Nearly one in three women may experience at least one urinary tract infection by the time they are 24 years old. Almost half of all women might experience one urinary tract infection during their lifetime. With these numbers highlighting its commonality, it's clear that urinary tract infections are more than just a routine inconvenience—they're a healthcare challenge that requires effective diagnosis and management strategies. (14)
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What Are Urinary Tract Infections?
Urinary tract infections (UTIs) are infections that occur within the urinary system, which comprises the kidneys, ureters, bladder, and urethra. Most UTIs occur within the lower urinary tract, specifically the bladder (cystitis) and the urethra (urethritis).
Urinary Tract Infection Signs & Symptoms
UTI presents with three hallmark symptoms:
- Pain with urination (dysuria)
- Frequent urination of small volumes
- Urinary urgency
Other common signs and symptoms associated with UTI include (10, 26):
- Foul-smelling and cloudy urine
- Blood in urine (hematuria)
- Lower abdominal or pelvic pain
- Confusion, fatigue, and weakness (more common in elderly patients)
- Suprapubic tenderness on physical exam
Fever, chills, back pain (costovertebral angle tenderness on physical exam), rapid heartbeat, nausea, and vomiting may indicate pyelonephritis (kidney infection).
Root Causes of Urinary Tract Infections
Understanding the root cause of a UTI can help personalize management plans to support the body's natural defenses and reduce the likelihood of future occurrences.
Pathogenic Organisms
UTIs are often caused by the presence of pathogenic microorganisms in the urinary tract.
More than 90% of bladder infections are associated with Escherichia coli (E. coli), a bacteria that resides in the gastrointestinal tract. Other bacteria that may contribute to UTIs include:
- Enterobacter
- Proteus
- Enterococcus
- Klebsiella
While less common, UTIs can also be associated with fungi and viruses. Candida albicans is the most common fungus linked to UTIs. Viral causes may include cytomegalovirus (CMV), type 1 human polyomavirus, and herpes simplex virus (HSV). (20)
Anatomy
Women are up to 30 times more likely than men to experience UTIs due to the anatomy of the female genitourinary system. The female urethra is much shorter than a man's, which may make it easier for bacteria to travel into and colonize the bladder. A woman's urethral opening is also close to the vagina and anus, which are sources of germs that can contribute to UTIs like E. coli. (25)
Anatomical variations in the urinary tract can affect the ability to completely empty the bladder, potentially increasing the risk of UTI. For instance, urethral strictures, bladder outpouchings, or urinary tract obstructions can impede the complete emptying of the bladder. Residual urine left in the bladder may provide a favorable environment for bacterial growth, leading to an increased risk of infection. (27)
Hormonal Changes
Changes in estrogen levels that occur prior to menstruation and during menopause may cause thinning and dryness of urethral tissues, making them more susceptible to infection.
UTIs are one of the most common infections during pregnancy. In addition to the uterus compressing the bladder, elevated progesterone levels can cause smooth muscle relaxation, potentially leading to urinary stasis and backward movement of urine from the bladder to the kidneys. (16)
How to Diagnose a Urinary Tract Infection
A comprehensive patient history is an important tool for diagnosing UTI. The onset of urinary frequency and dysuria in the absence of vaginal discharge has a positive predictive value for UTI of 90%.
A focused physical examination and laboratory urinalysis can complement the patient's medical history and support the diagnosis of a UTI.
Step 1: Perform Urinalysis
Urinalysis and urine culture performed on a midstream, clean-catch urine sample can improve the accuracy of a clinical UTI diagnosis. Urinalysis involves examining the physical and chemical properties of urine. Nitrites and leukocyte esterase on dipstick urinalysis may suggest UTI. (21)
Urine culture complements urinalysis by identifying the specific microorganism associated with the infection and determining their antibiotic susceptibility. A colony count greater than or equal to 103 CFU/mL of a uropathogen is considered diagnostic for UTI. Antibiotic susceptibility testing can guide targeted antibiotic therapy, supporting effective management. (10)
The following are urinalysis and culture testing options:
- Urinalysis w/ Reflex to Culture by Access Med Labs
- Urinary Tract Infection Panel by RealTime Laboratories
Step 2: Testing to Uncover Root Causes of Recurrent UTIs
Additional testing may help uncover the root cause(s) of UTI to support prevention. Recurrent UTIs are defined as at least two urinary tract infections in six months or three in one year. In a primary care setting, 53% of women over age 55 and 36% of younger women report a UTI recurrence within one year of a resolved infection. (13)
Microbiome Analysis
Vaginal and gastrointestinal pathogens can translocate into the urethra, potentially causing UTI. Dysbiosis in either the vaginal or intestinal environments, therefore, can be a source of recurrent UTIs. Assessing the microbial makeup of both environments can be done with comprehensive vaginal and stool cultures.
