Learning Objectives
By the end of this section, you will be able to:
- Define an upper urinary tract infection and the pathophysiology, diagnosis, management, and prevention of all types
- Define a lower urinary tract infection and the pathophysiology, diagnosis, management, and prevention of all types
- Define interstitial cystitis and the pathophysiology, diagnosis, management, and prevention of all types
- Identify nursing interventions to provide care for patients with urinary tract conditions
Urinary tract infections (UTIs) affect many patients, and persons assigned female at birth are more susceptible to them, likely due to their shorter urethral length (National Institutes of Health [NIH], 2023). Many times, the urinary tract infection is caused by bacteria, but patients can also experience urinary tract infections with an unknown etiology (NIH, 2023).
Lower Urinary Tract Infection
Lower urinary tract infections are common, and many persons AFAB will experience them. Cystitis refers to infection of the lower urinary tract and bladder, while urethritis is an infection of the lower urinary tract and urethra. Interstitial cystitis refers to a condition that causes chronic bladder pain.
Cystitis
Infection of the lower urinary tract and the bladder is called cystitis. Acute cystitis is often related to a bacterial infection in the bladder. Persons AFAB are at higher risk of getting cystitis because their urethra is shorter than that of persons born with a penis. Uncomplicated cystitis is a term used for an infection in otherwise healthy and nonpregnant persons, while complicated cystitis is a term used for an infection in persons with risk factors. Escherichia coli is the most common cause of both types of infection (Li & Leslie, 2023).
Epidemiology
Cystitis is very common in persons assigned female at birth. Approximately one-third of AFAB persons will have cystitis once by age 24, and 50 percent of all AFAB persons will have it once by age 32. Risk factors include recent sexual intercourse, a new sex partner within a year, and a personal and family history of UTIs. Use of spermicides may also increase the risk. Patients with diabetes mellitus or structural or functional abnormalities of the urinary tract are at increased risk (Gupta, 2023). Patients with a renal transplant are also at increased risk, especially during the first year after transplant (Li & Leslie, 2023). Approximately 8 percent of pregnant patients experience UTIs (ACOG, 2023). UTI in pregnancy can cause preterm delivery and a low-birth-weight infant (ACOG, 2023).
Signs and Symptoms
The most common signs and symptoms of cystitis are painful urination, urinary frequency, and suprapubic pain. Blood may be seen in the urine (Gupta, 2023). Urine could appear cloudy and have a foul odor (Li & Leslei, 2023).
Diagnosis and Treatment
The patient should have a history and physical. A urinalysis with white blood cells is often a good indication of a UTI. Nitrites are present only if there are bacteria, so a urinalysis may show nitrites (Li & Leslie, 2023). If there are no white cells or nitrites, a diagnosis of UTI is unlikely. A urine culture is a definitive test for a UTI and can determine what organism is causing the UTI and what antibiotics it is susceptible to (Gupta, 2023). It is acceptable to treat symptomatic patients with nitrites in their urine without getting a culture (Li & Leslie, 2023).
All pregnant patients should be tested with a urine culture early in pregnancy for asymptomatic UTI and, if positive, receive treatment with a 5- to 7-day course of targeted antibiotics. Repeat testing is not required (ACOG, 2023). Patients with symptoms during pregnancy should have a urinalysis and urine culture, and positive results should be treated with antibiotics. These patients should have a TOC in 1 to 2 weeks after treatment is complete if symptoms recur (ACOG, 2023). Treatment with an antimicrobial is appropriate and based on the culture results. Medications that are safe are cephalexin and fosfomycin. Nitrofurantoin and sulfamethoxazole-trimethoprim may be used during the first trimester. Amoxicillin and amoxicillin-clavulanate are safe but should not be started before culture results because they have a high degree of resistance (ACOG, 2023).
