Urinary Tract Infections

Key Points

• Urinary tract infections (UTIs) are infections of the urethra, bladder, ureters, and/or kidneys.

• People with Down syndrome have risk factors for getting a UTI due to issues related to not emptying the bladder well.

• It is important to instruct people with Down syndrome on healthy urinary behaviors. 

 

Introduction

Urinary tract infections are infections in the urinary system. The urinary system includes the:

• Two kidneys

  • The kidneys are organs within the abdomen in which urine is made.

• Two ureters

  • Ureters are the tube-like structures through which the urine passes from the kidneys to the bladder. Each kidney empties into one ureter and each ureter connects separately to the bladder. 

• One bladder

  • The muscular structure that collects the urine from the ureters and then contracts to push the urine out of the urethra.

• One urethra

  • The urethra is the tube-like structure that carries the urine from the bladder to outside the body.

Urinary tract infections (UTIs) are usually caused by bacteria entering the bladder through the urethra. This is usually called cystitis (bladder infection), a UTI, or a lower tract UTI. Sometimes the infection is primarily in the urethra, and it can be called urethritis. If it passes up into the kidney or kidneys it is called pyelonephritis. Much less commonly the kidneys can be infected from bacteria that is in the bloodstream from a different source or location.

Normally, there shouldn’t be any bacteria in the urine. However, if bacteria are in the bladder, they are removed from the bladder during urination.

 

Causes and contributing factors to UTIs

Not emptying the bladder regularly

A person may not empty their bladder regularly because of urinary retention (the inability to empty the bladder) or because they “hold” their urine (ignoring the signals from the brain that indicate it is time to urinate). When the bladder isn’t emptied for a prolonged period, bacteria that have made their way into the bladder from outside the body can grow and create an infection in the urine. Both urinary retention and “holding” the urine seem to be more common in people with Down syndrome.

Wiping from back to front

Wiping from back to front after urinating or having a bowel movement can contribute to UTIs, especially in women. Women tend to be more at risk for bladder infections due to the urethra being shorter and closer to the anus. The nearness to the anus increases the chance that bacteria from the stool can be transferred to the urethra. Wiping from back to front pulls stool bacteria towards the urethra.

Constipation

Constipation, which is a common issue for many people with Down syndrome, can contribute to developing UTIs.

Kidney or bladder stones

Stones that form in the kidney or bladder can increase the chance of getting an infection. Kidney or bladder stones seem as common (or perhaps less common) in people with Down syndrome compared to people without Down syndrome.

Sexual intercourse

Sexual intercourse, particularly in women, can introduce bacteria into the urethra.

Sexually transmitted infections

Sexually transmitted infections (STIs), such as gonorrhea or chlamydia, can cause infections in the urinary system. These infections are considered separate from urinary tract infections. In our practice, STIs are not common .  

Menopause

The changes in the tissue around the urethra associated with menopause can increase the risk of developing a UTI.

 

Symptoms and complications

• Pain

  • Infections in the urethra and bladder can cause discomfort, particularly when urinating. This is commonly described as a "burning" sensation with urination (dysuria). Pain may also occur in the pelvis or lower abdomen. When the infection spreads upwards into the ureters and kidneys, back (or "flank") pain is common. Infections in the ureters and kidneys can be unilateral (only one ureter/kidney is affected) or bilateral (both ureters/kidneys are affected).

• Fever

  • This is more common with infections that have spread to the ureter and kidney but can occur if it is only in the urethra and/or bladder.

• Blood in the urine (hematuria)

• A frequent urge to urinate often associated with incomplete voiding (emptying the bladder)

• Dark, cloudy urine or strong-smelling urine

• Fatigue

• Nausea and/or vomiting

• Poor intake of food or liquid

• Particularly when the infection has spread to the kidneys, individuals can become quite ill. Some individuals develop sepsis in which bacteria passes into the bloodstream. This can alter blood pressure, breathing, ability to think or function, and other serious systems.

• Infections of the kidneys, especially if they are recurrent, can cause kidney damage and reduced kidney function.

 

Diagnosis

History and physical examination

The health care provider will ask questions about symptoms including whether there are complications, previous history of UTIs, previous treatment, and whether any antibiotics have been used in the recent past. The physical exam will assess for signs of infection and help determine if the infection has spread to the kidneys.

Urinalysis 

A urine sample can be collected and evaluated for signs of infection including white blood cells (that fight infection), red blood cells, a substance called nitrite, bacteria, and protein. Abnormal results of the specific gravity (which measures how concentrated the urine is) and ketones can indicate the person is becoming dehydrated. An office version of a urinalysis can provide results within several minutes while it may take several hours or overnight to get a result on a urinalysis sent to a lab.

