Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Missing the obvious?
- Sharon J Williams (21 November 2003)
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Co-trimoxazole
- Gordon GJ Anderson (21 November 2003)
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Don't forget personal hygiene, allergies and other preventive methods
- Jai B Sharma, Monika Malhotra, St Thomas Hospital, London (23 November 2003)
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Been there, had that - CURED.
- Cynthia M Lewis (23 November 2003)
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The course and intercourse
- G Sivagnanam, Mohanasundaram J (23 November 2003)
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Soap - the commonest cause of dysuria
- Uffe Ravnskov (24 November 2003)
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10 minute consultation
- Peter Whelan (24 November 2003)
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RESOLUTION OF CONSTIPATION TO PREVENT RECURRENT URINARY TRACT INFECTIONS IN WOMEN
- MASSIMILIANO LANZAFAME, Alfio Lanzafame,M D,GENERAL PRACTITIONER (24 November 2003)
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diabetes
- honor a condliffe (25 November 2003)
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Recurrent urinary tract infection in women
- Shahid A. Kausar (26 November 2003)
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Culture and Sensitivity
- Jonathon D Olsburgh, Lara de Haas and Bernard Olsburgh (28 November 2003)
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Recurrent UTIs
- Antonia L Reed (30 November 2003)
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Teaching patients to collect urine samples.
- Leonardo G Fugoso Jr. (3 December 2003)
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Management of recurrent urinary tract infection
- Edmund J Lamb (5 December 2003)
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self-help in cystitis
- Angela Kilmartin (14 December 2003)
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Sharon J Williams, Retired Registered Nurse N/A
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Symptoms of urinary infections can easily be confused with allergic or sensitivity reactions. Women with apparent recurrent urinary infections should always be questioned about all of the following: Do they take showers or baths? If they insist on taking baths, how often do they clean the tub and what product do they use?- some products are corrosive or are not rinsed off properly, leaving a residue. Have they changed laundry products (soap, additives, fabric softener) recently? Have there been any dietary changes? Do they use scented tampons or pads? Do they use panty liners on a daily basis? Do they or their sexual partner use any scented product in contact with the genital area? Even the residue of scented hand lotion or cream can cause a reaction in a sensitive person. What is the state of their own and their sexual partner(s) personal hygiene? Are showers and meticulous handwashing always taken prior to engaging in sex? Are they engaging in anal intercourse and practising good hygiene afterwards and prior to engaging in other sexual activity? Does their partner practice good oral hygiene especially prior to oral sex? Do they use scented wipes for personal hygiene after urinating or defecating? Do they urinate immediately after sex? Are they using any artificial lubricant, scented or unscented? Are they using latex condoms or diaphragms or any inserted contraceptive product? If they shave the genital area, what do they use? Does either partner have an oral or sinus infection? Have viral cultures been done for genital herpes? Does either partner suffer from cold sores? Any and all of the above situations could result in either feeling like they have a urinary infection or be contributing factors to really having one. Many women find that taking showers instead of baths and eliminating the use of scented products in the genital area can stop the recurrence of urinary infections. Daily use of pantiliners helps promote bacterial growth by keeping the genital area warmer and damper - an ideal environment for bacterial growth. I personally know of many women who have virtually eliminated recurrent infections by adopting better genital health practices. For some, it is as simple as taking showers instead of baths and stopping the use of scented bath products or powders. Others have found that using unscented laundry products or changing to a non-irritating product does the trick. For some, the answer is to stop wearing underwear except for special occasions. Let's take a look at all possible contributing factors before starting yet another round of antibiotics. It's amazing how little people know about the effects of the products they use on their bodies. Competing interests: None declared |
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Gordon GJ Anderson, GP Cleethorpes
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The table of treatments and prophylactic measures lists co- trimoxazole as one alternative.How old was the source material? How does it tally with CSM advice? Competing interests: None declared |
