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Urinary tract infections (UTIs) are common and generally mild. But, left untreated – especially in older people – they can lead to severe, and occasionally surprising symptoms. Fans of the US drama Succession will note that in the most recent episode, patriarch Logan Roy (played by Brian Cox) suffered temporary confusion as a result of neglecting to take his medication for a UTI, making critical errors in the midst of a crucial board meeting and prompting daughter Shiv to say his “urethra has wrested control from his brain.”
In real life, former US president Bill Clinton was last month admitted to hospital for complications reportedly relating to a UTI, but what does that mean for him and others like him?
Here, we explore everything you need to know about some of the unusual symptoms associated with UTIs.
What is a UTI and who is most at risk?
Mild UTIs are common – particularly among younger women – but in people over 60 they can become surprisingly severe, requiring in-patient treatment. Professor Roger Kirby is a retired prostate surgeon, co-founder of The Urology Foundation and president of the Royal Society of Medicine. “Most people are treated at home for UTIs, but Bill Clinton [likely had] a severe infection,” he says. “This requires higher doses of intravenous antibiotics, to guard against the advance to septicaemia – a serious and potentially fatal blood infection.”
A UTI can affect any part of the urinary system, including the kidneys, bladder, ureter (the duct which connects the kidney to the bladder) and the urethra (the pipe connecting the bladder to the outside of your body). The infection is caused by the bacteria E. coli. The typical symptoms are a burning feeling when urinating; a frequent or intense urge to wee (though not passing much urine when you go); cloudy, dark, bloody or strange-smelling urine; feeling tired; having a temperature. You should seek urgent medical help if you have a temperature over 39C, you are shaking or you feel generally very unwell as this can be a sign the infection has spread, for example, to the kidneys. “The faster we get antibiotics into you, the better,” says Kirby.
In younger age groups, they are more common in women. It is widely agreed that a woman’s lifetime risk of having a UTI is one in two – and many have repeat infections. “Cystitis is a common infection, mainly due to E. coli being spread by sexual activity and the fact that some women have a shorter urethra,” says Kirby. It can also be caused by women “wiping from back to front” when they go to the loo, which transfers bacteria from the colon to the urethra.
UTIs in younger men are unusual, except for rare cases of prostate enlargement or kidney stones. Sexually transmitted infections can have similar symptoms (pain on urination).
Why do they become more common with age?
The risk of contracting a UTI can be increased by hormonal changes and frailty, a weakened immune system or any condition that affects urine flow such as a stroke, kidney stones or spinal cord injury.
“Sixty per cent of males over 60 have a condition called benign prostatic hyperplasia or enlargement of the prostate gland,” says Kirby. “Ninety per cent of men over 90 have it. It’s almost ubiquitous if you live long enough.” The condition raises the risk of a urinary infection, as it does the infection prostatitis, kidney stones and prostate cancer, so it’s important to have these ruled out if you’re suffering from regular UTIs. In mature women, kidney stones and bladder cancer need to be discounted, especially if painful urination is accompanied by blood in the urine.
Patients who spend longer periods in hospital where they are catheterised are also at higher risk of infection. Older adults often limit their fluid intake due to mobility problems and avoiding needing to go to the toilet, or concerns over incontinence, and dehydration is another UTI risk factor.
In older people, the symptoms of a UTI can be quite different and easily misdiagnosed – including confusion: as evidenced by the Logan Roy character. “UTIs can cause sudden confusion in older people and people with dementia,” says a spokesperson for the Alzheimer’s Society. “If your relative has a sudden and unexplained change in their behaviour, such as increased confusion, agitation or withdrawal, this may be because of a UTI.”
However, confusion alone is not a sign of a UTI. Two of the following need also be present: fever, an increase of urinary frequency and urgency, sudden pain with urination, or tenderness in the lower abdomen.
How should you treat and prevent them?
Mild UTIs often pass on their own – aided by the patient drinking lots of fluids. “We’ve only had antibiotics since the 1920s and the body will eventually have a natural resistance,” says Kirby. Many patients swear by cranberry juice, he says. “There haven’t been any clinical trials on cranberry juice as treatment for a UTI and there is no firm evidence. But it can’t do you any harm.”
For more troublesome cases, a call or trip to the GP is probably a good idea. “Your doctor will take a urine sample, which will get sent off to the lab for analysis,” says Kirby. “In 24 to 48 hours, you’ll receive a report on whether E. coli is present. However, a GP will normally start oral antibiotics immediately: normally ampicillin, amoxycillin or ciprofloxacin.”
It’s important to finish the course, because of the rise of increasing antibiotic resistance in many infections, including the urinary variety.
Experts believe that a fifth of women suffer from chronic UTI infections. People who suffer repeated UTIs – more than three a year – might be sent for an ultrasound, CT scan or MRI to investigate further. A doctor will consider a low-dose antibiotic over a longer period, or antibiotics for one or two days after symptoms appear.
If you are experiencing serious symptoms as detailed above, call 999. You may need admission to hospital and intravenous antibiotics.
To avoid UTIs, the advice is to drink lots of fluids, especially water, practise good personal hygiene and wipe from “front to back” if you are a woman, empty your bladder immediately after sex to help flush out bacteria, and avoid potentially irritating feminine products such as deodorant sprays.