Articles

Urinary Tract Infections (UTI)

Introduction

Infections of the urinary tract represent a wide variety of syndromes, including urethritis, cystitis, prostatitis, and pyelonephritis. Urinary tract infections are one of the most commonly occurring bacterial infections in medicine today and account for 7 million patient visits annually. (1) It is estimated that 20% of women will suffer a symptomatic urinary tract infection some time in their lives, with many having multiple recurrences. (2)

Under normal circumstances, the urinary tract is generally resistant to infection and colonization by bacteria, owing at least in part to the properties of urine itself. Its low pH, high concentration of urea, and extremes in osmolality help to inhibit or kill many microorganisms.

Infections of the urinary tract are classified by several methods, one being the anatomic site of involvement. Lower urinary tract infections include cystitis (bladder), urethritis (urethra), prostatitis (prostate gland), and epididymitis. Pyelonephritis is considered an upper urinary tract infection and involves the kidneys.

UTIs are also classified as complicated or uncomplicated. Uncomplicated urinary tract infections involve a patient who lacks structural or functional abnormalities that interfere with normal urine flow. These infections occur most frequently in women of child bearing age who are otherwise healthy individuals.

Complicated UTIs are the result of predisposing lesions of the urinary tract, such as congenital abnormality or distortion of the urinary tract, a stone, indwelling catheter, prostatic hypertrophy, obstruction, or neurologic deficit that interferes with the normal flow of urine and urinary tract defenses. Complicated infections occur in both genders and frequently involve the upper and lower urinary tract. (3)

UTIs are disorders involving a repeated or prolonged bacterial infection of the bladder or lower urinary tract. Most urinary tract infections occur in the lower urinary tract, which includes the bladder and urethra. Cystitis occurs when bacteria, with resultant inflammation infect the normally sterile lower urinary tract. Chronic or recurrent urinary tract infections include repeated episodes of cystitis (more than two occurrences in six months), or urinary tract infections that do not respond to usual therapies or that last longer than two weeks. UTIs are most common in women; however, men and children may experience them as well. About one in every five women will experience a UTI at least once in their lifetime, and many will have recurring infections. Also, the elderly population is at an increased risk for developing cystitis due to incomplete emptying of the bladder associated with such conditions as benign prostatic hyperplasia (BPH), prostatitis, and urethral strictures. Also, a lack of adequate fluids, bowel incontinence, immobility or decreased mobility, and placement in a nursing home, all place the person at increased risk for developing cystitis. (4)

The microbiologic etiology of urinary tract infections usually originates from the bowel flora of the host. The most common bacteria causing uncomplicated urinary tract infections is Escherichia coli, accounting for approximately 85% of community acquired infections. Staphlococcus saphrophyticus, Klebsiella pneumoniae, Proteus sp.,Pseudomonas aeruginosa, and enterococcus sp. are additional causative organisms. Staphlococcus epidermidis is frequently found and should be considered a contaminant unless repeat cultures are performed to help confirm the organism as a real pathogen. In hospitalized patients, the second most frequently found pathogen is Enterococcus faecalis. (5) In part, this finding may be related to the use of third-generation cephalosporin antibiotics, which are not active against enterococci. Enterococcus faecalis resistance to Vancomycin has become a major therapeutic concern as well as an infection control issue. (6)

The majority of UTIs are caused by a single organism, however in complicated urinary tract infections, more than one organism may be isolated. There are several possible routes by which bacteria gain entry into the urinary tract however, the ascending route is the most common. The female urethra, in particular is usually colonized with bacteria believed to originate from fecal flora. The short length of the female urethra, and its proximity to the perirectal area make colonization likely. Other factors that promote the colonization of the urethra are the use of spermacides and diaphragms as methods of contraception. (7) The fact that UTIs are more common in females than males due to the anatomic differences in location and length of urethra seems to support the theory that the ascending route is the most common acquisition route.

Hematogenous (descending) spread is another route by which infection of the kidney may occur. This generally occurs as a result of the spread of pathogens from a distant site of primary infection. Infections involving the descending route are relatively rare and account for less than 5% of documented UTIs.

A third route that has been postulated is through the lymphatic system. While there are lymphatic communications between the bowel and kidney, as well as the bladder and kidney, there is currently no evidence that bacteria are transferred via this route. Once bacteria reach the urinary tract, three factors usually determine whether or not infection will follow. Those are: size of the bacterial inoculum, virulence of the bacteria present, and the competency of host defense mechanisms. The majority of infections reflect a failure in host defenses.