Urine culture

Sometimes a urine sample will be sent to the lab to perform a culture. Bacteria from the urine are grown in the lab and analyzed to determine which bacteria is (are) present and what antibiotics the bacteria will respond to. The results for a urine culture usually take 2-3 days to be completed.

Imaging

If complications or kidney stones are suspected, ultrasound or computed tomography (CT) scan imaging may be done. If it is suspected that urinary retention is contributing to the infection, ultrasound of the bladder or a bladder scan may be done.

Cystoscopy

A cystoscopy (a scope passed via the urethra into the bladder) may be recommended to assess for a blockage or other abnormalities in the bladder that may increase the risk of UTIs.

 

Treatment

Treatments for UTIs include:

Hydration

Drinking plenty of fluids to prevent dehydration and to “flush” the urinary tract is important. Sometimes it is necessary to give intravenous (IV) fluids.

Pain control

Acetaminophen (Tylenol) or non-steroidal anti-inflammatory medications/NSAIDS (such as ibuprofen/Advil) can be used. If kidney dysfunction is present or suspected, avoiding NSAIDS is important since they can further impair kidney function.

For infections in the kidney or if kidney stones are present, stronger pain management is sometimes required.

Fever management 

As above for pain, acetaminophen or ibuprofen are common treatments for fever.

Urinary anesthetics 

Urinary anesthetics temporarily numb the bladder wall and can reduce discomfort from a UTI. Phenazopyridine is available as a prescription (Pyridium) or over the counter (Azo). It is recommended to only take it for a few days while the antibiotic is taking effect. It can temporarily change the urine to an orange or red color.

Anti-spasmodic medication 

If bladder spasms are part of the symptoms, a medication to reduce spasms is sometimes prescribed. However, we tend not to use these medications for infections for people with Down syndrome because they can cause urinary retention, and people with Down syndrome seem to be more susceptible to this side effect.

Antibiotics

Selection of the antibiotic to use depends on several factors. It is important to review the bacteria that caused previous infections and what antibiotics were used. Since the same bacteria can cause subsequent infections, it can be helpful to start with an antibiotic that worked previously or one that a previous evaluation determined by urine culture to be effective.

Bacteria can develop resistance to antibiotics. A certain antibiotic or multiple antibiotics may not be effective against those bacteria. It is important to select an antibiotic that will eliminate the bacteria. On the other hand, selection should choose the “least strong” antibiotic that is effective. Choosing a “less strong” antibiotic may limit side effects and helps “save” these strong antibiotics for infections caused by bacteria that don’t respond to the more commonly used antibiotics. Overusing the “strong” antibiotics contributes to bacteria changing over time and becoming resistant to antibiotics.

Other medical history can impact antibiotic selection. For example, some antibiotics are more likely to have a negative effect on kidney function, and avoiding those antibiotics would be important for those with kidney dysfunction.

Cranberries

Drinking cranberry juice or taking cranberry supplements may be helpful. There are conflicting results from studies assessing the effectiveness of cranberries in treating UTIs. Some studies indicate benefit, but others do not. Particularly if there are complications of a UTI, an antibiotic should be considered in addition to cranberry juice or cranberry supplements.

 

Prevention

• Do not hold urine. 

  • When the urge to urinate occurs, take the time to urinate. Consider urinating every 2-3 hours throughout the day. Some individuals with Down syndrome benefit from using a timer that reminds them to urinate every 2-3 hours. Taking the time needed when urinating to empty the bladder is also important. 

• Wipe from front to back.

  • Some individuals benefit from the use of a bidet or other toilet hygiene products. 

• Urinate after sexual intercourse.

• Drink plenty of fluids to stay hydrated and keep the urinary tract system "flushed."

• Prevent and/or address constipation.

• Treat tissue changes associated with menopause.

• Consider taking a probiotic supplement, particularly if UTIs are recurrent.

• Consider regular consumption of cranberry juice (although studies on the effectiveness of cranberry juice for preventing UTIs are conflicting).

• Consider a supplement.

  • Consult with your health care provider to confirm the supplement is safe for you and/or doesn't negatively interact with your medications. 

  • A vitamin C supplement may help improve immune function. 

  • Some individuals find taking garlic or garlic supplements helpful.

  • There are some data indicating taking D-mannose (a type of sugar) supplement may prevent recurrent UTIs.

• Wear loose clothing and practice good hygiene to avoid irritation and infections. 

 

Additional information

Why Do I Get Urinary Tract Infections So Often?  (article from Cleveland Clinic)

Can Cranberry Stop Your UTIs?  (article from Cleveland Clinic)

Vaginal Atrophy  (article from Mayo Clinic)