Generalized Symptoms In Adult Women With Acute Uncomplicated Lower Urinary Tract Infection: An Observational Study

Anders Baerheim, MD, PhD, Asbjørn Digranes, MD, Roland Jureen, MD, Kirsti Malterud, MD, PhD

Disclosures
In This Article

Discussion

Generalized symptoms of feeling out of sorts, especially feeling unwell, weak and tired, or irritable and restless were reported by a majority of the women with acute uncomplicated lower UTI, irrespective age or presence of bacteriuria. Acute dysuria and urinary frequency are the cardinal symptoms for acute uncomplicated lower UTI, but these symptoms cannot be evaluated in the present material as they constituted the criteria for inclusion.

The typical woman with acute, uncomplicated lower UTI presents with symptoms of a distressed bladder and feeling out of sorts.*

The validity of the symptom scores in the questionnaire depends on whether the women recognize the text of the question as valid for how she actually is feeling. We based the questions on the findings from a qualitative study of symptom descriptions by cystitis-prone women, carefully choosing the same way of phrasing in our questionnaire as patients in our former study phrased their symptoms.[7] This procedure supports the internal and conceptual validity of our results. The high scores on the inclusion symptoms as dysuria and/or urinary frequency are parallel to what is found in other materials.[9,10]

Readdressing the material independently by factor analysis, we identified 2 components parallel to the categories of symptoms we had found earlier.[7] We also specifically analyzed symptom score in our material for bacteriuric acute uncomplicated lower UTI, finding that symptoms were equally frequent whether the patient had bacteriuria or not. This further strengthens the internal validity of our results. Patients were recruited consecutively. Our material should therefore be fairly representative for adult women consulting for acute, uncomplicated lower UTI in general practice.

May we then be certain that the generalized symptoms in our material stem from a lower UTI? The vast majority of adult women consulting for UTI in general practice/family medicine have an acute, uncomplicated UTI.[2] We recruited patients consecutively, and excluded from our material any patient that might be suspected to have any factors indicating a complicated UTI or an upper UTI. Our results should therefore be representative for adult women consulting for UTI in general practice.

The combination of generalized symptoms in our material as feeling unwell, weak and tired, or irritable and restless is not identical to the malaise of upper UTI. Rather, the generalized symptoms of feeling out of sorts seem to be typical for acute uncomplicated lower UTI.

While the voiding related and local constant symptoms easily may be regarded as a consequence of the infected urinary bladder, it seems less easy to imagine how the infected bladder may cause the generalized symptoms. Further research in this area may increase our understanding of the pathogenesis and pathology in acute uncomplicated lower UTI.

Each of the symptoms in our questionnaire was scored equally often and to the same degree whether the patient had bacteriuria or not. We have previously shown that time from started antimicrobial treatment to symptom relief were the same for each symptom registered, irrespective of whether the patient showed bacteriuria or not.[11] When the presence of bacteriuria has no impact on neither presenting symptoms nor treatment results, detection of bacteriuria will be of limited impact both in the definition and management of acute uncomplicated lower UTI.

Suprapubic discomfort and low back pain figure in the literature as typical symptoms of lower UTI. The patients in our previous qualitative study used the term pressure, not discomfort.[7] Constant pressure in the genital area was the most frequent local symptom in our material, and this symptom is not frequently focused on earlier. It is most probable that ache in the lower back, and pressure in the genital area and suprapubically are all part of a continuum, local ache caused by the infected urinary bladder. Though these symptoms were more frequent among younger women, they frequently occur at any age.

Further, to our knowledge no one has ever described shudders in arms or legs while voiding as symptoms of acute lower UTI. Initially, we even omitted this symptom description from the qualitative analysis of our previous material.[7] It was infrequently occurring, and it seemed farfetched and odd from a medical perspective. Still, the descriptions by the informants were sufficiently consistent to maintain our curiosity. In the present study, we found that 18% of the women consulting for acute uncomplicated UTI reported dysuric symptoms in arms or legs. We have no explanation for this, although the mere existence of the question in the questionnaire may count for some of the registration.

Modern medicine have shortcomings when it comes to the understanding of hitherto medically unexplained disorders, such as chronic muscular pain, chronic fatigue syndrome, nonbacterial urethritis, whiplash associated disorder, tension headache, or persistent pelvic pain after pregnancy.[12] Symptoms from different groups of "unexplained" disorders lack satisfactory explanatory models. Any suggestion of hypotheses for explicability is welcomed, especially when the source is the patient herself. This may even be true for apparently well-explained conditions, such as UTI, where our study indicates that the traditional medical knowledge about symptom presentations is insufficient. Being aware of the diversity of cystitic symptoms, and the possibility of highly individual presentations, may lead to a better recognition of the out-of-mainstream patient, and to more adequate diagnosis, treatment, and care.

In conclusion, generalized symptoms of feeling out of sorts are frequent in adult women with acute uncomplicated lower UTI, and equally frequent in all ages whether the patient shows bacteriuria or not.

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