Urinary Tract Problems: Answers to Common Question

Frederick R. Jelovsek MD

• Urinary tract infection after sexual relations
• Symptoms of urinary tract infection
• Frequent urinary tract infections
• Urethral syndrome/Skene's glands
• Frequent UTIs, possible urethral syndrome
• Recurrent cystitis
• Feeling of full bladder and blood in urine
• Blood in urine
• Occult blood in the urine
• What treatment for large kidney stones?
  

Urinary tract infection after sexual relations

I've recently started having sex with a new partner. I have been experiencing pains in my lower abdomen and in my sides. It also hurts to urinate and I feel the urge to go often. Both of us have been in monogamous relationships up until now so there shouldn't be the chance of a STD. Any suggestions? I had a biopsy of my cervix about 2 months ago which came back OK, but I am suppose to have another one in April. Could this be related to the pain in any way?

It is very likely that you have a urinary tract infection which needs to be treated with antibiotics. You need a urinalysis to be sure, but usually you can just go to the doctor's office and have one done without an appointment.

The pain is not related to the cervical biopsy. It may be related to just the trauma of sexual intercourse in which the urethra can be "rubbed" quite hard and sometimes traumatically. Also with intercourse, even without an STD, bacteria from the vagina can be introduced into the female urethra. That is why you need to be checked for a bacterial infection. Sometimes, for awhile with a new partner, you may need an antibiotic after intercourse each time. This is how we treat urethral syndrome too.

Symptoms of urinary tract infection

I'm a 19 yo female. Yesterday when I urinated I had severe burning in the urethra and afterwards sharp pains in the pelvic area almost like cramps. Today I feel like I have to urinate all the time and when I do it stings and I feel a VERY strong pressure like there's something I need to pass through the urethra that just won't come and is very painful. I also have bumps on the pubic area. I just started shaving not too long ago, I'm wondering if that has something to do with it? What is going on?

It sounds as if you have a urinary tract infection. You should see a doctor right away because antibiotics may be needed to prevent a more serious kidney infection.

I do not think the probable urinary tract infection is related to your shaving, but the bumps might be or they could be something else and your doctor will be able to offer some more advice after examination.

Frequent urinary tract infections

I get a urinary tract infection about once every two months. I have been going to my HMO. All they do is give me antibiotics. These give me yeast infections. Anyway, is this a symptom of some kind of sexually transmitted disease or another type of disease. It seems abnormal.

If the urinary tract infection (UTI) follows sexual relations (even though it is not every time) you may be having chronic recurrent urinary tract infections or it may be urethral syndrome in which there is a burning or irritation with voiding but the infection or irritation is in the Skene's glands of the urethra rather than a UTI involving the lining of the urethra and bladder. If that is the case, the best treatment is taking an antibiotic each time right after sexual relations and voiding soon after sex.

Sexually transmitted disease (STD) is also a possibility and you will need to have a pelvic exam and cervical cultures done to check this.

Urethral syndrome/Skene's glands

I have had pain in my urethra for about 8 yrs. My urine tests are negative. I have had a scope of my bladder done and my urologist says it looks ok. I have had a total hysterectomy. When the urologist took a catheter urine specimen it was so painful that I could tell that was where my pain was coming from and he dilated my urethra. Now it is painful to have sex and my clitoris area gets swollen and hurts to touch. I constantly feel like I have to urinate and have pain around the urethra constantly. When my clitoris area is touched the painful urination feeling increases. My urologist doesn't know what to do.

The urethral pain sounds like urethral syndrome which is felt to be an inflammation of the Skene's glands at the opening to the urethra. Treatment for it is long term antibiotics and antibiotics after sexual relations. Usually there is no associated clitoral pain however. I'm not sure what that might be. You might get long term treatment with something like Bactrim or Septra if you are not allergic to sulpha drugs and see if the clitoral pain goes away. If it does not you might visit a gynecologist.