Treatment of nonpregnant persons consists of an antimicrobial, and the type depends on the risk of the patient having an infection caused by a multidrug-resistant (MDR) gram-negative organism. Patients are considered at high risk for this if they have had any of the following in the past 3 months:
- a culture showing a multidrug-resistant gram-negative organism
- an inpatient stay in a health-care facility
- use of a fluoroquinolone (Cipro), trimethoprim-sulfamethoxazole (Bactrim), or broad-spectrum beta-lactam (aztreonam)
- travel to areas with high rates of MDR organisms (e.g., India, Israel, Spain, Mexico)
For high-risk patients, oral beta-lactams are usually appropriate. Patients without risk factors can be treated with nitrofurantoin monohydrate/macrocrystals (Macrobid), trimethoprim-sulfamethoxazole, or fosfomycin (Monurol) (Gupta, 2023).
Clinical Safety and Procedures (QSEN)
Clean Catch Urine Collection
The nurse will do the following:
- Perform hand hygiene and don gloves and additional PPE based on isolation precautions or the risk of exposure to bodily fluids.
- Verify the correct patient using two identifiers.
- Explain the procedure.
- Have the patient perform hand hygiene with soap and water.
- Provide a specimen hat if the patient’s urinary output is being measured.
- Ensure that antiseptic cleansing wipes and sterile urine specimen collection container or specimen collection kit are within the patient’s reach.
The nurse will instruct the patient to follow these steps before and after collecting the specimen:
- Before collecting the specimen, open the urine collection container and place the lid with the flat side down and the sterile inside surface up. Do not touch the inside of the cup.
- Before collecting the specimen, carefully cleanse the urinary meatus using an antiseptic wipe or organization-approved cleansing cloth.
- Spread the labia minora with the thumb and forefinger or forefinger and middle finger of the nondominant hand.
- Use the dominant hand to cleanse the urethral area with antiseptic cleansing wipes, moving from front (above the urethral orifice) to back (toward the anus).
- While continuing to hold the labia apart, initiate a urine stream. After initiating a urine stream, pass the specimen container into the stream and collect the appropriate volume of urine per the organization’s practice.
- Remove the specimen container before the urine flow stops and before releasing the labia, and then finish voiding. Avoid contamination from feces or tissue paper because it renders the specimen invalid.
- After collecting the specimen, replace the specimen container cap securely (without touching the inside of the container), cleanse any urine from the exterior surface of the container with a paper towel, place the specimen container in the designated location, and perform hand hygiene.
In the presence of the patient, the nurse will label the specimen per the organization’s practice.
Transport the specimen to the laboratory immediately per the organization’s practice.
Discard supplies, remove PPE, and perform hand hygiene.
Document the procedure in the patient’s record.
Urethritis
Infection of the lower urinary tract that causes inflammation of the urethra is called urethritis. Urethritis is more commonly diagnosed in AMAB persons. Urethritis can be due to infectious or noninfectious causes (Young et al., 2022).
Epidemiology
Urethritis is often associated with sexually transmitted infections and can be gonococcal or nongonococcal in origin. Neisseria gonorrhoeae and Chlamydia trachomatis are the most common causes of urethritis. Trauma, such as a urinary catheter, can cause noninfectious urethritis, as can irritation. Urethritis affects 4 million Americans each year and is more common in persons assigned male at birth (Young et al., 2022).
Signs and Symptoms
Urethritis may not cause any symptoms, or the patient may have dysuria, pruritus, burning, or discharge at the urethral meatus (Young et al., 2022).
Diagnosis and Treatment
A diagnosis of urethritis is often made from a history and physical. A urethral swab may be tested for white blood cells as well as a first-void urine. A Gram stain or a methylene blue/gentian violet smear can also be used to make the diagnosis (Young et al., 2022).
Treatment consists of an antimicrobial, which should be based on the organism causing the infection. Urethritis caused by gonorrhea is usually treated with a single dose of ceftriaxone 500 mg IM injection, and urethritis caused by chlamydia is usually treated with a single dose of 1 gram of oral azithromycin or 100 mg doxycycline twice a day for 7 days (Young et al., 2022).
