INTRODUCTION

According to Mayo Clinic (2022) “A urinary tract infection (UTI) is an infection in any part of
the urinary system”. The urinary tract includes the bladder, urethra and kidneys (Mayo clinic,
2022). This happens when microbes overcome the body’s defenses in the urinary system (Sabih
and Leslie, 2023). UTIs are among the most common bacterial diseases worldwide, with
significant clinical and economic burden (CardwellI et al., 2016). They are one of the major
causes of morbidity and comorbidities in patients with underlying conditions, and it accounts for
the majority of the reasons for hospital visit globally (Odoki et al., 2019). It is the most common
diseases diagnosed in developing countries (Seifu and Gebissa, 2018). In pediatrics settings, it is
the most common bacterial infection encountered by pediatricians (Becknell et al., 2015).
Urinary tract infections are common in infants and young children. About 3% of girls and 1% of
boys will have a UTI by 11 years of age (Moreno, 2016). Urinary tract infections are also
common in female adolescents and young women; young women develop UTIs at more than 3
times the rate of young men (Moreno, 2016).

The prevalence of UTI is higher during adolescence, a period in which hormonal changes favour
vaginal colonization by nephritogenic strains of bacteria, which can migrate to periurethral area
and cause urinary tract infection (Srivastava, 2018). It was studied that UTIs affect
approximately 7.8% of children <19 years with urinary symptoms and/or fever (Stein et al,
2015). It is also documented that UTI is more common in females than in males (Haque et al.,
2015). The normal female urinary tract has a comparatively short urethra and therefore, carries
an inherent predisposition to proximal seeding of bacteria. This anatomy increases the frequency
of infections (Sabin and Leslie, 2023). More than 50% of all women and at least 12% of men
experience UTI in their lifetime (Mlugu et al., 2023). While very common in women, UTIs are
common in uncircumcised males and has been studied that the prevalence of UTI among
adolescent boys is very low. When UTI occur in circumcised male, by definition they are
regarded as complicated UTI (Sabih and Leslie, 2023).

It is mostly caused due to bacteria, but may also include fungal and viral infections (Sheifu and
Gebissa, 2018). It is caused by both Gram-negative and Gram-positive bacteria as well as by
certain fungi and virus (Flores-Mireles et al., 2015). Escherichia coli causes the vast majority of
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UTIs, followed by Klebsiella, but other organisms of importance include Proteus, Enterobacter,
and Enterococcus (Yamaji et al., 2018). Urinary tract candidiasis is known as the most frequent
nosocomial fungal infection worldwide. Candida albicans is the most common cause of
nosocomial fungal urinary tract infections; however, a rapid change in the distribution
of Candida species is undergoing (Behzadi et al., 2015).

Adolescent girls are more likely to present with typical cystitis symptoms including frequency,
urgency, dysuria, cloudy urine, hematuria, and lower abdominal discomfort. There are various
factors that is associated with UTIs in adolescent such as poor hygiene, dehydration, and even
sexual activities (Leung et al, 2019). Sexual activity is a special issue for this population that
requires additional attention (Srivastava, 2018).

The most diagnostic symptoms of urinary tract infections include change in frequency, dysuria,
urgency, and presence or absence of vaginal discharge, (Chu and Londer, 2018). To prevent the
effect and complications of UTIs, prompt diagnosis and appropriate treatment are very important
to reduce the morbidity associated with this condition. (Leung et al, 2019). The diagnosis of a
UTI can be made based on a combination of symptoms and a positive urine analysis or culture.
(Bono et al., 2023). Sound knowledge of these factors associated with UTI by healthcare may
allow timely intervention that can easily bring the disease under control (Odoki et al., 2019).

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AIM OF THIS SEMINAR

This seminar paper aim to provide comprehensive overview of urinary tract infections and it’s
risk factors, effect, prevention and treatment of UTIs among adolescents.

SPECIFIC OBJECTIVES,

The objectives of this study are;

1. To understand the concept of urinary tract infections

2. To determine the associated factors/ risk factors of UTI in adolescents

3. To explain management of UTIs in adolescents

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 URINARY TRACT INFECTIONS

Urinary tract infection (UTI) is an infection in any part of the urinary system (Mayo Clinic,
2022). UTIs are caused by pathogenic microorganisms in the urinary tract (the normal urinary
tract is sterile above the urethra) (Hinkle and Cheever, 2014). Urinary tract infections (UTIs) are
among the most common causes of sepsis presenting in hospitals (Sabin and Leslie, 2023). UTIs
in both community and hospital settings are estimated to affect around 405 million people
globally and nearly 0.23 million people died of UTIs, contributing to 0.5 million disability
adjusted life years (DALYs) in 2019 (Islam et al., 2022). It is a major public health problem in
terms of morbidity and mortality worldwide (Hailay et al., 2020).

The urinary tract includes several parts of the body, including the kidneys, the bladder, ureters,
and the urethra. The kidneys are 2 bean-shape organs located in the abdominal area that filter
blood to clean it and make urine as a byproduct. The urine travels down the ureters to the bladder
for storage. The urethra connects the bladder to the outside of the body where urine leaves the
body. Any of these parts of the urinary tract can get an infection called a urinary tract infection
(UTI) (Moreno, 2016).

Classification of Urinary Tract Infections

UTIs can be classified by location and the presence of functional or structural abnormalities.
This classification is important, because evaluation and treatment depend on accurate assessment
(Long and Koffman, 2018). Urinary tract infections (UTIs) are classified by location: the lower
urinary tract (which includes the bladder and structures below the bladder) or the upper urinary
tract (which includes the kidneys and ureters). They can also be classified as uncomplicated and
complicated UTIs (Hinkle and Cheever, 2014). The infection is named based on the site of
infection (Vasudevan, 2014).

Lower UTIs include bacterial cystitis (inflammation of the urinary bladder), bacterial prostatitis
(inflammation of the prostate gland), and bacterial urethritis (inflammation of the urethra). Upper
UTis are much less common and include acute or chronic pyelonephritis (inflammation of the
renal pelvis), interstitial nephritis (inflammation of the kidney), and kidney abscesses. Upper and
lower UTis are further classified as uncomplicated or complicated, depending on whether the

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UTI is recurrent and the duration of the infection. Most uncomplicated UTis are community
acquired (Hopkins et al., 2014).

Complicated lower or upper UTIs are often acquired in the hospital and related to
catheterization. It occurs in people with urologic abnormalities, pregnancy, immunosuppression,
diabetes and obstructions and are often recurrent (Hinkle and Cheever, 2014). Pyelonephritis,
which most commonly occurs when bacteria ascend to the kidney from the bladder, is the most
common presentation of upper UTI (Long and Koffman, 2018). Lower urinary tract symptoms
(LUTS) are common among adolescent girls (Fitzgerald et al., 2023).

