Urinary tract infection as a possible marker for teenage sex.

ABSTRACT

Background. Pediatric urinary tract infections (UTIs) are markers for genitourinary reflux or obstruction. Adult UTIs are treated by telephone triage without microbiologic study. The contrast between pediatric and adult UTIs prompted our retrospective review of adolescent UTIs.

Methods. Ninety-six adolescent girls without chronic illness, urogenital abnormalities, pregnancy, enuresis, or constipation had urine cultures with 100,000 colonies/[mm.sup.3].

Results. The 32 patients who were initially sexually active continued sexual activity (75%), became pregnant (25%), and had subsequent sexually transmitted diseases (STDs) (13%). There were no pregnancies, STDs, or subsequent UTIs in 9 patients who were not initially sexually active. The 55 patients with no documentation of sexual activity were comparable to those who were initially sexually active: 66% had evidence of sexual activity; 20% had subsequent pregnancy; 14% had subsequent STDs; and 42% had UTI recurrence.

Conclusion. Adolescents with UTIs have a significant frequency of sexual activity. Information about responsible sexual activity and access to care is important to adolescents, particularly those with UTIs.

**********

IN PEDIATRIC PATIENTS, urinary tract infections (UTIs) are viewed as markers for anatomic abnormalities, resulting from urinary obstruction or vesicoureteral reflux. (1-3) In contrast, adult women having acute cystitis may be treated by telephone triage for 3 days, without a microbiologic study. (4) In healthy women between the ages of 18 and 40 years, there is a positive association between the frequency of sexual intercourse and the frequency of UTIs, hence the term "honeymoon cystitis." (5,6) The contrast between the pediatric UTI experience and that of adults raises questions about the relationship of sexual activity to UTI for adolescents. We studied adolescent girls to measure the relationship of UTIs retrospectively to sexual activity.

METHODS

The study design involved a retrospective chart review of female adolescents between 10 and 18 years old with a diagnosis of UTI between January 1, 1996, and December 31, 1998. The study was approved by the Institutional Review Board at Scott & White Hospital in Temple, Texas. Medical information was obtained through the Scott & White system of computerized visit and laboratory reports. Patients included in the study were treated in the Scott & White Clinic and Hospital system (pediatric, family medicine, obstetrics and gynecology, or medicine clinics, the emergency department, or the hospital), and had confirmed urine culture of more than 100,000 colonies/ [mm.sup.3]. Initial sampling of patients from the Computerized Data Analysis Laboratory at Scott & White Clinic and Hospital identified 667 separate patient encounters for UTI; many patients had multiple encounters, particularly those with anatomically abnormal genitourinary systems. Patients were excluded if they had chronic illnesses (eg, cystic fibrosis , cerebral palsy, seizure disorders, diabetes, sickle cell disease) or known urogenital abnormalities (eg, vesicoureteral reflux, spina bifida), if they were pregnant at the time of UTI diagnosis, or if they had enuresis or constipation. Study variables included sexual activity, previous UTIs, and STDs. After inclusion and exclusion criteria were applied, 96 adolescent girls were enrolled in the study.

RESULTS

The average age was 16.1 years (range, 11 to 18 years), and 33% were 18 years old; 83% were aged 15 or older (Table 1). Of the 96 patients, 63 were white, 14 were black, 9 were Hispanic, and 10 were mixed/other. The dominant organism found was Escherichia coli with occasional Citrobacter, Klebsiella, or Staphylococcus species. Sexually transmitted diseases were chlamydiosis, trichomoniasis, gonorrhea, or herpes simplex virus 2. Comorbidity was absent, consistent with exclusion criteria, Of the 96 patients, 32 (33%) were sexually active at the time their UTI was diagnosed, 9 (9%) denied sexual activity, and 55 (57%) had no documentation of sexual activity at the time of initial UTI treatment. Subsequently, of those patients who were initially sexually active, 75% (24/32) continued sexual activity and 25% (8/32) became pregnant within 2 to 28 months of diagnosis. The recurrence rate for UTI in patients with continued sexual activity was approximately 40%; 4 of 32 (13%) had subsequent STDs (Table 2). There were no pregnancies, STDs, or history of subsequent UTI in the group of patients who initially denied sexual activity. The group with no documentation of sexual activity was comparable to the group who were initially sexually active (Table 2). Eighteen of the 55 (33%) had no evidence of further sexual activity, 11 (20%) had subsequent pregancy, 6 (14%) had subsequent STD, and 23 (42%) had at least one UTI recurrence.

DISCUSSION

Pediatric UTIs without vesicoureteral reflux (VUR) or obstructive uropathy are seldom associated with renal scarring (reflux nephropathy) or with deteriorating renal function. (2) Conversely, focal or generalized renal scarring from UTIs is associated with VUR or urinary obstruction. Renal insufficiency from reflux nephropathy progresses to renal failure and leads to dialysis or renal transplantation. The frequent occurrence of VUR or obstruction presenting as UTIs in small children prompts pediatric care providers to a heightened suspicion of VUR or obstruction. In contrast, 42% of adolescents have sexual experience by 16 years of age and 71% by 18 years of age. The national average age for first sexual intercourse for females is 16.2 years and for males, 15.7 years. (7) In adult women, UTIs may be related to sexual activity and treated by telephone triage with 1 to 3 days of antimicrobial drugs and without a microbiologic study. (4) Remis et al (5) found that the risk of having a UTI was 40 times higher in sexually active women than in abstinent women and that there is a dose-response relationship between UTIs and coital frequency. Foxman et al (6) found that 50% of all women have had a UTI by their late 20s. Engaging in vaginal intercourse once versus not at all increased the risk of UTI by 90%. (6) The distal female urethra is colonized with enteric and perineal organisms. Retrograde extension to the bladder occurs by several mechanisms, ie, trauma, intercourse, masturbation, and turbulent flow. (8) Simple cystitis is usually not associated with uropathy. (2) However, STDs are found in a significant number of patients with lower UTIs treated in emergency departments. (9) In small children, symptoms of cystitis may not be readily discernible or distinguishable from upper tract symptoms. The contrast between the pediatric UTI experience and that of adults raises questions about the relationship of sexual activity for adolescents with UTIs.

