Comprehensive assessment of holding urine as a behavioral risk factor for UTI in women and reasons for delayed voiding

The bacterial colonizers at the urethral opening are flushed out by micturition. Urinary tract infection (UTI) is an inflammation of the urothelium as a result of pathogenic invasion, affecting lower and upper urinary tract. [1]. Women have a greater predilection for UTI. In the age group of 16–35, women are 35 times more likely to be affected by UTI than men [1]. Higher susceptibility in women is a function of basic anatomic factors (shorter urethra and its proximity to bacterial reservoirs in the rectum and vagina) as well as behavioral factors [1]. Behavioral factors help microbial uropathogens capitalize on female anatomic vulnerability [2]. Urinary tract infections (UTIs) in otherwise healthy individuals with no structural or neurological abnormalities are termed as uncomplicated UTIs that are differentiated into cystitis (lower UTIs) and pyelonephritis (upper UTIs) [3]. Typical symptoms of a lower urinary tract infection include urgency, frequency and dysuria. Several risk factors have been reported to be associated with lower UTIs (particularly women) including socio-demographic factors [4], age, history of UTI, and diabetes [5] caffeinated beverage consumption and alcohol [6], inadequate water intake [7], sexual activity [8], international travel [9], lifestyle factors and co-morbidities [10], spinal cord injury and catheterization [11]. The term UTI in this study is used to represent lower UTI (Cystitis).

Apart from the above mentioned factors, behavioral risk factors are also associated with UTI in women. Sedentary lifestyle > 6 h/day, delayed voiding and sanitary hygiene were associated with an increased risk of recurrent UTI in postmenopausal women [12]. We have explored to assess the other associated potential risk factors for UTI in women like behavioral features and attitude. We hypothesized that if a woman delays urination by holding urine on regular basis for various reasons, it increases her chances of suffering from UTI multifold. We undertook a research study to test this scientifically with statistical analysis and also to find out the different reasons behind holding urine. We conducted epidemiological survey among institutionalized women students followed by microbiological analysis of uropathogens. Although with low morbidity lower UTIs resolve quickly, there are certain issues related to it and hence they must not be ignored. One is economic burden and the other is the propensity to recur. Apart from this, the bacterial pathogen may ascend and cause upper urogenital tract infections which are serious and can be fatal [13].

The most dominant causative agent for both uncomplicated and complicated UTIs is uropathogenic Escherichia coli (UPEC). In uncomplicated UTIs, for the causative agents involved UPEC is followed in prevalence by Klebsiella pneumoniae, Staphylococcus saprophyticus, Enterococcus faecalis, group B Streptococcus (GBS), Proteus mirabilis, Pseudomonas aeruginosa, Staphylococcus aureus and Candida spp. [3].

One of the objectives of the current study was to assess the prevalent organisms in our campus and their drug susceptibility pattern as UTI pathogen spectrum and their drug resistance pattern vary according to geographical location.

Our study provides insight about the symptomatic detection of UTI in young women from self-reported symptoms and its correlation with proposed risk factors like personal behavioural features and attitude about their personal health and as well as their menstrual hygiene. Various aspects of epidemiology of UTI in college women is studied by Foxman et al. like menstrual protection and intimate hygiene [20‐22]. UTI among college students is studied by different groups for prevalence, drug resistance and associated risk factors. [7, 17, 23].

Although we believe that holding back of urine for long time increases the chances of UTI by increasing the growth of microbes in bladder, but there is no scientific and statistical evidence in published literature till date. We hypothesized that holding urine is one of the major risk factor of UTI. We were also curious to know the possible reasons for holding urine.

In this study first time statistical information about attitude of women towards personal health and holding urine (delaying urination) on regular basis was obtained. The most interesting finding of the current research work is that there is a significant relationship between holding urine and prevalence of UTI. Women admitted to hold urine “always” or “sometimes” due to various reasons. Some of them are beyond their control and under those circumstances they are helpless like: during long non-stop travels with no washroom facilities are not available; 88.8% of women report to hold urine under such conditions. Similarly, unavailability of ladies’ toilets in public places was also found to be reason for 87.4% of women to hold urine. Apart from these infrastructural inadequacies, women reported to hold urine for other reasons too which are indicative of their attitude. 90.7% of women prefer to delay urination even if public toilets are available because they think that the sanitary conditions of public toilets are not agreeable to them. Cleanliness is a subjective term and apparently majority of women have fussy attitude towards use of public toilets. Holding urine once may not predispose a woman to UTI as harboured pathogens near urethral opening are flushed out in the process of micturition. If a woman makes it habit to hold urine for one or the other reason, it would give enough time for a bacterial pathogen to ascend and cause infection of kidneys which can be a serious health concern or even fatal. Periurethral colonization with the causative bacterial strain increases incidence rate of UTI [1]. rUTI can occur either by ascending reinfection (the source is outside genitourinary tract) or by reinoculation (the source is within genitourinary tract). Based on the outcome of our studies, we would recommend that women should not hold urine from voiding; by doing so and implementing other corrective behavioural measures they can minimize the risk of UTI and rUTI.

