OP: Urinary Tract Infections

Just some of the facts with regard to UTI's:
1. Cranberry juice (not the high sugar containing cocktail) does not treat a UTI. There has been many published studies showing the efficacy of cranberry juice at preventing UTI's, not through the change in acidity but by altering the bacteria's ability to adhere to the transitional epithelium of the urinary tract.

2. Try to avoid the use of OTC medications such as AZO, Uristat...unless you are seeking temporary relief until you can get into your physician's office. These medication are simply bladder analgesics and antispasmodics and do nothing to treat the underlying infection. Most women with a history of UTI's are aware of the need to see their physician for antibiotic management and use the OTC meds as a temporary measure until they can start treatment. Many of the younger girls, especially 1st time UTI's tend to delay treatment because they alter their symptoms and often arrive with a more serious kidney infection (pyelonephritis). The OTC medications also alter the the standard urinalysis and require microscopic observation and culture to confirm the diagnosis.

3. Low back pain does not mean your kidney is involved! Your kidneys actually reside high up on the back and the low back pain you are typically experiencing is the radiation pattern to the low back from bladder irritation.
If you have back pain (aka CVA tenderness) in conjunction with fever, nausea, UTI symptoms and either a positive U/A or C/s the diagnosis of pyelonephritis has been established and the proper treatment can be initiated.

4. Treatment of acute uncomplicated UTI's (cystitis) requires antibiotics and the duration of treatment is determined by what other underlying problems you have such as diabetes, whether you are pregnant, your age...
If you have no significant risk factors or chronic diseases that place you at increased risk of more significant problems such as sepsis, pyelonephritis, renal failure...a 3 day course of antibiotics are indicated and have been found to be just as effective as a 7 day course. The typical antibiotics we prescribe are Macrobid/Macrodantin (nitrofurantoin), Bactrim/Septra (trimethoprim sulfamethoxazole), Cipro (ciprofloxacin), and Levaquin (levofloxacin). There are others but these tend to be the most common. I personally treat my uncomplicated UTI's for 5 days. If you have risk factors or significant history of other medical problems that place you at risk for the development of more serious complications the duration of treatment is extended to 7-10 days.

The treatment of pyelonephritis usually involves either inpatient treatment for IV antibiotics or outpatient treatment if the facility is equipped to administer IV medications. The treatment usually involves either IV Rocephin (ceftriaxone) or Levaquin (levofloxacin) until your white counts begin to fall on your CBC (blood work) and until you are afebrile for at least 24 hours. After that time you are converted to the oral (PO) form of the antibiotics for an additional 7-10 days. Given the discomfort and nausea associated with pyelonephritis, your doctor will also usually prescribe a pain medication and antiemetic to prevent nausea/vomiting.

The antispasmodics/bladder analgesics most commonly used are Pyridium, Levsin (hyocyamine), Prosed DS, Urised, Methylene blue.. but many of these can and do turn your urine blue, orange....depending on which medication is used.

Most of the typical bacteria that cause UTI's originate from the GI tract with the most common being E. Coli and Enterococcus. Others include Proteus, Staphylococcus, Klebsiella, Pseudomonas.

Risk factors for UTI's are numerous. In younger children it can be due to poor hygiene, vesicoureteral reflux, infrequent voiding, diarrhea, urethral irritation from bubble baths...or an anatomical abnormality with regard to the ureter or kidney. In sexually reproductive age women, sexual intercourse tends to top the list. Postmenopausal women tend to have hormonal changes that predispose them to UTI's. Other causes can include but are not limited to previous pelvic surgeries such as a hysterectomy/bladder sling/...that can possibly alter the normal orientation of the anatomy which can lead to UTI's. Recent hospitalization, instrumentation, or catheter placement. Immunosuppression from diabetes, HIV, medications...can predispose you to UTI's. Kidney stones (especially struvite), polycystic kidneys, sickle cell disease, pregnancy, fistulas (connections between organs that should not be there such as between the colon and bladder. This can occur through instrumentation from other surgeries or from medical conditions such as crohns/UC), and even other diseases that are occuring simultaneously such as a yeast infection or bacterial vaginosis that irritate and inflame the urethra and set you up for a UTI. Needless to say there are many causes and treatments available but if you suspect that you have a UTI please go see your doctor and don't self treat.