Tests to assess the vaginal microbiome:
- Vaginal BiomeFx by Microbiome Labs
- Vaginosis Profile by Doctor's Data
Tests to assess the intestinal microbiome:
- GI-MAP by Diagnostic Solutions
- Microbiology Analysis by Genova Diagnostics
- Microbiology Profile by Doctor's Data
Comprehensive Hormone Testing
Imbalances in female sex hormones estrogen and progesterone can induce microbial and anatomical changes in the urogenital tract, potentially making it easier for pathogenic organisms to contribute to UTIs (6).
Chronic stress may affect the immune system, making it harder for the body to manage infections naturally. Salivary cortisol is a testing method commonly used to assess the HPA axis as a marker of chronic stress.
These panels are options to measure female reproductive hormones and cortisol:
- Female Hormone Panel by Precision Point
- Saliva Female Hormones by Ayumetrix
- Diurnal Cortisol by ZRT Laboratory
- DUTCH Plus by Precision Analytical (DUTCH)
Imaging
Imaging may be recommended for patients with recurrent UTIs or who don't respond to management to examine the urinary tract for anatomical anomalies, disease, and injury. Ultrasound, computed tomography (CT), and cystoscopy are typical imaging procedures ordered for a more extensive evaluation of the urinary tract. (23)
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Management Plan for Urinary Tract Infections
Below is a step-by-step management plan that can be personalized for individuals dealing with uncomplicated or recurrent UTIs.
1. Address the Infection
Here's Why This Is Important:
Promptly addressing a UTI may help prevent undesirable health complications if the infection spreads to the kidneys or into the bloodstream.
How Do You Do This?
Acute, uncomplicated UTIs can be managed with antibiotics or natural supplements.
The first-line antibiotics for managing acute, uncomplicated cystitis may include:
- Nitrofurantoin 100mg twice daily for five days
- Trimethoprim-sulfamethoxazole 160 mg/800 mg twice daily for three days
- Fosfomycin 3 grams in a single dose
Certain herbs and supplements may help support the body's natural defenses and prevent pathogens from adhering to the urinary tract's lining. Research suggests that the following supplements may support the management of uncomplicated UTIs.
- Uva-Ursi 300 mg three times daily
- Berberine 300-500 mg three times daily
- Cranberry extract at least 400 mg three times daily
- D-mannose 2 grams twice daily
2. Support Inflammation Management
Here's Why This Is Important:
UTIs can cause inflammation in the urinary system, contributing to symptoms even after the infection is addressed. Anti-inflammatory measures may help alleviate uncomfortable urinary symptoms during management and prevent symptoms from lingering after active management is complete.
How Do You Do This?
Water-soluble mucilage herbs, including corn silk and marshmallow root, are often taken in tea form to promote adequate hydration, increase urine flow, and help flush bacteria from the urinary system. Additionally, they may soothe irritated urogenital tissues.
3. Reestablish a Healthy Urogenital Microbiome
Here's Why This Is Important:
Lactobacilli species of bacteria are commonly found in the genitourinary tract of premenopausal women. Lactobacilli produce hydrogen peroxide, which may inhibit pathogens from adhering to the bladder walls.
How Do You Do This?
According to a systematic review, probiotics, especially Lactobacillus rhamnosus and reuteri, may help prevent recurrent UTIs in women. Studies on UTI management and prevention have used probiotic doses ranging from ten thousand to ten billion CFU daily for five days to 12 months.
4. Establish Good Hygiene Practices
Here's Why This Is Important:
Good hygiene may help prevent UTI by minimizing bacterial contamination of the urethra.
How Do You Do This?
The following hygiene practices may help prevent the spreading of bacteria into the urethral opening (22, 23):
- Wipe from front to back after using the toilet
- Urinate before and after sexual activity
- Stay well hydrated by drinking at least half your body weight in ounces every day
- Avoid douching
The Risks of Untreated Urinary Tract Infections
Untreated UTIs may increase the risk of the following serious health complications:
- Kidney infection and kidney damage
- Adverse pregnancy outcomes, including premature delivery and low birth weight, when UTI occurs during pregnancy
- Urethral narrowing
- Sepsis
UTI Case Study
Read about a real case study here:
How Megan Managed Her Recurring Urinary Tract Infections by Supporting Her Gut Health
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Key Takeaways:
- Effective diagnosis and management of urinary tract infections (UTIs) are important in alleviating symptoms, supporting overall well-being, and reducing the risk of complications.
- Management of acute infections should encompass antimicrobial and supportive therapies to address infection and alleviate urinary symptoms.
- Encouraging individuals to implement preventive measures may help reduce the burden of UTIs and minimize the risk of recurrent infections.
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