How Common Are UTIs in the Elderly?

According to a recent review in the journal Drugs in Context, UTIs are more common in women at any age because they have a shorter urethra, which is the tube that carries urine out of the bladder. This allows bacteria from the rectum to move up the urethra and infect the bladder. The majority if UTIs are caused by bacteria called E. coli. E.coli do not cause infections in the colon or rectum, but they do in other parts of the body like the bladder or kidneys.

UTIs increase with age in both men and women. After age 65, about 10 percent of women will experience a UTI, by age 85 almost 30 percent will get a UTI. For both older men and women, the risk of infection is much higher if they are living in a nursing home or a long-term care facility.

Why Are UTIs Overtreated in the Elderly?

The reason is a condition that is quite common in elderly men and women called asymptomatic bacteriuria. Up to 20 percent of older men and women may have this condition, and it occurs in up to 50 percent of elderly people in hospitals or nursing homes. Asymptomatic bacteriuria means you have bacteria in your urine without any other symptoms.

Asymptomatic bacteriuria is not dangerous. It may even be beneficial. Some studies show that low levels of asymptomatic bacteriuria may protect the bladder from more infectious bacteria. The danger of this condition is the unnecessary use of antibiotics. Multiple studies show that this does more harm than good. Antibiotic treatment may lead to antibiotic resistant bacteria that cause more dangerous and harder-to-treat UTIs.

Why Do Older Adults Have More UTIs?

One reason is that our body’s natural defense system – our immune system – becomes a little weaker with age. Another reason is that older adults may have long-term diseases that weaken the immune system or make it hard to maintain good bathroom hygiene. Having to be catheterized or have a catheter in place is a major risk, even up to two days after as catheter is removed. The biggest risk factor is a history of recurrent UTIs, which means a person has had three UTIs in the past year or two UTIs in the past six months.

When Do UTIs Need to Be Treated in Seniors?

Guidelines say that if an elderly person has bacteria in their urine and they have at least two symptoms of UTI, they should be treated. Some people assume that an older person who becomes confused (delirious) probably has a UTI. UTI can cause delirium in the elderly, but dehydration is a more common cause. These are the symptoms to watch out for at any age:

• Fever or chills
• Increased need to pass urine, called frequency and urgency
• Pain while passing urine, usually described as burning, called dysuria
• Tenderness in the lower belly (bladder pain), or tenderness in the back and flank (kidney pain)

Older adults may have any or all of these symptoms, but they may also have delirium, lethargy, incontinence, and loss of appetite. The good news is that once a diagnosis is made most UTIs will respond well to an oral antibiotic selected for E. coli and other common UTI bacteria.

Preventing UTIs in Older Adults

Avoiding dehydration and having good bathroom hygiene are effective preventive strategies. Two prevention strategies that many people try are cranberry juice and probiotics. A host of recent studies have not found that either of these strategies is effective. However, there are two new product that do seem to prevent UTIs, according to the studies:

• D-Mannose is a type of sugar supplement that sticks to receptors in the bladder that coli bacteria use when they cause an infection. This supplement has few side effects and is supported by some research studies.
• Xyloglucan is a natural substance extracted form tamarind seeds. It forms a protective film inside the bladder that seals bladder cells off from bacteria. Xyloglucan is combined with hibiscus extracts and gelatin in a product called Utipro Plus. Studies suggest that this product reduces the risk of UTI and also reduces symptoms like frequency, urgency, and incontinence.

Both D-Mannose and Utipro Plus are available at pharmacies without a prescription.

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The urinary system is basically a drainage system that consists of two main sections: the upper urinary tract, which includes two kidneys and two ureters; and the lower urinary tract, which includes the bladder and urethra. Every day your urinary system filters about 150 quarts of blood, removing waste and fluid from the blood, which produces about a quart of urine. The process and the parts are essentially the same for men and women, except for one crucial difference: the urethra. The urethra is a tube-like structure located at the bottom of bladder through which urine exits the body. In men the urethra is in the penis and therefore it’s much longer than in women. A shorter urethra is mainly why women are more susceptible to UTIs.

