Bladder infection: when antibiotics are needed
Urinary tract infection without antibiotics? Bacteriuria – gynaecologist Basel
FMH Gynecology
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SGGG
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Spalenvorstadt 3
4051 Basel
A bladder infection (cystitis) is an inflammation of the bladder with burning on passing urine, frequent urgency and pain above the pubic bone. This must be distinguished from asymptomatic bacteriuria: bacteria in the urine without any symptoms. That is not a disease and is simply normal in many phases of life.
The distinction decides the treatment. If every positive urine sample is answered with an antibiotic, the result is side effects, thrush and resistance – without preventing any later infection.
About one in two women experiences at least one urinary tract infection. Symptoms are especially common during sexually active years and after menopause, when oestrogen deficiency changes the mucosa.
Key facts
At a glance.
- Bacteria in the urine without symptoms are not treated outside pregnancy.
- For uncomplicated infections, watchful waiting over 48 hours is an equivalent option.
- Immediate treatment for fever, flank pain, chills, pregnancy or immunosuppression.
- In pregnancy without risk factors, current SGGG guidance no longer recommends routine screening for asymptomatic bacteriuria; with risk factors it is screened for and treated if bacteria are found.
- For recurrent infections, bacterial lysate, D-mannose and – after menopause – vaginal oestrogen help.
- A dipstick alone does not prove infection; your symptoms decide.
Causes
Background and risk factors.
In most cases the bacteria (usually Escherichia coli) come from your own bowel and reach the bladder through the short female urethra. Intercourse, a new partner, spermicides and diaphragms make this more likely.
After menopause, oestrogen is missing
the vaginal flora loses lactobacilli, the pH rises and bowel organisms colonise more easily. Rarely, residual urine, prolapse, stones or diabetes are the underlying cause.
Risk factors
- Intercourse, new partner
- Previous urinary tract infections
- Menopause and oestrogen deficiency
- Prolapse with residual urine
- Diabetes mellitus
- Spermicides, diaphragm
- Low fluid intake
Frequency
Urinary tract infection is one of the most common reasons for prescribing antibiotics to women – and one of the most commonly unnecessary ones.
Symptoms & findings
How does it present?
Typical symptoms
- Burning or pain when passing urine
- Frequent urgency with small volumes
- Pain or pressure above the pubic bone
- Cloudy or strong-smelling urine
- Slight blood in the urine
Common incidental findings
- Bacteria in the urine without any symptoms (asymptomatic bacteriuria)
- Positive nitrite or leucocytes on dipstick without symptoms
When it is urgent
Fever, chills, flank pain, nausea or vomiting suggest a kidney infection – please seek medical assessment straight away, outside office hours at an emergency department or hospital. Pregnant women, women with immunosuppression or diabetes and patients with a catheter should also not wait.
Diagnostics
How the diagnosis is made.
With typical symptoms and no warning signs the diagnosis is clinical: the consultation is usually enough, a dipstick may add information. A urine culture is not needed for every infection, but for recurrent infections, treatment failure, pregnancy and complicated courses.
Important
a positive dipstick without symptoms is not a reason to treat. With repeated infections we also look for residual urine, prolapse or stones on ultrasound and assess the vaginal mucosa.
Examinations
- Consultation and symptom pattern
- Urine dipstick (supplementary)
- Urine culture for recurrence, pregnancy or treatment failure
- Ultrasound of kidneys, bladder and residual urine for recurrent infections
- Assessment of the vaginal mucosa after menopause
What do the findings mean?
Bacteria in the urine are a finding, not an instruction. We treat symptoms – plus asymptomatic bacteriuria before urological procedures involving mucosal injury and in pregnancy with risk factors (previous preterm birth, previous late miscarriage, diabetes mellitus, immunosuppression, functional or structural urinary tract disorders, previous pyelonephritis). In an uncomplicated pregnancy the SGGG does not recommend routine screening, as the benefit is unproven; other societies (e.g. IDSA 2019) read the data differently.
Treatment
Possible approach.
Watchful waiting
Non-antibiotic approach over 48 hours
for an uncomplicated infection without fever you can start with ibuprofen or another anti-inflammatory painkiller, sufficient fluids and warmth. A substantial proportion of infections resolve this way.
We always agree on a clear limit
if things are not better after 48 hours, or clearly worse before that, or if fever, flank pain or blood in the urine appear, we switch to an antibiotic.
Medication
If an antibiotic is needed, treatment is short and targeted (usually nitrofurantoin or fosfomycin; in pregnancy adapted to culture and trimester).
For recurrent infections, prevention comes first
oral bacterial lysate as immune prophylaxis, D-mannose, adequate fluids, passing urine after intercourse and avoiding spermicides.
Surgery
After menopause, vaginal oestrogen is the single most effective measure against recurrent infections: low-dose local oestrogen restores the mucosa and the lactobacillus flora. The effect is local and systemic absorption minimal. Urological assessment makes sense for stones, residual urine, blood in the urine outside an infection or very frequent recurrences.
Prevention
What you can do yourself.
- Drink enough and empty the bladder regularly
- Pass urine after intercourse
- Avoid spermicides and diaphragms if infections cluster
- No intimate washes or vaginal douching
- Discuss vaginal oestrogen after menopause
- With more than three infections a year, plan prophylaxis instead of repeated antibiotics
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Frequently asked questions
FAQ.
Related topics
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Medically responsible.
Dr. med. Anna Margareta Wagner is a board-certified FMH specialist in gynecology and obstetrics with her own practice at Spalenvorstadt 3 in Basel. Special focus on surgical gynecology; further focus areas: gynecological check-ups, colposcopy and dysplasia consultations, intimate surgery, pregnancy care, and consultations for girls and adolescents.
- FMH specialist certification in gynecology and obstetrics
- Special focus: surgical gynecology
- SGGG member
- Certified colposcopy diploma
- Languages: German, English
- Service area: Basel-Stadt, Basel-Landschaft, northwestern Switzerland
The content on this page is reviewed regularly against current specialist medical recommendations.
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