Studies on urinary tract infections (UTIs) indicate that they are common in low and middle-income countries where health research is still emerging. Dr Corneille Killy Ntihabose, Director General of Byumba Hospital, says UTI is an infectious inflammation of the bladder and other organs of the urinary tract, such as kidneys, ureters, and urethra. When it affects the lower urinary tract, he says it’s known as a bladder infection (cystitis), whereas when it affects the upper urinary tract it is known as kidney infection (pyelonephritis). The medic notes that in general, there are three main mechanisms responsible for UTIs, they include; colonisation with ascending spread, hematogenous spread and peri-urogenital spread (affecting the urinary tract and reproductive organs). Prof Claude Bayingana, Associate Professor of Medical Microbiology, University of Rwanda, School of Medicine and Pharmacy, says symptoms from a lower urinary tract infection include pain with urination, frequent urination, and feeling the need to urinate despite having an empty bladder. Symptoms of a kidney infection, he says, include fever and flank pain usually in addition to the symptoms of a lower UTI, and that rarely, the urine may appear bloody. Globally, 8.3 million office visits and more than one million hospitalisations for an overall annual cost of $1 billion occurs for UTIs. An estimated 50 per cent of women report having had a UTI at some point in their lives. Studies have shown that one in five adult women experience a UTI at some point, confirming that it is an exceedingly common worldwide problem. Uncomplicated UTIs are much more common in women than men when matched for age. The incidence of UTI in women tends to rise with increasing age. He says that rates of infection are high in postmenopausal women because of bladder or uterine prolapse. This, Bayingana says, causes incomplete bladder emptying, loss of estrogen with changes in vaginal flora, which allows periurethral colonisation with gram-negative aerobes, such as E coli; and higher likelihood of concomitant medical illness, such as diabetes. RISK FACTORS Ntihabose says the most important risk factor for bacteria is the presence of a catheter. He, however, notes that 80 per cent of nosocomial (acquired at hospital setting) UTIs are related to urethral catheterisation. While five to ten per cent are related to genitourinary manipulation. He explains that catheters inoculate organisms into the bladder and promote colonisation by providing a surface for bacterial adhesion, causing mucosal irritation. Another risk factor, the medic says, is sexual intercourse. He notes that it contributes to increased risk, as do use of a diaphragm and/or spermicide. Besides, he adds that routine pelvic examinations are also associated with an increased risk of a UTI for seven weeks post-procedure. Women who are elderly, pregnant, or have preexisting urinary tract structural abnormalities or obstruction also carry a higher risk of UTI, Ntihabose says. For pregnant women, he explains that urinary tract infections are more concerning in pregnancy due to the increased risk of kidney infections. During pregnancy, he says high progesterone levels elevate the risk of decreased muscle tone of the ureters and bladder, which leads to a greater likelihood of reflux, where urine flows back up the ureters and towards the kidneys. Dr Janvier Rusizana, a general practitioner at La Nouvelle Clinique in Remera, Kigali, says while pregnant women do not have an increased risk of asymptomatic bacteriuria, if bacteriuria (bacteria in urine) is present they do have a 25 to 40 per cent risk of a kidney infection. Thus, if urine testing shows signs of an infection, even in the absence of symptoms, treatment is recommended, he says. He goes on to add that a kidney infection during pregnancy may result in premature birth or preeclampsia (a state of high blood pressure and kidney dysfunction during pregnancy that can lead to seizures). “Some women have UTIs that keep coming back in pregnancy and currently, there is not enough research on how to best treat these infections,” he says. Bayingana says kidney infection is also another risk factor for UTI. He says that if this occurs, it usually follows a bladder infection but may also result from a blood-borne infection. Diabetes, obesity, and family history are also some of the risk factors that can expose someone to develop UTI, according to Rusizana. In young children, Ntihabose says the only symptom of a urinary tract infection (UTI) may be a fever. He explains that this is so because of the lack of more obvious symptoms, when females under the age of two or uncircumcised males less than a year exhibit a fever, a culture of the urine is recommended by many medical associations. Meanwhile, he says that infants may feed poorly, vomit, sleep more, or show signs of jaundice. In older children, he says new-onset urinary incontinence (loss of bladder control) may occur. HOW TO GO ABOUT IT Prosper Dusengeyezu, a public health officer at Rwanda Pharmaceutical Students’ Association (RPSA), says diagnosis in young healthy women can be based on symptoms alone. In those with vague symptoms, he says diagnosis can be difficult because bacteria may be present without there being an infection. Whereas, he says that in complicated cases or if treatment fails, a urine culture may be useful. He adds that in uncomplicated cases, UTIs are treated with a short course of antibiotics such as nitrofurantoin or trimethoprim/sulfamethoxazole. Dusengeyezu says resistance to many of the antibiotics used to treat this condition is increasing. And that in complicated cases, a longer course or intravenous antibiotics may be needed. However, he notes that if symptoms do not improve in two or three days, further diagnostic testing maybe needed. MEASURES IN PLACE The Ministry of Health has decentralised health services by building health posts in each village. This, according to Ntihabose, will help the population to consult as early as possible and avoid complications. There is also health education to scale up preventive strategies, increase antenatal care coverage to screen for asymptomatic UTI for pregnant women. This, he says, is mainly to avoid any eventual complications, like preterm labour and sepsis.
