Treatments — Urinary Tract
Urinary Tract Infections — From Cystitis to Urosepsis
Urinary tract infections range from uncomplicated cystitis to life-threatening urosepsis. Mr. Jesuraj provides specialist assessment, immediate treatment, and thorough investigation to identify and address the underlying cause — not just repeated courses of antibiotics.
If you have fever, loin pain, rigors or feel acutely unwell with urinary symptoms — attend A&E immediately. This may be pyelonephritis or urosepsis requiring urgent hospital treatment.
The UTI Spectrum — From Mild to Critical
Bladder infection — burning, frequency, urgency. Usually uncomplicated in young women.
Urethral inflammation — often STI-related in younger patients. Needs specific investigation.
Kidney infection — fever, loin pain, systemic illness. Needs urgent treatment.
Life-threatening systemic infection from urological source. Medical emergency — A&E.
Introduction
Understanding Urinary Tract Infections
Urinary tract infections (UTIs) are among the most common bacterial infections in humans — affecting millions of people in the UK each year. They occur when bacteria enter the urinary tract and multiply, causing inflammation and infection anywhere from the urethra to the kidneys.
While a single uncomplicated UTI in a young woman is straightforward to treat, recurrent UTIs, UTIs in men, UTIs in older women, or UTIs with fever require specialist investigation. Simply prescribing repeated courses of antibiotics without investigation risks missing a treatable underlying cause — and contributes significantly to antibiotic resistance.
Mr. Jesuraj’s approach is to treat the infection promptly and then investigate systematically — finding and addressing whatever is predisposing to infection, whether that is an anatomical abnormality, kidney stone, hormonal deficiency, or functional problem.
When to See a Specialist
- Two or more UTIs in six months
- Any UTI in a man — always warrants investigation
- UTI with fever, loin pain or rigors
- UTI not responding to standard antibiotics
- Blood in urine associated with infection
- UTI in a patient with known kidney stones
- Recurrent infections in postmenopausal women
- UTI in a patient with diabetes or immunosuppression
- UTI in a patient with structural urological abnormality
- Catheter-associated recurrent infections
Types of Infection
Lower & Upper Urinary Tract Infections
The urinary tract is divided into lower (bladder, urethra) and upper (ureters, kidneys). Infection at different levels has different presentations, severity and management.
Cystitis — Bladder Infection
Lower UTICystitis is inflammation of the bladder lining, almost always caused by bacterial infection — most commonly E. coli ascending from the perineum. It is the most common form of UTI, particularly in women. In young healthy women, a single episode is often uncomplicated and can be managed with a short antibiotic course. However, recurrent cystitis always warrants investigation.
Symptoms
- Burning or stinging when urinating (dysuria)
- Frequent, urgent need to urinate
- Passing small volumes frequently
- Suprapubic discomfort or pressure
- Cloudy, offensive-smelling urine
- Blood in urine (haematuria) — always investigate
- No fever — fever indicates upper tract involvement
Urethritis — Urethral Infection
Lower UTIUrethritis is inflammation of the urethra — the tube carrying urine from the bladder. In younger sexually active adults, it is often caused by sexually transmitted infections (STIs), particularly Chlamydia trachomatis (non-gonococcal urethritis) or Neisseria gonorrhoeae (gonococcal urethritis). It can also follow instrumentation or urethral stricture.
Symptoms
- Urethral discharge — clear, white or green
- Burning on urination
- Urethral discomfort between voiding
- In men — tip of penis tenderness
- May be asymptomatic (especially Chlamydia)
- MSU often shows white cells but negative culture
Pyelonephritis — Kidney Infection
Upper UTI — UrgentPyelonephritis is a serious bacterial infection of the kidney — caused by bacteria ascending from the bladder, or less commonly via the bloodstream. It requires prompt treatment with appropriate antibiotics and may require hospital admission. If obstruction is present (e.g. by a kidney stone), drainage is a medical emergency.
Symptoms — distinguishing features
- Loin or flank pain — often severe, unilateral
- High fever and rigors (shaking)
- Nausea and vomiting
- Systemically unwell — not just urinary symptoms
- Tenderness over the kidney (renal angle)
- Often preceded by cystitis symptoms
- Positive urine culture — usually E. coli
Urosepsis — Life-Threatening Emergency
🚨 A&E ImmediatelyUrosepsis is sepsis originating from a urological source — most commonly an obstructed, infected kidney (pyonephrosis) or complicated pyelonephritis. It is a medical emergency with significant mortality risk. The combination of urinary tract infection with systemic signs of sepsis requires immediate A&E attendance and urgent urological intervention to drain the obstruction.
🚨 Sepsis Warning Signs — Call 999
Important Cause
Staghorn Kidney Stones — A Major Cause of Recurrent Infection & Urosepsis
Staghorn calculi are large kidney stones that fill the renal collecting system, taking on the branching shape of a stag’s antlers. They are almost always composed of struvite (magnesium ammonium phosphate) — formed by urease-producing bacteria such as Proteus mirabilis. This means the stone is itself a reservoir of infection — you cannot eradicate the infection without removing the stone.
