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Case History

image Miss P, aged 36 years, attends on Monday morning with haematuria, frequency and dysuria. She has been up all night with these symptoms and feels too ill to teach her classes. She has no loin pain and is mid-cycle. She uses condoms and a spermicide for contraception and has spent the weekend visiting her boyfriend in London. She is annoyed as this is the fourth time she has had this trouble in the past year. She is otherwise well but smokes 20 cigarettes a day.

What should you ask and what tests should you do?

What causes recurrent urinary tract infections (UTIs)?

What are the treatment options?

What are special considerations?

What are long-term management strategies?


image Cystitis is an inflammation of the lining of the bladder. It can be caused by a variety of inflammatory agents, such as a bacterial infection. Some women have significant bacteriuria without symptoms; this is known as asymptomatic bacteriuria. An uncomplicated urinary tract infection (UTI) is an infection in the bladder only in an otherwise well woman with no abnormality of her urinary tract and no predisposing factors (see Table 38.1). A complicated UTI is in a patient with anatomical or metabolic factors. All infections of the kidney (upper urinary tract) are regarded as complicated, as are those of men or children. A distinction also needs to be made between relapse (persistence of same pathogen in the urinary tract) or reinfection (the acquisition of a new pathogen). Kass, in the 1950s, quantitatively assessed the number of colony-forming bacteria per millilitre of voided urine in acute pyelonephritis in children. From his work, 105 colony-forming units (CFU) has now been adopted in laboratories around the world as an arbitrary cutoff, although Stamm has argued that this has a low sensitivity for ordinary UTIs and that 102 CFU is a more sensitive indicator of symptomatic UTIs in women.1 Certainly a lot of symptomatic women are told their urine culture is 'normal' in primary care, when what is actually meant is that they have less than 105 CFU; clinically this can cause confusion.

Table 38.1Risk factors for upper urinary tract infection

What should you ask and what tests should you do?

The key questions are:

  • How often are you passing water during the day, and at night?

  • Does it hurt? (Where?)

  • How soon did these symptoms start after sexual intercourse?

  • How long have you and your partner been together?

Dipstick testing. Testing a mid-stream urine sample with a ...

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