Some common UTIs in adolescent and their symptoms

Cystitis; cystitis presents with dysuria, urinary frequency and urgency, suprapubic pain, and
hematuria. Patients may also have a fever or other systemic symptoms (including chills, rigors,
or marked fatigue or malaise beyond baseline), which suggest that infection has extended beyond
the bladder (Saade et al., 2022).

Acute bacterial prostatitis; most commonly presents with fevers, chills, dysuria, pelvic or
perineal pain, and noticeably cloudy urine. Obstructive symptoms, such as dribbling of urine, can
also occur. On examination, the prostate is often firm, edematous, and markedly tender
(Reddivari and Mehta, 2023).

Pyelonephritis; classically presents with fever, chills, flank pain, costovertebral angle
tenderness, and nausea/vomiting. It may also be associated with symptoms of cystitis. Atypical
symptoms include pain in the epigastrium or lower abdomen (Parlak, 2020)

ETIOLOGY OF UTIs IN ADOLESCENTS

Most UTIs are due to the colonization of the urogenital tract with rectal and perineal flora.
Escherichia coli causes the vast majority of UTIs, followed by Klebsiella, but other organisms of
importance include Proteus, Enterobacter, and Enterococcus (Yamaji et al., 2018). Residential
care patients, diabetics, and those with indwelling catheters or immune-compromised can also be
colonized with Candida spp. (Tandoğdu et al., 2016).

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Pathogenic bacteria ascend from the perineum and rectum to the periurethral area, predisposing
women to UTIs. During adolescence, hormonal changes favour vaginal colonization by
nephritogenic strains of bacteria. In addition, the short female urethra allows uropathogens to
invade the bladder and lower urinary tract (Sabih and Leslie, 2023). Women also have much
shorter urethras than men, further contributing to their increased susceptibility (Sabih and Leslie,
2023). Uncircumcised status in male also predisposes them to UTI (Khan et al., 2018). UTI in
boys may be suggestive of anatomic or renal abnormalities (Storme et al., 2019). In addition,
sexual intercourse is also a common cause of UTI as it promotes the inoculation of bacteria into
the bladder (Maharjan et al., 2018). Sexually active men are at increased risk but to a lesser
extent than women.).

Other risk factors associated with UTI include: (Leung et al, 2019; Li and Leslie 2023; May et
al., 2023).

1. Incomplete emptying and neurogenic bladder

2. Abnormal urinary tract anatomy or function
3. Antibiotic use and increasing bacterial resistance
4. Dehydration
5. Diabetes
6. Frequent pelvic examinations
7. Incomplete bladder emptying
8. Immune system suppression or inadequacy
9. New or multiple sexual partners
10. Poor personal hygiene
11. Use of spermicides and diaphragms

A. Poor hygiene practice; UTIs can result from inadequate hygiene practices. Insufficient
wiping after toilet use or incomplete washing of the genital area allows bacteria to spread,
increasing the risk of UTIs (Srivastava, 2018).
B. Sexual Activity; Women are more likely to get bacteria in the urinary tract from sexual
contact. It is advisable to urinate before and after sexual activity to flush out bacteria.

C. Urine Flow Obstruction; Obstructions such as kidney stones or enlarged prostate glands
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can disrupt normal urine flow, creating stagnant urine that becomes a breeding ground for
bacteria. This raises the likelihood of developing a UTI.

E. Weakened Immune System; Certain medical conditions or medications that

compromise the immune system make individuals more susceptible to infections and
UTIs (Flores-Mireles, 2015).
F. Anatomical structure; The normal female urinary tract has a comparatively short
urethra and, therefore, carries an inherent predisposition to proximal seeding of bacteria.
This anatomy increases the frequency of infections (Sabih and Leslie, 2023). Infections
occurring due to anatomical abnormalities, for example, an obstruction, hydronephrosis, renal
tract calculi, or colovesical fistula (Sabih and Leslie, 2023).

ROUTES OF INFECTION OF UTIs

Bacteria enter the urinary tract in three ways: by the transurethral route (ascending infection),
through the bloodstream (hematogenous spread), or by means of a fistula from the intestine
(direct extension). The most common route of infection is transurethral, in which bacteria (often
from fecal contamination) colonize the periurethral area and subsequently enter the bladder by
means of the urethra (Grossman & Porth, 2014). In women, the short urethra offers little
resistance to the movement of uropathogenic bacteria. Sexual intercourse forces the bacteria
from the urethra into the bladder. This accounts for the increased incidence of UTis in sexually
active women. Bacteria may also enter the urinary tract by means of the blood from a distant site
of infection or through direct extension by way of a fistula from the intestinal tract (Hinkle and
Cheever, 2014).

THE IMPACT OF UTI ON ADOLESCENTS

The impact of UTI in adolescent can be significant and far-reaching, affecting various aspects of
their lives, including

1. Physical health; Urinary tract infections can lead to kidney damage or scarring, sepsis,
premature birth or low birth weight, recurrent infections, and other physical health issues.
2. Emotional and psychological well-being: Urinary tract infections can lead to anxiety,
depression, embarrassment, stigma, and reduced self-esteem.
3. Social relationships; Urinary tract infections can impact relationships with friends and
family, lead to social isolation, and difficulty forming intimate relationships.

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4. Daily activities; Urinary tract infections can cause missed school or work days, reduced
participation in extracurricular activities, and impact academic performance
5. Sexual health; Urinary tract infections can increase the risk of sexually transmitted
infections and impact sexual function and pleasure.
6. Reproductive health; Urinary tract infections can increase the risk of preterm labor and
low birth weight and impact fertility.
7. Mental health Urinary tract infections can increase the risk of anxiety and
8. Quality of life; Urinary tract infections can reduce overall quality of life and impact daily
functioning and well-being.

It is essential to address UTIs promptly and effectively in adolescents to prevent these potential
long-term consequences and ensure optimal physical, emotional, and social well-being (Moreno,
2016).

