22-year-old (Female) with Recurrent Urinary Tract Infections

00:00 Okay, guys. We have a super important clinical question here.

00:05 Highly likely that you will see it both on the boards and on USMLE so let’s buckle down.

00:11 A 22-year-old female presents to the office seeking evaluation for her recurrent urinary tract infections.

00:20 She describes frequent and burning urination.

00:24 This is her third UTI within the past year.

00:29 She has a past medical history of generalized anxiety disorder for which she takes paroxetine.

00:37 She has been sexually active with multiple partners within the past year.

00:42 The patient’s blood pressure is a 116/72, heart rate of 76, respiratory rate is 12 and her temperature is 36.8.

00:54 On physical examination, she is alert and oriented to time, place and person.

01:00 Her heart is without murmurs. Her lungs are clear to auscultation bilaterally.

01:05 Her abdomen is soft and nontender to palpation and the distance between her urethra and anus is shorter than average at her age.

01:17 Urinalysis and urine culture results are provided.

01:22 Urine culture results 200 colony forming units of Escherichia coli.

01:29 Leukocyte esterase positive, WBCs 7, nitrite positive, RBCs 3, epithelial cells 2 and pH 5.2.

01:43 Which of the following treatment recommendations would be most appropriate for this patient? Answer choice A: Trimethoprim-sulfamethoxazole plus urinating before and after intercourse.

02:00 Answer choice B: Urinating before and after intercourse.

02:05 Answer choice C: Cephalexin.

02:09 Answer choice D: Cranberry juice, or - Answer choice E: Trimethoprim-sulfamethoxazole.

02:17 Now take a moment to come to the answer by yourself before we go through it together.

02:23 Okay, guys. This is super important, let’s go into the question characteristics.

02:30 Now this is a family medicine question.

02:33 You're always going to have patients coming in the clinic complaining of urinary tract infections, your recurrent urinary tract infection or some complaint there often in family medicine clinic.

02:45 Now, this is actually a two step question.

02:48 You're told in the question stem that this patient has a UTI, but you have to go beyond that and figure out, well, what type of UTI is this? And then based on figuring out what type of UTI we're dealing with, we need to then figure out what's the best treatment strategy and of course the question stem really here is required and I would say with a strong attention to detail because we need to be able to carefully diagnose the type of urinary tract infection that we’re dealing with.

03:19 Now, first thing we gotta do, let’s hit the diagnosis and let’s do it accurately.

03:24 Okay, so we have a young female patient coming in and her chief complaint is that she is having recurrent urinary tract infections.

03:33 Now, so the first diagnosis we have here is recurrent urinary tract infections.

03:39 Now, urinary tract infection risk factors for this patient are going to be twofold.

03:46 The first is she does have pelvic anatomy abnormality.

03:52 We're told the distance between the urethra and the anus of this patient is shorter than average at her age.

03:59 And also, she has new and multiple sexual partners within the last year.

04:06 So based on these two variables she’s at increase risk for getting recurrent urinary tract infections.

04:14 Now, the patient is also telling us that she currently has what sounds like an acute urinary tract infection.

04:21 She is ongoing increase urinary frequency and also burning with urination so that’s a second diagnosis here which is an acute UTI.

04:32 Now, you can also determine the acute UTI by looking at her urinary results and that’s going to be having E. coli as the culture results, also having a positive leuk esterase and also a positive nitrite which is all consistent with an acute UTI.

04:52 Now, we need to figure out if it’s complicated or an uncomplicated UTI and how you do that is based on clinical exam.

05:00 Now, in the question stem, we're told that vitals are normal and essentially her exam is also normal.

05:07 Neuro exam, heart, lung, abdomen soft no tenderness to palpation, we don’t have any signs of her being septic, we don’t hear anything about flank pain, so sounds like an uncomplicated UTI.

05:21 So how are we going to carefully diagnose this patient is that she has recurrent UTI and a current episode of an uncomplicated UTI of Escherichia coli.

05:35 Now, that we know the diagnosis, step two, is determining the most appropriate treatment for this patient.

05:42 Now, this patient needs two types of treatment.

05:47 The first thing we need to do is treat her current acute UTI and then second, we need to prophylactically come to a treatment strategy to prevent her recurrent urinary tract infections.

06:00 Now, we know we're gonna treat the acute UTI and that’s going to require antibiotics.