UTIs Occur Mostly in the Bladder

UTI is an umbrella term for infections that develop anywhere along the urinary tract. The bladder is the most common infection site. Inflammation of the bladder is referred to as “cystitis,” often caused by a bacterial infection. Overgrowth of the bacterium Escherichia coli (E. coli) is responsible for most UTIs.

“A UTI is diagnosed using a urinalysis and subsequent urine culture along with clinical symptoms, such as burning with urination, and/or increased urgency and frequency,” says OBGYN Amy Rosenman, MD, UCLA Center for Women’s Pelvic Health. “There could also be pressure and pain above the pelvic bone, blood in the urine, and more rarely, a fever and flank or kidney pain.”

Causes and Risk Factors

Women are four times more likely to experience a UTI compared to men. Risk factors include bacteria from the bowel that reach the urethra and bladder (be sure to wipe front to back), sexual intercourse (urinating after sex can help clear bacteria), and older age. Prior to menopause, a woman’s vagina has more protective bacteria, such as lactobacillus. As estrogen drops after menopause, so too do protective bacteria.

While men are far less likely to get UTIs, they are not immune. Most infections in men are the result of problems that restrict normal urine flow, such as an enlarged prostate. Also called benign prostatic hyperplasia (BPH), prostate gland enlargement becomes more common as a man ages. When the prostate enlarges, it can constrict the urethra and reduce the flow of urine out of the bladder. This may lead to bladder infections and/or kidney problems. Risk factors for UTIs in men include not drinking enough fluids and engaging in anal intercourse, which exposes the urethra to more bacteria.

Men and women also can acquire a UTI in the hospital. According to the Centers for Disease Control and Prevention (CDC), among hospital-acquired UTIs, about 75% are associated with a urinary catheter, which is a tube inserted into the bladder through the urethra to drain urine.

Appropriate Antibiotic Use

Sometimes a UTI will resolve on its own. But many people seek treatment for symptoms, which is ultimately aimed at preventing infection from spreading to the kidneys. Antibiotics definitely work. But overuse of antibiotics promotes antibiotic resistance. That’s why it’s important to use the right antibiotic for the prescribed length of time.

“Nitrofurantoin is targeted to the urinary tract,” explains Dr. Rosenman. “A five-day course usually works. A three-day course of sulfonamide antibiotics also can work well. These regimens have been studied

and are effective. More is not better. We want to prevent antibiotic resistance and C. diff from overexposure to antibiotics.”

C. diff (also known as Clostridioides difficile or C. difficile) is a germ (bacterium) that causes severe diarrhea and colitis (an inflammation of the colon). According to the CDC, it’s estimated to cause almost half a million infections in the United States each year. About one in six patients who get C. diff will get it again within two to eight weeks. The infection can be fatal, especially in older people.

Though some studies have shown promise in using probiotics to treat UTIs, results have been mixed. If you’re interested in trying probiotics, it’s best to discuss this approach with your physician.

UTIs, Delirium, and Dementia

There’s quite a bit of confusion surrounding UTIs as a cause of delirium in people with dementia. The connection simply may be that some people with more advanced dementia are unable to clearly express the distress from a UTI or other health conditions.

“UTI is not a cause of delirium, but sepsis is,” says Dr. Rosenman. “In severe infections, especially involving the kidneys, with a fever and a positive blood culture, delirium may occur. In patients with a positive urine culture without sepsis and with an altered mental status, the positive urine culture is not the cause of the mental state.”

She advises that these patients be investigated for other causes of delirium. “Treating them with antibiotics leads to worse outcomes and longer hospitalizations and missed diagnoses of the true cause of the delirium.”

Bacterial growth in a urine culture without accompanying symptoms is known as asymptomatic bacteriuria (ASB) and is frequently misdiagnosed as a UTI. A 2019 study published in JAMA Internal Medicine evaluated factors and outcomes associated with treating ASB with antibiotics. Of the 2,733 patients in the study with ASB, 2,259 were treated with antibiotics for seven days. Most of the patients were women, average age 77. According to the study, high treatment rates persist despite national guidelines recommending against the use of antibiotics for ASB. The researchers also concluded that such treatment may be associated with longer hospital stays for older people.