The invasion of the bladder by bacteria stimulates micturition and efficient emptying of the bladder. Individuals who cannot completely empty their bladder are at greater risk of developing UTIs, and have a greater recurrence of infection. Also, patients who have even a slight amount of residual urine seem to respond less favorably to treatment. An important factor in the virulence of bacteria is their ability to adhere to urinary epithelial cells. Normally, the epithelial cells are coated with a mucus called glycosaminoglycan which acts as an antiadherence mechanism preventing bacterial colonization and infection. When this layer is removed by dilute acidic solution, the result is rapid colonization by bacteria. In addition, another glycoprotein produced by the ascending limb of Henle, known as the Tamm-Horsfall protein is secreted into urine and contains mannose residues. These residues bind with the hair like projections of E-Coli and they are then washed out with urine flow.

Some invading bacteria have fimbriae (rigid hair like appendages) of their cell wall. That is mannose resistant. These bacteria are resistant to washout or removal by glycosaminoglycan, and are able to multiply and invade tissue, especially the kidney.

Statistic

American Society for Microbiology, 2002.

  • There are an estimated 150 million urinary tract infections per annum worldwide.

National Institute of Diabetes and Digestive and Kidney Diseases, 1999.

    Each year, urinary tract infections (UTIs) account for about 9.6 million doctor visits. Women are especially prone to UTIs for reasons that are poorly understood. One woman in five develops a UTI during her lifetime. UTIs in men are not so common, but they can be very serious when they do occur. Nearly 20 percent of women who have a UTI will have another, and 30 percent of those will have yet another. Of the last group, 80 percent will have recurrences.

Signs and Symptoms

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Typical symptoms of lower UTI include dysuria, urgency, frequency of urination, nocturia and suprapubic heaviness. Women will frequently report gross hematuria. Systemic symptoms such as fevers are usually absent in this setting. Sometimes patients with significant bacteruria are asymptomatic.

Symptoms of upper urinary tract infections typically include flank pain, costovertebral tenderness, abdominal pain, fever, nausea and vomiting, and malaise. Lower urinary tract infection symptoms may or may not precede those of upper urinary tract infection, but often occur 1-2 days prior to systemic symptoms.

Symptoms of acute bacterial prostatitis include perineal, sacral, or suprapubic pain, a fever and urinary retention, or other urinary tract symptoms.

Lower Urinary Tract Infections

    Dysuria Urgency Frequency of urination Nocturia Suprapubic heaviness Women will frequently report gross hematuria with systemic fevers usually absent in this setting

Upper Urinary Tract Infections

    Flank pain Costovertebral tenderness Abdominal pain Fever Nausea and vomiting Malaise

Treatment Options

Conventional

The goals of treatment are to 1.) prevent or treat systemic symptoms, 2.) eradicate the invading organism, and 3.) prevent reoccurrence of infection. Ideally, the antimicrobial chosen should be well tolerated, have a spectrum of activity limited to the known or suspected pathogen, well absorbed, and achieve high urinary concentrations. Initial selection is primarily based on presenting signs and symptoms, site of infection, and whether the infection is determined to be uncomplicated or complicated.

Oral therapy includes the use of:

Trimethoprim-sulfamethoxazole—highly effective against most aerobic enteric bacteria except Pseudomonas aeruginosa. High urinary tract levels are achieved. Also effective as prophylaxis for recurrent infections.

Penicillin—Ampicillin is the standard penicillin with broad-spectrum activity. Increasing resistance has limited its use. Amoxicillin clavulanate is preferred for resistance problems.

Quinolones—The newer quinolones have a greater spectrum of activity that includes P. Aeruginosa. These agents are effective for prostatitis and pyelonephritis.

Nitrofurantoin—Effective both as a therapeutic agent and prophylactic in patients with recurrent UTI. Its main advantage is lack of resistance, even after long courses of therapy. Adverse effects may limit use. (GI intolerance, neuropathies, pulmonary reactions.)

Azithromycin—single dose therapy for chlamydial infections.

Fosfomycin—single dose therapy for uncomplicated infections.

Methenamine hippurate/mandalate—These agents are used for prophylactic therapy or suppressive use between episodes of infection.

Cephalosporins have shown no advantages over other agents in treatment of UTIs and are more expensive. They may be useful in cases of resistance to amoxicillin and trimethoprim-sulfamethoxazole. (not active against enterococci)

Tetracyclines have been used for initial episodes, but resistance develops rapidly. These agents can also lead to candida overgrowth. Their primary use is in treating chlamydial infections.

