I’m a GP – your UTI symptoms may not actually be a UTI

At his famous tea party in Wonderland, the Mad Hatter asked a peculiar question of Alice – why was a raven like a writing desk? She struggled to work out why, but then it turned out he hadn’t the slightest idea either. That’s how I sometimes initially feel about patients experiencing urinary symptoms, and are concerned they may have a urinary tract infection – commonly known as a UTI. They’re such a common part of my working life as a GP that when a patient reports a burning or stinging sensation when passing urine, going to the loo more frequently, or lower abdominal pain, then it’s an almost knee-jerk reaction to suspect one. It’s estimated that UTIs count for up to six per cent of GP consultations – a really quite staggering statistic. I’d be tempted to say it’s even more. I can’t actually recall a clinical day where I haven’t seen at least two or three. That’s because every morning, at least eight or 10 urine samples are dropped off at the surgery by patients noting these sorts of symptoms. They then go to our practice nurse who performs a dipstick test – where a test strip is dipped into the urine to see what substances are present besides water and urea. What we’re looking for to diagnose a UTI is either white blood cells (suggesting inflammation, and an immune response to an infection), or nitrites – these compounds, made by bacteria, are generally a better indicator. Sometimes infection causes irritation of the bladder or the urethra (the pipe carrying urine out of the body) so, on occasions, traces of blood can also be picked up.We may send the urine sample off to the lab for further analysis. This will tell us if there are any bacteria in the urine, and if so, which antibiotics will work to clear them. We often start patients on antibiotics before these test results come back – especially if a UTI seems likely, the patient is uncomfortable, or at risk of developing complications. If the symptoms are mild, or the diagnosis is in question, we might hold off for a bit. Then we play the waiting game. It usually takes two to three days to get the results back. A UTI is only a UTI when there’s an “I” – a clear infection. In most cases, it’s a bacterial one, caused by bacteria from the gut. E-coli is the most common cause, a bacterium that lives harmlessly in our guts, but can make it’s way into the urinary tract from the perineal area. That’s why more women suffer from UTIs than men – that distance is shorter and more straightforward because of female anatomy. Men can get UTIs, too, although they’re much less common. The patient may have gotten worse, or stayed the same. Sometimes the antibiotic we’ve given initially doesn’t work against the bacteria, so we have to switch to something else. Sometimes, though, they feel better. But was that because of the antibiotics? Or was it because they were going to get better in the first place anyway, without antibiotics? And sometimes the sample comes back, completely clear: no “I”. So what is it then? When a UTI is not a UTI When a patient has symptoms but lab results fail to demonstrate an infection, one alternative explanation is urethral syndrome – a poorly understood disorder where patients experience urinary symptoms without infection. The exact cause is unknown, but associations have been made with stress, hormonal changes, having sex, and irritation from certain cosmetics or clothing. The use of antibiotics is controversial, though interestingly some patients do respond to them, so there could still be some component of infection to it. Like a UTI, patients are encouraged to drink lots of water to flush the urinary tract through, and wearing loose cotton underwear can also help. Another possibility is interstitial cystitis, or bladder pain syndrome. This typically affects women over 40 – it’s thought to arise when the wall of the bladder becomes inflamed or irritated. As a result, it’s easily misdiagnosed as recurrent UTIs – leading to symptoms coming back and back again, while antibiotics will have no effect. Other treatments can be used to retrain the bladder and reduce spasms. Let’s talk about sex… Sex is closely associated with UTIs, since it can introduce bacteria from the perineum towards urethra and the bladder. Some women can experience UTI-symptoms after using condoms, perhaps as a result of reaction to latex or lubricants. Hormonal changes during the menopause can also contribute – declining levels of oestrogen can cause vaginal dryness and thinning, increasing susceptibility further. And sexually transmitted infection (STIs, like chlamydia or gonorrhoea) can also cause remarkably similar symptoms to a UTI. Genital discharge and pelvic pain might provide additional clues, but might be absent. That’s why sexual health awareness and screening is important in anyone sexually active present with urinary symptoms. We can also screen for STIs via urine samples or swabs, which it’s important to do as their treatment is really quite different – and to prevent spread to other sexual contacts. When UTIs become problematic In many instances, UTIs are relatively minor ailments that are easy to treat and resolve with antibiotics, sometimes on their own and with time. But not everyone with a UTI experiences typical urinary symptoms. They may instead, or also, have other symptoms: some describe lower back pain; others may note mild fever, or nausea and vomiting. Some may notice a change in bowel habit, including diarrhoea. In elderly patients, UTIs can also present as new confusion, since they can trigger inflammatory processes which upset normal brain function. Co-existent fever and dehydration may also make the problem worse, too. However, sometimes symptoms don’t improve, they get worse. Sometimes, a “lower” UTI can spread upwards through the ureters – the tubes that convey urine from the kidney to the bladder. If infection reaches the kidney, a condition called pyelonephritis occurs. This can cause pain felt higher in the back or in the flanks. It can also make patients feel very sick and unwell with a high fever, chills or shakes, and vomiting. In some instances, hospital treatment is needed, and infection spreading into the bloodstream causes sepsis. These are symptoms not to be ignored. For others, problems resolve and then return, sometimes days, weeks or months afterwards. These recurrent UTIs can become extremely uncomfortable and distressing for patients. An ultrasound scan might be suggested to look for underlying problems – kidney stones, masses and an enlarged prostate gland can slow urinary flow, making an infection more likely. In some instances, bladder cancer can also cause similar issues and mimic recurrent UTIs. In addition, they can cause blood in the urine – another reason to go and speak to your doctor if you notice any persistent symptoms. And there are also some people whose urine contains bacteria, but who have no symptoms at all. We call this condition asymptomatic bacteriuria. Treatment with antibiotics is controversial since the problem may have been there harmlessly for months, though there are some exceptions (e.g. in pregnancy). And finally, some myths Firstly, don’t go by smell or appearance alone when examining your own urine – or indeed someone else’s. Dark or offensive urine could potentially suggest a UTI, but I’ve never encountered a urine sample that smelt of roses. Even normal urine can still carry a strong odour of ammonia, especially if the patient is dehydrated. Other very peculiar smells can be caused by diet – like asparagine from eating asparagus (which can really make your urine stink) – and lull you into thinking it’s a UTI. Best to look out for other symptoms or do a urine sample for dipping. Then there’s cranberry juice, which leapt up in popularity when evidence emerged years ago that those little red pocket rockets could help prevent recurrent infections. However there’s no convincing evidence that suggests that it can treat an existing UTI, or move things along quicker. I’m very happy for my patients to drink cranberry juice if they’d like, as hydration is really important, too. I’m just saying it could be water instead. So, a UTI can really be a UTI, look like a UTI, or not be a UTI at all. It’s the combination of symptoms, signs and lab results that can help us accurately determine what’s going on, and work out the best means of treatment. And when things don’t add up, we need to consider alternatives, and not automatically reach for antibiotics – or take out shares in cranberries.