Urinary and sexually transmitted infections

Urinary tract infections and sexually transmitted infections are two of the most common reasons people come to a gynecology office, and both are frequently handled poorly - treated over the phone without a culture, or tested for incompletely. A first, straightforward bladder infection can reasonably be treated quickly. A repeat infection deserves a culture and an explanation. STI screening here is routine, confidential and free of commentary about your life. Because our group includes urology in the same practice, a urinary problem that needs a deeper workup does not have to be sent elsewhere and started over.

Three different problems that all get called a UTI

Uncomplicated cystitis is a bladder infection in a non-pregnant person with a normal urinary tract: burning, urgency, frequency, sometimes blood in the urine, and no fever or flank pain. In a healthy person having a first episode, it is reasonable to treat promptly with a short course of a narrow-spectrum antibiotic. A complicated infection is the same organism in a setting that changes the calculation - pregnancy, poorly controlled diabetes, a stone, a catheter, an anatomic abnormality, immune suppression, or recent instrumentation. Those infections are less predictable, more often resistant, and a poor candidate for a prescription issued blind.

Pyelonephritis is infection that has reached the kidney, and the tell is systemic rather than local: fever, chills, flank pain, nausea, feeling genuinely unwell rather than merely irritated. It should be seen the same day, because the antibiotic choice differs, the course is longer, and a few people need intravenous treatment rather than pills. If you have bladder symptoms and then spike a fever, that is a different problem rather than a worse bladder infection, and the timeline matters.

Why the culture is worth an extra day

A dipstick tells us there is inflammation and probably bacteria. A culture tells us which organism is there and what it is actually susceptible to. Treating while the culture runs is sensible for a first straightforward episode, but for a second episode within six months, an infection that did not clear, a prior resistant organism, or pregnancy, guessing is the wrong instinct. Resistance among common urinary organisms has risen enough that an antibiotic which worked reliably a decade ago is no longer a safe assumption.

The other reason to culture is that not everything that burns is an infection. Vulvar irritation, yeast, bacterial vaginosis, herpes, interstitial cystitis and the tissue changes of menopause all produce symptoms a reasonable person reads as cystitis. A negative culture is information rather than a dead end, since it redirects the evaluation instead of committing you to a third antibiotic that cannot help. Repeated courses aimed at something that is not bacterial also damage the vaginal and gut microbiome.

Recurrent urinary tract infection

Recurrent UTI usually means two culture-proven infections in six months or three in a year. It deserves a structured evaluation rather than an open standing prescription. The first step is documentation, because a good share of what gets labeled recurrent UTI turns out to be one unresolved infection, or a run of negative cultures treated anyway. After that the history does most of the work: the relation of episodes to intercourse, contraceptive method, bowel habit, menopausal status and stones.

What the workup includes

For most people the evaluation is modest: cultures taken during actual episodes, a measurement of how completely the bladder empties, and a pelvic exam. Imaging and cystoscopy are not needed for everyone, and testing everybody for everything is not thoroughness but a way to generate incidental findings that lead nowhere. They become appropriate with blood in the urine between infections, an unusual organism that keeps reappearing, a history of stones or urinary surgery, or a pattern that does not fit.

Prevention, honestly rated

Some preventive measures have solid evidence behind them, some are plausible, and some are folklore repeated often enough to sound official. The list runs roughly in order of how well each holds up, which is not the order in which they are usually recommended. None of them substitutes for working out why the infections are happening.

• Vaginal estrogen after menopause - the best-supported item here, and the one most often skipped.
• Post-coital single-dose prophylaxis when episodes clearly follow intercourse, which keeps total antibiotic exposure low.
• Continuous low-dose prophylaxis for a defined period - effective while taken, at the cost of resistance, so a bridge not a destination.
• Methenamine hippurate, a non-antibiotic urinary antiseptic, in selected patients.
• More fluid, in people who currently drink very little - a modest but genuine effect.
• D-mannose and cranberry - harmless and popular, on evidence far weaker than the packaging implies.

After menopause, this is usually not a bladder problem

Recurrent infection that begins in the years after menopause is usually a manifestation of genitourinary syndrome of menopause. Falling estrogen thins the vaginal and urethral tissue, raises vaginal pH, and drives out the lactobacilli that keep the local environment hostile to bowel organisms. Urgency, frequency, discomfort with sex and repeated infections all come from that one change, which is why treating each episode separately never gets anywhere. Low-dose vaginal estrogen addresses the cause, carries minimal systemic absorption, and takes several weeks to work - which is why women give up on it too soon.

A recurrent urinary tract infection is a question, not a diagnosis. The useful work is finding out why it keeps happening, and after menopause the answer is often not in the bladder at all.

When infections continue despite a sound preventive plan, or the workup points to something structural, the next step is urology. Our urologists are part of the same physician-owned group, so that referral is an internal handoff rather than a fresh start. You keep the same chart and the same culture history, and you do not wait months for a new-patient slot across town.

Testing for sexually transmitted infections

The most important fact about sexually transmitted infections is that most produce no symptoms at all. Chlamydia in particular is usually silent, which is why it is found by screening rather than complaint, and why an untreated case occasionally surfaces years later as pelvic inflammatory disease or tubal infertility. Screening here is age- and exposure-based rather than moralistic: annual chlamydia and gonorrhea testing for sexually active women under 25, and for women 25 and older with a new partner, more than one partner, or a partner who has others. HIV testing is recommended at least once for every adult and repeated by exposure, and syphilis testing is broadly reasonable again as rates have climbed.

The testing itself is undramatic. Chlamydia and gonorrhea are molecular tests run on urine or on a vaginal swab you can collect yourself, and throat or rectal testing is added where relevant, since a genital-only test misses those sites. Trichomonas is found on the same kind of test, and HIV, syphilis and hepatitis are blood draws. Herpes blood testing is not part of routine screening for people without symptoms, because a positive result in someone with no history is hard to interpret and often causes more distress than it resolves.

We will ask direct questions about which sites are exposed and about partners, because the answers determine which tests to order and nothing else. There is no version of this visit in which you are lectured, and no assumption is made about your relationships. Most of these infections are cured with antibiotics and the viral ones are managed, so a positive result is a treatable clinical finding and nothing beyond that.

Partners and reinfection

Treating you and not your partner is the main way people end up infected twice. Partners from roughly the preceding two months should be tested and treated, and where a partner cannot realistically get to a clinician, expedited partner therapy - treatment provided for them without a separate visit - is permitted in New York and we will use it where it fits. Gonorrhea is more constrained, since the recommended treatment is an injection. Retesting about three months later is advised for chlamydia, gonorrhea and trichomonas, because reinfection is common.

Where HPV fits

Human papillomavirus is the most common sexually transmitted infection, and in most people it is transient and cleared within a year or two. It is not part of a routine STI panel, because a positive result usually changes nothing beyond what cervical screening already covers. HPV testing has a specific role alongside the Pap, where the viral type and whether it persists determine how closely you are followed, and an abnormal screen leads to colposcopy.