Nutritional Supplementation


Vitamin A

Vitamin A is a micronutrient that is essential for immune function, cellular differentiation, epithelial surface maintenance, growth, reproduction, and vision. It may provide a two-fold benefit when used in conjunction with urinary tract infections. Vitamin A plays a role in maintaining the integrity of epithelial tissues and mucous membranes. Vitamin A plays a role in the maintenance of healthy epithelial cells, such as those in the bladder and helps facilitate effective barriers against infection. (8) Adequate intake of vitamin A has even demonstrated a reduced risk to various epithelial-cell cancers, including that of the bladder. (9) , (10)


Vitamin C

Vitamin C and its ability to reduce the severity and duration of the common cold as well as other infectious processes has been well debated. The first evidence of vitamin C’s antibacterial activity was published back in 1937, where it was reported that vitamin C inhibited the growth of the tuberculosis bacterium. (11) There is evidence indicating the 1-3 gram doses provides a variety of immunostimulatory effects. (12) Levels of various immunoglubulins including IgA, IgM, and C-3 complement are reported to increase with regular ingestion of 1 gram of vitamin C for 75 days. (13) Regular consumption has also been reported to increase interferons and lymphocytes in human subjects. (14) , (15)

Herbal Supplementation


Uva Ursi

Uva ursi has been used worldwide as a diuretic, astringent, and antiseptic for centuries. It has historically been recommended for nephritis, kidney stones, cystitis, and as a tonic for the liver. (16) Its antiseptic activity is claimed to soothe the membranes of the urinary tract in much the same manner as phenazopyridine.

Arbutin is an antiseptic phenolic glycoside that reportedly may relieve pain from kidney stones, cystitis, and nephritis. (17) It is converted to hydroquinones in the body and may have disinfecting properties if the urine is alkaline. (18) If arbutin is given alone, it is broken down in the GI tract. However, when the whole plant is taken, the other components protect it from degradation and enhance absorption. Other constituents in the plant are believed to contribute to making the urine alkaline.


Cranberry

Cranberry fruit juice is for individuals with urinary tract infections, with research supporting its uses. (19) , (20) , (21) , (22) Cranberry is a close relative of the American blueberry and European bilberry. It has been used for centuries in cooking and as a garnish. In the United States, urinary tract infections (occurring with dysuria, frequency, and urgency) account for a significant number of the bacterial infections that are reported each year. Only strep throat accounts for more prescriptions written annually for infections in adults. By some estimates, more than 50 million cases of urinary tract infections (UTI) are treated annually. One of every five women in the U.S. will suffer from a UTI at some time in her life. The infection is usually caused by the bacteria E. coli (in more than 90 percent of the cases), with the bacteria adhering to the wall of the bladder and causing inflammation, pain, and fever. Although these infections are not usually life threatening or even a significant health risk for most individuals, there is increasing concern over bacterial resistance. One natural therapy, cranberry, has been reported to be clinically useful in treating and managing UTI.

Cranberry has been used to prevent kidney stones, as well as to remove unwanted toxins from the body. (23) As early as the 1840's, German researchers were examining the connection between using the cranberry and the incidence of UTI. Researchers thought that cranberry worked for UTI by acidifying the urine, preventing the bacteria from growing. In 1984, a researcher reported that cranberry does not acidify the urine sufficiently to produce an antibacterial effect in the bladder. (24) Instead, cranberry prevented E. coli from adhering to the cells lining the bladder wall, thus preventing infection. Research has reported that this property may be due to a glycoprotein found in the cranberry fruit. Further research reported that cranberry was a potent inhibitor of the most virulent strains of E. coli from attaching to the bladder wall. (25) Studies also report that other members of the Vaccinium genus have similar properties, including bilberry and blueberry. (26) The anti-adhesive qualities of cranberry may prevent E. coli from colonizing in the gut as well. (27)


Grapefruit Seed

Grapefruit seed extract has been reported to be a broad-spectrum antimicrobial both in vitro and in vivo. Studies indicate that the antimicrobial activity of grapefruit seed extract exists in the cytoplasmic membrane of the invading bacteria, where the uptake of amino acids is prevented, there is disorganization of the cytoplasmic membrane and leakage of low molecular weight cellular contents ultimately resulting in inhibition of cellular respiration and death. (28)


Olive Leaf

Olive leaf extract has been reported to be an effective antimicrobial agent against a wide variety of pathogens, including Salmonella typhi, Vibrio parahaemolyticus and Staphylococcus aureus (including penicillin-resistant strains), Klebsiella pneumonia, and escherichia coli, causal agents of intestinal or respiratory tract infections in man. (29) The component usually associated with olive leaf’s antimicrobial properties is oleuropein. (30) , (31) Oleuropein also has been reported to directly stimulates macrophage activation in laboratory studies. (32)

Olive leaf extract has reported antiviral activity, reportedly caused by the constituent calcium elenolate, a derivative of elenolic acid. (33) , (34) As an antifungal and antiviral agent, olive leaf extract is currently used as a supportive agent in maintaining bowel flora, beneficial in problems such as Crohn’s disease. Recent laboratory studies in laboratory animals reported hypoglycemic and hypolipidemic activity. (35) , (36) The constituent with the activity was reported to be oleuropein, with a proposed mechanism of action being: (1) potentiation of glucose-induced insulin release, and (2) an increase in peripheral blood glucose uptake.

