C H A P T E R Painful Micturition and Increased Frequency of Micturition 1 1 Patients may complain of a painful or burning sensation when they pass urine or may tell you that the number of times that they pass urine each day has increased. Both of these problems may be a sign of a urinary tract infection. This chapter will discuss the diagnosis and management of some of these infections which is important to prevent serious complications. c Micturition means the passing of urine. c Dysuria means a painful or burning sensation on passing urine. c Frequency means an increase in the number of times urine is passed each day. c Urinary tract infection (UTI) is an infection of the urinary tract. It may occur anywhere from the urethra up to the kidney. A lower urinary tract infection refers to the involvement of the bladder and urethra. An upper urinary tract infection occurs in the ureter or kidneys. (Pyelonephritis). This chapter will discuss: c Cystitis - a lower urinary tract infection c Pyelonephritis - an upper urinary tract infection c Urinary tract infections in males c Urinary tract infections in children c How to take a urine sample for testing Above is a diagram of the urogenital tract in both male and female.
Cystitis - a lower urinary tract infection Urinary tract infections are more common in women than in men. Petronella Manga is a 29 year old woman who complains of a two day history of dysuria - a burning sensation on micturition. She also needs to pass urine more frequently than usual. Each time she passes urine, the amount is very small. It is likely that Mrs Manga has cystitis. What is cystitis? Cystitis is an inflammation of the lining of the bladder - it is commonly caused by a bacterial infection. Signs and symptoms of cystitis include: c Dysuria. This is a burning or painful sensation on micturition. The lining of the urinary tract is inflamed and very sensitive in a patient with cystitis. Urine is a little acidic, so it burns the inflamed urinary tract when urine is passed. c Frequency. This is the need to pass urine many times a day. Only a small amount of urine is passed each time. Often patients also need to wake up at night to pass urine. c Mild and vague suprapubic abdominal pain. c The urine may smell offensive and be cloudy in colour. A dipstix test may show blood in the urine. Blood in the urine is called haematuria. White blood cells may also be found in the urine. Any infection in the body results in a sudden increase in the number of white blood cells. If the infection is in the urinary tract, the white blood cells pass into the urine. Normally there are about 5-10 white blood cells in each millilitre of urine. But you may find hundreds or thousands of white blood cells in each millilitre of urine when a person has a urinary tract infection. Urine white blood cells are easily assessed using a urine dipstick. In a UTI, there may be an increase in the number of WBC s, elevated nitrites and possibly mild elevations in the protein level on the dipstick Cystitis presents with dysuria, frequency of micturition and many white blood cells in the urine What causes cystitis? Cystitis is usually caused by a bacterial infection. It may develop in any of the following ways: c Contamination of urinary tract by faecal bacteria. Normally the urinary tract is free of bacteria. However contamination of the urethal area may occur after bowel movements or during sexual intercourse.
c There may be no obvious cause of the cystitis. One theory is that women have a much shorter urethra than men do. This makes it easier for bacteria to travel up the urethra and into the bladder. This is perhaps why females get cystitis more commonly than males. c Bilharzia may cause irritation of the bladder and recurring cystitis. In severe cases, it may cause damage to the uterus and kidneys as well, which predisposes to pyelonephritis. c Symptoms of dysuria may also occur in the following conditions: sexually transmitted diseases inflammation of the vulva drying of the mucus membranes that may occur after menopause Contamination of the urethral tract by faecal bacteria may cause cystitis The management of cystitis? There are a number of ways to treat a patient with cystitis. c Drinking lots of water. Encourage the person to drink plenty of water. Water helps to flush out the urinary tract. This makes it harder for the bacteria to survive in the urinary tract. c Antibiotics An antibiotic is important to treat cystitis, in order to prevent the infection from spreading to the kidneys. The following antibiotics are appropriate choices:- amoxycillin orally 250mg 8 hourly for 3 days. trimethoprim/sulfamethoxazole (Bactrim) (80mg/400mg) orally 2 tablets twice daily for 3 days ciprofloxacin (Ciprobay) orally 500mg twice daily for 3 days. c Advice on hygiene after defecation You may also have to advise the patient to alter her hygienic practices. This may be a sensitive subject which needs careful counselling. Instruct the patient to clean themselves from front to back after defecation, to reduce the introduction of bacteria to the urinary tract. The different treatments that have been mentioned will usually successfully treat cystitis. However, occasionally a patient will return to you with repeated attacks of cystitis. Refer the patient to a doctor if she gets recurrent attacks of cystitis