This study indicates that adolescents with UTIs have a significant frequency of sexual activity at the time of diagnosis or subsequently, increasingly so as they approach adulthood. Similar findings have been described in hospitalized adolescents with clinical upper tract infection. (3) In our sample, the concurrent and subsequent rate of sexual activity was 66 of 96 (69%). The 95% confidence interval of 58% to 78% probably underrepresents the true frequency of concurrent or subsequent sexual activity. There may not have been complications, care may not have been sought, or patients may have been seen outside the Scott & White system. The personal and societal costs of teen pregnancy and STDs are much greater than the costs of UTI. However, the frequency of current/subsequent sexual activity and the rate of subsequent pregnancy and STD indicates that adolescent UTI should be treated as a possible marker for adolescent sexual activity and may represent another complication of sexual activity. (3,10) The practi tioner should explore in detail the sexual history and then provide diligent counseling and follow-up.

Sexual activity history may or may not have been sought in those cases for which it was not noted. Those patients subsequently showed medical evidence of sexual activity with the same frequency as those admitting to sexual activity initially. Those whose denial of sexual activity was documented showed a disparate frequency of complications or markers compared with either of the other groups.

Our study lacks a control group, ie, teenagers with complications of sexual activity without UTIs, the abstinent group without UTI, and the sexually active without UTI. Patients with complicated UTI were excluded. Our study does not address the role of unsuspected sexual activity in teens with complicated UTIs. Finally, it remains to be shown if vigorous counseling of UTI patients for responsible sexual activity will alter the frequency of subsequent UTI or the complications of continued sexual activity.

In summary, although limited by the absence of suitable control samples, our study argues that UTI in an otherwise healthy adolescent is frequently associated with complications of sexual activity. (3,10) Information about responsible sexual activity and how to access further care is important to all adolescents, particularly those with UTIs.

TABLE 1

Age Distribution of Adolescent Patients With Urinary Tract Infection

Age  No. of Patients

11          2
12          4
13          5
14          5
15         13
16         17
17         18
18         32
TABLE 2

Similar Frequency of Subsequent Pregnancy, Sexually Transmitted Disease,
and Urinary Tract Infection in Patients Having UTI With and Without a
History of Sexual Activity

                                           Subsequent Outcome

Sexual History                     STD           Pregancy  UTI

Denied sexual activity initially    0               0       0
 (9/96)
Initially sexually active (32/96)  13%             25%     40%
Initially no information (55/96)   14%             20%     42%

References

(1.) American Academy of Pediatrics Practice Guideline. The diagnosis, treatment, and evaluation of the initial urinary tract infection in febrile infants and young children (AC9830). Pediatrics 1999; 103:843-852

(2.) Marks MI, Arrieta AC: Urinary tract infections. Textbook of Pediatric Infectious Diseases. Feigni RD, Cherry JD (eds). Philadelphia, WB Saunders Co, 4th Ed, 1998, pp 483-503

(3.) Weir MR, Lampe RM: Urinary tract infections in children. Am Fain Physician 1984; 29:147-153

(4.) Hooton TM, Stamm WE: Diagnosis and treatment of uncomplicated urinary tract infection. Infect Dis Clin North Am 1997; 11:551-581

(5.) Remis RS, Gurwirth MJ, Gurwirth D, et al: Risk factors for urinary tract infection. Am J Epidemiol 1987; 126:685-693

(6.) Foxman B, Geiger AM, Palin K, et al: First-time urinary tract infection and sexual behavior. Epidemiology 1995; 6:162-168

(7.) Jadack RA, Keller ML: The development of sexual risk taking in adolescence. Annu Rev Nurs Res 1998; 16:117-138

(8.) Bowie WR, Floyd JF, Miller Y, et al: Differential response of chlamydial and ureaplasma-associated urethritis to sulphafurazole (sulfisoxazole) and aminocyclitols. Lancet 1976; 2:1276-1278

(9.) Berg E, Benson DM, Haraszkiewicz P, et al: High prevalence of sexually transmitted diseases in women with urinary infections. Acad Emerg Med 1996; 3:1030-1034

(10.) Weir M, Brien J: Adolescent urinary tract infections. Adoles Med 2000; 11:293-313

RELATED ARTICLE: KEY POINTS

* Adolescents with urinary tract infections (UTIs) have concurrent or subsequent sexual activity with complications.

* Adolescents with UTIs and a history of sexual abstinence lack frequent subsequent pregnancies, sexually transmitted diseases, or UTIs.

* Adolescents should know about access to care and about recognition, treatment, and prevention of complications of sexual activity.

From the Department of Pediatrics, Scott & White Clinic and Memorial Hospital, Scott, Sherwood and Brindley Foundation, Texas A&M University Health Science Center, College of Medicine, Temple.

Supported by the Computerized Data Analysis Laboratory Research and Education grant No. 1596, Scott & White Clinic.

Reprint requests to Michael Weir, MD, Scott & White Clinic, 2401 S 31 St, Temple, TX 76508.