Urology/UTI

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Question
I've had a urinary tract infection for over six weeks.  When it started I went to urgent care and was prescribed cipro. I was on that until the lab report came back and said the bacteria was resistant to cipro.  I was switched to macrobid and was on that for 5 days (I think it was 5 anyway). The day after I stopped that medication the UTI came back with a burning vengeance. I went back and they cultured the urine again and this time I was given bactrim for 7 days.  It wasn't working so I went to my regular doctor.  She had the report from urgent care faxed over and said the bacteria was an antibiotic resistant e-coli that would not respond to cipro or levaquin and only to bactrim or macrobid. She gave me another prescription for bactrim.  After 5 more days it was not working so she switched me to macrobid again, this time 4x day for 10 days (nitrofurantoin).  It's been 6 days and my lower abdominal pain is getting worse.  I'm worried and don't know if I should continue taking it or ask to try something different. Can you make any suggestions?  Also, if it the bacteria will "only" respond to bactrim or macrobid and these things are not working, what should the next steps be?

Answer
Sharon, I would suggest that you see a urologist in consultation.  Either the bacteria has changed sensitivities to the antibiotics or there is something going on structurally in the urinary tract that is predisposing you to the infection.  This can be an obstruction, foreign body (such as a stone), etc.  In the interim, I would continue the medication, drink extra fluids, get a repeat urine culture, and make an appointment with the urologist ASAP.   To follow is some information that I have written on UTIs in women that you may find informative.

Urinary tract infections (UTIs) in women are very common compared to men.  This is due to the relatively short length of the female urethra.  This results in the bladder being nearer the external environment.  The most likely sources of bacteria are from the rectum, colonization in the vagina, or introduction via sexual activity.  Frequent bathing, as opposed to showering, also allows bath water to reflux into the bladder.  This may also be an entry path for bacteria.  In addition, refluxed soap residues often will irritate the lining of the bladder and urethra (mucosa) causing symptoms.  Females can lessen the likelihood of infection by not ignoring the desire to void, by emptying the bladder just prior to and soon after intercourse, by taking showers rather than baths and by always wiping from the urethra toward the rectum – NEVER the reverse!  The use of a diaphragm and spermicidal jellies also increase the risk of UTIs.  The typical symptoms of a UTI are frequency, burning, and urgency.  With more severe inflammation, blood may appear in the urine.  If bleeding occurs, you should seek consultation with a urologist once you are better to ensure that there are no other causes for the bleeding.  If the infection spreads from the bladder into the kidneys, the patient is much more ill and typically exhibits flank (kidney) pain, fever and chills.    If untreated, kidney infections may spread into the blood stream causing a life threatening disorder called septicemia.  This requires hospitalization, intravenous antibiotics and intensive care.

Most UTIs involve the lower urinary tract (urethra and/or bladder).  A tentative diagnosis is made by doing a urinalysis which typically demonstrates white blood cells (“pus cells”) and bacteria.  A positive dip stick test of the urine for nitrates or leukocyte esterase strongly suggests a UTI but culturing the urine for bacteria provides a definitive diagnosis.    Sensitivity studies are then done on the culture to determine which antibiotics will destroy the germ.  Most routine UTIs require 3-7 days of antibacterial therapy.  If the infections are frequent, long-term low dose daily or post-coital prophylactic antibacterial therapy may be needed.  In younger women, there is some evidence that cranberry products may prevent the recurrence of UTIs.  However, the dose is not standardized and they have not been successful in treating UTIs.   In the post-menopausal female, topical vaginal estrogen therapy may be of benefit.  Patients with recurrent (or persistent ones as in your case) UTIs  need to consult with a urologist to have their urinary system evaluated to try and find the reason for the frequent problems.  This usually involves imaging studies of the upper urinary tract, cystoscopic examination of the bladder and a measurement of residual urine (that urine still left in the bladder after urinating).    Good luck.

Urology

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Arthur Goldstein, M.D.

Expertise

Problems or questions related to the field of urology; ie urinary stone disease, urinary cancers (kidney, bladder, prostate, testis, etc.), urinary infections, etc. I no longer answer questions related to erection problems or male sexual dysfunction.

Experience

I am retired from the active practice of urology. My 34 years was totally in the clinical field and involved the entire gamut of genitourinary problems, with special interest in endourology.

Organizations
American Medical Association, American Urological Association, American College of Surgeons

Education/Credentials
College degree - BS Medical degree - MD Master of Science - MS

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