If you have a negative urinalysis in the office most doctors will still treat with antibiotics because it is possible to have a UTI with a negative in office urine. If the cultures consistently come back negative and you are experiencing urinary tract symptoms we start looking for other potential causes that can mimick the symptoms of a UTI such as a bacterial vaginosis, an STD such as gonorrhea/chlamydia, medications, yeast infection, or interstitial cystitis. These obviously require other diagnostic tests such as cultures, KOH and wet prep, cystoscopy, ultrasound.....

Another interesting tidbit of information: anything that is inflamed and touching the bladder can cause blood in the urine and urinary tract symptoms such as a ovarian cyst, appendix, diverticulitis, PID...so don't delay in seeking medical treatment. Especially if other symptoms are present (fever, abdominal pain, vaginal discharge, dyspareunia...) in addition to the urinary symptoms (dysuria, urgency, frequency...).

5. If you are a female that consistently gets UTI's following intercourse and you have tried all the recommendations to prevent this (bathing after intercourse, voiding your bladder after intercourse..), it is reasonable to take a single dose of the antibiotic after a sexual encounter. This is taking into account that you are in a stable monogomous relationship where there is no risk of contracting an STD and you have culture proven UTI's.

Sorry for the run on sentences and the basic nature of the response but it is easy to get lost in the medical terminology and get nothing out of the information being presented.

OP: Ram MD 08/04/2008

Posted: 23 Sep 02:40

RAM,

As a general rule here, the few med pros we have do not get into naming the drugs - that is left up to the doctor who will be seeing them and there are possibilities for having people treating themselves with the wrong stuff. Yes, there are medical sites where that can be found but I do not wish to be the one who caused a person to not see a doctor when necessary. Most people do not need all the qualifiers such "if the facility is equipped .... "

There is also the suggestive factor in giving people too much information.

OP Brandye 08/04/2008

Posted: 23 Sep 02:42

This is where we sort of disagree. Patients should be informed consumers of their health care and by listing the medications that you typically prescribe to treat a specific problem doesn't change the fact that they have to see their doctor to get it. There will always be patients out there that disregard your instructions, self medicate with OTC drugs, use old prescriptions to treat current ailments...This will never change! I wish patients were better informed of the medications they are receiving. There is not a day that goes by that I don't see another doctors patient that is taking the wrong medication for their problem or medications that are no longer indicated due to resistence and/or a multitude of other factors. I pride myself on my patient education and I stress the importance of taking the medications as prescribed. There is nothing out there that states the medications, their indications, their side effects, their interactions with other medications and so on are the sole ownership of the physicians that prescribe them or that they influence a patient's decision to self medicate. Patient's will always self diagnose, self medicate, and self treat regardless of what they are told or what they read. If this were the case we should do away with Web MD where individuals can attempt to self diagnose...We should also do away with most OTC medication as well. Not every case of dysuria, urgency, and frequency is a UTI! Why is there Azo and Uristat OTC for these people? Having these medications available can lead to more severe urinary tract infections and inaccurate diagnosis in a clinical setting. I can name off 30 plus conditions that are included in the differential diagnosis of dysuria/urgency/frequency....this is what distinguishes the patient from their MD.

"Most people don't need all the qualifiers - equipped facility"
I wish patients understood the qualifications possessed by the physician and the facility within which they practice. Every patient that uses my facility knows my qualifications, where I trained, and what types of services I am able to offer. I feel fortunate that I can stabilize an MI in my office prior to transport, treat pyelonephritis as an outpatient, surgically repair a tendon, definitively diagnose an acute appendicitis or ectopic pregnancy before sending them to the surgeon, and .......
Why? I'm trained to do it, but my facility is also equipped with a CT scanner, ultrasound, EKG, digital X-ray, full lab capable of obtaining stat troponins, CKMB, BNP, D dimer, CMP, CBC.......I employ registered nurses efficient at placing IV's and pushing medications, I have trained lab personnel, I have an employed Radiologist that rereads my films, and I have a very strong subspecialty support system in place.

I have also practiced in a clinic that is capable of only performing a strep screen and running a UA and that is about all. Patients that come to such a facility should know the limitations and risks associated with seeking treatment there. If you are coming in for a strep throat that is OK, a BP medication refill that is OK, a DVT? Nope!, Syncope? Nope!, Chest pain? Nope!
Why delay treatment when timing is of the essence when the physician and facility are not equipped to handle it. This would appear to be common sense to most but unfortunately it isn't. They know you are a physician and assume that you can diagnose and treat just about anything that walks through your front door. In my facility we have the technology to assist in doing this but in other places they do not. It has nothing to do with the diagnostic skill of the physician but more to do with what the physician has available at his disposal to aid in diagnosing and treating the patient.