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Jai B Sharma, Assistant Professor in Obst & Gynaecology All India Institute of Medical Sciences, New Delhi 110029, Monika Malhotra, St Thomas Hospital, London
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Urinary tract infections ( UTIs ) are very common in women due to short urethra and close proximity to anus a potential site of infection especially if perineal hygiene is not taken care of properly especially during abluting after defecation as is customary in India or when wiping and by mistake if direction of cleaning is from anus towards vagina. Even use of dirty underwears can act as a sorce of infection. We are aware of women who det UTI whenever they use a dirty public toilet like in bus stands and train stations. So proper care of perineal hygiene, monogamous and stable sexual activity, avoidance of use of dirty underwears and irritating powders and local scents and intake of nutritious and healthy diet including multivitamins, trace elements and anti-oxidants can go long way to prevent recurrent UTIs in women. Once infection occurs, it has to be treated with a course of antibiotics as suggested by the authors. Other notable and useful antibiotics are pefloxacin, gatefloxacin, lomefloxacin and levofloxacin which can be given as single dose for first time infection or for few days for recurrent UTIs. However one has to rule out pregnancy before prescribing antibiotics when ampicillin, amoxycillin, coamoxyclov or cephalosporins should be given depending upon the sensitivity report. The practitioners need to be aware of their local hospital policy and the common urinary pathogens in their locality including sensitivity pattern for best outcome. Finally for recurrent and unexplainable UTIs one has to rule out urinary tract anomalies especially in young and sexually inactive girls. By using these preventive and therapeutic modalities one can manage most of these women successfully. Competing interests: None declared |
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Cynthia M Lewis, retired Derbyshire DE4 5HS
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I was this patient 40 years ago. But with an anatomical problem (reflux) I suffered repeated episodes of pyelo-nephritis. It was related to sex. Was my future partnership to be blighted by this? A consultant prescribed maintenance sulpha drugs with "stronger" antibiotics to be used when necessary. Was I condemned to spend the rest of my life taking antibiotics? And then a tip from a GP. "Try having a pee after sex and before going to sleep", he suggested, "It might just flush the system out". It works. I learnt to "manage" my problem and, thanks to this tip, I've had a very happy and fulfilling sex life. I was never able to properly thank this GP: I hope he reads this. Competing interests: I was once a sufferer |
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G Sivagnanam, Additional Professor of Pharmacology Chengalpattu Medical College, Chengalpattu, Tamilnadu 603 001, India, Mohanasundaram J
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We would like to point out certain minor deficiencies a. The dose of ciprofloxacin for treatment has been mentioned as 100 mg twice a day which is an inadequate (course) regimen. The usual dose recommended for ciprofloxacin is 250 to 500 mg twice a day for an adult. Inadequate dosage is also a prime reason for the development of resistance and may also be a reason for the recurrence of infection. b. It has been mentioned, to explain to the patient that frequent sexual intercourse as a risk factor for recurrent UTI. How frequent is ‘frequent’ is any body’s guess! Rather than undermining the fundamentals of physiology (to follow prudent sexual practice), it would be more appropriate to advise the patient regarding proper hygienic practices following each intercourse. c. Microscopy of urine from symptomatic patients can be of great diagnostic value. Bacteriuria, which is best assessed with Gram-stained uncentrifuged urine, is very specific. Further the "dipstick" method is less sensitive than microscopy in identifying pyuria. We do hereby declare that there is no competing interest involved. Competing interests: None declared |
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Uffe Ravnskov, Independent researcher Magle Stora Kyrkogata 9, S-22350 Lund, Sweden
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Car
and Sheikh1 mentioned several causes of urinary frequency and pain on
micturition, but missed the most important one. In a prospective study of 50
women, who consulted me because of dysuria and/or frequency I found that all of
14 women with the urethral syndrome (dysuria without bacteriuria), 15/17 with
uncomplicated, lower urinary tract infection (dysuria with bacteriuri), but only
6/19 with asymptomatic bacteriuria used soap or other detergents on the sexual
organs regularly.2
Competing interests: None declared |
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Peter Whelan, Consultant Urologist St James's University Hospital Beckett Street Leeds West Yorkshire LS 9 7TF