Frequent UTIs, possible urethral syndrome

I have been getting urinary tract infections on and off for about three years. The most recent one that I had, I was urinating blood (only about 5-6 drops). The doctors always just put my on some antibiotic, and then it comes back within the next month. It usually occurs while I'm sexually active, but I do urinate right after sex. The last infection came with greater abdominal pains than any of the other times. What can I do so I won't get these infections anymore, and I am going to the wrong doctors? (I go to the campus health center.)

This can be recurrent infection of the bladder or urethra, recurrent trauma to the urethra (from sexual relations) or an entity called urethral syndrome which probably is a very low grade infection of the tiny glands in the outer portion of the urethra. If they are doing urinary cultures and they are always positive, you are having recurrent infection of the bladder. If you have some blood but no bacteria, then it's trauma with or without urethral syndrome.

The treatment is an active 7 day course of antibiotics (sulfa like Bactrim DS® or Septra DS® if not sulfa allergic) then, if symptoms all gone, one tablet of sulfa immediately before or right after sexual relations. Occasionally I've had to put women on one a day with an extra tablet after relations. This almost always works. See if your doctor will let you try this.

I've included some abstracts below. Some primary care physicians may not be aware of this. Usually permanent college health service physicians are quite aware of this entity but sometimes if there are just moonlighting MDs, they may not be attuned to this.

Managing urinary tract infection in women.

Drug Ther Bull 1998 Apr;36(4):30-32

Each year, around 5% of women present to their GPs with dysuria and frequency. About half have a urinary tract infection, as confirmed by the presence of a threshold ('significant') number of bacteria in their urine (usually defined as > or = 10(5)/mL). In the remaining women, symptoms occur in the absence of bacterial infection: this condition is referred to as urethral syndrome. In this article, we discuss the diagnosis and treatment of urinary tract infection in women.

The urethral syndrome and its management.

Hamilton-Miller JM

J Antimicrob Chemother 1994 May;33 Suppl A:63-73
Department of Medical Microbiology, Royal Free Hospital School of Medicine, London, UK.

The urethral syndrome and its management are reviewed. Urethral syndrome is defined as 'symptoms suggestive of a lower tract urinary infection but in the absence of significant bacteruria with a conventional pathogen' with three provisos concerning symptomatology and the definition of significant bacteruria and conventional pathogens. The urethral syndrome is a very common condition; about half the patients visiting their General Practitioner by reason of frequency and/or dysuria do not have significant bacteriuria. Both infective causes (such as lactobacilli and sexually-transmitted pathogens) and non-infective causes (such as trauma, allergies, anatomical features and co-existing medical conditions) have been suggested as causes and are discussed. Treatment options include antibiotics in the case of acute urethral syndrome, since it is not possible to distinguish between urinary infection and the urethral syndrome in the consulting room. For those with chronic urethral syndrome, treatment depends upon whether attacks are associated with bacteriuria or if urological investigations reveal any abnormalities.

Female urethral syndrome. A female prostatitis?

Gittes RF, Nakamura RM

West J Med 1996 May;164(5):435-438

Department of Surgery, Scripps Clinic and Research Foundation, La Jolla, California, USA. The cause of the female urethral syndrome has previously been obscure, as it has been associated by definition with a lack of objective findings but a plethora of subjective complaints of retropubic pressure, dyspareunia, urinary frequency, and dysuria. There is now strong evidence that the microscopic paraurethral glands connected to the distal third of the urethra in the prevaginal space are homologous to the prostate. They stain histologically for prostate-specific antigen and, like the prostate, are subject to both infection and cancer. The most important aspect of recognizing this microscopic "female prostate" as an anatomic feature is that its infections may completely explain many cases of the urethral syndrome. Further, the diagnosis is not elusive if trained clinicians palpate for localized and objective paraurethral tenderness through the anterior vagina wall to one or both sides of the urethra. Treatment parallel to that for male prostatitis is usually rewarded by the elimination of symptoms and the objective finding of the loss of tenderness of the paraurethral glands. As with prostatitis, the localized problem often recurs. It is time to alert primary care physicians to this disorder and to eliminate the widespread practice of treating affected women with either invasive urethral dilation or tranquilizers.