06:05 So based on that alone test taking strategy, we can eliminate the ones or the answer choices that don’t include antibiotics.

06:13 So we can get rid of choices B, urinating before and after intercourse; and also D, cranberry juice.

06:20 We can just delete those two right off the back because they don’t have antibiotics and we need antibiotics to be able to treat the acute infection.

06:29 Next, we can actually also delete or eliminate answer choice C of Cephalexin because this is a second line antibiotic choice while trimethoprim-sulfamethoxazole is a primary answer choice, so right of the back we can get rid of Answer choices B, C, and D leaving us with just a 50/50 shot between Answer choices A and E which is going to be antibiotics plus urinating techniques or just antibiotics alone.

07:01 Now, we know that to treat the acute UTI we're gonna need to give antibiotics and antibiotics are present in both Answer choices A and E, but we also need to come up with a prophylactic technique to try to prevent all these recurrent urinary tract infections and that’s going to be the technique of urinating before and after intercourse so the correct answer here is Answer choice A which is trimethoprim-sulfamethoxazole, the antibiotics to treat the acute infection plus the behavioral change of urinating before and after intercourse.

07:37 Now, let’s talk about this by going through the answer choices in a little bit more detail.

07:42 Now, if you look at Answer choice A which is the correct answer, what we're doing here is we've diagnosed the patient with her third episode of a urinary tract infection within the last year.

07:55 Now if a male or female experiences at least three episode of urinary tract infection within one year or two episodes within six months or less, individuals are said to be experiencing a recurrent UTI.

08:12 Now, you can look at the algorithm here of our flow diagram to see the techniques as to how we determine and then treat these recurrent UTIs. I’ll go through that diagram with you at the very end here of this recording.

08:26 Now, a recurrent UTI is present in this patient at the same time she has new UTI symptoms and that’s going to be due to the E. coli infection that she has.

08:40 Now, what's going to happen is we can use the term recurrent UTI when you have an ongoing infection due to a different bacterial species at least two weeks following the end of a previous UTI treatment course, so you treated someone two weeks later you get another UTI a different one we call that a recurrent UTI.

09:04 But what -- okay, so you probably heard this term, what about a relapse? So how is that different than a recurrence? Now a relapse is said to occur when the pathogen is the same not different and it re-infects prior to two weeks following treatment of the original infection.

09:22 That’s the key difference between a recurrent infection and a relapse of an infection.

09:27 Now, many factors place individuals especially women at a risk for having recurrent urinary tract infections and really here the variables to consider are one, the vaginal colonization with uropathogens or genetic components such as P1 being a non-secretor or CXCR1 phenotypes.

09:51 If a patient has used spermicide within the last year that increases the risk; having a new sexual partner within the last year as we saw in this patient’s question stem; having your first UTI before the age of 15, or having a mother with a UTI history or even having pelvic anatomy abnormalities which is also seen on this patient.

10:15 Now, what's interesting is that post menopausal women are more predisposed to urinary tract infection and even recurrent urinary tract infections given their special circumstance related to insufficient bladder emptying seen commonly in post-menopausal stage.

10:34 Now, UTIs may also be caused by lack of voiding before or after intercourse.

10:41 Now the urine within the bladder allows for a suitable environment for foreign microbes to cause a urinary tract infection and in this situation what we have the patient do is urinate prior and after intercourse to kind of help themselves decrease the risk.

11:00 Now, prophylactic treatment following intercourse also known as post-coital prophylaxis is also something that can be done with antibiotics and the first line treatment for that is trimethoprim-sulfamethoxazole or nitrofurantoin so that all relates to these recurrent urinary tract infections, giving antibiotics and changing behavior.

11:25 Now if you look at Answer choice B, urinating before and after intercourse, this is good.

11:30 It will be a good prophylactic agent for the patient to try to prevent infections in the future but it doesn’t treat the acute infection so no antibiotics, wrong.

11:40 Cephalexin, Answer choice C is a second line agent, we would never go there first unless we're told something about resistance to another antibiotic so wrong, eliminate.

11:51 Answer choice D, cranberry juice, this one is actually interesting.

11:56 Now, cranberry juice has actually proven effective at preventing urinary tract infections and recurring urinary tract infections associated with E. coli and it does this by preventing the microbe from adhering to the urinary tract itself.

