Urinary Tract Infections
Key Points
- UTI includes lower tract disease (cystitis, urethritis) and upper tract disease (pyelonephritis).
- Persons assigned female at birth have higher risk, and approximately 8% of pregnant patients experience UTIs.
- Urine culture is definitive; urinalysis with white blood cells and nitrites strongly supports diagnosis.
- Pregnancy requires early culture screening and targeted antibiotic treatment to reduce preterm birth and low-birth-weight risk.
Pathophysiology
UTIs occur when microorganisms, most commonly bacteria, colonize the urinary tract and trigger mucosal inflammation. Lower urinary infections involve the bladder or urethra, while upper urinary infection reflects ascending spread to the kidneys with systemic illness risk.
The source identifies Escherichia coli as the most common cause of cystitis and pyelonephritis. In pyelonephritis, bacterial ascent can progress from local inflammation to renal involvement, increasing risk for severe complications such as abscess formation or acute renal injury.
Classification
- Lower UTI: Cystitis: Bladder infection with dysuria, frequency, suprapubic pain, and possible hematuria.
- Lower UTI: Urethritis: Urethral inflammation, often related to sexually-transmitted-infections; may present with dysuria, discharge, or pruritus.
- Interstitial cystitis: Chronic bladder pain syndrome with no known cause and no curative therapy.
- Upper UTI: Pyelonephritis: Kidney infection with fever, flank pain, nausea, or vomiting; complicated disease includes pregnancy and immunocompromise.
Nursing Assessment
NCLEX Focus
Priority questions often test which findings require escalation to upper UTI concern, especially fever with flank pain.
- Assess dysuria, urinary frequency, urgency, suprapubic pain, and urine changes (cloudiness or foul odor).
- Screen for upper-tract cues including fever, costovertebral tenderness, nausea, and vomiting.
- Review risk factors: pregnancy, diabetes, urinary abnormalities, recent resistant cultures, and recent inpatient exposure.
- Obtain and interpret urinalysis findings (white blood cells, nitrites, possible hematuria/proteinuria).
- Ensure urine culture collection when indicated and monitor for recurrent symptoms after treatment.
Nursing Interventions
- Support prompt collection of clean-catch urine using contamination-reduction technique and immediate transport.
- Reinforce medication adherence to prescribed antimicrobial duration and monitor treatment response.
- Educate on recurrence prevention: hydration, voiding before/after intercourse, and front-to-back hygiene.
- In pregnancy, prioritize culture-based screening and treatment coordination per prenatal protocols.
- Escalate severe findings (fever, flank pain, persistent vomiting, or pregnancy with pyelonephritis) for higher-level care.
Pregnancy Risk
Untreated UTI during pregnancy can contribute to preterm delivery and low-birth-weight outcomes.
Pharmacology
| Drug Class | Examples | Key Nursing Considerations |
|---|---|---|
| antibiotics | Cephalexin, fosfomycin | Use targeted therapy when culture data are available. |
| nitrofurantoin | Nitrofurantoin monohydrate/macrocrystals 100 mg twice daily for 5 days | Do not use in the last 2-4 weeks of pregnancy per source warning. |
| urinary-analgesics | Phenazopyridine | Teach expected bright orange urine discoloration. |
Clinical Judgment Application
Clinical Scenario
A pregnant patient presents with dysuria and urinary frequency; urinalysis shows white blood cells and nitrites, and later reports fever with flank discomfort.
Recognize Cues: Lower UTI symptoms, positive urinalysis markers, progression to systemic signs. Analyze Cues: Clinical picture may be evolving from cystitis toward pyelonephritis. Prioritize Hypotheses: Highest priority is upper UTI in pregnancy with maternal-fetal risk. Generate Solutions: Obtain urine culture, start appropriate antimicrobial therapy, and escalate for possible inpatient management. Take Action: Coordinate urgent provider evaluation and monitor hydration, fever, and pain. Evaluate Outcomes: Symptoms improve, culture-directed therapy is completed, and no progression to severe renal complication occurs.
Related Concepts
- cystitis - Lower urinary tract bladder infection subtype.
- urethritis - Lower urinary tract urethral inflammation with infectious and noninfectious causes.
- pyelonephritis - Upper urinary tract infection with systemic risk.
- clean-catch-urine-collection - Correct specimen technique improves diagnostic accuracy.
- asymptomatic-bacteriuria - May not require treatment except in pregnancy per source guidance.
Self-Check
- Which symptom combination most strongly suggests progression from lower UTI to pyelonephritis?
- Why is urine culture prioritized early in pregnancy even without symptoms?
- Which medication teaching point for nitrofurantoin and phenazopyridine is most important for safety?