COMPLICATIONS OF UTIS

1. Renal scaring; The most consequential long-term complication of acute pyelonephritis is

renal scarring, which may increase the risk of hypertension or chronic kidney disease later in life
(Mattoo and Shaikh, 2021).
2. Perinephric abscess; this results from perirenal fat necrosis. More than 75% of
perinephric abscesses are now due to complications of urinary tract infection. perinephric
abscess can occur through the hematogenous spread of infection from a focus outside the kidney
or local spread of a related urologic infection. These abscesses are usually due to ascending
infection from the urinary bladder with associated pyelonephritis (Okafor and Onyeaso, 2023).
Urosepsis is a treatable condition. However, delayed management can lead to severe
consequences, including renal failure, septic shock, and death (Grüne et al., 2020).
3. Sepsis; it is a systemic inflammatory response to infection that can lead to multi-organ
dysfunction, failure, and even death. Urosepsis is sepsis caused by infections of the urinary tract,
including cystitis, or lower urinary tract and bladder infections, and pyelonephritis, or upper
urinary tract and kidney infections (Porat et al., 2023).
4. Emphysematous pyelonephritis (EPN), emphysematous cystitis (EC), and
emphysematous ureteritis (EU) are defined as infections of acute, severe, necrotizing natures
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resulting in the accumulation of gas within the renal parenchyma, collecting system, the
perinephric space, and the wall and lumen of the urinary tract (Yap et al., 2019). Pathogens
implicated in the causation of EUTIs include Escherichia coli, which remains the most common,
and other anaerobes such as Klebsiella spp. and Proteus spp., which ferment glucose resulting in
necrosis and the formation of gas (Lu et al., 2016). Diabetes mellitus patient are at risk of
emphysematous cystitis (Sapkalova et al., 2023).
5. Repeated infections, which means you have two or more UTIs within six months or three
or more within a year. Females are especially prone to having repeated infections.
6. Permanent kidney damage from a kidney infection due to an untreated UTI.
7. A narrowed urethra in male from having repeated infections of the urethra (Mayo Clinic,
2022).

ASSESSMENT AND DIAGNOSTIC FINDINGS

Medical history

In taking patient medical history, the site, episode, symptoms, and complicating factors are
identified. This includes questions on primary (first) or secondary (recurring) infection, febrile or
non febrile UTIs; malformations of the urinary tract (eg, pre- or postnatal ultrasound screening),
previous operations, drinking, and voiding habits; family history; whether there is constipation or
the presence of lower urinary tract symptoms; and sexual history in adolescents (Stein, 2015).

Results of various tests, such as bacterial colony counts, cellular studies, and urine cultures, help
confirm the diagnosis of UTI. In an uncomplicated UTI, the strain of bacteria determines the
antibiotic of choice (Grossman and Porth, 2014). A UTI diagnosis is a combination of signs,
symptoms, and urinalysis results confirmed with a urine culture (Bono et al., 2023)

Urine Specimen Collection

A properly collected, clean urinalysis specimen is needed. Patients should wash their hands
before obtaining a sample. Midstream voided clean catch specimens are very accurate and
preferred in non-obese women and men, assuming the patient follows the correct technique. Men

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should wipe the glans, start the urine stream to clean the urethra, and obtain a midstream sample
(Bono et al., 2023).

Urinalysis

Do not base the diagnosis of a UTI solely upon visual inspection of the urine. The most helpful
dipstick values diagnostically are PH, nitrites, leukocyte esterase, and blood. The most helpful
dipstick values diagnostically are pH, nitrites, leukocyte esterase, and blood. Remember that in
patients with symptoms of a UTI, a negative dipstick result does not rule out the UTI, but
positive findings can suggest the diagnosis. Look for the presence of bacteria and/or white blood
cells (WBC) in the urine on microscopic urinalysis. Dip stick is often includes testing for WBCs,
known as the leukocyte esterase test, and nitrite testing (Grossman and Porth, 2014).

Urine Culture

Urine cultures are useful for documenting a UTI and identifying the specific organism present.
UTI is diagnosed of bacteria in the urine culture. A colony count greater than 100,000 CFU/mL.
of urine on a clean-catch midstream or catheterized specimen indicates infection (Fischbach and
Dunning, 2015). However, UTI and subsequent sepsis have occurred with lower bacterial colony
counts. The presence of any bacteria in specimens obtained by suprapubic needle aspiration of
the urinary bladder, straight catheterization (insertion of a tube into the urinary bladder), or
during surgery or cystoscopy is considered clinically significant (Fischbach and Dunning, 2015).

Ultrasonography

Ultrasonography and kidney scans are extremely sensitive for detecting obstruction, abscesses,
tumors, and cysts (Grossman and Porth, 2014).

MANAGEMENT OF UTIS

Management of UTIs typically involves pharmacologic therapy and patient education.

Various prescribed medication regimens are used to treat UTI (Hinkle and Cheever, 2019).
Treatment success involves proper antibiotic selection, appropriate dosage adjustment, and
correct duration of therapy (Sabih and Leslie, 2023).

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Examples of medications used to treat urinary tract infections (Hinkle and Cheever, 2014).

Drug Classes Generic (Brand) Name Major Indications

Anti-infective, urinary tract Nitrofurantoin (Macrodantin, UTI

Bactericidal Furadantin) cephalexin
Genitourinary infection
(Keflex)

Cephalosporin Cefadroxil (Duricef, Ultracef) UTI

Fluoroquinolone Ciprofloxacin (Cipro) UTI

Ofloxacin (Floxin) pyelonephritis

Norfloxacin (Noroxin)

Gatifloxacin (Zymar)

Fluoroquinolone Levofloxacin (Levaquin) Uncomplicated UTI

Penicillin Ampicillin (principen, UTI – not commonly used

omnipen) amoxicillin alone due to Escherichia
(Amoxil) coli resistance

Pyelonephritis

UTI – not commonly used

alone due to Escherichia
coli resistance

Trimethoprim- Co-trimoxazole (Bactrim, UTI

sulfamethoxazole combination septra)
pyelonephritis

Urinary analgesic agent Phenazopyridine (pyridium) For relief of burning pain,

and other symptoms

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 associated with UTI

1. PHARMACOLOGIC THERAPY
a. Acute Pharmacologic Therapy

The ideal medication for treatment of UTI is an antibacterial agent that eradicates bacteria from
the urinary tract with minimal effects on fecal and vaginal flora, thereby minimizing the
incidence of vaginal yeast infections. The antibacterial agent should be affordable and should
have few adverse effects and low resistance. Because the organism in initial, uncomplicated
UTIs in women and men is most likely E. coli or other fecal flora, the agent should be effective
against these organisms. Various treatment regimens have been successful in treating
uncomplicated lower UTIs in women: single-dose administration, short-course (3-day) regimens,
or 7-day regimens (Hopkins et al., 2014). The trend is toward a shortened course of antibiotic
therapy for uncomplicated UTIs, because most cases are cured after 3 days of treatment.

