“Bugs in the bladder” are not necessarily an infection

A new study from the University of Alberta shows that roughly half of older patients admitted to University Hospital with urinary tract infections (UTIs) have been misdiagnosed.

Dr. Bill Gibson is a geriatrics specialist and Assistant Professor in the Medicine and Dentistry faculty at U of A. He says doctors are relying on a test that detects bacteria in urine—but the presence of bacteria does not necessarily indicate an infection.

“In older adults, particularly older women, the urine isn’t always sterile,” he said. “If I went to West Edmonton Mall and grabbed every woman over the age of 65 and tested their urine, about one in five of them would have bacteria in it at any one time, just living there not causing any problems.”

The infection happens when those bacteria move from the urine into the bladder wall and cause inflammation in the bladder, Gibson says. “And that’s when you get the classic symptoms of urinary tract infection—things like burning when you pee, having to pee more frequently, new incontinence, and that kind of thing.”

Often older patients will have non-specific symptoms like generally not feeling well, perhaps feeling a bit more confused than usual, or even falling. A urine test may show bacteria, and from there a physician might conclude there is a UTI present.

“We then treat them with antibiotics, but we also treat them with a bag of fluids, and treatment to treat their constipation,” Gibson said. “And we adjust their medications and we do lots of other things as well—which is actually what makes things better.”

In other words, something in the whole battery of treatments is working; but it might not be the antibiotics, simply because there wasn’t an infection to begin with.

“It may be that these people are constipated, to use a classic example. They’re dehydrated, or maybe they’re taking medications that are making them feel unwell.

“We address all those things as well. But we also give them antibiotics and then you have sort of a positive-feedback loop for the for the physician, because you’re giving them antibiotics and they’ve got better—so it must have been a UTI,” he said. 

There’s another problem: sometimes a patient will have symptoms that are consistent with an infection, and the urine test shows “bugs in the bladder” as Gibson puts it. But the antibiotics don’t work.

 “After the menopause there are lots of changes that occur to the urethra, which is the pipe you pee through, and to the vulva and the vagina. These also cause discomfort, itching, burning, stinging when you pee, things like that,” he said. 

“Those are treated with estrogen cream, so local hormone replacement therapy, But again, you get these symptoms, you do a urine test, you find bugs in the bladder, then you get antibiotics. But the antibiotics don’t work. 

“That’s why it’s not working—not because the antibiotics are wrong, it’s because the diagnosis is wrong.”

Obviously it’s important to patients that they get the proper diagnosis so they can get the appropriate treatment. Gibson says misdiagnosis is also harmful to the healthcare system.

“We are spending a lot of money on these antibiotics and tests. I think we do something like 60,000 unnecessary urine tests a year at the University Hospital,” he said. At a dollar per test, these are not particularly expensive.  “But that’s still a healthcare aide’s salary for a year, isn’t it? These little bits of money here and there add up to large amounts of money. So we do need to stop and think and make sure we’re actually getting the right diagnosis.”

The other problem is the growing issue of bacteria evolving to be resistant to antibiotics. The more an antibiotic is used, the greater the probability that resistant bacteria strains will survive and reproduce.

“We are running out of antibiotics that work. One of the common antibiotics that we used to use for bladder infections, trimethoprim, is largely useless in parts of the world now because so many bacteria are completely resistant to it,” Gibson said.

Urinary tract problems are common, but treatable. According to Gibson about 10 per cent of the population over the age of 65 will experience incontinence, and in older people with dementia that rises to 30 or 40 per cent. “It’s an extremely, extremely common problem, but it is very treatable,” he said.

“The other thing it’s important to say is that although incontinence and bladder problems are extremely common, they are not a normal part of aging. If you are experiencing a change in your bladder or experiencing incontinence, go and have a chat with your family doctor—assuming  you have a family doctor—to say ‘these are symptoms that I am living with, what can we do about it?’

“There’s lots of exercises that we can ask people to do. There are various medications that we can use that can help incontinence, there’s pelvic floor exercises, all sorts of things we can do. It’s definitely not something that you need to live with.”

Gibson says it’s important for patients and their caregivers to know their symptoms, and for patients and doctors to keep an open mind. What is typically taken to be a UTI may not actually be one; and getting it right can make treatment and recovery easier.

“Be aware that there are lots of problems with the bladder which are not related to infection,” he said. 

But at the same time, be open and forthcoming.

“These are not normal parts of aging, and they are not inevitable. And they are often largely treatable. But if we don’t know about them, we can’t possibly make them better.”