Recurrent cystitis

I have been experiencing what I call recurrent cystitis. It starts upon arising in the morning. After I first urinate, I feel the constant urge to go again. It becomes very frequent and painful--sometimes accompanied by a tinge of blood. I also notice at the same time that I have what I call a "full" feeling in my vaginal area. I take OTC Pyridium®, which relieves the feeling of having to urinate so much and the pain, then I apply Vagisil® to the vaginal area. After a few hours, all of these symptoms disappear. I find it difficult to see my gynecologist, as I have an HMO that makes me see the primary care doctor first. All he does is prescribe Bactrim® for a bladder infection. My question is this: do I actually have bladder infection, or is the vulvitis (inflammation of the vagina) causing the symptoms of cystitis, and what can I do to avoid this?

It is difficult to say for sure without examining the urine microscopically and examining your vulvar area when you are having symptoms. If this is happening primarily on the mornings after sexual relations, urethral syndrome comes to mind. This is a direct irritation of the urethra due to sexual relations (often referred to as "honeymoon cystitis" although it can happen long after the initial relations with a new partner). Usually the urine culture is negative but sometimes there is blood cells in the microscopic.

If this is happening everyday regardless of sexual relations, it may represent an active urine infection that has not been well treated or just keeps coming back.

If you think it is just burning because the urine hits an irritated vulva, try to void when you get up in the morning by sitting in a bath tub and void in the water. If the burning is not present then, it is because of vulvar irritation and that is what needs to be checked out. This would be called an irritant vulvitis. If the burning is still present, it is urethral in origin and that should be the focus of diagnosis.

Another woman answers -- I have in the past (first few years of marriage) gone through a similar situation that you described. Save yourself some time and pain--ask your doctor to do a "culture" of your urine. Sometimes the Bactrim® won't clear up certain infections and you need to custom prescribe for it. After they did this, my infection was quickly cleared up. Also, make sure they check your blood sugar. These are small, legitimate tests to ask for that are more than reasonable to justify asking your doctor to perform. The HMO should not object. I am not a doctor but sometimes you have to be your own advocate.

Feeling of full bladder and blood in urine

All day yesterday I had the feeling of a full bladder but when I went to the bathroom, only a few drips would pass. The vaginal area was also very tender. I did not have burning when urinating, but I did have some light watery looking blood when wiping that I do not think is menstrual because my period was finished about 2 weeks ago. Also, late last night my lower back around the waist line was very sore as if I just finished a major aerobic work out. Today the sore back is gone and the urge to urinate is not as bad. What could this be?

The main worry would be a urinary tract infection or just urethral or bladder irritation from sexual intercourse. UTIs probably go away sometimes on their own and they may not always have frequency. If the blood you wiped was from the urethra and not the vagina, I would go with urinary tract as a source and stop by your doctor's office for a urinalysis. If at all positive, treatment with antibiotic will likely help even though symptoms are decreasing now.

Another possibility is something to do with ovulation since this came on about 14 days after your LMP. Sometimes there can be some bleeding or pelvic swelling with ovulation that can give fullness or even bladder pressure. It usually goes away in a day or two as your symptoms seem to do. If you are on DepoProvera® or normal dose birth control pills, this is less likely because they suppress ovulation, but not always.

Just an update. I did have a bladder infection and was given Pyridium® that is completed and Bactrim® which I am still taking. NOW the only symptoms I'm having are a low fever (99.4) and light nausea. What is causing this? I don't believe I am pregnant because I just finished my period this week but it was shorter and lighter than the usual 7-10 days of heavy bleeding and cramps.

Blood in urine

I had blood in my urine test, so they took another test and it came back negative for bladder infection, but there are still blood cells in it. I can't see anything when I go, have no pain or urgency. My right side has a little pain way down but it's nothing. What could be wrong? I have to go back in a week for another urine test.

Blood in the urine can be due to infection, stones, non bacterial inflammation such as interstitial cystitis, bladder or kidney cancer or polyps or sometimes just unknown. Rarely endometriosis may cause blood in urine and of course trauma to the kidneys or abdomen.

How long has the pain been present and what is it like?

The pain is like a dull ache and kind of hurts in my back a little. It has only been for about a week.