Regardless of the regimen prescribed, the patient is instructed to take all doses prescribed, even
if relief of symptoms occurs promptly. Longer medication courses are indicated for men,
pregnant women, and women with pyelonephritis and other types of complicated UTIs.
Hospitalization and intravenous (IV) antibiotics are occasionally necessary (Hopkins et al.,
2014).

b. Long-Term Pharmacologic Therapy

Although brief pharmacologic treatment of UTIs for 3 days is usually adequate in women,
infection recurs in about 20% of women treated for uncomplicated UTIs. Infections that recur
within 2 weeks of therapy do so because organisms of the original offending strain remain.
Relapses suggest that the source of bacteriuria may be the upper urinary tract or that initial
treatment was inadequate or given for too short a time. (Hinkle and Cheever, 2014). Recurrent
infections in men are usually caused by persistence of the same organism; further evaluation and
treatment are indicated (Hopkins et al., 2014). lf infection recurs after completing the
antimicrobial therapy, another short course (3 to 4 days) of full-dose antimicrobial therapy
followed by a regular bedtime dose of an antimicrobial agent may be prescribed. If there is no
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recurrence, medication is taken every other night for 6 to 7 months. Long-term use of
antimicrobial agents decreases the risk of reinfection and may be indicated in patients with
recurrent infections.

If recurrence is caused by persistent bacteria from preceding infections, the cause (i.e., kidney
stone, abscess), if known, must be treated. After treatment and sterilization of the urine, low-dose
prophylactic therapy (trimethoprim with or without sulfamethoxazole) each night at bedtime may
be prescribed (Hopkins et al., 2014). High recurrence rates and increasing antimicrobial
resistance among uropathogens threaten to greatly increase the economic burden of these
infections (Flores-Mireles et al., 2019).

c. Prophylactic therapy

UTIs are commonly treated with antibiotics but due to increasing development of multidrug
resistant strains, there is a need for alternative and complementary remedies. (Loubet et al.,
2022).

Daily intake of cranberry juice can help prevent and control symptoms of UTI (Bass-Ware et al.,
2014; Hopkins et al., 2014). One group of researchers reported that daily consumption of
cranberry juice over an 8-week period decreased symptoms (i.e., urgency, frequency, nocturia,
dysuria, and pain) in women diagnosed with a UTI in an ambulatory setting (Bass-Ware et al.,
2014).

D-mannose, a monosaccharide naturally found in fruits, is commonly marketed as a dietary

supplement for reducing the risk for UTIs (Ala-Jaakkola et al., 2022). D-mannose has been used
as a prophylactic agent, and there is evidence that it may provide some benefit (Barea et al.,
2020). D-mannose is a sugar which is part of a normal diet and is believed to create a non-skin
surface on the bladder wall, as well as around the bacteria. It is thought that the bacteria is then
expelled when urinating, thus preventing the growth of bacteria which leads to an infection
inside the bladder or urinary tract (Cooper et al., 2022).

2. PATIENT EDUCATION

The nurse instructs the patient on the following information:

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A. Hygiene

1. Shower rather than bathe in the tub because bacteria in the bathwater may enter the
urethra.

2. Clean the perineum and urethral meatus from front to back after each bowel movement.
This will help reduce concentrations of pathogens at the urethral opening and, in women the
opening the vaginal opening (Hinkle and Cheever, 2014).

3. Avoid potentially irritating feminine products. Using them in the genital area can
irritate the urethra. These products include deodorant sprays, douches and powders (Mayo
Clinic, 2022).

B. Fluid intake

1. Drink liberal amounts of fluids daily to flush out bacteria. It may be helpful to include at
least one glass of cranberry juice per day.

2. Avoid coffee, tea, colas, alcohol, and other fluids that are urinary tract irritants.

C. Voiding habits

Void every 2-3 hours during the day, and completely empty the bladder. This prevent over
distention of the bladder and compromised blood supply to the bladder wall. Both predispose the
patient to urinary tract infection. Precautions expressly for women include voiding immediately
after sexual intercourse (Hinkle and Cheever, 2014).

Patients should be informed of the importance of taking their medication as prescribed without
stopping midway through the antibiotic course, even if they feel better. Patients should also be
warned not to take prophylactic antibiotics unless prescribed, as future increased bacterial
resistance may develop, making it more challenging to treat subsequent UTIs. Preventative
strategies to avoid UTIs are essential in reducing incidence and recurrence, especially in females.
All women, particularly those at increased risk, should be educated regarding the following
strategies:

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1. Women should urinate after sexual intercourse as bacteria in the bladder can increase
tenfold after sexual activity.
2. After urination, women should wipe from front to back, not from the anal area forward,
which will contaminate the introitus and periurethral areas with pathogenic enteric organisms
from the rectum.
3. Vigorous, high-volume urine flow is helpful in prevention.
4. Baths should be avoided in favor of showers.
5. A gentle, liquid soap without fragrance, liquid baby soap, or baby shampoo should be
used in bathing. Liquid soaps are cleaner than bar soap that can collect bacteria.
6. When bathing, the soap should be applied using a freshly cleaned, soft cotton or
microfiber washcloth.
7. The vaginal area should be cleaned first to avoid unnecessary contamination of the
periurethral area with bacteria on the washcloth if used elsewhere first (Bono et al, 2023).
8. Avoid using condoms coated with spermicide or a diaphragm for birth control. If you get
UTIs often, ask your doctor about taking antibiotics right after sexual intercourse to prevent
recurrent UTIs.
9. Keep the tip of the penis clean, especially those that are not circumcised. The foreskin
can trap bacteria, which can then get into the urinary tract and cause infection (Mayo Clinic,
2023).

CHALLENGES ASSOCIATED WITH THE PREVENTION AND MANAGEMENT OF

UTIs IN ADOLESCENTS.

1. Behavioral challenges: Many adolescents may not consistently practice good personal
hygiene, such as wiping from front to back or regular washing of the genital area, which is
critical in preventing UTIs. Adolescents are also known to have poor hydration and consumption
of bladder irritants like caffeine and sugary drinks which are common among adolescents,
increasing the risk of UTIs (Vyas et al, 2015).

2. Social Challenges: Adolescents may be embarrassed and Stigmatized when they discuss
symptoms of UTIs, especially those related to sexual activity, resulting in delayed diagnosis and
treatment (Srivastava, 2018).
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3. Lack of Education: There is often insufficient education about UTIs, their causes, and
prevention methods among adolescents. Schools and families may not adequately cover these
topics (Jelly, et al., 2022).

4. Delayed medical attention: Adolescents might delay seeking medical attention due to
embarrassment, lack of awareness, or underestimating the severity of symptoms, leading to more
severe infections. Adolescents may worry about confidentiality, particularly when seeking
treatment for sexually transmitted infections or UTIs, which can prevent them from accessing
necessary healthcare (Mboweni and Sumbane, 2019).

