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Urinary Tract Infections Diagnosis and treatments

Getting a Diagnosis
Most UTIs can be treated by your gynecologist or family physician. If the diagnosis is difficult or the treatment fails, your doctor will refer you to a urologist.

First Doctor's Visit
You will be asked to provide a urine specimen that will either be analyzed in the doctor's office or sent to an outside laboratory. A large number of white blood cells indicates that your body has made an effort to fight some kind of infection. The presence of bacteria can also be directly confirmed. This is done quickly in a process called urinalysis.


DIVERTICULA: A LONG-TERM SOURCE OF TROUBLE

If a pouch develops at weak point in the wall of a tube such as the urethra, it's called a “diverticulum.” A trap for all sorts of debris, it can become a permanent reservoir of chronic infection. Diverticula in the urethra can become inflamed, causing discomfort whenever you urinate. Diverticula can also develop in the lower intestine, leading to inflammation, bleeding, obstruction, and even life-threatening abdominal infection.


If the doctor wants to find out exactly which bacteria have invaded, he or she will order a urine culture, which takes 24 to 72 hours. The laboratory may also be asked to determine which antibiotic will destroy those bacteria most effectively, so that your doctor can prescribe the most beneficial medication. (You will probably already have been given a small prescription for a broad-spectrum antibiotic— one that works against most bacteria—and for a painkilling medication to get started fighting the infection and discomfort right away.)

Other reasons for a urine culture are:

Suspicion of a more serious infection, such as gonorrhea;
Pregnancy or diabetes;
An infection that returns within 3 weeks;
Symptoms that continue for more than 7 days despite taking medication;
Recent surgery of the genital or urinary tract or insertion or removal of a catheter.
If you could be pregnant or your doctor suspects an anatomical problem, such as a cystocele or a tumor, your doctor will also do a pelvic exam.

More Complex Tests
If your medication doesn't work or the doctor suspects a physical abnormality that cannot be seen, you will probably be referred to a urologist for more complex procedures. They may be performed at the doctor's office or a hospital.

A cystoscope, allows the doctor to look directly into your urethra and bladder to check for irritation or a small tumor. First you will be given a local or general anesthetic. Then the scope will be passed through your urethra and into your bladder. Through the scope, the doctor can insert tiny instruments to collect small samples of urine and tissue for the laboratory to analyze. This procedure takes about 10 minutes once the cystoscope is in place.

With cystourethrography, a chemical is inserted into the bladder through the cystoscope. X-rays are taken as you urinate. The doctor watches to see if urine is backing up instead of flowing out.

Cystometry measures how well your bladder is functioning by gauging its ability to expand and contract. After introducing water or carbon dioxide into the bladder through a catheter, technicians note the amount you urinate each time you report the urge. The test takes about 30 to 60 minutes and is usually done in a hospital. Local anesthesia will prevent pain during the procedure.

An intravenous pyelogram (IVP) is performed by a radiologist and an x-ray technician in the outpatient department of a hospital. They will take a preliminary x-ray of your abdomen. Then you will lie down and a needle will be inserted into a vein in one arm. Special dye, called contrast material, is injected through the needle. Within a few minutes, the dye is carried by the blood to the kidneys and then through the urinary tract.

The goal is to find any blockage, such as kidney stones, or slight anatomic variations in the urinary tract, that might make it easier for an infection to take hold. X-rays are taken at regular intervals, such as after 1, 5, 10, and 15 minutes. After about an hour, the radiologist should have a good idea of what's going on in your urinary tract. This test is not suggested for women who are pregnant or those who have ever had an allergic reaction to x-ray contrast material.

Treating UTIs: Many Good Choices
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The drugs available to treat UTIs today are extremely effective. However, because not all medications work equally well against all bacteria or for all women, you and your doctor may have to experiment, especially if you have recurring infections.

Drug Therapy
Eighty percent of the time, cystitis can be cured with a single dose of trimethoprim (Trimpex) or 3 to 5 days of trimethoprim/sulfamethoxazole (Bactrim, Septra, others) or sulfisoxazole (Gantanol, Gantrisin, others). If you are allergic to sulfa drugs, you may be given one of the new quinilone antibiotics such as ciprofloxacin (Cipro), norfloxacin (Noroxin), ofloxacin (Floxin), enoxacin (Penetrex), or lomefloxacin (Maxaquin). Sulfa drugs should not be taken during the last 4 weeks of pregnancy because they can cause jaundice in the newborn. Other popular antibiotics are cephalexin (Keflex), cefixime (Suprax), and cefuroxime (Ceftin, Kefurox, Zinacef).