Inconclusive and Unproven Treatments

Because the urinary tract is the source of entry for most UTIs, some women may think that douching with vinegar or another liquid could eliminate the problem. But douches don’t work, and neither does inserting lactobacillus or yogurt into the vagina. Cranberry extract and cranberry supplements (not cranberry juice cocktail) may be useful in preventing E. coli from attaching to the lining of the bladder and thus thwarting infection. A 2013 study that analyzed 1,616 women concluded that extracts reduced occurrence of UTIs compared to placebo. However, in another study of 176 who drank just cranberry juice, the juice did not reduce risk.

Here are some steps that are known to help prevent UTIs. Avoid dehydration by drinking plenty of fluid (water is recommended). This can help flush germs out of the urethra. Maintaining good hygiene and making sure all urine has been voided can help prevent UTIs (see side box for more tips).

Use of Bidets

The toilet paper shortage during the pandemic created a rush for purchasing bidets. Proponents claim, that in addition to cleaning your private parts, bidets may reduce infections. But some people wonder if the risk is increased when water splashes from back to front.

“Bidets have been around forever and are beneficial for rinsing, especially if there are anorectal issues like hemorrhoids,” says Dr. Rosenman. “Your vagina and urethra live in the same neighborhood all the time as your rectum. The splash would not be sufficient to infect you.”

A 2018 study explored the relationship between bidet use and incidences of hemorrhoids and urogenital infections. In total, 10, 305 subjects were randomly selected and asked about their frequency of bidet toilet use and receipt of a doctor’s diagnosis or subjective symptoms of hemorrhoids and urogenital infections. Researchers did not find a significant correlation between infections and bidet use during the course of the three-year study.

Early signs of urinary tract problems include more frequent urination, leaking urine, difficulty urinating, and the inability to completely void urine. Talk with your doctor if you notice any of these signs. Catching problems early may prevent more severe complications in the future.

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1. Poor posture

This is a major risk factor for middle back pain, particularly if you have a desk job and are in the habit of hunching over a keyboard for long periods of time. You can stop middle back pain (and upper back pain) before it starts by getting into the habit of sitting up straight and doing frequent shoulder rolls and lifts in order to loosen the muscles of your upper back.

2. Muscle strain

Use the correct lifting technique to help you avoid middle back pain due to muscle strain—bend at the knees, and carry heavy objects close to your body.

3. Vertebral fractures

These are especially common in older adults, due to the bone-thinning disease osteoporosis. If you have osteoporosis, follow your doctor’s advice when it comes to taking osteoporosis medications, eating a calcium-rich diet, and supplementing with vitamin D if you don’t get sufficient sun to top up your vitamin D levels. (See also our post 10 Vitamin D Deficiency Symptoms You Can Identify Yourself.)

4. Herniated spinal disk

A herniated disk bulges out from between the vertebrae and may press on the spinal nerves, causing middle back pain. In some cases, surgery may be needed to remove a herniated disk.

5. Myofascial pain

Myofascial pain affects the fascia (the connective tissue in and between muscles), and is characterized by knotty “trigger points” that hurt if pressed. If your middle back pain is a burning, tingling sensation, it may be myofascial in nature, especially if you play sports that require heavy use of the large shoulder muscles. A physical therapist can show you exercises to stretch and strengthen your muscles, and your middle back pain also may respond to massage, trigger-point therapy (pressure applied to areas of knotted muscle), and trigger point injections (lidocaine shots directly into the trigger points).

Serious Causes of Middle-Back Pain

Rarely, middle back pain can herald a serious underlying condition, so always mention the pain to your doctor, particularly if it comes on suddenly or has no obvious cause, or is preceded or accompanied by other symptoms.

Look out for these back pain red flags:

6. Heart Attack

Women in particular may develop referred middle back pain from a heart attack. Call your doctor immediately if your middle back pain is accompanied by a feeling of tightness or pressure in your chest that radiates to your shoulders and arms, shortness of breath, dizziness, nausea, and/or vomiting.

7. Aortic aneurysm

Middle back pain can also be a symptom of aortic aneurysm. The aorta is your largest artery, and carries oxygenated blood and vital nutrients to all parts of your body, including the heart. A healthy aorta has elastic walls that expand and contract with the ebb and flow of blood, but if any part of the aorta is rendered fragile by disease, the abnormal tissue can bulge or balloon out to form an aneurysm. Aortic aneurysms are a serious health risk because the pressure exerted on the aneurysm by normal blood flow may cause it to dissect or rupture. This causes severe chest pain, and rapid blood loss that can be life threatening.