12:15 However, in this patient, we still need to give antibiotics to treat the acute infection so we can eliminate this one as well, it’s wrong.

12:23 And, Answer choice E, trimethoprim-sulfamethoxazole, which is going to be the first line treatment for treating the acute and the recurrent urinary tract infections but in this case, we also want to give the patient a prophylactic technique to prevent the next infection so that is wrong because we also need behavior change.

12:44 Now, let’s review some high-yield facts of urinary tract infections.

12:48 Now, the urinary tract infection can happen in any part of the urinary tract.

12:54 It can be a lower urinary tract infection which is involvement of the bladder which is much more common than the upper urinary tract infection which is when it involves the kidneys which is called pyelonephritis.

13:07 Now, the most common bacterial infection in women is a urinary tract infection and it’s more common in women than men because of the female anatomy of the urethra being closer to the anus and having E. coli having the opportunity to go into the urethra and crawl upwards.

13:27 Another risk factor is having sexual intercourse or changing partners.

13:32 Now, most commonly, UTIs are caused by E. coli, and again, the E. coli in the anus and gut region crawling up into the UTI or urethra.

13:42 Now, we gotta pay attention to the signs and symptoms of UTI.

13:48 Now, a lower UTI infection is just increase urinary frequency and burning with urination, but an upper urinary tract infection that’s gonna be a sick patient.

13:59 That’s going to be fever, flank pain, in addition to urinary frequency and burning with urination.

14:06 And the way you diagnose an infection of the urinary tract is based on the signs and symptoms alone that’s why I highlighted and emphasized the symptoms of lower and upper urinary tract infections and of course you treat them with antibiotics in the acute phase to treat them and in the case of recurrent urinary tract infections, treatment is really going to be directed at prophylaxis.

14:32 Now, to make better sense of that, let’s refer to our flow diagram we have here.

14:38 Let’s go through it together to understand how can we treat these recurrent infections.

14:43 Now, looking at the top it says, nonpregnant woman with a history of at least two UTIs in six months or at least three within 12.

14:53 That’s how we're going to define recurrent urinary tract infections.

14:58 Now, once you have a recurrent urinary tract infection, it can either be non-symptomatic or the symptoms suggests an uncomplicated UTI as we had mentioned and you can just treat them or the symptoms are going to be complicated where we can see pyelonephritis which is an upper urinary tract infection or a patient has pregnancy or they have sexually transmitted infections or some type of alternative diagnosis which of course we would evaluate and treat accordingly for that more complex cause.

15:30 Now, after you figure out what's going on with the recurrent urinary tract infection, the next thing we have to do is consider, and I would say just do it, verify normal genitourinary anatomy.

15:43 You wanna make sure there's no fistula between the urinary and bowel system, make sure the anatomy isn't grossly abnormal just to kinda make sure structure is not the problem.

15:53 And once you do, you start to give recommendations so if the structures normal or mildly abnormal, you can give the recommendations of voiding after intercourse and avoiding the use of spermicide.

16:05 Cranberry products, you know, just drinking cranberry juice or taking cranberry pills in the premenopausal women or using topical estrogen in post menopausal women or you can even give prophylactic antibiotics.

16:20 Now, that’s a touchy subject. Not all patients feel comfortable taking prophylactic antibiotics and that’s where were gonna hit this dichotomy in our flow diagram.

16:31 So say a patient desires prophylactic antibiotics.

16:36 Now, if the infections are temporally related to intercourse, that is, whenever they have intercourse then they get a UTI that’s a temporal relation, then postcoital antibiotic used is favored over low dose antibiotic use daily, that is, if they have intercourse and get a UTI that seems to be their trend, then treat them accordingly.

17:01 After they have intercourse, take an antibiotic pill, but if the infections are not temporally related to intercourse, then instead, you know, they just kinda get them randomly and they're not associated with intercourse episodes, then we wanna use a daily low dose antibiotic instead of a postcoital antibiotic.

17:22 Now, say on the other part of our diagram here, the patient actually declines prophylactic antibiotics and you may see that these days, plenty of patients don’t wanna take antibiotics, well, what you can do is you can offer an antibiotic prescription for the patient and they can initiate it then or for future episodes.

17:43 Now, if the patient doesn’t wanna do that, well then, they can just come to you each time they get an infection and you can just treat them, or, if they are willing to take the script, then they can just fill the script and take the pill themselves whenever they get the infection.