The short-term therapy that is commonly used today is far better than the former standard of 7 to 14 days of antibiotics. That regimen was somewhat self-defeating, since vaginal yeast infections are one side effect of long-term antibiotic therapy—and yeast infections can trigger UTIs! Other side effects included diarrhea and allergic reactions.

Treatment will be longer and require different or additional drugs if the urine culture shows tougher bacteria than E. coli, such as Staphylococcus, Chlamydia, or Mycoplasma. More than one kind of bacterium may be present; if so, they must all be eradicated.

Some doctors prefer to prescribe other drugs. Amoxicillin (Amoxil, Trimox, Wymox) and ampicillin (Omnipen) are less effective for some women, but might work well for you. Nitrofurantoin (Macrodantin) and cephalosporins antibiotics such as Ancef and Kefzol can be used as well.

To relieve pain almost immediately, you may also be given a prescription for an antispasmodic, such as methenamine (Prosed, Urised) or flavoxate (Urispas). These drugs relax the bladder muscle, reducing the constant urge to urinate. Also commonly prescribed is a local anesthetic, phenazopyridine hydrochloride (Pyridium).

Be sure to do your part to make your treatment work. Finish all prescribed antibiotics, even though your symptoms will probably stop within hours. Painkillers kill pain but not the bacteria that cause them. Your doctor may ask you to make an appointment to return for a repeat urine culture in a week or two—and keep the appointment even if you feel fine. Remember that UTIs can come back quickly and with a vengeance.

Hospitalization
Urinary tract infections rarely send anyone to the hospital. Hospitalization is necessary for surgery to correct certain physical conditions, such as a large cystocele protruding into the vaginal wall. If a kidney infection develops, hospitalization is often required to supply strong drugs or pain relief through an IV line. Since the nausea and vomiting that frequently accompany a kidney infection can lead to dehydration, an IV line can also supply fluids to prevent that from happening.

Controlling UTIs Yourself
So many women are pestered by chronic cystitis that some doctors are now teaching some of them to treat themselves. Starting treatment at home without waiting for an office visit reduces pain at the first sign of infection, and taking antibiotics right away will begin to kill bacteria before they have a chance to proliferate. Self-treatment can save money as well.

If you have had cystitis several times in the past year and believe you can follow directions carefully, ask your doctor about self-treatment; he or she will tell you exactly what to do. In the meantime, here are some temporary measures you can take.

Tips for Self-Care
If you feel pain, don't suffer. Unless your doctor has instructed otherwise (and if you don't have your prescribed painkillers on hand), take one or two extra-strength non-aspirin painkillers (Tylenol, Advil, others) until you can have your urine tested.
As soon as you can, relax and put your feet up. Hold a heating pad or hot-water bottle against your abdomen or even directly in the urethral area (don't let it get too hot). If your genital area is warmer than the urine waiting to be excreted, it won't burn as much when you urinate.
The Cranberry Connection
Should you drink gallons of cranberry juice for a UTI? Like any citrus juice, cranberry juice keeps the urine in an acid state, which discourages bacterial growth. An extra attraction of cranberry juice—and blueberry juice as well, one group of researchers found— is that it contains compounds that seem to make the walls of the bladder slippery. As a result, bacteria slide off (and out) instead of sticking around to cause infection.

WHEN IT FEELS LIKE A UTI, BUT ISN'T
Symptom: Frequent Urination
Potential Culprits:

Drinking a lot of liquids
Drinking alcohol or beverages containing caffeine (coffee, tea, cola)
Stress and anxiety
Physical changes of pregnancy or menopause
Pressure on the bladder by a pelvic mass
Symptom: Painful Urination

Potential Culprits:

Vaginal infection
Active genital herpes infection or other sexually transmitted disease
Bruising from sexual intercourse, bicycling, horseback riding
Chemical irritation from:

Tight jeans
Non-cotton underwear, tights, pantyhose
Laundry soaps used to wash underwear or nightwear
Bath oils
hygiene sprays or similar products
Talcum powder
Gynecologic surgery
Having a catheter (tube for urine) inserted after surgery
Interstitial cystitis (rare)
Bladder cancer (rare)
Symptom: Blood in the urine

Potential Culprits:

Many diseases, including sickle cell anemia
Long-distance running (“jogger's hematuria”)


However, it takes a tremendous volume of unsweetened, undiluted cranberry juice to keep urine acidic, especially if you are drinking and urinating a lot anyway, as you should be. One alternative is to grind fresh cranberries with honey and eat them with plain yogurt every night. Some cystitis sufferers take a 250-milligram tablet of vitamin C every 4 hours (or 1,000 milligrams of the time-release type once a day) to prevent recurrent infections.