8. Pleurisy

Pleurisy (inflammation of the lining surrounding the lungs) is another chest condition that can cause sharp, stabbing chest pain that radiates to cause pleurisy back pain. Pleurisy is not serious, but it can signal serious conditions like pneumonia and lung cancer.

Abdominal Pain vs. Middle Back Pain

What if the pain in your midsection isn’t related to bone- or muscle-related causes, or to the other conditions described above? It could, for example, involve kidney pain, which can seem as if it emanates from the mid-back region. Kidney pain could indicate a brewing infection that could severely damage your kidneys, particularly if you’ve recently had a urinary tract infection.

Also, pancreas pain caused by pancreatitis can radiate to the mid-back region from the abdomen, so tell your doctor immediately if you experience this type of radiating discomfort. It also may indicate pancreatic cancer. In one study, 17 percent of pancreatic cancer patients reported pain in the middle of their back as a symptom.

Originally published in 2016, this post is regularly updated.

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Kidney failure results in things that you need, such as proteins, calcium, and red blood cells, escaping in your urine while urea and other wastes continue to circulate in your bloodstream. This imbalance interferes with other systems in the body by potentially causing anemia and proteinemia while waste products continue to build up.

Kidney disease can lead to edema, cardiovascular disease, anemia, weak bones, poor immune response to infections, and even personality disorders or seizures. Your kidneys play a huge role in keeping your body healthy and functional!

Kidney Failure Symptoms

Unfortunately, there are no black-and-white symptoms of kidney disease or kidney failure. Patients may show no signs at all until the kidneys have undergone extensive damage and can no longer compensate. Symptoms that do occur are generic and can be caused by various other conditions. That said, these symptoms may indicate kidney failure:

• Fatigue. This could be attributed to poor oxygenation of tissues due to anemia, or the buildup of wastes.
• Nausea and vomiting.
• Changes in urination. You might find yourself needing to visit the restroom more often that usual, or only rarely.
• Edema. Because the kidneys are not able to properly control the amount of water in the body, excess water may stay in the bloodstream. This water then pools in areas of the body such as the feet and ankles, or around the heart and lungs.
• Shortness of breath. Fluid buildup in or around the lungs will make it difficult to breathe.
• Chest pain. Fluid buildup around the heart makes it more difficult for the heart to pump.
• Loss of appetite.

Several medical conditions increase the risk of developing kidney failure. These include diabetes, high blood pressure, cardiovascular disease, lupus, obesity, and smoking.

Diagnosing Kidney Failure

As you might expect, it is best to catch kidney disease early before too much damage has been done. While symptoms that you notice at home are not the most reliable signs, routine exams and lab work done by your doctor can catch kidney disease early.

Kidney problems are often found during routine urinalysis. Every time your doctor asks you to pee in a cup, your kidney function is being evaluated. Urinalysis checks for protein, glucose, blood, and other cells present in the urine, plus any foreign invaders such as bacteria or yeast. If there are a lot of blood cells or high levels of protein in your urine, your doctor will know to investigate further. For patients with predisposing factors, such as diabetes or high blood pressure, even a slight increase in urine protein levels may be cause for concern.

Blood tests to evaluate kidney function measure the levels of creatinine and blood urea nitrogen (BUN). Elevated creatinine and/or BUN indicate kidney damage.

If your doctor suspects that you have kidney disease, you may also need an ultrasound and/or kidney biopsy. Ultrasound allows the doctor to view your kidneys to evaluate their health and measure them. Kidney stones and obstructions can often be viewed via ultrasound. A kidney biopsy involves removing a small piece of the kidney so that it can be viewed under a microscope. There are two types of kidney biopsy: needle or open. A needle biopsy is done with a local anesthetic to numb the area so that the clinician can insert a needle into the kidney. Often an imaging technique such as ultrasound or CT scan is used to guide needle placement. An open biopsy requires general anesthesia so that the clinician can make an incision in the skin to access the kidney. As kidney biopsies are the most invasive diagnostic method, they are generally reserved for cases where it is difficult to determine the cause of the kidney damage.