Staghorn stones are among the most important structural causes of recurrent UTI, pyelonephritis and urosepsis. They can grow silently for years, causing progressive and irreversible renal damage, before presenting as a serious infection episode. This is why investigation of recurrent UTIs must always include imaging of the upper urinary tract.
Struvite staghorn stones harbour bacteria within their crystalline matrix. Antibiotics alone cannot eradicate the infection — stone removal is required for cure.
Staghorn stones can grow for years with minimal symptoms, causing progressive renal cortical loss. By the time infection occurs, significant irreversible kidney damage may already have occurred.
When a stone fragment obstructs the ureter in the context of an infected upper urinary tract, the result is pyonephrosis — a urological emergency requiring urgent drainage.
Percutaneous nephrolithotomy (PCNL) is the standard treatment for staghorn stones — a minimally invasive surgical procedure accessing the kidney through a small flank incision under image guidance. Mr. Jesuraj will arrange specialist referral for PCNL where indicated.
Men
Underlying Causes in Men
UTIs are uncommon in young men and should always prompt urological investigation — there is almost always an underlying anatomical or functional cause.
Prostatic enlargement causes incomplete bladder emptying — residual urine is a reservoir for bacterial growth. BPH is the single most common structural cause of recurrent UTI in older men. Treatment of BPH resolves the predisposing factor.
Scarring of the urethra from previous infection (especially gonorrhoea), catheterisation, or trauma causes obstruction, poor flow, and elevated post-void residual — predisposing to recurrent infection. Cystoscopy and urethroplasty may be required.
Chronic bacterial prostatitis is a reservoir for organisms that can seed repeated bladder infections. Characterised by recurrent UTIs with the same organism, perineal pain, and may require prolonged antibiotic courses to eradicate.
Stones — particularly struvite staghorn calculi — act as a reservoir for infection and prevent eradication with antibiotics alone. CT KUB identifies all stone burden. Stone removal is required for cure.
Diabetes impairs immune function and promotes bacterial growth in glucose-rich urine. Recurrent UTIs in diabetic men may be complicated by emphysematous cystitis or pyelonephritis — serious complications requiring specialist management.
Neurological conditions causing incomplete bladder emptying — spinal cord injury, MS, Parkinson’s disease — create persistent residual urine predisposing to infection. Management focuses on improving bladder emptying, often with clean intermittent self-catheterisation.
Congenital abnormalities including vesicoureteric reflux, duplex kidney, or pelviureteric junction obstruction may not present until adult life. CT urogram and specialist assessment identify these.
Long-term urethral or suprapubic catheters are invariably colonised within weeks — catheter-associated UTI (CAUTI) is a specific clinical challenge. Management focuses on catheter care, appropriate antibiotic use, and catheter changes.
Women
Underlying Causes in Women
Women are anatomically more susceptible to UTIs — but recurrent infections are not inevitable and have identifiable, treatable causes.
Women have a shorter urethra (3–4cm vs 20cm in men), which is in close proximity to the vaginal and rectal introitus — facilitating bacterial ascent. This is why UTIs are 30 times more common in women than men. However, anatomy alone does not explain recurrence.
This is one of the most commonly overlooked and undertreated causes of recurrent UTI in women. After the menopause, falling oestrogen levels cause significant changes to the urogenital tissues — the vaginal and urethral epithelium thin (atrophy), vaginal pH rises, and the protective Lactobacillus flora is lost. This creates conditions strongly favouring E. coli colonisation and ascent.
Postmenopausal women with recurrent UTIs should be assessed for genitourinary syndrome of menopause (GSM) — and treated accordingly. Topical (vaginal) oestrogen is highly effective, reduces recurrence by up to 50%, and is safe for long-term use because systemic absorption is minimal.
Topical Oestrogen — What to Know
As in men, stones act as an infection reservoir. Struvite staghorn calculi in women often present as recurrent infections rather than pain. Upper tract imaging is essential in all women with recurrent complicated UTI.
Retrograde flow of urine from the bladder into the ureter and kidney predisposes to pyelonephritis. May be detected on cystoscopy or MCUG. Mild reflux can be managed conservatively; severe reflux may require surgical correction.
Incomplete bladder emptying in women — due to pelvic floor dysfunction, bladder neck obstruction, or previous pelvic surgery — creates residual urine predisposing to infection. Urodynamic assessment and post-void residual measurement are key investigations.
Diabetes impairs immune defences and elevates urinary glucose — an ideal bacterial growth medium. Immunosuppressive medications (e.g. post-transplant, steroid therapy) similarly impair bacterial clearance and promote recurrence.
“Honeymoon cystitis” — UTI following sexual intercourse — is common in young women. Voiding immediately after intercourse and prophylactic antibiotics (post-coital single dose) are effective preventive strategies.
Bladder prolapse (cystocele) causes incomplete emptying and creates a urinary reservoir promoting infection. Persistent residual urine associated with prolapse should be identified and addressed — sometimes surgical correction of the prolapse resolves the recurrent UTIs.
Diagnosis
Investigating Recurrent or Complicated UTIs
A structured investigation pathway — identifying the underlying cause so that treatment addresses the root problem, not just the current episode.
