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Urinary Tract Infections and the Urostomist
So you suspect you may
have a urinary tract infection? There are a number of signs and
symptoms which will suggest this to you. Let’s look at those
first:
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Cloudy urine
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Thick and/or offensive smelling
urine
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Visible blood in the urine
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High fever (39 C or greater),
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Rigors (this is uncontrollably
shaking like shivering)
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Flank pain (pain in the back and
side around the kidney region which is often worse on one side)
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Nausea, vomiting, and diarrhoea.
Symptoms will develop
rapidly over a few hours or a day. Not all of the above may be
present, certainly not at first. The usual first sign is a change
in urine. If you notice this, should you ‘wait and see’ so that
you don’t bother your GP unnecessarily, or should you go to your
doctor straight away? The answer is very definitely the second
one - go to your doctor as soon as possible. There are a number
of reasons for this. The longer the time before effective
treatment begins, the worse the infection will get, with
increasing temperature until convulsions and/or unconsciousness
result. People die of this! The longer the delay, the longer
that treatment will take as the infection will have taken a firm
hold by then. In addition, leaving it to ‘wait and see’ may
result in your having to be admitted to hospital for intravenous
antibiotic treatment as an emergency.
The problem is that many
doctors may not understand that a urinary tract infection in a
urostomist is not the same as a urinary tract infection in a
normal person. Let me explain why. In a normal person with a
bladder, there are valves at the ends of the ureters (the tubes
from the kidneys to the bladder) where the ureters enter the
bladder. When our ureters were joined to the section of ileum or
small intestine used to make our ileal conduits or urostomies, we
lost these protective valves. The purpose of the valves is to
prevent the back flow of urine, and hence infection from the
bladder to the kidneys. Without these valves, any germs getting
into our urostomies will almost certainly end up in our kidneys.
Therefore, for the urostomist, a urinary tract infection is, in
fact, complicated (because we have an abnormal urinary
tract due to our urostomies) acute pyelonephritis - kidney
infection. Many doctors, especially hospital doctors in A&E (and
I speak from bitter personal experience!) do not realise this. If
treatment is delayed by more than 48 hours from the onset of
infection, permanent kidney damage may occur.
What should we expect
when we go to the doctor with these symptoms? The doctor should
collect (or arrange for his practice nurse to collect) a urine
sample. This can be tested on the spot using a test strip. This
can show up high levels of blood, protein and ketones, all of
which indicate a urinary infection. A sample should be sent away
for testing for antibiotic sensitivity - to see which antibiotic
will best treat the infection. The doctor may take your
temperature and will certainly prod and poke you in your flanks
around the kidney area to look for tenderness caused by the
infection. If your doctor tries to poke your abdomen where your
bladder used to be, gently remind him or her that they’re wasting
their time as you don’t have a bladder to be tender and inflamed
(It does happen! The doctor would normally poke the abdomen
first, then check the renal angles - the flanks - as virtually all
of his other patients have bladders to be infected.)
What treatment should
you be getting? There are recommended treatments set out in the
‘British National Formulary’ and in ‘Prodigy’ - Department of
Health produced guidelines for GPs. The recommended treatment is
as follows:
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An immediate injection of a broad
spectrum antibiotic such as cefuroxime or a quinolone (usually
ciprofloxacin) especially if the patient is severely ill;
gentamicin can also be used.
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A broad-spectrum cephalosporin
or a quinolone such as ciprofloxacin. A minimum of a 14 day
course of antibiotic should be given.
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Because a urostomist has
complicated acute pyelonephritis, the doctor’s guidelines actually
recommend that he should consider hospital admission. If this
takes place, then the hospital will often do a renal ultrasound to
check that no kidney damage has occurred and that the problem is
not due to kidney stones.
What you should not
be offered as an antibiotic is nitrofurantoin which does not
have any effect on a kidney infection or trimethoprim. These two
antibiotics are the ones recommended for what your GP will usually
see - a lower urinary tract infection which we can’t have as our
lower urinary tracts have been removed!
The most common bacteria
causing us to have infections are coliforms - bacteria from the
bowel. Of these, the most common is E Coli (about 80% of all
urinary tract infections) and other bacteria include Enterococcus
faecalis, Klebsiella and Proteus species, Unfortunately
trimethoprim is frequently not effective against
these coliforms which is why it should not be used for urostomists.
Our general
practitioners have a problem in that we are a very special group
requiring a treatment regime very different from the normal
patient presenting with a urinary tract infection. Because of
this, doctors sometimes don’t realise that we do need that
different treatment because our infection will always involve one
of both kidneys whereas the vast majority of his or her patients
will have a lower urinary tract infection of bladder and urethra.
It may help to point your GP in the direction of the British
National Formulary, section 5, Table 1, Urinary Tract Infections
and section 5.1.13, and suggest, politely (of course!) that the
section which applies to you is the one on acute pyelonephritis.
The vast majority of you
can stop here, but there remains the ‘awkward squad’, of which I’m
a fully paid up member. Why? Because some of us suffer from
short bowel syndrome. In my case this is because I have an
ileostomy (formed first) and a urostomy. In the process, rather
more small intestine than normal was removed, meaning that people
in the same situation suffering from short bowel syndrome cannot
absorb tablet antibiotics properly. If you know this to be the
case with you, gently suggest to your doctor that you are tried on
the ciprofloxacin suspension which is absorbed more easily. If
this fails, then, I’m afraid, it means definitely hospital
admission to receive your antibiotics by intravenous methods.
Terry Gallagher
Sources of information: the Electronic BNF at
British
National Formulary , the NHS
Direct on-line encyclopaedia and Prodigy at
Prodigy Guidance - Pyelonephritis - acute |
