LOWER URINARY TRACT INFECTIONS IN WOMEN
Aspects of pathogenesis and diagnosis.

By Anders Baerheim

This dissertion had a triple aim: a) to evaluate some folkloristic notions on causes for acute cystitis in women, b) to assess the efficacy of the clean-catch midstream voiding technique in women, and c) to compare ideal procedures for urine sampling, handling and analysis with the practical procedures usually adopted in general practice.

a) Voluntary postphoned voiding, and having been cold on hands, posteriors or feet seemed in a case-control study to precede the onset of symptomatic cystitis in women. The effect of being cold on the feet were assessed experimentally. 29 cystitis-prone females had their feet and lower legs cooled down to 12 C during 20-30 minutes. Six subjects developed typical lower urinary symptoms 55 (±9%) hours after the intervention. Five of these had a bacteriologically verified cystitis.

b) 150 females bringing a urine sample to the surgery, were asked about sampling technique. Only those holding labia apart during voiding showed a significant reduction in the contamination of the urine sample, but only 13% reported having done so. Then, in an experimental design, 110 female students studying nursing and medical laboratory technology were instructed to produce morning urine samples, using steps, and combination of steps, of the clean-catch midstream technique. Compared to use no sampling technique at all, we noted a 63% increase in sterile samples, and a 58% reduction in samples containing >105 cfu/ml when the women held labia apart while voiding. Midstream technique added little to this, while cleansing gave results no different from using no technique at all.

c) We compared uninstructed urine samples brought to the surgery by 150 female patients with samples from the same patients taken at the surgery after thorough instruction in the clean-cetch midstream technique. The two sets correlated well for the diagnosis of leucocyturia (K=0.80, but less well for the diagnosis of bacteriuria (K=0.52).

Lastly, leucocyturia was assessed by three observers in 56 blinded urine samples, using a hemocytometer and high-power-field microscopy of urine sediment. The two methods yelded corresponding diagnostic results (R=0.91), and the interobserver reliability was high (K=0.92 vs. K=0.81-91). The diagnostic limit of 8 leucocytes/mm3 corresponded to 2 leucocytes/high-power-field.

We conducted an open, non-randomized study as the first step to find out whether cooling of the feet may cause symptomatic lower urinary tract infection (UTI) in cystitis-prone women. Twenty-nine healthy women, aged 19-68 (mean 42.5) years, who had had three or more symptomatic episodes of UTI last 12 months were included. They registered symptoms and carried out a strip urinalysis at each urination during a control period of 72 hours. Their legs were then immersed in increasingly cold water for 30 minutes. Another 72 hour period of registration followed. Six subjects developed acute lower urinary symptoms at a mean of 55 (05% confidence interval 50 to 61) hours after the cooling, compared to none in the control period. Five of the six had bacteriologically verified lower UTI (P=0.03 v. the control period). Cooling of the feet seems to provoke symptomatic lower UTI in cystitis-prone women. .

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Department of Public Health and Primary Health Care, last updated 16.10.96