Painful Urination

Geraldine Bradbury is a 22 year old nulligravida who saw me in the clinic because of painful urination. Whenever she would urinate, it would hurt, particularly at the end of urination. She said she was urinating all the time, like two or three times in an hour and producing only a small amount of urine.

After talking to her, looking at the external genitalia of evidence of herpes blisters or ulcers. Many women with herpes vulvitis will come in complaining of painful urination from the hot, salty urine hitting the open sores. In the case of Miss F.C., she didn’t have any herpes lesions.

Next, I performed a limited digital exam, using a single vaginal finger to put pressure on her urethra. As I did this, I told her, “I’m pressing on your urethra and that shouldn’t hurt. If it does hurt, please let me know.” She said, “no, that doesn’t hurt.”
Next, I inserted the single finger all the way into the vagina and curled it upward, compressing her bladder between my finger and the back of the pubic bone. I said, “Now I’m pressing on your bladder and this shouldn’t hurt either, although it may make you feel like you have to urinate.” At this point, she said, “ouch, that hurts.” So I stopped pressing on the bladder. What I’ve done with this digital manipulation is to confirm that her bladder is inflamed (as I suspected), and that her urethra is not inflamed. The bladder is normally not tender, but in the presence of infection becomes inflamed and tender. The urethra is also normally not tender. Had the urethra been tender, then I would have diagnosed her as having urethritis, likely due to gonorrhea or Chlamydia. I would have cultured her for Chlamydia and gonorrhea, two common organisms that can cause urethritis that can mimic the symptoms of bladder infection. Also, it’s certainly possible to have more than one thing wrong with you, and the combination of a bladder infection plus an STD should be considered.

After my pelvic exam, I had her sit up and firmly percussed over both kidneys, looking for any costovertebral angle tenderness that would indicate a possible ascent of the infection up into the kidneys, a more serious situation.

I asked her to give me a sterile, mid-stream, clean catch urine specimen that I could dipstick to look for nitrates or leukocyte esterace. The specimen could also be sent for a urine culture, although in a simple, uncomplicated case of urinary tract infection, most of us would not send a culture. The benefit of the culture is definitive diagnosis of not only the presence of infection, but the causative organism and its’ antibiotic sensitivities. The problems with cultures are its high cost and lack of results until several days have passed. So the answer to the question: “should women suspected of having a bladder infection have a urine culture?” is “usually no, sometimes yes.” Factors that would make me want to get a urine culture would include the complicated patient, those in whom I suspect pyelonephritis, and frequent, recurring infections.

Based on her story, that included most of the classical symptoms of bladder infection (dysuria, frequency, urgency) and a clinically tender bladder, I diagnosed her as having a bladder infection. Bladder infections are usually not life-threatening, but are very annoying, and some of them have the potential for ascending infection up the ureters and into the kidneys, a life-threatening problem.

I treated her with macrodantin or nitrofurantoin 100 mg orally, twice a day for seven days. I could just have easily treated her with a flourooquinolone such as ciprofloxacin, or a sulfa drug like Bactrim. The important thing about antibiotic coverage of these organisms is that coliforms are the common organisms, with e. coli being present in about 80% of acute, uncomplicated cases. With this spectrum of pathogens, there are many antibiotic choices that can give good results.

I then spent some time educating her about bladder infections and how to avoid them. I told her that most bladder infections in women her age are related to sexual intercourse. During sex, bacteria that are normally present in the vagina and on the vulva get nudged up into the bladder. The longer intercourse goes on and the more vigorous, the more bacteria are inoculated into the bladder. The use of vaginal spermicides is another predisposing factor, probably because of alteration of the normal vaginal flora. Among menopausal women, other predisposing factors include urinary incontinence, the presence of a cystocele and significant post-voiding residual volume.

So the thing I find interesting is not so much why a woman might occasionally get a bladder infection, but why they don’t constantly have bladder infections. An the answer is that there are some natural protective mechanisms at work. First, there is a constant supply of fresh, sterile urine coming out the ureters and into the bladder, diluting the bacteria and leading to urination which helps flush out the bacteria. Second, there is a mucous lining to the bladder that provides a protective barrier between the bacteria and the epithelium. The mucous is also bacteriostatic, inhibiting rapid growth of the bacteria. That said, there are ways in which these protections might be thwarted.

If the woman is at all dehydrated, then the flow of fresh sterile urine will slow to a trickle, losing much of its protective effect. If intercourse has been unusually energetic, then the trauma from the thrusting can stretch the bladder lining, creating potential breaks in the mucous layer of protection. If the woman is not optimally lubricated during intercourse, even normal thrusting can lead to traumatic distruption of the mucous layer and an unusually large deposition of bacteria inside the bladder.

I then explained to her how to avoid bladder infections in the future. I encouraged her to empty her bladder both before and just after intercourse, to flush out many of the bacteria that will have collected. I recommended that if she ever experienced suboptimal lubrication during intercourse, to make use of commercially-available personal lubricants, such as Astro Glide, or K-Y. I suggested that after intercourse, she drink a glass of water or other neutral liquid to insure steady urine flow. I also recommended that she take a Vitamin C pill after intercourse. Vitamin C is ascorbic acid and very little of it is absorbed…most of it is excreted in the urine, where it will turn the urine slightly acidic. Bacteria hate an acidic environment and will not grow in it, so taking the Vitamin C will help inhibit bacterial growth.

Another alternative is the drinking of cranberry juice before or after intercourse. Like Vitamin C, cranberry juice is highly acidic and promotes a low pH in the urine. Further, at least two studies have shown that cranberry juice inhibits the adhesion of uropathogens to bladder epithelium, possibly mediated by fructose.

Other physicians sometimes recommend a single antibiotic pill, such as macrodantin or nitrofurantoin, right after intercourse. This antibiotic prophylaxis works well, but Vitamin C has a very long shelf life, is inexpensive and doesn’t require a prescription, so I favor that approach in uncomplicated situations.

Some physicians will also routinely get a urine culture. Of course, the results won’t be known for another couple of days, so these physicians often will initiate treatment on the basis of their clinical diagnosis, and then look to the urine culture results if the patient hasn’t gotten better in a couple of days. Most patient’s symptoms will resolve in 24 to 48 hours, so a persistence of symptoms is a warning sign that the antibiotic you have prescribed may not be effective in treating the organisms responsible for the infection.

I also recommended that she pick up some Pyridium or phenazopyridine. This is an Azo dye, which when taken orally, is excreted promptly in the urine, turning a bright orange/red color. It functions as a bladder anesthetic agent, relieving the symptoms of bladder infection within a couple of hours. Of course, it doesn’t do anything for or against the underlying infection, so that will still need to be treated. But it can provide great relief for the patient. Patients normally take one pill orally three times a day for two days before stopping it.