Desmopressin for enuresis.
Authors: S. R. Meadow, J. H. Evans
Journal: BMJ (1989)

Four times as many baby boys have covert bacteriuria as girls,3 and infections, whether causing symptoms or not, should be thoroughly investigated because of the high pro- portion of associated urological abnormalities, such as reflux, stones, and obstruction.'Investigations include ultrasono- graphy, followed in selective cases by urography and cystography.Treatment of any infection will depend on the urinary pathogen and any underlying structural abnormality.Proteus species and other less common Gram negative bacilli may be found more often in boys (especially in those who are uncircumcised)5 and management will require close co- operation between laboratory and doctor.Urinary symptoms in men aged between 15 and 55 should prompt a thorough search for their cause.Cystitis due to Gram negative or Gram positive organisms is uncommon and possibly related to the low rate of covert bacteriuria (0-5%),6 but dysuria and frequency with or without urethral discharge may be caused by urethritis due to Neissenia gonorrhoea, Chlamydia trachomatis, and possibly Mycoplasma hominis or Ureaplasma urealyticum.Such patients should be managed in a genitourinary clinic.Reports from the United States that urinary infections are more common in homosexual than in heterosexual men78 have not been confirmed in Britain.9The prevalence and incidence of urinary infections among patients with AIDS are unknown.Genitourinary tract infections apart, there remains a group of patients with prostatitis with or without epididymitis whose condition is difficult to define, diagnose, and manage.'0The prevalence of prostatitis is unknown, and diagnosis by the four glass method" is not widely practised.Culture of prostatic secretions or semen may yield a positive diagnosis.Most clinicians, however, rely for diagnosis on a combination of symptoms (backache, fever, frequency, and dysuria), prostatic tenderness, and positive results on culture of urine (attempts to culture chlamydia should be made).Treatment is aimed at achieving adequate antibacterial concentrations of agents such as erythromycin, cotrimoxazole, or tetracycline (rather than 3 lactam antibiotics).Treatment should continue for at least two and probably four weeks.Patients who have frequent relapses or in whom infection is difficult to clear may be suffering from "chronic prostatitis" and will require longer courses of antibiotics or, as a last resort, surgery.Men with urinary tract infections due to conventional pathogens should always be investigated as urological abnormalities are likely to be present.'2Recurrent infections, unusual organisms, and early relapse also suggest structural abnormalities of the urinary tract.Single doses or short courses of antimicrobial drugs are probably wrong, and treatment for two weeks is recommended.Patients with sterile pyuria or haematuria also merit investigations to exclude tuberculosis, malignancy, stones, and, when appro- priate, schistosomiasis.The prevalence of covert bacteriuria increases with age, approaching one in four men over the age of 70'3 and is even higher in institutionalised elderly patients."'Predisposing factors include instrumentation of the urinary tract, prostatic hypertrophy, the presence of urethral catheters, dementia, and concurrent infections such as pneumonia.The presence of infection has prompted studies of long term antimicrobial prophylaxis,'4 which have concluded that routine treatment, short term or long term, is not justified in patients with asymptomatic bacteriuria.Treatment should be reserved for patients with symptoms, including those with bacteraemia, or before operations on the urinary tract.