Other diagnostic assessment

The clinician usually bases the diagnosis of UTI on the history, physical examination, and laboratory data.2 If urinary retention and obstruction to urinary outflow are suspected, urography, abdominal sonography, or computed tomography (CT) may be needed to determine the site of obstruction or the presence of calculi.9 Voiding cystourethrography is used for the diagnosis of suspected cases of vesicoureteral reflux.9 Lastly, cystoscopy is often performed when there is a history of recurrent UTIs (more than 3 or 4 per year).1 Cystoscopy can identify abnormalities that may have contributed to the development of cystitis such as urethral strictures and bladder calculi.12 It remains the only accurate means of diagnosing interstitial cystitis.12

Medical and nursing interventions

Drug therapy

Antibiotic therapy is the usual prescription in the patient with a UTI.2 In postmenopausal women, drug therapy is influenced by numerous factors. The organisms causing UTIs in this population differ from the contributing sources in younger women.2 Staphylococcus  is rarely isolated, whereas gram-negative bacteria and enterococci are frequent (E coli remains the most common causative organism).13 Pharmacokinetic and pharmacodynamic changes also control medication options to limit drug toxicity and interactions.13

Studies have revealed that a 3-day antibiotic regimen is equally effective and better tolerated than a 7-day course among postmenopausal patients.12 Use of trimethoprim/sulfamethoxazole is preferred therapy according to national guidelines, with a 94% bacterial eradication rate.14 Other drug therapy options that have shown equivalency include ciprofloxacin, levofloxacin, and gatifloxacine.14 Studies have shown that the use of sulfonamides, ampicillin, and amoxicillin is less effective than the use of trimethoprim/sulfamethoxazole and the fluoroquinolones and should not be considered as first-line therapy.2 It is important to note that while nitrofurantoin is frequently used in pregnancy, it has not been studied among the postmenopausal population.2

Diet therapy

Unless medically contraindicated, fluid intake needs to be at least 2 to 3 L/day for adequate flushing of urine through the system.12 Drinking cranberry juice has been shown to decrease symptomatic UTIs because of the proanthocyanidin-inhibiting attachment of urinary pathogens to the urinary tract of epithelial cells.2 According to recent data, cranberry juice must be consumed for 3 to 4 weeks to be effective.8

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Exogenous estrogen

It has been hypothesized that exogenous estrogen can prevent recurrent cystitis by reversing genitourinary mucosal atrophy and restoring a more normal milieu in the vagina.2 Estrogen therapy increases vaginal pH and reverses the microbiologic changes that occur in the vagina after menopause.15 In one randomized, open-label study, the use of an estrogen-impregnated ring or topical estriol cream was associated with a significant reduction in recurrent infections, but the researchers concluded that further studies with larger sample sizes are needed.15 Although small studies have suggested a benefit associated with oral estrogen replacement therapy, there is currently no rationale for prescribing oral estrogens to treat or prevent recurrent cystitis.15

Methenamine salts

Methenamine salts have long been used as an alternative strategy for the prevention of UTI. They generate the production of formaldehyde in acid urine, which, in turn, acts as a bacteriostatic agent.9 As an oral agent, methenamine salts are well tolerated, and adverse effects are generally mild and include abdominal cramps, anorexia, and rash.9

Other pain relief measures

To relieve the burning pain and urgent need to urinate, phenazopyridine hydrochloride (phenazopyridine) can be recommended. Not an antibiotic and available without a prescription, phenazopyridine is a bladder analgesic agent that provides pain relief to the lower part of the urinary tract.16 The decline in renal function that can be associated with advanced age should be kept in mind prior to recommending this drug. Several studies have shown that pyridium can cause drug-induced renal failure when not taken properly or taken at excessive doses.16

Non-pharmacologic methods are also useful. A warm sitz bath taken 2 or 3 times a day for 20 minutes may provide comfort and some relief of local symptoms.8 Proper perineum cleansing, wiping front to back to prevent contaminating the urethra with bacteria from the anal area, has been shown to reduce UTI prevalence.8 Cooling of the feet has been shown to promote pain control in an acute UTI.1

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Surgical management

Surgical interventions for patients with UTI treat the conditions that predispose to recurrent UTIs, such as the removal of obstructions and treatment of calculi.8 Procedures may include cystoscopy to identify and remove calculi or obstructions.9

Conclusions

UTI is a common medical problem for women throughout their lifetime. The physiologic changes that women experience as they age have been shown to be markers of increased risk for UTI. Estrogens especially have an important physiologic effect on the female urinary tract causing symptomatic and functional changes. Vaginal atrophy, a manifestation of estrogen withdrawal after menopause, is often accompanied by urinary symptoms. Clinicians must be cognizant of the differing pathogens of UTI that commonly affect the older female patient for antibiotic treatment. In addition, it is reasonable to use cranberry juice, methenamine salts, and estrogen cream in postmenopausal women as a way of minimizing antibiotic exposure.

Anna Posner, FNP-BC, is a certified family nurse practitioner, Female Pelvic Medicine and Reconstructive Surgery, Penn State Hershey Milton S. Medical Center, in Hershey, Penn.

References

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This article originally appeared on Clinical Advisor