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Referral and warning signs
When to refer
Refer if: Suspected pyelonephritis (fever, flank pain). Symptoms persist or recur after adequate treatment. Recurrent UTIs requiring investigation/prophylaxis. Complicated UTI (male patient, pregnancy, diabetes, immunosuppression, structural abnormality). Haematuria persisting after UTI treatment.
Red flags
- Fever (>38°C)
- Chills / Rigors
- Flank pain or costovertebral angle (CVA) tenderness
- Nausea / Vomiting
- Signs of sepsis
- Known urinary tract abnormality
Signs and symptoms
- Dysuria (painful or burning sensation during urination).
- Urinary frequency (needing to urinate often).
- Urinary urgency (sudden, strong need to urinate).
- Suprapubic pain or discomfort.
- Haematuria (blood in urine - microscopic or gross).
- Cloudy or foul-smelling urine.
- Nocturia (waking at night to urinate).
- Absence of systemic symptoms like high fever, chills, flank pain (which suggest pyelonephritis).
Risk factors
- Female gender (shorter urethra)
- Sexual activity
- Use of spermicides/diaphragms
- History of previous UTIs
- Pregnancy
- Postmenopausal status (oestrogen deficiency)
- Urinary tract abnormalities (stones, strictures, reflux)
- Incomplete bladder emptying (BPH, neurogenic bladder)
- Urinary catheterization
- Diabetes mellitus
- Immunosuppression
Diagnosis
Clinical assessment
Diagnosis often based on characteristic lower urinary tract symptoms (dysuria, frequency, urgency) in the absence of vaginal discharge/irritation (ruling out vaginitis) and systemic symptoms (ruling out pyelonephritis). Differential diagnosis: Urethritis (STI-related), Vaginitis, Prostatitis (men), Pyelonephritis, Interstitial cystitis/painful bladder syndrome.
Investigations
- Urinalysis (Midstream Urine - MSU): Dipstick testing often shows positive leucocyte esterase and/or nitrites. Microscopy shows pyuria (white blood cells) +/- bacteriuria, +/- haematuria.
- Urine Culture & Sensitivity (MSU): Not always necessary for uncomplicated cystitis in women, but recommended for: Men, Pregnant women, Complicated UTI (diabetes, immunosuppression, structural abnormalities), Suspected pyelonephritis, Recurrent UTIs, Failure of empirical treatment.
Diagnostic criteria
Presence of typical lower urinary tract symptoms +/- positive urinalysis (leucocytes, nitrites). Culture confirms bacteriuria and guides therapy if performed.
Management
Non-pharmacological management
- Increased fluid intake.
- Regular bladder emptying.
- Wipe front to back after toileting (women).
- Voiding after intercourse (may help some women).
Pharmacological treatment
- Antibiotics (Short course usually sufficient for uncomplicated cystitis):
- - First-line (UCG 2023): Nitrofurantoin 100mg PO Q6H for 5-7 days (avoid if GFR <30-40 or near term pregnancy). Take with food.
- - Second-line/Alternative: Ciprofloxacin 500mg PO BID for 3-7 days (Avoid in pregnancy/children unless essential). Fosfomycin 3g PO single dose (often good option). Trimethoprim-Sulfamethoxazole (TMP-SMX) - resistance common, use if local susceptibility known. Amoxicillin/Clavulanate.
- - Adjust based on culture/sensitivity results if available.
- - Longer courses (7-14 days) for complicated UTI or men.
- Phenazopyridine: Urinary analgesic, can provide symptomatic relief from dysuria (turns urine orange). Use for 1-2 days only.
- Management of Recurrent UTIs (≥2 in 6mo or ≥3 in 1yr): Investigate underlying cause, consider prophylactic strategies (low-dose nightly antibiotics, post-coital antibiotic, cranberry products - evidence mixed, topical oestrogen for postmenopausal women).
Monitoring
Monitor for symptom resolution within 2-3 days of starting antibiotics. Follow-up urine culture usually not needed if symptoms resolve in uncomplicated cases.
Complications
- Ascending infection -> Pyelonephritis
- Recurrent UTIs
- Sepsis (rare with uncomplicated cystitis)
- In pregnancy: Risk of pyelonephritis, preterm labour, low birth weight.
Prevention
- Adequate fluid intake.
- Proper hygiene (wiping front to back).
- Voiding after intercourse.
- Avoid spermicides (if recurrent UTIs).
- Consider cranberry products (proanthocyanidins may inhibit bacterial adherence - evidence inconsistent).
- Topical vaginal oestrogen (postmenopausal women).
- Antibiotic prophylaxis (for recurrent cases - specialist guidance).
Patient education
- Explain UTI and bacterial cause.
- Importance of completing antibiotic course.
- Fluid intake advice.
- Hygiene measures.
- Symptoms of pyelonephritis (fever, flank pain) requiring urgent attention.
- Strategies for preventing recurrence if applicable.
Uganda-specific notes
Very common. Empirical treatment based on likely pathogens and local resistance important (Nitrofurantoin/Ciprofloxacin listed). Urine culture often unavailable. Rule out STIs (urethritis/vaginitis) based on history/exam. Treat aggressively in pregnancy.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 7, Section 7.2.1