In general, I’m not one to treat patients over the phone for gynecologic conditions. There’s nothing like taking a careful history and laying eyes (and hands) on a patient when it comes to making the right diagnosis. So in general, if you call me with a complaint, I’m going to get you in to see me.
Except if it’s a urinary tract infection (UTI).
Research has shown that most run-of-the–mill cases of bladder infection (also known as cystitis) in otherwise healthy women can be quickly and accurately diagnosed and treated over the phone. The advantage to such rapid treatment is prevention of more serious infection of the upper urinary tract and kidney that can occur if treatment is delayed. Not to mention quick relief of the incredibly uncomfortable symptoms of frequent, painful urination.
Not all practices offer phone treatment of UTI’s, preferring to bring the patient in to confirm the diagnosis before treating with antibiotics. There’s nothing wrong with this approach, and many of my patients do prefer to come in and confirm the diagnosis before taking antibiotics that could have potential side effects. But in most cases, two simple questions – that can be asked over the phone – can provide the info needed for an accurate diagnosis.
The Two Most Important Questions in Determining a UTI
- Are you urinating more often than normal? A real tip off is that the amounts you are urinating are small, and as soon as you’ve finished, you feel like you need to urinate again (we call that urgency), despite your now empty bladder.
- Does it hurt when you urinate? Some typical descriptions of the pain: a drawing sensation of the urethra, or at its worst, a feeling like you are peeing cut glass. It’s also not uncommon to have midline pain just above the pubic bone (that’s where your full bladder sits), but it’s usually mild and occurs after urination but not all the time.
A “Yes” answer to these two questions will accurately diagnose 80% of uncomplicated UTI’s. They work so well as a diagnostic tool that urinalysis and culture actually can muddy the picture rather than clarifying the diagnosis in some cases.
I find two more questions useful in supporting the presumed diagnosis of UTI.
- Have you had sex recently? Another tip off that it’s a UTI is that the symptoms started a few hours to a day after having sex for the first time in awhile. Which explains the fact that Sunday morning is one of my high volume UTI call times. In the old days we called it “honeymoon cystitis”. Now it’s something we sometimes see in women with long distance relationships or post menopausal women reinitiating sex after a long hiatus. And mom, if your teenage daughter gets a UTI, she may be doing something more than just wiping in the wrong direction.
- Is there a urinary odor? For some women, a bad urinary odor is their early warning sign, presenting a day or more before frequency and painful urination develop. Urinary odor can be misleading however, as vaginal infections may present as well with odor, so it’s not the most specific of symptoms.
Red Flags (Literally)
These symptoms are worth mentioning if your clinician doesn’t ask about them, as they can sometimes indicate more serious infection or other conditions.
- Is your urine pink or red? That can mean blood in the urine, (hematuria), and will often cinch the diagnosis, as it is extremely common finding in UTI’s. But hematuria can also be cause by other things, including bladder cancer, a post coital laceration or vaginal bleeding. So I’ll likely ask you to come in if you notice blood in the urine.
- Any fever or back pain? Mention a fever or back pain, and I may bring you in to rule out a kidney infection and get a culture so I can get you on the right antibiotic for the bug you’ve got. Not to mention I want to lay eyes on you to be sure you don’t need to be admitted to the hospital for IV antibiotics.
- Bad Abdominal Pain? Just get on in now.
- Late period? Ditto. In you come.
Conditions that can masquerade as a UTI
I find extremely helpful to keep these conditions in mind when getting phone calls from patients who think they have a UTI.
- Vaginal or vulvar pain, vaginal discharge or itching. UTI’s usually don’t cause discharge, vaginal itching or vulvar pain. So if you’ve got painful urination but no urinary frequency or urgency, I’m going to bring you in. Ditto if you have vaginitis symptoms. You would not be the first patient to misdiagnose a bad yeast infection or primary herpes outbreak as a UTI.
- Pregnancy. One if the early signs of pregnancy is urinary frequency. So if your period is late, and you find yourself in the bathroom more than normal, think pregnancy before UTI.
- Post menopausal bladder. Urinary frequency and urgency are extremely common symptom in post menopausal women with vaginal atrophy. Sometimes these women will also have some burning with urination, as the acidic urine hits the thinned out irritated vulva. SO if you’re older, I’m more likely to ask you to come on in. I don’t want to give you antibiotics when what you need is a little vaginal estrogen. On the other hand, post menopausal women are more prone to UTI’s, so it’s a fine dance we do here.
- Ovarian cancer. I hate to raise the flag on this zebra, but it must be done. One of the early signs of ovarian cancer can be urinary frequency. So if your urinary symptoms are accompanied by abdominal pain, bloating and you have little to no pain with urination, get on in to see me rather than asking for antibiotics over the phone.
- Bladder tumors. Benign and cancerous bladder tumors can cause recurrent bouts of what look like UTI’s, but are not. Typically, these present with frequency and blood in the urine, but not so much painful urination. So if you’re having recurrent symptoms after treatment, get in for a culture to confirm or rule out the diagnosis of urinary tract infection. And if you have blood in your urine, I’m likely to ask you to come in for a culture.
- STI’s. Gonorrhea, chlamydia and trichomonas can cause urethritis, an inflammation of the urethra more common in men, but not entirely unknown in women. If you’ve got a vaginal discharge, a new partner and especially if you’ve had unprotected sex, get in for screening.
When a phone call isn’t good enough
- If you’ve never had a UTI before, and it’s not a night or weekend, it’s not a bad idea to come in and get a culture to confirm your suspicions. I’ve had patients who’ve been self-diagnosing and phone treating for years, only to find that what they think are UTI’s are really a recurrent herpes outbreaks.
- If you have recurrent UTI’s, get in for a confirmatory culture and exam next time you think it’s a bladder infection. It could be we’ve given you the wrong antibiotic the last time. Let us get a culture to be sure we give you the right drug for your bug.
- You get UTI’s every time you have sex. It could be that you also need to be taking an antibiotic after you have sex to prevent post-coital infections. Or that you have a vaginal bacterial overgrowth that is seeding the bladder with bacteria. Come on in to find out.
- You’re not sure what is going on. That’s what I’m here for. Come on in, let’s figure it out together.