There are reports that comment that avoidance of urine holding isn’t a demonstrable beneficial risk reduction strategy [1]. Delayed voiding has been reported to be a behavioural risk factor of recurrent urinary tract infection in Chinese postmenopausal women [24]. Our research clearly indicates that urine holding on regular basis is associated risk factor for UTI in women. We also investigated in detail the reasons for holding urine some of which are related to infrastructural issues like that of unavailability of toilets but some attribute to the fastidious outlook of women.

On urine analysis, amongst 20 isolates 9 were antibiotic resistant. Drug resistant UTI are responsible for longer stay in hospitals, increased expenses, higher rates of treatment failures, and mortality [25]. Independent research studies by Hsueh et al. [26] and Tandogdu and Wagenlehner [5] emphasized on epidemiological data on local resistance patterns as according to geographical location UTI pathogen spectrum and their resistance to common antibiotics vary [5, 26]. In Peru, ESBL (extended-spectrum b-lactamase) E. coli accounted for more than 40% of CA (community acquired)—UTIs during 2015 [27]. In Hungary treatment of drug resistant uropathogens Citrobacter, Enterobacter, and Serratia species (CES bacteria) is challenging for clinicians [28].

Data from 13 countries in the Asia–Pacific region shows that antibiotic resistance is a serious problem [29]. In the Asia–Pacific region, around 33% of urinary E. coli isolates exhibited ESBL-resistance with highest prevalence in India (60%), High level of drug resistance present a therapeutic challenge. For selection of empiric therapy for UTI, accurate population surveillance data with updates is needed [11]. These results underline the importance of antimicrobial stewardship [25]. Urinary isolates of E. coli with ESBL resistance is reported from France [22, 30], Thailand [31], India [32, 33] and other countries. A retrospective analysis of around 50,000 hospitalised patients with UTI indicates the presence of organisms resistant carbapenem which are used as “antibiotics of last resort” to treat drug resistant bacteria [34]. This not only has worse outcomes but also alarms the worrisome situation for UTI therapy. The resistance to the commonly prescribed drugs warrants antibiotic stewardship and implementation of GLASS (Global Antimicrobial Resistance Surveillance System) launched by World Health Organization (WHO). To limit emergence of drug resistant microorganisms and to maximize clinical cure antimicrobial stewardship is required [25]. Implementation of GLASS in Thailand in 2015 has been found to be more beneficial than laboratory-based surveillance [32]. At the same time, alternative treatments that are rationally designed are need of the hour. Perturbations/dysbiosis in the urogenital microbiome [35] are associated with UTI implying that correcting dysbiosis could possibly be an effective preventive measure for UTIs and rUTIs.

One more thing to be noticed in this context is attitude of women towards their own health. Though many of the participants responded with answer that the UTI symptoms are serious enough to consult a doctor (72%) but interestingly very few (32%) of them actually have seen a doctor in the past in such case (Fig. 3) that indicates why we could get isolate of MDR (multiple drug resistant) uropathogens from the participants.

Our data suggests that women are negligible about their personal health. Qualitative interview study conducted by Leydon et al. in UK on women’s views on UTI found that women prefer to wait and self-manage UTI since onset of symptoms before visiting a doctor [36]. It was also found that women avoid taking antibiotics and they attribute their UTI to poor cleanliness and negligence.

In younger women recurrence of UTIs within 6 months is common. Recurrent UTIs (rUTIs) present societal as well as personal burden. The psychological effects have a negative impact on quality of life (QoL) and self-esteem in young women. Recurrent UTIs are associated with symptoms of anxiety and depression [37]. To minimize the incidence of UTIs and rUTIs, it is important to have data on prevalence of the infection and associated risk factors in a given population. This can help to devise intervention and/or awareness programs if suitable. In a study conducted at Boston, USA, depressive symptoms were associated with increased odds of lower UTI across all sex and racial/ethnic groups [10]. Girls are more prone to develop renal scars as a result of recurrent UTIs in comparison with boys [35]. Therefore, it is important to identify young women at high risk for recurrent UTIs and develop interventions to minimize the risk of rUTIs. A (Theory of planned behavior) TPB-based educational awareness talks on promoting the preventive behaviors of UTI was found to be effective in minimizing UTI in Iran [38], we recommend using such strategy as a trial in institutionalized stays. The study limitation is that it was done using a single site (university campus) with a limited age group range and it cannot be used to generalize the results of the study for the entire women population. As information about signs and symptoms of UTI was provided by the participants was entirely self-reported, possibility of bias cannot be ruled out. Additionally, larger number of samples should be analyzed to create data on uropathogens spectrum and understand their antimicrobial resistance pattern.

The prevalence of UTI among the participants was found to be 24.3%. In conclusion, there are substantial burdens of UTI in the hostel-dwelling women population, prompting growing interest in the issues of UTI. The results showed that holding back urine and persnickety attitude towards use of public facilities are significantly associated with UTI. Effective preventive measures to reduce the prevalence of MDR-UTI are needed. The study limitation is larger number of samples should be analyzed to create data on uropathogens spectrum and their antimicrobial resistance.