Urine Tests
Dipstick urinalysis — immediate assessment for leucocytes, nitrites, blood, protein and glucose. Midstream urine (MSU) culture and sensitivity — identifies the causative organism and the antibiotics to which it is sensitive. Essential before antibiotic prescribing in recurrent or complicated UTI.
Blood Tests
Full blood count, CRP, renal function (U&E, creatinine), glucose (HbA1c), PSA in men. Blood cultures if fever is present or urosepsis is suspected — identifying the bacteraemia organism guides definitive antibiotic therapy.
Bladder Scan — Post-Void Residual
A quick, non-invasive ultrasound scan immediately after urination to measure residual urine volume. Significant residual urine (typically over 100ml) indicates incomplete emptying — a major predisposing factor for recurrent infection that must be addressed.
Upper Tract Imaging
Renal ultrasound — assesses kidney size, hydronephrosis, large stones, and bladder wall changes. CT KUB (non-contrast CT of kidneys, ureter and bladder) — the gold standard for stone detection, identifying all stones regardless of composition. CT urogram (contrast-enhanced) — for haematuria investigation, structural abnormalities, and upper tract assessment.
Flexible Cystoscopy
Direct visual inspection of the bladder and urethra — identifying bladder tumour (important to exclude if haematuria is present), bladder stones, bladder wall trabeculation (sign of chronic outflow obstruction), urethral abnormalities, or ureteric orifice pathology. Performed under local anaesthetic in clinic.
Urodynamic Studies
Where voiding dysfunction is suspected as the underlying cause — particularly in women with recurrent UTI and suspected incomplete emptying, or neurological conditions — urodynamic pressure-flow studies define the specific functional problem and guide targeted management.
Treatment
Treatment — Immediate & Long-Term
Immediate treatment of the infection, followed by targeted management of the underlying cause.
Antibiotic Therapy
Culture-guided antibiotic therapy is the cornerstone of UTI management. Empirical antibiotics (trimethoprim, nitrofurantoin, cefalexin) are used initially; therapy is refined once culture and sensitivity results are available. Duration varies by infection severity — 3 days for uncomplicated cystitis to 14 days or more for pyelonephritis.
Culture-guided wherever possibleProphylactic Antibiotics
For women with frequent recurrent UTIs without an identifiable correctable cause — low-dose nightly prophylaxis (nitrofurantoin, trimethoprim) or post-coital single-dose prophylaxis significantly reduces recurrence frequency. This is a short-to-medium term strategy while other preventive measures are established.
Recurrent uncomplicated UTITopical Vaginal Oestrogen
For postmenopausal women with recurrent UTIs — vaginal oestrogen (cream, pessary or ring) restores urogenital epithelial health, re-establishes protective Lactobacillus flora, and reduces UTI recurrence by up to 50%. Highly effective, safe long-term, and fundamentally addresses the hormonal root cause rather than just treating each episode with antibiotics.
★ Highly effective — postmenopausal womenStone Removal
Where stones are the predisposing cause — particularly struvite staghorn calculi — stone removal is required for cure. Antibiotics alone cannot eradicate infection in the presence of stone. PCNL (percutaneous nephrolithotomy), ureteroscopy, or ESWL depending on stone size and location. Mr. Jesuraj will arrange specialist referral for stone surgery where indicated.
Essential where stone is the causeTreatment of Structural Causes
BPH causing outflow obstruction and residual urine — Aquablation, Rezūm, or medical therapy. Urethral stricture — dilatation, urethrotomy or urethroplasty. Bladder prolapse — surgical repair. Vesicoureteric reflux — conservative or surgical correction depending on grade.
Targeted to the cause foundBladder Management
Where voiding dysfunction or neurogenic bladder is causing incomplete emptying — clean intermittent self-catheterisation (CISC) to ensure complete bladder emptying, reducing the bacterial reservoir. Indwelling catheter management and regular changes where long-term catheterisation is required.
Voiding dysfunction and neurogenic bladderPrevention
General Preventive Measures
Aim for 1.5–2 litres of water daily. Good hydration dilutes urine and promotes regular bladder emptying, reducing bacterial concentration.
Urinating promptly after sexual intercourse flushes bacteria that may have entered the urethra — a simple and effective preventive measure for women prone to post-coital UTI.
A naturally occurring sugar that inhibits E. coli adhesion to the bladder wall. Evidence supports its use as a non-antibiotic preventive strategy — available over the counter as a daily supplement.
Cranberry proanthocyanidins reduce E. coli adhesion. Evidence is modest but consistent for a modest reduction in recurrence — useful as an adjunct, not a replacement for medical evaluation.
Perfumed soaps, bubble baths, vaginal deodorants, and spermicides alter the periurethral microbiome and increase UTI susceptibility. Gentle, unperfumed cleansing is recommended.
As detailed above — the single most effective preventive intervention for postmenopausal women with recurrent UTIs and evidence of genitourinary atrophy.
Don’t Just Treat the Infection — Find the Cause
Appointments at Best Life Clinic, Stockton-on-Tees — Monday, Thursday and Friday. Most patients seen within 7 days. No GP referral required.