Homeopathic

Benzoicum acidum

Typical Dosage: 6X or 6C, 30X or 30CIrritation of the bladder; Dark-colored urine that has a very strong odor

Cantharis

Typical Dosage: 6X or 6C, 30X or 30CStrong, persistent painful urge to urinate; Sudden onset; Urine is passed in drops that burn intensely; Small of back may ache

Mercurius corrosivus

Typical Dosage: 6X or 6C, 30X or 30CIntense straining that produces scant; Dark-colored urine; Burning when urinating

Nitricum acidum

Typical Dosage: 6X or 6C, 30X or 30CPrickly pains; Frequent but scanty urination; Prickly, burning in urethra upon urination

Staphysagria

Typical Dosage: 6X or 6C, 30X or 30CBurning pains in the urethra that are relieved by urinating; "Honeymooner’s" cystitis; Irritable

Sulphur

Typical Dosage: 6X or 6C, 30X or 30CPain in kidney region; Scanty urine; Frequency and urgency of urination

Acupuncture & Acupressure

Gu treated 30 cases of chronic urinary tract infection with acupuncture. The following acupoints were selected for treatment: Shen Shu, Pi Shu, Yin Lin Quan, San Yin Jiao (all bilateral points), and Guan Yuan. The patients received the treatment daily, and ten sessions constituted one course of treatment. The results were that 23 cases were resolved (no more frequency of micturition, vesical tenesmus, or discomfort in the lower abdomen, and no relapse within 3 months of treatment), 6 cases improved (symptoms improved), and 1 case did not respond to the treatment. (37)

Kang treated 96 cases of urinary tract infection with acupuncture and a modified Ba Zheng San formula (a classic formula for UTI). The acupoints selected for this treatment were Pang Guang Shu, Zhong Ji, Yin Lin Quan, Xing Jian, and Tai Xi. The result of this study shows that 95.8% of the cases were resolved. (38)

Li treated 50 cases of urinary tract infection with acupuncture. The acupoints selected for treatment were Cheng Jiang and Guan Yuan. The results were: 80% of the cases were resolved, and the remaining 20% improved. (39)

Traditional Chinese Medicine

Urinary Tract Infections (UTI)

Extensive information regarding the treatment of this health condition using Traditional Chinese Medicine is available through the link above.

Clinical Lab Assessment

Some of the following laboratory testing can provide information necessary for diagnosis and treatment. In addition, the tests listed may also give insight to functional metabolism and functional nutrient status in the body.

Chemistry Profile (Blood)

A multifactorial assessment of chemistry profile values can reveal useful information regarding concurrent disorders and possible nutrient imbalances.

Urinalysis

This screening test offers a general indication of overall health as well as health of the urinary tract. Bacterial counts of >100,000/ml are significant in the evaluation of urinary tract infection and may have an impact on general physiologic response.

CBC

A CBC may suggest the involvement of secondary infections, inflammation, and/or nutrient deficiencies. Mean corpuscular volume (MCV) may not be sufficient to assess iron status. Analysis of serum iron, total iron binding capacity, and ferritin may be indicated. The CBC includes screening for leukopenia (low WBC) and thrombocytopenia (low platelet count).

Clinical Notes

Probiotics (Lactobacillus acidophilus and Bifidobacterium bifidus): Individuals suffering from urinary tract infections will likely be using a short coarse of antibiotics to treat the infection. Many women will develop multiple UTIs over a given period of time. Multiple courses of antibiotics, and some individuals using antibiotics chronically as prophylaxis against recurrent UTIs will adversely affect the healthy flora present within the gastro-intestinal (GI) tract. This may lead to a disturbance in the balance between the beneficial and pathological bacteria within the GI tract. If probiotics are not taken following a course of antibiotics, pathological bacteria that are normally present in only small concentration can compete equally with the few remaining beneficial bacteria. A condition known as dysbiosis can develop, which can cause multiple health problems. In order to insure good intestinal health, probiotic supplementation is recommended during and following a course of antibiotics.

References

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