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RE: 10 minute consultation of recurrent urinary tract infection in women This was an appallingly misogynistic article. It is more than 20 years since Angela Kilmartin wrote, pleading with doctors not to take a simplisctic view of recurrent urinary tract infections. Where was the discussion concerning: a. That this is an ascending infection. b. Individual patients susceptibility with host defence mechanism anomalies related to static antibodies, mucopolyasccarhids surface changes, etc. c. Clustering effects at menarche and menopause. d. Relationship of UTI to the menstrual cycle. e. Adequate voiding and adequate drinking. f. Use of prophylactic antibiotics. g. Contribution of doctors to recurrent infections by too frequent short course therapy with antibiotics etc etc. This condition needs care and not condemnation and a solution of no sex and a touch of cranberry juice is both inadequate and condescending. One expects better. Competing interests: None declared |
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MASSIMILIANO LANZAFAME, medical doctor, specialist in Infectious Diseases Divisione Clinicizzata di Malattie Infettive,Ospedale Civile Maggiore,Verona ,C.A.P.37100, Alfio Lanzafame,M D,GENERAL PRACTITIONER
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Car and Sheikh, in their article,do not report ,among predisposing factors,constipation.It has been showed that chronic constipation may,by causing uninhibited bladder contractions,contribute to recurrence of urinary tract infections (1).In our experience we have prevent recurrence in many women ,with no anatomical abnormalities of urinary tract and undergone to long-term,low-dose prophylactic antibiotic treatment without success, with the resolution of constipation.We think that any family physicians should keep in mind the importance of this contributory factor to the development of recurrent urinary tract infections. REFERENCES 1)Derrick FC Jr.Urinary tract infections in the adult.The Postgraduate Medicine Lecture.Postgrad Med.1975;57(3):66-70 Competing interests: None declared |
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honor a condliffe, ED Registrar Dunedin, NZ
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How about screening for diabetes? Recurrent infections of any system may be a pointer to this. Competing interests: None declared |
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Shahid A. Kausar, Consultant Physician/Geriatrician City Hospital, Dudley Road, Birmingham, B18 7QH
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Editor- I read with interest the paper by Car et al and would like to raise the following points on this topic by presenting a case1. A 70-year lady with multiple sclerosis was referred for rehabilitation after undergoing nephrectomy of her left kidney for pyonephrosis. She was treated for recurrent lower urinary tract infection with several courses of antibiotic prior to admission. We were very keen to explore all means of preventing another urinary tract infection as she was on an indwelling long-term urinary catheter. An adequate fluid intake was suggested as per body weight. This may prevent recurrence of infection and this has not been discussed in this paper2. Other possibly significant risk factors include poor hygiene and poor nutrition that results in decreased immunity2. It is worth doing a plain Abdominal X-ray (Kidney-ureter-baldder; KUB) to exclude stone in renal tract as 90% of renal stones are radio-opaque and can cause recurrent UTIs (Urinary Tract Infection), this was normal in our case. Patient’s medication needs careful reviewing. Our patient was on oxybutinin 5mg tds, which was started when she had symptoms of over-active bladder and continued taking since then. This was stopped as it could have been contributing to atonic bladder. Ranitidine was changed to a PPI (Proton Pump Inhibitor) as ranitidine has anticholinergic properties that too reduce bladder tone. She is now on prophylactic antibiotic and cranberry juice to prevent its recurrence1. Urologist’s opinion was sought if suprapubic catheter insertion would reduce the frequency of infection, as urethral catheter may be prone to more frequent infection because of its proximity to perineum, which is a rich source of bacteria3, 4. This has been planned in a few months time. Antibiotic impregnated catheters have the potential to reduce nosocomial catheter related UTIs in comparison to silicone-coated Foleys catheter5. We are in the process of exploring if one type of catheter is better than another in a situation like this. Shahid A. Kausar 1. Car J, Sheikh A. Recurrent urinary tract infection in women. BMJ 2003; 327:1204 2. MacMillan RD. Complicated urinary tract infections in patients with voiding dysfunction. Can J Urol 2001;8(1): 13-7 3. Dinneen MD et al. Urethral strictures and aortic surgery. Suprapubic rather than urethral catheters. Eur J Vas Surg 1990; 4(5): 535-8 4. Moore KN et al. Pathogenesis of urinary tract infection: a review. J Clin Nurs 2002; 11(5): 568-74 5. Al-Habden I et al. Assessment of nosocomial urinary tract infection in orthopaedic patients: a prospective and comparative study using two different catheters. Int Surg 2003; 88(3) 152-4 Competing interests: None declared Editorial note
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Jonathon D Olsburgh, SpR Urology Northwick Park Hospital, London, HA1 3UJ, Lara de Haas and Bernard Olsburgh
