Bacterial Urinary Tract Infections

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(See also Gram-Negative Bacilli; see Benign Prostate Disease: Prostatitis; see
Infections in Infants and Children: Urinary Tract Infection [UTI].)

Bacterial UTIs can involve the urethra, prostate, bladder, or kidneys. Symptoms
may be absent or include urinary frequency and urgency, dysuria, lower
abdominal pain, and flank pain. Systemic symptoms and even sepsis may occur
with kidney infection. Diagnosis is based on analysis and culture of urine.
Treatment is with antibiotics.

Among adults aged 20 to 50 yr, UTIs are about 50-fold more common in women.
The incidence increases in patients > 50 yr, but the female:male ratio decreases
because of the increasing frequency of prostate disease.

Pathophysiology

The urinary tract, from the kidneys to the urethral meatus, is normally sterile and
resistant to bacterial colonization despite frequent contamination of the distal
urethra with colonic bacteria. Mechanisms that maintain the tract's sterility
include urine acidity, emptying of the bladder at micturition, ureterovesical and
urethral sphincters, and various immunologic and mucosal barriers.

About 95% of UTIs occur when bacteria ascend the urethra to the bladder and, in
the case of acute uncomplicated pyelonephritis, ascend the ureter to the kidney.
The remainder of UTIs are hematogenous. Systemic infection can result from
UTI, particularly in the elderly. About 6.5% of cases of hospital-acquired
bacteremia are attributable to UTI.

Complicated UTI is considered to be present when there are underlying factors

that predispose to ascending bacterial infection. Predisposing factors include
urinary instrumentation (eg, catheterization, cystoscopy), anatomic
abnormalities, and obstruction of urine flow or poor bladder emptying. A
common consequence of anatomic abnormality is vesicoureteral reflux (VUR),
which is present in 30 to 45% of young children with symptomatic UTI (see
Infections in Infants and Children: Urinary Tract Infection [UTI]). VUR is
usually caused by a congenital defect that results in incompetence of the
ureterovesical valve. It is most often due to a short intramural segment (the ureter
normally transits the bladder wall at an angle; the resultant lengthy segment is
more readily closed by muscular contraction than the shorter segment that occurs
when the ureter passes straight through the wall). VUR can also be acquired in
patients with a flaccid bladder due to spinal cord injury. Other anatomic
abnormalities predisposing to UTI include urethral valves (a congenital
obstructive abnormality), delayed bladder neck maturation, bladder diverticulum,
and urethral duplications. Urine flow can be compromised by calculi and tumors.
Bladder emptying can be impaired by neurogenic dysfunction (see Voiding
Disorders: Neurogenic Bladder), pregnancy, uterine prolapse, cystocele, and
prostatic enlargement. UTI caused by congenital factors presents most
commonly in childhood. Most other factors are more common in the elderly.

Uncomplicated UTI occurs without underlying abnormality or impairment of

urine flow. It is most common in young women but also somewhat common in
younger men who have unprotected anal intercourse, an uncircumcised penis,
unprotected intercourse with a woman whose vagina is colonized with urinary
pathogens, or AIDS. Risk factors in women include sexual intercourse,
diaphragm and spermicide use, antibiotic use, and a history of recurrent UTIs.
Even use of spermicide-coated condoms increases risk of UTI in women. The
increased risk of UTI in women using antibiotics or spermicides probably occurs
because of alterations in vaginal flora that allow overgrowth of Escherichia coli.
In elderly women, soiling of the perineum from fecal incontinence increases risk.
Patients of both sexes with diabetes have an increased incidence and severity of
infections.

Etiology

Commensal colonic gram-negative aerobic bacteria cause most bacterial UTIs. In

relatively normal tracts, strains of E. coli with specific attachment factors for
transitional epithelium of the bladder and ureters are the most frequent causes.
The remaining gram-negative urinary pathogens are other enterobacteria,
especially Klebsiella , Proteus mirabilis, and Pseudomonas aeruginosa.
Enterococci (group D streptococci) and coagulase-negative staphylococci (eg,
Staphylococcus saprophyticus) are the most frequently implicated gram-positive
organisms.

E. coli causes > 75% of community-acquired UTIs in all age groups; S.

saprophyticus accounts for about 10%. In hospitalized patients, E. coli accounts
for about 50% of cases. The gram-negative species Klebsiella , Proteus,
Enterobacter, and Serratia account for about 40%, and the gram-positive
bacterial cocci Enterococcus faecalis and S. saprophyticus and Staphylococcus
aureus account for the remainder.

Classification

Urethritis: Infection of the urethra with bacteria (or with protozoa, viruses, or
fungi) occurs when organisms that gain access to it acutely or chronically
colonize the numerous periurethral glands in the bulbous and pendulous portions
of the male urethra and in the entire female urethra. The sexually transmitted
pathogens Chlamydia trachomatis (see Sexually Transmitted Diseases (STD):
Chlamydial, Mycoplasmal, and Ureaplasmal Infections), Neisseria gonorrhoeae
(see Sexually Transmitted Diseases (STD): Gonorrhea), Trichomonas vaginalis
(see Sexually Transmitted Diseases (STD): Trichomoniasis), and herpes simplex
virus (see Herpesviruses: Herpes Simplex Virus (HSV) Infections) are common
causes in both sexes.