5. Healthcare-Related Challenges: Limited access to healthcare services, particularly

confidential care, can hinder adolescents from seeking timely treatment. The financial burden
associated with medical visits, diagnostic tests, and treatment can be a barrier for some
adolescents and their families (Mboweni and Sumbane, 2019).

6. Antibiotic Resistance: Misuse and overuse of antibiotics contribute to the development of

antibiotic-resistant bacteria, complicating treatment and necessitating the use of more potent
medications (Brookes-Howell et al., 2019).

7. Management Barriers: Adolescents might struggle to adhere to prescribed treatment

regimens, such as completing a full course of antibiotics, due to forgetfulness or
misunderstanding the importance of adherence. The chances of UTIs to recur can complicate
management. Recurrent infections require continuous medical oversight and can lead to
antibiotic resistance if not managed properly (Foxman, 2014).

NURSING THEORIES

Several nursing theories support the understanding and management of UTIs in adolescents and
associated factors. Here are a few examples:

1. Self-Care Deficit Theory (Orem, 1991): This theory posits that individuals have the ability to
care for themselves, but may require assistance when faced with health challenges like UTIs.
Nurses can support adolescents in developing self-care skills to prevent and manage UTIs.

2. Health Promotion Model (Pender, 1996): This model emphasizes the importance of healthy
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behaviors and lifestyle choices in preventing health problems like UTIs. Nurses can encourage
adolescents to adopt healthy habits like proper hygiene, adequate fluid intake, and regular
voiding.

3. Social Cognitive Theory (Bandura, 1986): This theory suggests that learning and behavior
change occur through observation, imitation, and reinforcement. Nurses can educate adolescents
about UTI prevention and management, and encourage them to adopt healthy behaviors by
modeling and reinforcing positive habits.

4. Family Systems Theory (Friedman, 1998): This theory views the family as a dynamic
system, and recognizes that family members influence each other's health behaviors. Nurses can
involve family members in the care and education of adolescents with UTIs, promoting a
supportive environment for healthy habits.

Associated factors like poor hygiene, sexual activity, and underlying medical conditions can also
be addressed through these theories, by promoting healthy behaviors, education, and family
support.

EMPIRICAL STUDIES

In the year 2018, Shubha Srivastava did a research on Analytical study of urinary tract infection
in adolescent girls and stated that hormonal changes during adolescence create an environment
conducive to bacterial growth, leading to UTIs. In the study they highlighted that UTIs have a
negative impact of low self-esteem, poor quality of life, social isolation, and depression on
adolescents.

Factors like inadequate hydration, infrequent urination, and poor menstrual and sexual hygiene
contribute to UTIs during adolescence. The study included adolescent girls aged 10-19 who
visited the gynecology OPD with urinary complaints. A questionnaire gathered demographic
data, symptoms, and treatment history. The Investigations comprised urine routine examination
and culture. Ultrasound was reserved for recurrent UTI cases. Key findings: Most common
symptom: burning during urination (60%). Recurrent UTI prevalent in sexually active
adolescents. Inadequate water intake, holding urine, and poor menstrual and sexual hygiene were
significant etiological factors. At the end of the research it was concluded that urinary tract
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infections are a common issue during adolescence, causing discomfort and school absenteeism.
Inadequate hydration, poor sanitation, and poor menstrual and sexual hygiene increase the risk of
UTIs. Educating girls about good hygiene practices and ensuring access to clean sanitation
facilities is crucial. The study highlights the need for targeted interventions to prevent and
manage UTIs in adolescent girls.

In the year 2019, Srikala Prasad and Jessima Subahani did a study on the prevalence of urinary
tract infection among school going adolescent girls in rural part of Chennai, Tamil, Nau, India. In
the study they discussed that Urinary tract infection (UTI) can affect any part of the urinary
system, counting the kidneys, bladder, and urethra. Bacteria from the rectum or vagina can cause
UTIs. The study objectives were to assess the knowledge of adolescent girls regarding urinary
tract infection and determine the association between knowledge regarding urinary tract infection
and selected demographic variables. This observational study was done in 2017-2018 at
Department of Urogynecology, Institute Of Social Obstetrics, Government Kasturba Gandhi
Hospital, Chennai. 200 female adolescents were included in the study. There was a significant
association between prevalence of UTI and improper perineal washing technique, malnutrition,
presence of vaginal discharge and use of unsanitary pads during menses. They mention the need
is to give immediate health education about the causes, prevention, and treatment of UTI among
adolescent girls of both the villages and treatment of the identified cases with the urinary
antibiotics etc. Long term measures include a periodical screening of the adolescent girls for
UTI. UTIs are common and potentially serious bacterial infections of childhood and prevalence
varies with age, peaking in young infants, toddlers and older adolescents. In conclusion the study
stated that the prevalence of urinary tract infection is high among school going adolescent girls
in rural parts of Chennai. The risk factors include improper perineal washing technique,
malnutrition, presence of vaginal discharge and use of unsanitary pads during menses. Health
education and periodical screening are recommended to prevent and treat UTIs.

In the year 2021, Mattoo, T. K, Shaikh, N., and Nelson, C. did a research on urinary tract
infections in children and adolescents did a study that covers the definition, symptoms,
diagnosis, treatment, and prevention of UTIs in children and adolescents, with a focus on the
importance of prompt diagnosis and treatment to prevent complication: The contemporary

18
management of urinary tract infection. The key findings from these studies include: UTIs are
common especially girls, and can have serious complications if left untreated, Prompt diagnosis
and treatment are crucial to prevent complications such as renal scarring., the use of antibiotics is
essential in treating UTIs, but the overuse and misuse of antibiotics can lead to antibiotic
resistance, Prevention measures such as good hygiene and voiding habits can help reduce the risk
of UTIs. Overall, these studies highlight the importance of prompt diagnosis, effective treatment,
and prevention measures in managing UTIs in children and adolescents.

IMPLICATIONS TO NURSING

By addressing these implications, nurses can significantly improve the prevention, early
detection, and management of UTIs in adolescents, thereby enhancing their overall health and
quality of life

1. Health Promotion and Prevention: Developing and delivering health education programs in
schools and community settings will help nurses raise awareness about UTIs and their
prevention. The can also create informational materials that are adolescent-friendly and
culturally sensitive, focusing on hygiene, nutrition, and lifestyle factors.

2. Patient Education and Counseling: Nurses will health educate adolescents about proper
hygiene practices, the importance of hydration, urinating regularly, maintaining genital hygiene
and the signs and symptoms of UTIs. Providing counseling on safe sexual practices and the use
of barrier protection to reduce the risk of UTIs related to sexual activity.