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Car and Sheikh (1) recommend urine dipstix testing and an empirical course of Trimethoprim in their 23 year old female patient, followed by urine microscopy at three days if symptoms are no better. Surely, dipstix test and urine microscopy, culture and sensitivity at the initial consultation is the key to making the correct diagnosis – that of urinary tract infection and to the most appropriate treatment. Whilst nitrite positive dipstix is a relatively specific and sensitive test for UTI, leucocyte dipstix test is not. There is likely to be false negative urine culture after 3 days blind antibiotic treatment. Therefore, take the urine culture at the same time as the dipstix test. The culture result will be available by day three. Appropriate action can then be taken, without further delay, if no bacterial growth or antibiotic resistance is present. There is always a possibility the patient may be pregnant. Without discussing this further, Trimethoprim should not be used as it can have harmful effects on the foetus in the first trimester (2). We feel that the patient should be informed that if her symptoms do not respond to the current treatment plan, a specialist referral would be made. 1 Car J, Sheikh A. Recurrent urinary tract infection in women. BMJ 2003;327:1204. 2 British National Formulary 2003; 46, Appendix 4 Competing interests: None declared |
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Antonia L Reed, GP locum Dingwall, Ross-shire, IV7 8ES
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In their article on a 10 minute consultation on recurrent UTI in women Car and Sheikh make two suggestions I disagree with. Firstly that a three day course of antibiotics is sufficient. I changed over to giving only three days supply of drugs in the best practice of evidence bassed medicine in 2001. However I found that many women returned. They then had urine culture and five days antibiotics (meaning 8 days in total). This created extra workload for the practice and dissatisfaction in the women. I have gone back to issuing 5 days initially. Secondly they do not recommend urine culture. I entirely agree with this for uncomplicated UTI but surely in the case of recurrent UTI it must be proven to be infection prior to commencing either repeated or prophylactic antibiotics. Competing interests: None declared |
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Leonardo G Fugoso Jr., Attending, Neurology and Movement Disorders St. Lukes Medical Center, E. Rodriguez Boulevard, Quezon City 1102, Philippinesz
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May I add that patients should be taught the proper way to collect urine? A clean catch mid stream urine collection is essential. I knew one woman who was repeatedly treated with antibiotics after her urine samples kept turning positive for bacteria. On questioning, it was evident that she submitted the first stream of urine that she passed for analysis. After I instructed her to get a clean catch mid stream urine her urinalysis tested negative. She has not been on antibiotics since then. Competing interests: None declared Editorial note
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Edmund J Lamb, Consultant Clinical Scientist Kent and Canterbury Hospital, East Kent Hospitals NHS Trust, Canterbury, Kent CT1 3 NG
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Dear Editor I was surprised that options for the further management of recurrent urinary tract infections provided by Car and Sheikh (1) did not include advice that sufferers should always empty their bladder completely and double-void after intercourse. This appears to be standard guidance in most medical textbooks (e.g., Oxford Handbook of Clinical Medicine). I would be interested in the authors comment on this. 1. Car J, Sheikh A. Recurrent urinary tract infection in women. BMJ 2003;327:1204 Competing interests: None declared |
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Angela Kilmartin, self-help pioneer London
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Cystitis is mainly self-caused, unwittingly, by the sufferer, especially in the 15-45 yr age group. Hygiene as shown in my books, most recently The Patient's Encyclopaedia of Cystitis, Sexual cystitis and Interstitial Cystitis, is of the kind practised worldwide in most other countries but ignored in Western societies. In Asia for instance, women I have interviewed have never heard of it; they and their menfolk, wash their perineums or shower before sex and always after a bowel movement. Moslem and Jewish men are circumcised and both sexes wash before sex. Buddhist men are uncircumcised but wash properly as do their women. In all these societies washing works and my mission is to get westerners to copy these excellent examples. Cystitis in later years is usually due to atrophy, joint stiffness preventing quality perineal hygiene, and excess sugars. Each woman's lifestyle is so important in defining individual causes and I have nothing but sadness for doctors who cannot take time in consultation to sort it but resort constantly to operations, investigations, urodynamics and such which seldom provide the cure and may even scar already delicate and inflamed tissues. Competing interests: None declared |
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