Why can cystitis occur repeatedly? It is not always clear why cystitis recurs. However, some reasons include: c The infection was not adequately treated and so cystitis recurs. The bacteria may not be sensitive to your choice of antibiotic. In this case you should send a sample of urine for bacterial culture to a laboratory. The laboratory can often advise you as to which antibiotic is best. c Cystitis may recur if the patient has repeated vulvo-vaginal infections. For more information on this, refer to SEXUALLY TRANSMITTED DISEASES. c The anatomy of the patient's urinary tract may be abnormal e.g. an abnormally dilated ureter. This can cause repeated infection. This can only be diagnosed with special X-rays. Cystitis may cause serious complications if it is not adequately treated. Always refer the patient to a doctor if she gets recurring cystitis. The most serious consequence of cystitis is that the infection may spread up to the kidneys in the upper urinary tract. An infection in the upper urinary tract is called pyelonephritis. Pyelonephritis - an upper urinary tract infection Pyelonephritis is a serious disease. If it becomes chronic, or is untreated it can eventually destroy the kidney and cause permanent chronic renal failure and/or hypertension. A patient will eventually die of chronic renal failure unless a kidney transplant is done, or a kidney dialysis machine is used. It is obviously very important that primary health care workers should be able to diagnose and manage patients with pyelonephritis. How to diagnose pyelonephritis When pyelonephritis occurs, the patient often complains of the following symptoms: c As in cystitis you will usually find frequency and burning on micturition. c The patient will have a general feeling of being ill. She will probably have a high pyrexia (38-39C) as well as hot and cold chills. These shaking chills are called rigors. Note: Pyrexia and rigors are not generally caused by simple cystitis. c The patient may have renal angle tenderness. This is the area of the back, next to the spine and between the bottom of the ribs and the top Percussion of the renal angle for tenderness.
of the pelvis. This means gently percussing the renal angles usually causes pain. c A urine microscopy usually shows many white blood cells. There are also clumps white blood cells in the urine. These are called white blood cell casts. c Milder cases of pyelonephritis may be treated by a primary health care worker. Patients with a severe attack should be referred to a doctor. How to treat pyelonephritis If a patient is not very ill, but you suspect pyelonephritis, they may receive a trial of the following oral antibiotics: amoxycillin 500mg 8 hourly for 7-10 days trimethoprim/sulfamethoxazole (80/400mg) 2 tablets twice daily for 7-10 days. In severe cases, where there is high fever, severe renal angle tenderness or shock, the patient needs intravenous antibiotics and should be referred to the doctor. While waiting to go to hospital the patient should receive: ampicillin 500mg IV 6 hourly or ceftriaxone (Rocephin) 1g daily IV fluids will also be important in these patients as bacterial infection may be present in the blood (sepsis) and lead to shock. Careful follow-up is very important for all patients with pyelonephritis. A patient who has more than one attack of pyelonephritis needs to be investigated for urinary tract abnormalities. Remember that repeated attacks of a urinary tract infection should be referred to a doctor. Urinary tract infections in males This section will look at: c What is prostatitis? c What are the signs and symptoms of prostatitis? c How would you manage prostatitis? What is prostatitis? Prostatitis is an inflammation of the prostate gland. It is usually caused by infections from sexually transmitted diseases and other bacteria. It may also be associated with an infection of the epididymis and the testis. In the diagram of the male genital tract, note the position of the prostate gland.