What to Expect

If you are diagnosed with kidney disease, your doctor will advise you on lifestyle changes and medications to slow the progression. High blood pressure should be treated to reduce strain on the kidneys, and high cholesterol levels should be addressed. Eating a healthy diet with restricted salt and protein and balanced minerals will decrease the kidney’s workload.

In advanced kidney failure, it may become necessary to start dialysis to artificially filter your blood or to get a kidney transplant to replace the damaged kidneys.

Preventing Kidney Failure

There are several steps you can take to protect your kidneys. Keep active and eat a healthy diet to keep off excess weight. Follow the instructions on all medications, including over-the-counter drugs, and don’t smoke—your kidneys are involved in the excretion of many drugs and also filter out the waste products from smoking. If you have a serious health problem, particularly one that predisposes you to kidney damage, keep up with appointments and medications to keep yourself in your best health. And even if you are generally healthy, don’t skip your annual physical—routine exams are the best way to catch developing problems early!

SEE ALSO:

Top 10 Foods That Cause Kidney Stones
Kidney Pain: What’s Behind It?
Natural Diuretics: How to Reduce Fluid Retention Safely

This article was originally published in 2018. It is regularly updated. 

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Also, the location of kidney pain in back can be on either or both sides of your mid and upper region. It typically presents with other symptoms, including:

• Fever
• Pain and/or burning on urination
• Nausea and vomiting

(See also our post Kidney Failure: Symptoms, Diagnosis, and Treatment.)

What Causes Kidney Pain?

Kidney pain relief will depend on the underlying cause for your pain—your doctor will likely order blood and urine tests in order to diagnose the cause, and imaging tests such as ultrasound, a computed tomography (CT) scan, and magnetic resonance imagine also may be used. Causes for kidney pain can vary, including:

• • Urinary tract infections: While urine is sterile, it is possible for bacteria to cause a urinary tract infection (UTI) at the opening of the urethra, where urine exits the body. The infection can then spread up into the urinary tract. You are more at risk for urinary tract infections if you have kidney stones or conditions that prevent you from fully emptying your bladder (for example, an enlarged prostate). Poor bathroom hygiene also can result in the spread of E. coli bacteria to the urethra from the anus, so make a point of wiping from front to back.
  • Kidney infection: Rarely, a urinary tract infection can be serious enough to cause pyelonephritis, which is a serious kidney infection. Prompt treatment is vital, since pyelonephritis can permanently damage the kidneys, so contact your doctor immediately if UTI symptoms aren’t improving despite treatment, or if a UTI is accompanied by bloody urine, fever, nausea and vomiting, and a steady, aching kidney pain in your back and sides.
  • Kidney stone pain: If it is caused by kidney stones, kidney pain location will generally be lower down, in the groin and flanks. About one in 20 people develop a kidney stone in their lifetime—risk factors include dehydration, gout, a diet high in protein, sodium, and sugar, and certain medications (including corticosteroids and high blood pressure drugs). Kidney stones generally cause no or few symptoms unless they exit the kidney and get into the bladder. If this happens, you will experience cramping kidney pain that can be severe, and you also may notice blood in your urine.

A small kidney stone may be passed out of the body in the urine (drinking plenty of water can help), but larger stones may need a medical procedure to break them up so they can pass out of the body, or may need surgical removal.

Other rare conditions related to kidney pain causes include disruption of blood flow to the kidneys by a blood clot, bleeding in the kidneys (kidney hemorrhage), kidney tumors (these typically don’t cause kidney pain unless they are large), and polycystic kidney disease, which causes clusters of cysts to form in the kidneys.

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You should see your doctor if:

• You’re 70 years or older and have the onset of new lower back pain.
• You have the bone-thinning disease osteoporosis.
• Your lower back pain follows a fall.
• Your immune system is weak, you’ve had cancer, or you’ve taken corticosteroids for a long time.
• The pain persists even when lying down, or it awakens you from sleep.
• You have leg weakness or develop new sexual, bowel, or bladder dysfunction.
• You have an unexplained fever or weight loss.
• The lower back pain spreads into the lower leg, especially if the leg feels weak.
• The pain does not improve within four weeks.

