Thursday, 29 March 2007

Elderly Females and UTIs

UTI in elderly patients is a relatively easy diagnosis to make especially with urine analysis and urine culture providing the best clues.

Often, elderly patients present with fever and no urinary symptoms or they may present with just new or worsening confusion.

Obvious causes include long term Foley catheter usage and faecal incontinence causing contamination of the genital tract.

Atrophic female genitalia and with advancing age are other risk factors especially as the female urethra is shorter compared to the male.

Bacteriuria in the elderly is very common and may also be asymptomatic.

When a patient presents with recurrent UTI then further investigation may be warranted.

Patients in hospital or care homes may be infected by medical staff due to poor hygiene or other infectious patients in close proximity.

The infection may be due to a multi-drug resistant bacteria that was not effectively treated previously or the patient has been auto-infected in some way.

Of course, in younger patients, UTI can be precipitated from sexual intercourse. Also remember, elderly patients may also still be sexually active!

Other more unusual things to consider include fistula between bladder and bowel which might be due to malignancy, inflammatory bowel disease, diverticular disease as examples, which leads to direct faecal contamination of the urine.

Questions to ask include: Is your urine dark brown and cloudy? Faeces in the urine. Are there bubbles in your urinary stream on passing urine ? (not just bubbles in the toilet); this is pneumaturia and signifies gas from the bowel escaping into the urine.

The other questions of urinary frequency, nocturia, suprapubic discomfort, dysuria, haematuria, sexual activity and bowel symptoms should also be asked.

With the problem of re-infection, one question to ask the female patient is how they clean themselves following defecation. Females may put themselves at risk of faecal contamination of their genitourinary tract if they clean their anus from posterior to anterior i.e. downwards and forwards between their legs rather than away from the genitourinary tract (inferior to superior direction) i.e. from below upwards and behind them.

As mentioned, the female genital tract is anatomically more at risk of infection as the urethra is shorter than that of the male and it is more exposed to potential contamination.

Recently, on advising a junior doctor of this line of quite intimate questioning for a patient with her second severe UTI, I was met with a look of astoundment from the doctor that this question should be asked at all.

However, when he did ask the question, it was soon determined that the patient was indeed contaminating her genitourinary tract with faeces when finishing defecation and hence, she was auto-infecting herself causing recurrent UTI.

I appreciate that this questioning is delicate and perhaps embarrassing for both doctor and patient, but if established as the cause of the recurrent UTI, then the patient can be advised on how to avoid such problem in the future. Please consider!

Finally and perhaps most importantly, it should be noted that Foley catheters should only be introduced if the patient actually needs a catheter and not for aiding the nurses by reducing their workload. Remember, nursing care also includes patient toileting and if you as doctors are pressurised into inserting a catheter as the nurse is too busy to toilet the patient, then you may be putting your patient at risk of developing a UTI. If the patient does have a catheter, it should be removed as soon as possible and when practicably possible.

Also, hospitals and care homes should have appropriate Infection Control procedures whereby patients with severe infections e.g. pseudomonas, MRSA, are moved to areas where they pose less danger to other patients. That may mean putting patients in single rooms until the infection is cleared.

Infection control staff also advise medical staff on proper hygiene such as hand washing, disinfection and how to manage outbreaks and their importance in the hospital and community setting cannot be taken for granted.

Please let me know your opinions !!!

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