It's difficult to say at this point what's going on. The next step is to repeat the urinalysis and possibly a urine culture as you have indicated is already scheduled. If the nature of the pain changes, either getting worse or improving, that would also be a time to reassess and look at the urine specimen again. Sometimes these things do go away by themselves with us never knowing for sure what was going on.

The minimum you should have done at this point to investigate this is to have a kidney xray (IVP) and urine specimens sent times 3 for cytology looking for possible malignant cells. If these studies are negative, then a cystoscopy (looking into the bladder) should be done. If that study plus the rest are negative, then the blood in the urine can just be followed.

Occult blood in the urine

I recently discovered that I have occult blood in my urine. Three separate urinalysis were done, all of which were positive for blood in the urine. The numbers were about 3 times the normal number of blood cells in a normal reading. I have absolutely no symptoms of infection and no pain. I was referred to a urologist who performed a cystoscopy as well as X-Rays of my kidneys. All the tests were inconclusive. Although I was relieved, I am still worried that no diagnosis could be made. Should I be seeking a second opinion? What else could this be? I am an otherwise healthy 29 year old woman.

Isolated hematuria (just red blood cells in the urine which I am assuming you have) is associated with bleeding from the urethra to the kidney. Common causes are stones, neoplasms, tuberculosis, and trauma. A cystoscopy evaluates the bladder and urethra. It does not evaluate the ureters or kidney. The way to do this is by retrograde pyelography or arteriography. These are things you may discuss with your urologist. Are there any other medical problems such as diabetes?

No, there are no other medical conditions - No diabetes. I did have pyelography already (I was injected with Iodine, then X-Rays were taken). This was also inconclusive.

Then the only additional study necessary is to have urine specimens collected for cytology to check for malignant cells. If that test is negative then nothing further needs to be done.

I know it is very frustrating to have blood in the urine and not know what is causing it. Remember that everyone passes some red blood cells in their urine. It is just a matter of how many are there. Occult (no visible blood) hematuria is quite common. Note in the abstract below, most asymptomatic microscopic hematuria in women is due to insignificant areas of bladder inflammation.

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Int Urogynecol J Pelvic Floor Dysfunct 1999;10(6):361-4
Asymptomatic microscopic hematuria in women: case series and brief review.
Singh GS, Rigsby DC
Department of Obstetrics and Gynecology, Hospital of the University of Pennsylvania, Philadelphia 19104, USA.

Recommendations for the work-up of asymptomatic microscopic hematuria (AMH) often derive from studies including both men and women. This study was undertaken to determine whether that work-up is appropriate for a female patient population. We studied 49 women referred to a urogynecologist for AMH. Patients underwent formal urinalysis, urine culture and cytology, cystoscopy, and either renal ultrasound or intravenous urography (IVU). Highly significant lesions diagnosed were one renal cell carcinoma and one acute tubular necrosis (ATN). Moderately significant lesions included one candidal urinary tract infection. Insignificant lesions included bladder inflammation in 46 patients and renal cysts in 5. Our findings confirm the importance of the work-up of AMH in women. Ultrasound was effective in diagnosing upper tract lesions, with less cost and morbidity than IVU. Larger studies are needed to determine who should be screened, whether the work-up should differ for younger women, possible treatments for benign findings, and appropriate follow-up.

What is the treatment for large kidney stones?

I have a kidney stone that I believe the nurse said is 10 cm. What kind of treatment do you think the doctor with use? Will he laser it or is it too large? What kind of recovery period is there?

The usual management of kidney stones has a medical and surgical approach. Once a stone is identified treatment consists of watchful management in stones less than 5 mm until you spontaneously pass the stone. Stones that are less than 2 cm but more than 5mm in diameter are best treated with shockwave lithotripsy alone. Stones more than 2 cm in size or those greater than 1cm and in the lower poles of the kidney may be treated with percutaneous nephrostolithotomy. This involves inserting a scope-like instrument into the kidney through a small incision in the back or side. This may be what your doctor will recommend.

After treatment, the prevention of future stones should be addressed and this often requires analyzing the stone itself and implementing proper treatment from there. Discuss with your doctor the options of treatment and how you can prevent stones in the future.