Prostatitis usually presents with similar signs and symptoms as cystitis. But you should remember that in men the prostate gland is commonly the source of infection in cases of cystitis. What are the signs and symptoms of prostatitis? c Dysuria and frequency of micturition may be present. c The urine may be offensive smelling and cloudy in colour. c A dipstix test may show blood in the urine. c Many white blood cells will be found if the urine is examined with a dipstick. c There may be a mild urinary obstruction. The urethra passes through the prostate gland. In prostatitis the prostate gland may become inflamed and put pressure on the urethra. This causes urinary obstruction. The patient may complain of difficulty when beginning to pass urine. c The prostate gland will feel enlarged and tender when a rectal examination (PR) is done. The patients discomfort will also often get worse when having a bowel movement. Management of prostatitis? Prostatitis is more difficult to treat than simple cystitis, as antibiotics have difficulty entering the prostate gland. Penicillins are not good choices for this reason. The following antibiotics are appropriate: trimethoprim/sulfamethoxazole (80/400) orally 2 tablets twice daily for 14 day or ciprofloxacin 500mg orally 1 tablet twice daily for 14 days
Urinary tract infections in children Urinary tract infections in children are not always easy to detect, as the signs and symptoms are not always obvious. Always consider the possibility of a urinary tract infection if any of the following signs and symptoms are present: c the child fails to gain weight c the child has unexplained abdominal pains and /or vomiting c there is a sudden onset of bed wetting c the child has unexplained pyrexia. There will also be an increased amount of white blood cells when a urine microscopy is done c the parents may complain that the child s diapers are more foul smelling than usual Refer any child with a urinary tract infection to a doctor. Referral is necessary because there is a possibility of an underlying defect in the urinary tract. This can result in chronic renal disease if the defect is not diagnosed early. In a confirmed case of a urinary tract infection, the doctor should investigate the child's condition further and look for such a defect. How to take a urine sample for testing The following steps are involved in taking a urine sample for bacterial culture and microscopy. It is always important to collect clean, uncontaminated urine samples. c Clean the external opening of the urethra with soap and water. Clean the tip of the penis in males. Clean the opening of the urethra in females. c In the female, spread the labia apart so that the urine stream flows freely. c Collect the mid portion of the urine stream in a sterile container. You can do this by waiting a second or two after the urine stream has begun, then collecting the urine. c Send the urine sample to the laboratory immediately if necessary or perform a urine dipstick test. If you need to wait for transport to get the sample to the laboratory, then keep the sample in the refrigerator. Summary: Painful and frequent micturition Cystitis is an infection of the lower urinary tract. It is more common in women than in men. The signs and symptoms of cystitis are as follows: c dysuria c frequency of micturition c cloudy urine c blood in the urine c suprapubic pain c increased white blood cells in the urine
The causes of cystitis may be as follows: c sexually transmitted diseases c inflammation of the vulva c poor hygienic practices, sexual intercourse, menopause Cystitis is treated with oral fluid and antibiotics. Repeated attacks of cystitis should be referred to a doctor. Pyelonephritis is an infection of the kidney i.e. an upper urinary tract infection. The symptoms and signs of pyelonephritis are as follows: c high pyrexia c rigors c pains in the loins to percussion c renal angle tenderness c frequency of micturition and dysuria c white blood cells in the urine c white blood cell casts Pyelonephritis can lead to chronic renal failure or hypertension. Most cases of pyelonephritis need to be referred to a doctor. Mild cases can be treated with antibiotics and fluids. Careful follow up of a patient with pyelonephritis is necessary. Males occasionally get urinary tract infections. These infections are usually associated with prostatitis. Prostatitis is an inflammation of the prostate gland and is treated with antibiotics. The symptoms of prostatitis are: c dysuria c frequency of micturition c cloudy urine c blood in the urine c increased amounts of white blood cells in the urine c a mild urinary obstruction c a tender, enlarged prostate on PR examination c there may also be a spread of the infection to include the testis and the epididymis. Old people with dysuria and blood in the urine on microscopic examination may have bladder cancer. They should be referred to a doctor immediately. Urinary tract infections in children may go unnoticed as the signs and. symptoms are not always obvious. These infections in children may present with: c failure to gain weight c bed wetting c pyrexia of unknown cause c unexplained abdominal pain and/or vomiting
Urinary tract abnormalities may be the cause of urinary tract infections in children. You should refer all children with definite urinary tract infections to a doctor for investigation. When collecting urine samples for analysis, be sure that the sample is clean and uncontaminated.