Remote Primary Health Care Manuals

Urine problems — over 12 years

Urine problems include

  • Cystitis (bladder infection)
  • Pyelonephritis (kidney infection)
  • Haematuria (blood in urine)

Also consider

Risk factors for complicated UTIs — medical consult

  • Pregnancy — management different — see Urine infections in pregnancy
  • Adult males
  • Kidney stones
  • Chronic kidney disease
  • Recent urinary tract procedure, eg surgery, catheter — especially long term catheter
  • Spinal cord problems, eg paraplegia
  • Weakened immune system — taking prednisolone, cancer chemotherapy, organ transplant
  • Residents of an aged care facility
  • UTI caused by pathogens other than e-coli or an ESBL e-coli that is resistant to first line antibiotics
  • Previous treatment failure, eg recurrent UTIs or just finished a treatment for a UTI which has returned
  • Previous allergy to antibiotic treatment options

Ask

  • UTI symptoms — Table 7.35
    • Can have upper and lower UTIs at same time
  • History of recurrent UTIs
  • Risk factors for complicated UTIs — ALSO check file notes
  • STI symptoms — discharge, ulcers, sores, dyspareunia (pain when having sex)

Table 7.35 Upper and lower UTI symptoms

Upper UTI symptoms Lower UTI symptoms
  • Flank/loin pain — pain in back or side between ribs and pelvis
  • Nausea, vomiting

If present — see Pyelonephritis (kidney infection)
  • Burning, discomfort, dysuria (pain when passing urine)
  • Passing urine more often than usual (frequency)
  • Urgency, urinary incontinence
  • Lower abdominal pain
  • Haematuria (blood in urine)

Check

  • Calculate REWS — AVPU, RR, O2 sats, pulse, BP, Temp
  • Weight, BGL 
  • U/A, pregnancy test
  • Head-to-toe check with attention to
    • Abdominal examination

Interpreting U/A

  • Positive nitrites usually means UTI  if symptomatic — but negative nitrites doesn’t mean no UTI
  • Positive leucocytes common in well women AND in men and women with UTIs or STIs
  • If blood — can be UTI ALSO see Haematuria (blood in urine)
  • If protein — can be UTI  ALSO see Testing for kidney disease

Do

Bladder infections

Possible cystitis — males

Pain when passing urine in men usually STI

Do

Follow-up

  • All men with confirmed UTI need
    • Medical follow-up
    • Renal tract ultrasound for stones and abnormalities
  • Add recall for test of cure post treatment
  • If symptoms return within 2 weeks of treatment — medical consult about more/different antibiotics, other tests

Possible cystitis — females NOT pregnant

Pain when passing urine in females can be UTI OR STI if sexually active

Do

  • Standard STI check
  • Treat as STI straight away
  • Urine for MC&S
  • If pain on passing urine and frequency — give trimethoprim oral — 300mg, once a day for 3 days
    • OR nitrofurantoin oral — 100 mg, 4 times a day (qid) for 7 days
  • Encourage oral fluids
  • Urinary alkalinisers may help relieve symptoms but do not treat infection

Persistent UTI (doesn’t get better)

UTI that doesn’t get better with treatment OR relapse (comes back within 2 weeks of finishing treatment) AND is not PID

  • If urine not sent for MC&S — send
  • If urine sent for MC&S — treat for 7 days according to antibiotic sensitivities
  • Medical consult

Recurrent UTI (comes back)

3 or more UTIs in 1 year

  • Talk to person about preventative lifestyle changes — drink lots of water (2-3L/day)
  • Always send urine for MC&S
  • Arrange renal tract ultrasound
  • Medical consult for preventive antibiotics AND/OR topical oestrogen for postmenopausal women

Pyelonephritis (kidney infections)

  • Work out level of kidney infection and manage accordingly

Table 7.36  Levels of kidney infection 

Mild kidney infection Moderate/severe kidney infection

Mild kidney infection

Do 

  • Urine for MC&S before giving antibiotics
  • Give amoxicillin+clavulanic acid oral — 875+125 mg, twice a day (bd) for 10-14 days based on clinical response
    • If allergy to penicillin — medical consult
  • Give pain relief

Follow-up

  • Review next day AND after 3 days
  • If getting better after 3 days — finish antibiotics
    • Repeat urine MC&S 2 weeks after antibiotics finished
  • If not getting better after 3 days or keeps getting infections
    • Blood for UEC
    • Medical consult
    • Refer for renal ultrasound

Moderate/severe kidney infection

Do

  • Medical consult to send to hospital
  • Put in IV cannula
    • Run normal saline 125mL/hr — give faster if vomiting, not eating/drinking, low BP
  • Urine MC&S, blood cultures before giving antibiotics
  • Give ceftriaxone IV — over 12 years 1g, single dose
    • If unable to give IV — give ceftriaxone IM — 1g mixed with lidocaine (lignocaine) 1%
    • If allergy to penicillin — medical consult
  • Give pain relief

Follow-up

  • If renal ultrasound not done in hospital — arrange referral
  • Repeat urine MC&S 2 weeks after antibiotics finished

Haematuria  (blood in urine)

Can be caused by infection (bladder, prostate, kidney), glomerulonephritis (kidney problem), renal or bladder stones, hard physical activity, injuries, severe dehydration, menstruation (periods) and other bleeding from uterus in women, cancer, anticoagulant therapy

Ask

  • UTI symptoms — upper and lower
  • Colour of urine
  • Injury, trauma, physical activity

Check

  • Calculate REWS — AVPU, RR, O2 sats, pulse, BP, Temp
  • Weight, BGL 
  • U/A, pregnancy test
  • Head to toe exam — attention to
    • Abdominal examination
    • Oedema (swelling of face and feet)

Do