Pharmacology Connections
Nitrofurantoin monohydrate/macrocrystals (Macrobid)
- Generic Name: nitrofurantoin monohydrate/macrocrystals
- Trade Name: Macrobid
- Class/Action: antibiotic
- Route/Dosage: 100 mg 2 times a day for 5 days
- High Alert/ Black Box Warning: Do not take Macrobid if you are in the last 2 to 4 weeks of pregnancy.
- Indications: used to treat urinary tract infections
- Mechanism of Action: destroys bacteria by inhibiting bacterial enzymes involved in the synthesis of DNA, RNA, cell wall protein synthesis, and other metabolic enzymes
- Contraindications: allergy, severe kidney disease, jaundice or liver problems during previous use, if you are in the last 2 to 4 weeks of pregnancy
- Adverse Reactions/Side Effects: headache, dizziness, gas, upset stomach, mild diarrhea, vaginal itching or discharge
- Parent/Family Education: Take with food. Finish all medication unless otherwise directed. Call your doctor if you experience bloody or watery diarrhea; if you have sudden chest pain, wheezing, or new cough; if you have nauseas, loss of appetite, or jaundice; or if you have joint pain or swelling with fever, swollen glands, muscle aches, or unusual thoughts or behavior.
Interstitial Cystitis
Chronic bladder condition that causes pain and has no known cause is called interstitial cystitis. It is a complex syndrome that mostly affects the bladder. Interstitial cystitis causes inflammation of the bladder’s lining. The long-term symptoms can affect a person’s quality of life (Lim et al., 2023).
Epidemiology
Interstitial cystitis is an uncommon condition. It affects more persons assigned female at birth than persons assigned male at birth. The cause of interstitial cystitis is unknown, but these patients may have urothelial abnormalities (Clemens, 2023).
Signs and Symptoms
Signs and symptoms of interstitial cystitis include pain, pressure, discomfort, or spasms in the bladder. Discomfort often worsens when the bladder is filling and is relieved when the bladder is emptied. Foods, drinks, stress, or activities such as exercise or sex may worsen symptoms (Clemens, 2023). The nurse should educate the patient about foods to avoid, which are known to cause irritation to the bladder. Foods with a high acid content, potassium, or capsaicin are irritating. Other foods to avoid include:
- Indian, Mexican, and Thai food
- vinegar, spices, MSG, Worcestershire sauce, hot sauces such as Tabasco
- sweeteners (particularly artificial sweeteners such as saccharin)
- chili, horseradish, hot peppers, pickles, sauerkraut
- ketchup, pizza, tomatoes, tomato sauce
- chocolate
- citric acid, citrus
Drinks also can cause irritation, and these include:
- alcohol
- caffeine and carbonated beverages
- tea
- cranberry juice and tomato juice (Lim et al., 2023)
Diagnosis and Treatment
Diagnosis is usually made when the patient has experienced bladder pain for weeks and there is no bacterial cause or treatment has been completed. A urinalysis can be done to rule out white blood cells or blood in the urine. If there is blood in the urine, cystoscopy should be performed to rule out malignancy. Sexually transmitted infections should also be ruled out (Clemens, 2023).
There is no cure for interstitial cystitis. The goal is to manage symptoms and avoid conditions that increase pain (Clemens, 2022).
Upper Urinary Tract Infection: Pyelonephritis
Bacterial infection of the upper urinary tract that causes inflammation of the kidneys is called pyelonephritis. It is a complication from a UTI when the bacteria travel to the kidneys and can be classified as uncomplicated or complicated. Complicated pyelonephritis occurs when the patient has the following risk factors:
- pregnancy
- uncontrolled diabetes
- kidney transplant
- urinary anatomical abnormality
- immunocompromise
- hospital-acquired bacterial infection (Belyayeva & Jeong, 2022).