The downside of highly acidic urine is that it stings badly when passing through an inflamed urethra. Some women who have rejected cranberry juice and other acidic drinks after just that experience recommend the opposite: that you neutralize (alkalinize) your urine, making it less acidic, and therefore, less painful when you urinate.

Thus, if cranberry juice has proved unbearable, you might try the opposite route. At the first sign of a UTI, drink a pint of hot or cold water mixed with 1 teaspoon of sodium bicarbonate (baking soda). Follow this with a large glass of water every 20 minutes for 3 or 4 hours. Once an hour, stir another teaspoonful of bicarbonate into the water you're about to drink. (If you have a heart condition or high blood pressure, ask your doctor first.) The bicarbonate can be mixed with jam instead. If bicarbonate makes you queasy, try potassium citrate. Alternatively, some women chew or swallow commercial antacids, such as Rolaids and Tums, to relieve the burning of urination. The “best” method is whatever works for you.

Other dietary changes that have helped some women are avoiding citrus fruits and spicy foods, and decreasing intake of refined starches and sugars, vegetable fats, onions, beans, and chocolate.

There are also some age-old home remedies you can try, such as tea made from yerba buena, uva-ursi, comfrey, or lemon balm (available at health food stores). Another non-drug remedy that works for some women is six to eight tablets of dolomite every few hours. You should, however, consult your doctor before trying any remedy.

Preventing UTIs—the First or the Tenth
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While antibiotics and self-treatment remedies take care of an infection once you have it, there are also many ways to try to prevent recurring urinary tract infections. Experiment to see what works for you.

Diet
As part of any healthy diet, you should drink six to eight glasses of water a day and minimize your intake of alcohol and caffeine. If you do drink alcohol or caffeinated drinks, try to counteract their effects by drinking plenty of water.

Some of the dietary changes that relieve the pain of UTI may also help prevent them. Try to cut back your intake of refined starches and sugars, vegetable fats, onions, beans, and chocolate.

Toilet, Bathing, and Menstrual Habits
Try to urinate every two to three hours rather than “holding it in.” After the flow of urine has stopped, lean forward on the toilet and gently press out the last few drops. This is known as double emptying. Most important though is to keep your genital area clean by wiping from front to back after bowl movements and cleaning the urethral area with moist cotton balls. You should wash your entire genital area every day with mild, unscented soap, then rinse and pat dry with a clean, soft, cloth.

Some doctors believe that women with frequent UTIs should always take showers rather than baths. Others believe a hot bath during a bout of UTI will help kill the bacteria. If you decide on baths, do not use bath oils or bubble bath and limit them to one or two a week, with no more than five minutes of soaking time. Hot water can excite the urethra.

Do not use oils, feminine hygiene sprays, or talcum powder in your genital area and don't douche with any chemical substances. All of these agents irritate the skin.

When you have your period, frequently change whatever form of sanitary protection you use. Both sanitary napkins and tampons have been known to provide a route for bacteria. In addition, tampons may put pressure on the urethra, encouraging infection. If you think your brand is the problem, switch to a different product.

While at home, wear long skirts without underwear for several hours a day if you can. This can increase circulation while eliminating genital contact with potential infection-bearing material.

Clothes and Laundry
Avoid nylon-crotch underwear and tight jeans, both of which create a moist environment in which bacteria can grow. Instead, it's best to wear only cotton-crotch underwear and pantyhose and to change them at least once a day. Similarly, if you've been swimming, change into a dry suit after you come out of the water, particularly if you were in a chlorinated pool. Use a mild laundry detergent and make sure that your clothes, nightwear, and sheets are well rinsed. Do not use a public laundry to wash your underwear since soap and detergent deposits can accumulate in the washers. If you don't have your own washing machine, the best and oldest method of sterilizing underwear is boiling it in a pot.

Sex
Urinate and drink a glass of water before having intercourse. Within 10 minutes after sex, urinate again to flush out any bacteria that may have entered the vagina. If you find that UTIs are a constant problem, try washing your vaginal area with a hand-held shower attachment after sex.

If you use a diaphragm, make sure it is the correct size with a snug but comfortable fit. Pressure from the rim of the diaphragm can lead to UTIs. If you've lost or gained more than 10 pounds, have your diaphragm refitted. Remember that many forms of birth control can create situations that encourage a UTI. If necessary, talk to your doctor about alternatives.

A Healthy Future
In the great majority of cases, the prognosis for urinary tract infections is excellent. Improved drugs now provide fast relief of symptoms as the infection is cleared up. Also remember that even if you're plagued with recurrent infections, there are plenty of measures you can take to fight back. Between your own efforts and your doctor's treatments, you can keep this painful problem at bay.

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