Cystitis: In women, sexual intercourse usually precedes uncomplicated cystitis

(honeymoon cystitis). In men, bacterial infection of the bladder is usually
complicated and generally results from ascending infection from the urethra or
prostate or is secondary to urethral instrumentation. The most common cause of
recurrent cystitis in men is chronic bacterial prostatitis.

Acute urethral syndrome: Acute urethral syndrome, which occurs in women,

produces dysuria and pyuria (dysuria-pyuria syndrome) due to bacterial urinary
pathogens. Occasionally, it is caused by N. gonorrhoeae, TB, or fungal disease or
by trauma or inflammation of the urethra. Patients with acute urethral syndrome
have dysuria, frequency, and pyuria, but urine culture in these patients shows
colony counts that are <105/mL, which is less than the traditional criterion for
bacterial UTI.

Asymptomatic bacteruria: Certain patients, primarily elderly women and patients

with diabetes or those who require long-term use of indwelling catheters, have
persistent bacteriuria with changing flora that is both asymptomatic and
refractory to treatment. WBC count in urine may be modestly elevated. Most of
these patients are best left untreated, because the usual result of treatment is the
establishment of highly resistant organisms. Asymptomatic bacteriuria can also
occur in pregnant women and may cause infection of the urinary tract, sepsis,
low birth weight, and premature delivery (see Pregnancy Complicated by
Disease: Urinary Tract Infection in Pregnancy), so treatment is indicated.

Acute pyelonephritis: Pyelonephritis is bacterial infection of the kidney

parenchyma. The term should not be used to describe tubulointerstitial
nephropathy unless infection is documented. About 20% of community-acquired
bacteremias in women are from pyelonephritis. Pyelonephritis is uncommon in
men with a normal urinary tract.

Although obstruction (strictures, calculi, tumors, prostatic hyperplasia,

neurogenic bladder, VUR) predisposes to pyelonephritis, most women with
pyelonephritis have no demonstrable functional or anatomic defects. Cystitis
alone or anatomic defects may produce reflux. This tendency is greatly enhanced
when ureteral peristalsis is inhibited (eg, during pregnancy, by obstruction, by
endotoxins of gram-negative bacteria). Pyelonephritis or focal abscess may be
due to hematogenous spread, which is infrequent and usually results from
bacteremia with virulent bacilli (eg, Salmonella sp, S. aureus). Pyelonephritis is
common in young girls and in pregnant women after instrumentation or bladder
catheterization.

The kidney usually is enlarged because of inflammatory PMNs and edema.

Infection is focal and patchy, beginning in the pelvis and medulla and extending
into the cortex as an enlarging wedge. Chronic inflammatory cells appear within
a few days, and medullary and subcortical abscesses may develop. Normal
parenchymal tissue between foci of infection is common. Papillary necrosis may
be evident in acute pyelonephritis associated with diabetes, obstruction, sickle
cell disease, pyelonephritis in renal transplants, pyelonephritis due to candidiasis,
or analgesic nephropathy. Although acute pyelonephritis is frequently associated
with renal scarring in children, similar scarring in adults is not detectable in the
absence of reflux or obstruction.

Symptoms and Signs

In the elderly, UTIs are often asymptomatic. Elderly patients, and those with a
neurogenic bladder or an indwelling catheter, may present with sepsis and
delirium but without symptoms referable to the urinary tract.

When symptoms are present, they may not correlate with the location of the
infection within the urinary tract because there is considerable overlap; however,
some generalizations are useful.

In urethritis, the main symptoms are dysuria and, primarily in males, urethral
discharge. Discharge tends to be purulent when due to N. gonorrhoeae and
whitish and mucoid when not.

Cystitis onset is usually sudden, typically with frequency, urgency, and burning
or painful voiding of small volumes of urine. Nocturia, with suprapubic and
often low back pain, is common. The urine is often turbid, and gross hematuria
occurs in about 30% of patients. A low-grade fever may develop. Pneumaturia
(passage of air in the urine) can occur when infection results from a vesicoenteric
or vesicovaginal fistula or from emphysematous cystitis.

In acute pyelonephritis, symptoms may be the same as those of cystitis; 1/3 of

patients have frequency and dysuria. However, with pyelonephritis, symptoms
typically include chills, fever, flank pain, nausea, and vomiting. If abdominal
rigidity is absent or slight, a tender, enlarged kidney is sometimes palpable.
Costovertebral angle percussion tenderness is generally present on the infected
side. In children, symptoms often are meager and less characteristic (see
Infections in Infants and Children: Urinary Tract Infection [UTI]).

Diagnosis

• Urinalysis
• Sometimes urine culture

Diagnosis by culture is not always necessary. If done, diagnosis by culture

requires demonstration of significant bacteriuria in properly collected urine.