra) and injuries that can happen during sexual acts. There are several misconceptions regarding urinary tract infections both among lay people and many doctors. Colonisation of the urinary tract by organisms is called urinary tract infection. The urinary tract consists of a collecting system in the kidney, the ureter (tube from the kidney to the bladder), the bladder and lastly the urethra. The kidneys and the ureter constitute the upper urinary tract. The bladder and urethra constitute the lower urinary tract. The urinary tract is devoid of organisms till the terminal portion where it is exposed to the atmosphere. Infections occur once organisms ascend to the bladder and the kidneys. Males get urinary tract infections either in the first year of life due to abnormalities in the urinary tract from birth or after the age of sixty when the prostate gland blocks the urinary tract. Otherwise during the sexually active period, it is predominantly a disease of females.

Urinary infections can be community-acquired or acquired in the hospital due to instrumentation of the urinary tract (bladder catheterisation). Community-acquired infections are bacterial in origin and the commonest organism is called E.Coli. Hospital- acquired infections can be caused by resistant bacteria and fungi.

Classical symptoms of urinary infections are painful urination (dysuria) and increased frequency of urination. This results from an irritation of the bladder and urethra. Urinary infections normally should not be diagnosed in the absence of these symptoms. Discolouration and passing of blood in urine in isolation (i.e) without dysuria do not indicate urinary infections. Fever and loin pain occur in upper urinary tract infection. Lower abdominal pain and frequency of urination alone are features of lower urinary tract infection. In the absence of symptoms if an organism grows in the urine in the laboratory, it is called asymptomatic bacteriuria. This is a laboratory test and does not require treatment except in rare situations. Dysuria or painful micturition can happen in the absence of urinary infection due to inflammation or injury to urethra (urethral syndrome). Thus differentiation between upper and lower urinary tract infection and urethral syndrome is important to decide the line of treatment.

It is essentially by symptoms, sudden onset of dysuria with increased frequency is almost diagnostic of urinary infection. Laboratory test only confirms the diagnosis and helps decide the choice of drug.

Presence of pus cells in the urine indicates an inflammation of the urinary tract. The commonest cause of this is infection. However, stones, tumours and nephritis can all produce pus cells in the urine. Presence of albumin is not a feature of uncomplicated urinary tract infection. It indicates a disease of the kidneys. Presence of the epithelial cells indicates contamination during collection of urine sample. The ideal way to collect is to first clean the private part with water, discard the initial few ml in urine and subsequently collect in a clean/sterilized container. This is called a mid stream sample or clean catch specimen and should be transported to the laboratory immediately.

This test is fraught with errors due to poor collection. It is absolutely essential to mention the colony count while giving the result of culture. Colony counts more than 1 lakh are considered significant. Beware of urine culture reports without colony counts. Apart from the type of bacteria, culture reports should contain the list of drugs with antibacterial sensitivity. This will help to decide the drug to be given for treatment. The drug with least toxicity, narrow spectrum of action and good tissue penetration should be chosen.

Detailed investigations like ultrasound, x-rays and cystoscopies are required in certain situations such as those mentioned below.

• All males with urinary tract infection.
• Females in childhood or above the age of sixty.
• Sexually active females if there are recurrent of repeated urinary tract infections.

This depends upon whether it is community-acquired or hospital-acquired, and if it is an upper or lower urinary tract infection. Lower urinary tract infections acquired in the community can be treated with simple drugs including single-dose antibiotics. Other infections require longer period of antibiotics.

• Good personal hygiene and passing of urine after sexual act.
• Low dose antibiotic after sexual act.
• Prolonged night time low-dose antibiotic

Consumption of large quantities of water can reduce urinary tract irritation. However it can also dilute the antibiotic administered.

Alkaline mixtures can also symptomatically relieve urinary irritation. However it cannot eradicate infections.

High animal protein in diet leads to highly acidic urine. This can increase urinary irritation. Vegetables reduce the acidity of urine and make it alkaline.

• Urinary infections are diagnosed using patient history and examination (CLINICAL DIAGNOSIS). The laboratory is used only for confirmation. In the absence of symptoms urinary infections are not treated except in special situations.
• Laboratory examinations are fraught with errors.
• Need to differentiate between upper and lower urinary tract infections.
• Investigate persons who are not vulnerable (other than sexually active females).
• Prevent urinary infections by simple measures.