Epidemiology
Pyelonephritis is one of the most common diseases of the kidney, and the main cause is gram-negative bacteria, most commonly Escherichia coli. E. coli can adhere to and colonize the urinary tract and kidneys. There are 15 to 17 pyelonephritis infections per 10,000 persons assigned female at birth in the United States (Belyayeva & Jeong, 2022).
Signs and Symptoms
The most common signs and symptoms seen are fever, flank pain (costal vertebral tenderness), and nausea or vomiting. A patient may not have all these symptoms. Symptoms usually develop in a few hours up to a day. Persons assigned female at birth may also report dysuria, and hematuria may be present (Belyayeva & Jeong, 2022). Fever and flank pain are the two most common signs seen in pyelonephritis (Belyayeva & Jeong, 2022).
Diagnosis and Treatment
A urinalysis will likely show white blood cells and may also show hematuria and proteinuria. A complete metabolic blood panel can determine kidney function, and a complete blood count is used to look for elevated white blood cells. Urine cultures should be sent to determine the causative organism. An abdominal and pelvic computed tomography (CT) scan may also be useful, but they are not always required (Belyayeva & Jeong, 2022).
Treatment for pyelonephritis usually consists of antibiotics, analgesics, and antipyretics. Antibiotics should be given empirically but then adjusted based on the results of the urine culture (Belyayeva & Jeong, 2022). Complicated cases of pyelonephritis may need inpatient treatment with IV antibiotics (Belyayeva & Jeong, 2022). Pregnant patients with pyelonephritis should initially be managed in the inpatient setting. These patients should also complete a 14-day course of antibiotics (ACOG, 2023).
The nurse should offer the patient some basic recommendations:
- Avoid dehydration. Drink plenty of fluids.
- Void immediately before and after sexual intercourse.
- Always wipe front to back when urinating and defecating (Belyayeva & Jeong, 2022).
Complications
Pyelonephritis can cause abscesses to form in or around the kidneys. Renal vein thrombosis or acute renal failure is possible. Emphysematous pyelonephritis is a necrotizing infection of the kidney that is a severe complication (Belyayeva & Jeong, 2022).
Link to Learning
The University of Rochester Medical Center has created a quiz on urinary tract infections where you can test your knowledge.
Nursing Interventions and Patient Education
Patients should void after sexual activity to reduce recurring urinary tract infections. Improving personal hygiene may also help. These suggestions include:
- washing hands before voiding
- using adult or baby wipes instead of toilet paper
- wiping just once, from front to back
- taking showers instead of baths
- using a nontoxic liquid soap with minimal chemicals or perfumes to clean the vaginal area
- using soft cotton or microfiber washcloths rather than hands while washing
- washing the vaginal opening first to avoid contamination (Li & Leslie, 2023)
If the UTI was caused by an STI, the patient should be educated about safe sex practices and partner testing and treatment.
For any patient with a UTI and dysuria, a urinary analgesic, such as phenazopyridine may be used. Nursing education should include the urine changing color to a bright orange while taking this medication. This is available over the counter. Patients with recurring infections should have urine cultures and radiographic imaging to look for abnormalities (Gupta, 2023).
Patients with interstitial cystitis must deal with symptoms long term. Heat or cold over the bladder may help to lessen symptoms. Avoiding foods and activities that worsen symptoms can help. Some patients find that increasing fluids helps, while others find that decreasing fluids helps with symptoms, but extremes should be avoided. Amitriptyline (Elavil) can be used to manage pain. Physical therapy can help with interstitial cystitis (Clemens, 2022).
Misconceptions about UTIs include the idea that confusion in older patients always indicates a UTI. This is not always the case and should not be assumed. Urinalysis should not always be used for diagnosis if the patient does not have symptoms. Asymptomatic bacteriuria can occur and does not always require antibiotics, except during pregnancy, when asymptomatic UTIs should be treated. The patient should increase their fluid intake. Cranberry juice or probiotics are often recommended to prevent UTIs, but there is not enough evidence to support their use (Cleveland Clinic, 2023).