GPSI in Urology Dr Nikhil Chopra addresses key challenges in the management of urinary tract infections and urinary incontinence in the elderly, including the role of dipstick testing, preventing and treating infections in catheterised patients and how to diagnose and manage urinary incontinence in elderly men and women
- Know the key symptoms and signs of UTI in the elderly
- Understand best practice in diagnosis and treatment of UTI in the elderly, including in catheterised patients
- Recognise key differences between elderly men and women with UTI
- Know how to manage recurrent UTI in elderly men and women
- Understand approaches to urinary incontinence in elderly women
- How to distinguish overactive bladder from prostate issues and manage it appropriately
1. GPs are aware that urinary tract infections (UTIs) may well present differently in the elderly compared with younger patients. What are the key features we should look out for?
Uncomplicated urinary tract infections are the most common type. Dysuria, frequency, urgency and suprapubic pain are common symptoms and patients may have one or more of the symptoms.
Occasionally patients will present with a more complicated picture with fever and flank pain. They may also present with foul smelling urine or cloudy urine – although these do not confirm urinary tract infection, they are helpful markers, especially in those patients who have no obvious cause for this presentation.
More commonly in the elderly the mental state of a patient may change. Patients often report similar cognitive symptoms to those they have had in the past, which can be a useful indicator of a repeat infection.
Elderly men should be asked if they experience perineal pain, to explore potential prostate pathology.
Consider UTI in patients with unexplained tiredness but who are otherwise asymptomatic.
Microscopic haematuria should always be considered to be possible infection and cultured if appropriate. Repeat dipstick testing approximately two weeks later, to confirm haematuria has cleared, is useful to make sure other, more sinister underlying causes are not missed.
2. Acute confusional states are often attributed to UTIs in the elderly, sometimes on flimsy grounds. How likely are UTIs to be the cause of confusion in the elderly, especially if the patient is not unwell/febrile? What clinical pointers should direct us to, or away from, the diagnosis?
UTIs account for almost 25% of all infections in the elderly, while delirium is prevalent in up to 30% of elderly patients, but whether the two are linked is unclear. 1
UTIs in the elderly are overdiagnosed and overtreated, but when they do occur can have a significant impact on both physical and mental state. Non-specific signs such as confusion, falling, anorexia and lack of appetite, dizziness, reduced coordination and agitation should trigger a consideration of a UTI in the elderly. Risk factors include diabetes, catheters, prostate enlargement, immobility and occasionally poor hygiene and toileting habits.
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Dr Nikhil Chopra is a GPSI in Urology and education secretary for the Primary Care Urology Society
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