3. Holistic care approach: Nurses will adopt holistic approach to care for patients that
considers the physical, emotional, and social aspects of health and well-being.

4. Comprehensive care: nurses will Collaborate with other healthcare providers, such as
pediatricians, gynecologists, and mental health professionals, to provide comprehensive care.

5. Confidentiality and Trust: nurses will establish a good and trustworthy relationship with
adolescent patients to encourage open communication about symptoms and concerns, ensuring
confidentiality to reduce stigma and embarrassment. Nurses will be trained to be sensitive and
non-judgmental when dealing with adolescents, particularly around issues related to sexual

19
health.

6. Research: nurses will support and engage in researches to better understand the prevalence,
causes, and effective treatments of UTIs in adolescents. Using evidence-based guidelines to
inform clinical practice and improve patient outcomes.

7. Effective Management and Treatment: nurses will Administer prescribed antibiotics and
educate patients on the importance of completing the full course of treatment to prevent
recurrence and antibiotic resistance. Monitoring for side effects of medications and ensuring
follow-up care to assess treatment efficacy and address any complications

8. Advocacy: Advocating for policies that improve access to confidential and affordable
healthcare services for adolescents, including sexual and reproductive health services. Nurses
and will that adolescents have access to appropriate diagnostic tests and treatments without
financial or logistical barriers.

20
 CONCLUSION

Urinary tract infections (UTIs) in adolescents are a significant health concern that necessitates
comprehensive understanding and proactive management. Throughout this seminar, we have
explored the different aspects of UTIs, including their physiological, behavioral, social, and
healthcare-related challenges. Adolescents face unique barriers in the prevention, treatment, and
management of UTIs, influenced by hormonal changes, hygiene practices, sexual activity, and
access to healthcare. Effective management requires adherence to prescribed treatments and
addressing the growing issue of antibiotic resistance. Education and awareness are crucial,
empowering adolescents with knowledge about proper hygiene, the importance of hydration, and
recognizing symptoms early. Moreover, addressing social and psychological impacts, such as
embarrassment and stigma, is essential in encouraging adolescents to seek timely medical
attention. Ensuring confidential and accessible healthcare services can mitigate barriers related to
cost and confidentiality concerns .Healthcare providers, educators, and parents must collaborate
to create supportive environments that promote healthy practices and reduce the risk of UTIs. By
implementing tailored interventions and providing holistic care, we can improve the health
outcomes and quality of life for adolescents affected by UTIs.

21
 RECOMMENDATIONS

To individual

1. Health educate adolescents and even their parents on UTIs, it’s effect, symptoms and
prevention.

2. Prioritize self care and seek support from healthcare and loved ones.

3. Lifestyle modifications such as good hygiene practice, adequate hydration, abstinence

and practice of safe sex.

Health care providers

1. Ensure appropriate antibiotics use to combat antibiotic’s resistance.

2. Educate adolescents about UTI symptoms, diagnoses, prevention and treatments.

3. Ensure appropriate antibiotics use to combat antibiotics resistance, there preventing

antibiotics misuse

4. Optimal interprofessional team collaboration significantly enhances patient outcomes.

Government

1. Launch public health campaigns to raise awareness about UTi in adolescents, its
prevention and management.

2. Ensure access to health care services.

3. Establish surveillance systems to monitor UTI incidence and antibiotics resistance.

22
REFERENCES

Ala-Jaakkola, R., Laitila, A., Ouwehand, A. C., & Lehtoranta, L. (2022). Role of D-mannose in
urinary tract infections - a narrative review. Nutrition journal, 21(1), 18.
https://doi.org/10.1186/s12937-022-00769-x

Barea, B. M., Veeratterapillay, R., & Harding, C. (2020). Nonantibiotic treatments for urinary
cystitis: an update. Current opinion in urology, 30(6), 845–852.
https://doi.org/10.1097/MOU.0000000000000821

Bass-Ware, A., Weed, D., Johnson, T., & Spurlock, A. (2014). Evaluation of the effect of
cranberry juice on symptoms associated with a urinary tract infection. Urologic
nursing, 34(3), 121–127.

Becknell, B., Schober, M., Korbel, L., & Spencer, J. D. (2015). The diagnosis, evaluation and
treatment of acute and recurrent pediatric urinary tract infections. Expert review of anti-
infective therapy, 13(1), 81–90. https://doi.org/10.1586/14787210.2015.986097

Bono, M. J., Leslie, S. W., & Reygaert, W. C. (2023). Uncomplicated Urinary Tract Infections.
In StatPearls. StatPearls Publishing.

Brookes-Howell, L., Thomas-Jones, E., Bates, J., Bekkers, M. J., Brugman, C., Coulman, E.,
Francis, N., Hashmi, K., Hood, K., Kirby, N., Llor, C., Little, P., Moore, M., Moragas, A.,
Rumsby, K., Verheij, T., & Butler, C. (2019). Challenges in managing urinary tract
infection and the potential of a point-of-care test guided care in primary care: an
international qualitative study. BJGP open, 3(2), bjgpopen18X101630.
https://doi.org/10.3399/bjgpopen18X101630

Brusch J., L. (2024). Urinary Tract Infection (UTI) and Cystitis (Bladder Infection) in Females
medscape https://emedicine.medscape.com/article/233101-overview

Cardwell, S. M., Crandon, J. L., Nicolau, D. P., McClure, M. H., & Nailor, M. D. (2016).
Epidemiology and economics of adult patients hospitalized with urinary tract infections.
Hospital practice (1995), 44(1), 33-40. https://dpi.org/10.1080/21548331.2016.1133214

23
Chu, C. M., & Lowder, J. L. (2018). Diagnosis and treatment of urinary tract infections across
age groups. American journal of obstetrics and gynecology, 219(1), 40–51.
https://doi.org/10.1016/j.ajog.2017.12.231

Devi, N., Rani, K., Kharb, P., & Prasad, M. (2021). Herbal Medicine for Urinary Tract Infections
with the Blazing Nanotechnology. Journal of nanoscience and nanotechnology, 21(6),
3495–3512. https://doi.org/10.1166/jnn.2021.19002

Edlin, R. S., Shapiro, D. J., Hersh, A. L., & Copp, H. L. (2014). Antibiotic resistance patterns of
outpatient pediatric urinary tract infections. The Journal of urology, 190(1), 222–227.
https://doi.org/10.1016/j.juro.2014.01.069

Fischbach, F., & Dunning, M. B. (2015). A manual of laboratory and diagnostic tests (9th ed.).
Philadelphia, PA: Lippincott Williams & Wilkins.