Long story short, it is very important for patients to research their physicians, know what their specialty is in, know whether they are board certified, how long they have been in practice, what services does their practice offer, what hospitals are they affiliated with, what subspecialists do they utilize, can they perform minor surgery and take X-rays, what lab studies are offered and how long does it take to get the results....

Be an informed patient! Patients knowing the names of the antibiotics used to treat a UTI doesn't imply that they will self medicate and not seek the proper medical attention. I'm not telling someone that if you have symptom X/Y/Z take medication A/B/C. I thought I was straight forward in saying that there are many problems that can predispose one to getting a UTI but also many problems that mimick one as well. Information on the web regardless of the source should never be used in place of seeing your physician face to face and having the necessary examination and studies performed. That being said, people will do what they want regardless of what you you write on this forum. This is meant to be a stepping stone from which to gain additional insight and information.

What I did isn't much different than what you did with the blood in the cum post. There you informed the patient that this was probably due to prostatitis which would require rather specific antibiotic managemnt to treat. Yes, acute bacterial prostatitis does require antibiotics but there are lots of other potential diagnosis' at play that do not require antibiotic management. Eventhough it is impossible to diagnose over the phone, web...you and I know that a vast majority of the diagnosis can be made off the history alone. No where did they list any supporting symptoms to suggest a bacterial etiology. This appears to be asymptomatic hermatospermia which would probably resolve over the next few weeks with no evaluation at all. Should they still be evaluated by their MD, Yes! It is possible that an infection is at the root of the problem but many other more suitable diagnosis exist from what was explained by the patient's GF.

The point is, what if the couple walks into the office and isn't diagnosed with prostatitis and leaves the MD office without antibiotics? They will be left to wonder if their physician made the proper diagnosis of if the online MD did. There is never a substitute for seeing your physician in their office just as you recommended and just as I did. You listed the need for antibiotics for their condition, I listed the types of antibiotics used to treat a UTI. Perhaps both of us are at fault for giving out too much information!

OP: Ram MD 08/04/2008

Posted: 23 Sep 02:43

This the very reason when a person on-line has low abdominal pain; I advise to see the doc immediately, such as with women. I will not mention E. Pregs. I am fearful of a rampant amount of posts and unnecessary concerns.

Dosing? If something seems odd a poster writes such as treatment for 4 days only on a UTI; I tell them they need to call the prescriber it's generally longer. Locally, here where I am, Macrobid is the choice; geography separates all of us, which med we use, and why. None of us will ever agree-100%. Pyridium is about the only choice of the ones you listed to alleviate the discomfort which is carried by the pharmacy's in my area.

I am fearful of getting to in depth that a younger poster, new to sex, does not wish to tell a parent the need to go to a doc and will look in the medicine cabinet & self medicate. See what mom has or a friends mom to see if they are compatible. If they look it up on line, names of meds; I am also fearful they will not take the correct amount, the right pill, or have an allergic reaction and no one will know why. Much seen in EDs as you know.

Similarly, I know the old meds for a TOP early staged prior to the RU becoming available--I will never post the info. The only reference I have put up was on Emergency contraception (a link) for a couple in their teens who just had a mishap over missing a pill when they could not get to a store to purchase a morning after pill. Additionally, I have posted that the MAP can be mail ordered or will post info on how to get to Planned Parenthood or County Clinic.

I believe this is really the common thread; each wishes to help. Education is great but in ways, when the PDR became available to patients, I nearly cried since too much info. they refuse to take the Dig. Proper Patient MD/DO/PA/NP teaching to the patient is essential. It's reinforced by the RN & Pharmacist. I recall years ago when Cipro came out; ask how many docs knew nothing about no caffeine with the med! Patients were bouncing off the walls.

In a nutshell, there is no substitute for good, direct, proper patient & health care provider. The only reason I wrote the sticky initially was due to many women becoming sexually active and complaints of urinary frequency or post-sex irritation. A few the initial symptoms wore off and other's were debating seeking medical care. A few came back with a UTI DX; however, they were not told about how to prevent and why you need to watch out of them--it was evident in the posts which were ongoing at the time.

OP: Sera300 08/04/2008

Posted: 23 Sep 02:43