Urinary Tract Infections (UTI) are commonly seen cases in the Emergency Department (ED) and is a suitable inclusion in GPNext. The following feature shares how UTI can be managed at primary care.
By Dr Thiruchelvam Jegathesan
Associate Consultant, Department of Urology
Tan Tock Seng Hospital
UTI occurs as either upper tract (kidneys and ureter) or lower tract (bladder, urethra and prostate) infections.
Upper tract infections should be suspected with cases that present with symptoms of flank pain with high fever, or if the patient is generally unwell. Such cases should ideally be referred to the ED for further assessment.
Lower tract UTIs can be simple or complicated. Simple UTIs refer to infection in a healthy patient with an anatomically and functionally normal urinary tract. This is commonly seen in fit and young female patients of childbearing age.
Aids to Diagnose Instances of Lower Tract UTIs
|Symptoms of acute onset||▶||Dysuria, frequency or urgency|
|Urine dipstick||▶||Positive for nitrites or leucocytes|
|Urine cultures (Not compulsory for initial presentation)||▶|
- If symptoms persist despite initial empirical treatment
- Recurrent UTI
Treatment of Simple UTIs in General Practice
First line antibiotic treatment includes a short course of up to a week of Co-trimoxazole if there are no contraindications. Amoxycillin/Clavulanate and Ciprofloxacin should be avoided as a first line of treatment due to the side effect profile.
Recurrent UTI is defined as 2 or more UTI episodes in 6 months or 3 or more UTI episodes in 12 months.
Follow Up of Simple UTIs in General Practice
|Symptoms resolved||No further investigations|
|Recurrent UTI in postmenopausal women||Trial of vaginal estrogen cream or pessaries (oral estrogens should not be used)|
|Recurrent UTI in sexually active women||Postcoital short course antibiotic prophylaxis|
Patients suspected to have a complicated UTI may need an emergency or specialist referral as deemed appropriate. Such patients may present with recurrent UTI or chronic symptoms.
The following groups of patients fall under the complicated category and may warrant further investigations and specialist referral:
- Men: may be associated with Benign Prostatic Hyperplasia
- Pregnant women: higher risk of pregnancy-related complications
- Children: higher risk of having an underlying anatomical or functional abnormality
Complicated UTIs can be due to the following but are not exhaustive:
- Anatomic or functional abnormality of the urinary tract
- Benign Prostatic Hyperplasia
- Neurogenic bladder
- Urinary stones
- Immunocompromised states
- Multidrug-resistant bacteria
Other conditions mimicking UTIs should be excluded:
Left ureteric stent on
plain abdominal X-ray
- Gross haematuriamalignancies need to be excluded
- Nodular prostate on digital rectal examination may be suggestive of a prostate malignancy
- Enlarged prostate may imply BPH
- Recent pelvic or urological procedures or foreign bodies such as ureteric stents
- EAU Guidelines. Edn. Presented at the EAU Annual Congress Copenhagen 2018 ISBN 978-94-92671-01-1
- Wieder JA: Pocket Guide to Urology. Fifth Edition. J.Wieder Medical: Oakland, CA, 2014