Urinary tract infections in women: diagnosis and management in primary care

doi:10.1136/bmj.332.7533.94

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Josip Car, clinical research fellow (josip.car@imperial.ac.uk)1

¹ Department of Primary Care and Social Medicine, Imperial College, London W6 8RP

Urinary tract infections are the second most common infections, causing considerable anxiety and morbidity in women. Care is not always optimal—prophylaxis is rarely considered and unnecessary investigations are requested. This evidence based approach to management of urinary tract infections in women highlights that some common recommendations, such as postcoital voiding, have no evidence base

Cystitis is an infection of the lower urinary tract which causes pain when passing urine and causes frequency, urgency, haematuria, or suprapubic pain not associated with passing urine.1

Upper urinary tract infection (pyelonephritis) is suggested by the presence of fever, flank pain, nausea, or vomiting. White blood cells are usually present in the urine, and occasionally white blood cell casts are also seen on urine microscopy.^w1

Who gets them?

Urinary tract infections affect up to 15% of women each year.2 3 More than 25% of women who have had an infection will experience a recurrence.^w2

The most important risk factors for acute cystitis in young women are a history of previous episodes of cystitis and frequent or recent sexual activity.^{w3 w4} The relative odds of acute cystitis increase by a factor of 60 during the 48 hours after sexual intercourse.^w4 The use of spermicidal agents increases the odds of infection by Escherichia coli or by Staphylococcus saprophyticus by a factor of two to three, irrespective of whether the exposure occurs with the use of a diaphragm or a spermicide coated condom.3 ^{w5 w6}

Urinary tract infections are common during pregnancy. Infections, and untreated asymptomatic bacteriuria, during pregnancy have been associated with an increased risk of pyelonephritis, premature delivery, and fetal mortality. Because of hormonal changes associated with pregnancy, the incidence of pyelonephritis is highest at the end of the second and beginning of the third trimesters.^w7 All pregnant women should be …