Fitzgerald, C. M., Cunningham, S. D., Berry, A., Gahagan, S., Joinson, C., Lindberg, S.,
Newman, D. K., Schmitz, K. H., Smith, A. L., Sutcliffe, S., Shoham, D. A., & Prevention
of Lower Urinary Tract Symptoms (PLUS) Research Consortium (2023). Is there an
association between physical activity and lower urinary tract symptoms in adolescent girls?
Results from the Avon Longitudinal Study of Parents and Children. International
urogynecology journal, 34(12), 2995–3003. https://doi.org/10.1007/s00192-023-05639-6.

Flores-Mireles, A. L., Walker, J. N., Caparon, M., & Hultgren, S. J. (2015). Urinary tract
infections: epidemiology, mechanisms of infection and treatment options. Nature reviews.
Microbiology, 13(5), 269–284. https://doi.org/10.1038/nrmicro3432

Flores-Mireles, A., Hreha, T. N., & Hunstad, D. A. (2019). Pathophysiology, Treatment, and
Prevention of Catheter-Associated Urinary Tract Infection. Topics in spinal cord injury
rehabilitation, 25(3), 228–240. https://doi.org/10.1310/sci2503-228

Foxman B. (2014). Urinary tract infection syndromes: occurrence, recurrence, bacteriology, risk
factors, and disease burden. Infectious disease clinics of North America, 28(1), 1–13.
https://doi.org/10.1016/j.idc.2013.09.003

Grossman, S. C., & Porth, C. M. (2014). Porth's pathophysiology: Concepts of altered health
24
 states (9th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

Grüne, B., Viehweger, V., Waldbillig, F., Nientiedt, M., Kriegmair, M. C., Rassweiler-Seyfried,
M. C., & Ritter, M. (2020). Preoperative urine culture - Is it necessary to prevent infectious
complications following ureterorenoscopy?. Journal of microbiological methods, 173,
105933

Hailay, A., Zereabruk, K., Mebrahtom, G., Aberhe, W., & Bahrey, D. (2020). Magnitude and Its
Associated Factors of Urinary Tract Infection among Adult Patients Attending Tigray
Region Hospitals, Northern Ethiopia, 2019. International journal of microbiology, 2020,
8896990. https://doi.org/10.1155/2020/8896990

Haque, R., Akter, M. L., & Salam, M. A. (2015). Prevalence and susceptibility of uropathogens:
a recent report from a teaching hospital in Bangladesh. BMC research notes, 8, 416.
https://doi.org/10.1186/s13104-015-1408-1

Hinkle, J. L., & Cheever, K. H. (2017). Brunner & Suddarth's textbook of medical-surgical
nursing (14th ed., pp. 1615-1620). Wolters Kluwer Health. ISBN 978-1496347992

Hopkins, L., McCroskey, D., Reeves, G., Smith, J., Mitchell, E., & Moore, K. (2014).
Implementing a urinary tract infection clinical practice guideline in an ambulatory urgent
care practice.The Nurse Practitioner, 39(4), 50-54. doi:
10.1097/01.NPR.0000447171.15231.41

Islam, M. A., Islam, M. R., Khan, R., Amin, M. B., Rahman, M., Hossain, M. I., Ahmed, D.,
Asaduzzaman, M., & Riley, L. W. (2022). Prevalence, etiology and antibiotic resistance
patterns of community-acquired urinary tract infections in Dhaka, Bangladesh. PloS
one, 17(9), e0274423.

Jelly, P., Verma, R., Kumawat, R., Choudhary, S., Chadha, L., & Sharma, R. (2022). Occurrence
of urinary tract infection and preventive strategies practiced by female students at a tertiary
care teaching institution. Journal of education and health promotion, 11, 122.
https://doi.org/10.4103/jehp.jehp_750_21

Keren, R., Shaikh, N., Pohl, H., Gravens-Mueller, L., Ivanova, A., Zaoutis, L., Patel, M.,
25
 deBerardinis, R., Parker, A., Bhatnagar, S., Haralam, M. A., Pope, M., Kearney, D.,
Sprague, B., Barrera, R., Viteri, B., Egigueron, M., Shah, N., & Hoberman, A. (2015). Risk
Factors for Recurrent Urinary Tract Infection and Renal Scarring. Pediatrics, 136(1), e13–
e21. https://doi.org/10.1542/peds.2015-0409

Khan, A., Jhaveri, R., Seed, P. C., & Arshad, M. (2019). Update on associated risk factors,
diagnosis, and management of recurrent urinary tract infections in children. Journal of the
Pediatric Infectious Diseases Society, 8(2), 152-159. https://doi.org/10.1093/jpids/piy065

Leung, A. K. C., Wong, A. H. C., Leung, A. A. M., & Hon, K. L. (2019). Urinary Tract Infection
in Children. Recent patents on inflammation & allergy drug discovery, 13(1), 2–18.
https://doi.org/10.2174/1872213X13666181228154940

Li, R., & Leslie, S. W. (2023). Cystitis. In StatPearls. StatPearls Publishing.

Long, B., & Koyfman, A. (2018). The Emergency Department Diagnosis and Management of
Urinary Tract Infection. Emergency medicine clinics of North America, 36(4), 685–710.
https://doi.org/10.1016/j.emc.2018.06.003

Loubet, P., Ranfaing, J., Dinh, A., Dunyach-Remy, C., Bernard, L., Bruyère, F., Lavigne, J. P., &
Sotto, A. (2020). Alternative Therapeutic Options to Antibiotics for the Treatment of
Urinary Tract Infections. Frontiers in microbiology, 11, 1509.
https://doi.org/10.3389/fmicb.2020.01509

Maharjan, G., Khadka, P., Siddhi Shilpakar, G., Chapagain, G., & Dhungana, G. R. (2018).
Catheter-Associated Urinary Tract Infection and Obstinate Biofilm Producers. The
Canadian journal of infectious diseases & medical microbiology = Journal canadien des
maladies infectieuses et de la microbiologie medicale, 2018, 7624857.
https://doi.org/10.1155/2018/7624857

Mattoo, T. K., Shaikh, N., & Nelson, C. P. (2021). Contemporary Management of Urinary Tract
Infection in children. Pediatrics, 147(2), e2020012138. https://doi.org/10.1542/peds.2020-
012138

May, M., Schostak, M., Lebentrau, S., & MR2- study group (2019). Guidelines for patients with
26
 acute uncomplicated cystitis may not be a paper tiger: a call for its implementation in
clinical routine. International urogynecology journal, 30(2), 335–336.
https://doi.org/10.1007/s00192-018-3851-8