Lower Back Pain Causes

Common causes of lower back pain include:

• Degenerative disk disease, which occurs naturally as we age, causes the spinal disks (the soft, elastic material that forms a shock-absorbing cushion between the spinal vertebrae) to break down. The disks become thinner and less flexible, and also may develop tiny cracks that can bulge, rupture, or break (a condition called herniated disk). The subsequent lack of cushioning between the vertebrae can put you at higher risk for lower back pain.
• Degenerative spondylolisthesis also is related to wear and tear on the muscles and ligaments of the lower back, which gradually become less able to keep the spinal vertebrae aligned. This makes it possible for the vertebrae to press on the spinal nerves, causing lower back pain that radiates down the legs. Other symptoms include a feeling of weakness in the legs. Many sufferers find that leaning forward while sitting relieves the pain because it increases the space available for the spinal nerves. (See also our post “Is a Pinched Nerve Causing Your Pain?“)
• Ankylosing spondylitis is a type of arthritis that tends to affect younger adults. It causes the cartilage that cushions the ends of joints to wear away, so that the bones rub together. In severe cases, the disease stimulates new bone growth that fuses together the vertebrae in the spine.
• Spinal stenosis develops when the space around the spinal cord narrows, putting pressure on the spinal cord. The most common underlying cause for spinal stenosis symptoms is osteoarthritis, to which your body may respond by forming bony outgrowths called bone spurs. These narrow the space the spinal nerves pass through, eventually pinching the nerves that travel down to the legs. This results in lower back pain, along with numbness, weakness, and/or pain in the legs, groin, hips, and buttocks. These symptoms are usually worse when you’re walking or standing; as with degenerative spondylolisthesis, the discomfort tends to decrease when you sit and lean forward, since this increases the space available for the nerves.

Treating and Preventing Lower Back Pain

Most instances of lower back pain can be relieved by over-the-counter painkillers, among them acetaminophen and ibuprofen. Some anti-seizure drugs, such as gabapentin (Neurontin), and pregabalin (Lyrica), can be taken to reduce pain caused by damaged nerves, and corticosteroid injections into the space around the nerves also can help relieve pressure on the nerves by reducing inflammation. However, the latter can only be given a few times a year, because repeated steroid injections can weaken nearby bones and connective tissue.

Alternative methods of pain relief, such as acupuncture and yoga, also can be effective at easing lower back pain, as can weight loss (excess weight increases the burden on your lower back).

For long-term relief, you also should aim to modify the way you use your body, and work to strengthen the muscles in your back. Try these steps:

• Modifying your body mechanics. Use the correct lifting technique (bend at the knees when lifting things, and carry heavy objects close to your body) to lessen the strain on your lumbar region. It’s also important to avoid spending long periods of time sitting in slumped positions that place stress on your back.
• Boosting muscle strength. The abdominal and lower back muscles support the spine, but in older adults especially, these often are weak. Active rehabilitation can rebuild strength, and physical therapy that focuses on strengthening core muscle groups in the abdominal area and the lower back has demonstrated positive effects in patients with lower back pain. A physical therapist can show you the most effective exercises for lower back pain, and make sure you’re doing them correctly.

Is Surgery a Good Idea?

Often, lower back pain clears up within two months, so surgery isn’t usually necessary unless conservative approaches haven’t helped ease your discomfort, and your lower back pain is affecting your mobility. Disk replacement surgery (in which a damaged disk is removed and replaced with an artificial disk) and spinal fusion (in which the damaged disk is removed and the vertebrae are fused together with bone grafts and screws, to immobilize the painful area) are the main surgical options for treating degenerative disk disease.

For spinal stenosis symptoms, a procedure called laminectomy has about an 80 percent success rate at improving walking abilities. Laminectomy enlarges the spinal canal by removing bone spurs, bone, and ligaments that may be pressing on the spinal nerves.

Keep in mind that surgical procedures for back pain mean a long recovery time afterwards, and many people gain little relief. For these reasons, surgery to alleviate lower back pain should be seen as a last resort.

See also our post “UHN Blog: How to Relieve Lower Back Pain.”

Originally published in 2016, this post is regularly updated.

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