Doctors are rethinking women’s urinary-tract infection care | Expert Opinion

Frequent urination. An uncomfortable burning sensation. A sudden urge to go to the bathroom. Our patient, a 55-year-old woman, was experiencing these symptoms every few weeks.

She also knew all too well the typical diagnosis: urinary tract infection. Every few weeks, after she developed painful, frequent urination, she rushed to urgent care where, after minimal testing, she was prescribed another antibiotic to address worries that the infection might spread to her kidneys.

Over time, the patient became resistant to at least three antibiotics. These medications also caused side effects, and she grew increasingly frustrated that her symptoms continued to recur. What surprised her most was a recent conversation with her primary care doctor, who explained that UTIs are rarely dangerous and often improve on their own with supportive care — and without antibiotics. The information helped her see a new path toward managing her symptoms while avoiding unnecessary treatments.

Here’s the problem: 50% of women will develop an uncomplicated urinary tract infection (UTI) in their lifetime. Each year, 10 million episodes are treated with antibiotics, but half of the time subsequent urine testing fails to confirm an infection. These 5 million cases treated with unnecessary antibiotic prescriptions a year can cause harm. Antibiotics kill both the “good” and the “bad” bacteria in our body, which makes women more prone to future UTIs and help bacteria to become resistant to antibiotics. This leads to more complicated infections, sickness, and hospitalizations, especially in older adults and underserved populations.

While they can be uncomfortable, UTIs rarely lead to serious consequences like kidney or blood infection. Most will actually get better on their own – antibiotics generally only decrease symptoms by one day. For many women, urinary discomfort can be treated without antibiotics and instead by taking pain relievers that are available over-the-counter or with a prescription. New research of the bladder microbiome – the bacteria that live normally in the bladder – shows that the best “probiotic” is “no antibiotic.”

That’s not to say that UTIs are never a problem, especially in older adults. But reality may not be as scary as the common misconception that, if left untreated, the mere presence of bacteria in the urine can lead to confusion and other mental changes in older adults. In fact, the American Geriatric Society recommends against using antibiotics to treat bacteria in the urine of older adults with confusion or mental changes. This is because antibiotic treatment in these situations can result in serious harm including delayed recovery, side effects of antibiotics , and C. difficile infections.

At Penn Medicine’s primary and specialty care practices, we are changing how we diagnose and treat urinary symptoms. When patients call or come to the office with urinary symptoms, we are encouraging nurses and doctors to use a symptom scorecard. Patients with mild, low-risk symptoms may not need urine testing and can be treated with pain medication alone. Those women with moderate to severe symptoms, or older adults with mental status changes, require urine specimen examination under a microscope (microscopic urinalysis) in the lab to look for white blood cells, a marker for inflammation. Common urine dipsticks and over-the-counter test kits are often inaccurate. Specimens that show inflammation will be sent for culture, and the results will guide treatment with antibiotics if needed. Three to five days of treatment will usually suffice.

If your care provider similarly recommends a new approach to diagnosing and treating UTIs, make sure to ask questions. Change takes a while to catch on, but our goal is always to help you feel better, with as few complications as possible, while preserving the power of antibiotics for when they are truly needed. No two patients, or practices, are the same, and a range of diagnostic approaches may be appropriate – so long as you feel like a partner in the process.

Jeffrey Millstein is an internist and regional medical director for Penn Primary and Specialty Care. Lily Arya is a professor, urogynecologist, and surgeon specializing in ob-gyn care at Penn Medicine.