Mayo Clinic (2022, Sept. 14). Urinary Tract Infection UTI. https://www.mayoclinic.org/diseases-
conditions/urinary-tract-infection/symptoms-causes/syc-20353447

Mboweni, R., & Sumbane, G. (2019). Factors contributing to delayed health seeking behaviours
among adolescents. Global Journal of Health Science, 11(3), 67.
https://doi.org/10.5539/gjhs.v11n13p67

Mlugu, E. M., Mohamedi, J. A., Sangeda, R. Z., & Mwambete, K. D. (2023). Prevalence of
urinary tract infection and antimicrobial resistance patterns of uropathogens with biofilm
forming capacity among outpatients in morogoro, Tanzania: a cross-sectional study. BMC
infectious diseases, 23(1), 660. https://doi.org/10.1186/s12879-023-08641-x

Moreno, M., A. (2016). Urinary Tract Infections in Children and Adolescents. JAMA
pediatrics, 170(9), 916. https://doi.org/10.1001/jamapediatrics.2016.2163

Odoki, M., Aliero A., A., Tibyangye, J., Nyabayo M., J., Wampande, E., Kato C., D., Agwu, E.,
& Bazira, J. (2019). Prevalence of Bacterial Urinary Tract Infections and Associated
Factors among Patients Attending Hospitals in Bushenyi District, Uganda. International
journal of microbiology, 2019, 4246780. https://doi.org/10.1155/2019/4246780

Okafor, C. N., & Onyeaso, E. E. (2023). Perinephric Abscess. In StatPearls. StatPearls

Publishing.

Olowe, O. A., Ojo-Johnson, B. B., Makanjuola, O. B., Olowe, R. A., & Mabayoje, V. O. (2015).
Detection of bacteriuria among human immunodeficiency virus seropositive individuals in
Osogbo, south-western Nigeria. European journal of microbiology & immunology, 5(1),
126–130. https://doi.org/10.1556/EUJMI-D-14-00036

Öztürk, R., & Murt, A. (2020). Epidemiology of urological infections: a global burden. World
journal of urology, 38(11), 2669–2679. https://doi.org/10.1007/s00345-019-03071-4

27
Parlak E. (2020). A case of glomerulonephritis caused by brucellosis. Tropical doctor, 50(4),
360–361. https://doi.org/10.1177/0049475520929505

Porat, A., Bhutta, B. S., & Kesler, S. (2023). Urosepsis. In StatPearls. StatPearls Publishing.

Prasad, T. S., & Subahani, J. (2019). Prevalence of urinary tract infection among school going
adolescent girls in rural part of Chennai. International Archives of Integrated Medicine,
6(3),278282.https://www.iaimjournal.com/wpcontent/uploads/2019/03/iaim_2019_0603_4
3.pdf

Reddivari, A. K. R., & Mehta, P. (2023). Prostatic Abscess. In StatPearls. StatPearls Publishing.

Sabih, A., & Leslie, S. W. (2023, November 12). Complicated Urinary Tract Infections. In
StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. Retrieved from
https://www.ncbi.nlm.nih.gov/books/NBK436013/

Sapkalova, V., Zhan-Moodie, S., Oberle, M., & Terris, M. K. (2023). A rare case of
emphysematous cystitis due to Candida glabrata. Urology case reports, 50, 102487.
https://doi.org/10.1016/j.eucr.2023.102487

Schaeffer, A. J., & Nicolle, L. E. (2016). Urinary tract infections in older men. The New England
Journal of Medicine, 374(6), 562-571.

Seifu, W. D., & Gebissa, A. D. (2018). Prevalence and antibiotic susceptibility of Uropathogens
from cases of urinary tract infections (UTI) in Shashemene referral hospital,
Ethiopia. BMC infectious diseases, 18(1), 30. https://doi.org/10.1186/s12879-017-2911-x

Simões E Silva, A. C., Oliveira, E. A., & Mak, R. H. (2020). Urinary tract infection in pediatrics:
an overview. Jornal de pediatria, 96 Suppl 1(Suppl 1), 65–79.

Srivastava, S. (2018). Menstrual hygiene and urinary tract infection among adolescent girls.
International Journal of Reproductive Contraception, Obstetrics and Gynecology, 7(10),
4241-4246. https://www.ijrcog.org/index.php/ijrcog/article/download/4639/3349/16363

Stein, R., Dogan, H. S., Hoebeke, P., Kočvara, R., Nijman, R. J., Radmayr, C., Tekgül, S.,
European Association of Urology, & European Society for Pediatric Urology (2015).
28
 Urinary tract infections in children: EAU/ESPU guidelines. European urology, 67(3), 546–
558. https://doi.org/10.1016/j.eururo.2014.11.007

Storme, O., Saucedo, T., J., Garcia-Mora, A., Dehesa-Dávila, M., & Naber, K. G. (2019). Risk
factors and predisposing conditions for urinary tract infection. Therapeutic advances in
urology, 11, 1756287218814382. https://doi.org/10.1177/1756287218814382

Tandoğdu, Z., Bartoletti, R., Cai, T., Çek, M., Grabe, M., Kulchavenya, E., Köves, B., Menon,
V., Naber, K., Perepanova, T., Tenke, P., Wullt, B., Johansen, T. E., & Wagenlehner, F.
(2016). Antimicrobial resistance in urosepsis: outcomes from the multinational, multicenter
global prevalence of infections in urology (GPIU) study 2003-2013. World journal of
urology, 34(8), 1193–1200. https://doi.org/10.1007/s00345-015-1722-1

Tullus, K., & Shaikh, N. (2020). Urinary tract infections in children. Lancet (London,
England), 395(10237), 1659–1668. https://doi.org/10.1016/S0140-6736(20)30676-0

Vasudevan R. Urinary tract infection: an overview of the infection and the associated risk
factors./ Microbiol Exp. 2014;1 (2):42-54. DOI: 10.15406/men.2014.01.00008

Vyas, S., Sharma, P., Srivastava, K., Nautiyal, V., & Shrotriya, V. P. (2015). Role of Behavioural
Risk Factors in Symptoms Related to UTI Among Nursing Students. Journal of clinical
and diagnostic research : JCDR, 9(9), LC15–LC18.
https://doi.org/10.7860/JCDR/2015/10995.6547

Yamaji, R., Friedman, C. R., Rubin, J., Suh, J., Thys, E., McDermott, P., Hung-Fan, M., & Riley,
L. W. (2018). A Population-Based Surveillance Study of Shared Genotypes of Escherichia
coli Isolates from Retail Meat and Suspected Cases of Urinary Tract
Infections. mSphere, 3(4), e00179-18. https://doi.org/10.1128/mSphere.00179-18

29