Urinary tract infection

A urinary tract infection (UTI) is a bacterial invasion of the urinary tract. They are among the commonest bacterial infections managed in general practice, and are the reason for 1–3% of all GP consultations (National Institute for Health and Care Excellence (NICE), 2015).

The urinary tract is constantly exposed to bacteria from the exterior environment, particularly because of the anatomical placement of the urethra in the vicinity of the rectum in females (Okragla et al, 2014).  Women are more frequently affected with a UTI than men, often requiring antibiotic treatment (Babar et al, 2018).

In severe cases, a UTI is a debilitating condition and can produce the onset of painful urination (dysuria), urinary frequency, the inability to start urinating (hesitancy) and the sensation of the sudden need to urinate (urgency) (Bono and Reygaert, 2018).

The lower urinary tract consists of the ureters, the bladder, the trigone and the urethra (Watson, 2011). The bladder has three distinct layers (Patel and Chapple, 2008):

• the outer tissue layer, known as serosa
• the middle smooth layer, mainly consisting of the detrusor muscle, which is responsible for the contractions that set off the sensation to void
• the innermost lining layer, called the urothelium, which comprises transitional cell epithelium that provides an elastic barrier that is impervious to urine.

Mysorekar and Hultgren (2006) reported that an infection of the lower urinary tract occurs when bacteria invade the urethra, migrate to the urothelium and colonise the cells of the epithelium of the bladder. When the superficial bladder cells have been invaded, the uropathogens rapidly begin to replicate inside the bladder cells, forming intracellular communities, also known as intracellular colonisation. Intracellular pathogens, such as Escherichia coli, hijack bladder cells that line the

In most cases, when patients report lower urinary tract symptoms, this is indicative of a sudden or worsening onset of a UTI, also known as an acute flare. It may present as storage, voiding and incontinence symptoms (Haylen et al, 2010).

Using a validated tool to make an assessment of symptoms offers a systematic method for measuring and assessing the presence of urinary frequency, urgency, urinary incontinence, voiding symptoms and bladder pain (Al-Buheissi et al, 2008), as well as the impact of these on a patient's quality of life. Available tools include the Female Lower Urinary Tract Symptoms (FLUTS) questionnaire (Jackson et al, 1996) and the quality-of-life questionnaire for urinary incontinence (I-QOL) (Wagner et al, 1996).

It is good practice for nurses to use a validated assessment tool and, depending on the clinical setting, such as hospital, community or outpatient department, local assessment tools may have been developed based on

Urine samples and diagnostic testing

A UTI is often diagnosed by examining a urine sample. In nursing practice, there are two main methods for obtaining a specimen (Dougherty et al, 2015):

• the clean-catch midstream urine method (MSU), capturing the middle part of the urinary stream
• the catheter specimen method (CSU), which is the insertion of a catheter along the urethra and into the bladder to obtain a specimen.

Collection-method selection depends on the patient's clinical case, but a midstream urine method is the more common method for testing.

A dipstick urinalysis is generally used in clinical practice, because it is a rapid and inexpensive diagnostic test. It is performed in conjunction with, or in place of, a urine culture (Huysal et al, 2013). A dipstick urinalysis measures the markers of pyuria (urinary leukocytes) and bacteriuria (urinary nitrites), the two diagnostic factors often associated with a UTI (Turner et al, 2014). Not

Nurses have the ability to assess and identify the presence of UTI with appropriate training. When a UTI has been identified, nurses should refer the patient to a doctor or a nurse prescriber who will then proceed with treatment options.

Acute and chronic UTIs are often managed by prescribing antibiotics. Methenamine hippurate is an effective bladder antiseptic for preventing the progression of a UTI (Lee et al, 2012). Treatment cessation is usually permitted when there is a reduction in lower urinary tract symptoms and a visible reduction in urinary pyuria (Swamy et al, 2018).

It is important that nurses encourage patients to report the initial onset of bladder symptoms, as early intervention often helps to prevent the progression of the infection. The fundamental role of the nurse when managing a UTI is to conduct a comprehensive symptom assessment. An assessment using validated questionnaires is an integral part of urology practice

References

Al-Buheissi S, Khasriya R, Maraj BH, Malone-Lee J. A simple validated scale to measure urgency. J Urol. 2008;179(3):1000–1005; discussion 1005. https://doi.org/10.1016/j.juro.2007.10.075 

Anderson GG, Palermo JJ, Schilling JD, Roth R, Heuser J, Hultgren SJ. Intracellular bacterial biofilm-like pods in urinary tract infections. Science. 2003;301(5629):105–107. https://doi.org/10.1126/science.1084550 

Babar A, Leblanc V, Dudonne S et al. Standardised high dose versus low dose cranberry Proanthocyanidin extracts for the prevention of recurrent urinary tract infection in healthy women [PACCANN]: a double blind randomised controlled trial protocol. BMC Urol. 2018;18(1):29. https://doi.org/10.1186/s12894-018-0342-7 

Betschart P, Abt D, Schmid H-P et al. Readability assessment of commonly used urological questionnaires. Investig Clin Urol. 2018;59(5):297–304. https://doi.org/10.4111/icu.2018.59.5.297 

Bono MJ, Reygaert WC. Urinary Tract Infection. Treasure Island (FL): StatPearls Publishing; 2018 

Collier S, Matjiu F, Jones G et al. A prospective study comparing contamination rates between a novel mid-stream urine collection device (Peezy) and a standard method in renal patients. J Clin Pathol. 2014;67(2):139–142. https://doi.org/10.1136/jclinpath-2013-201686 

Davies EM, Lewis DA. Bacteriology of urine.