How to identify and avoid UTIs in older adults

Julie Manco sees plenty of female patients at Herself Health — a primary care practice for women 65 and older — who are suffering from urinary tract infections (UTIs), which are more commonly associated with heterosexual, sexually active women decades younger.

“It’s very prevalent, a common issue,” says Manco, doctor of nursing practice and a nurse practitioner at Herself Health in the Highland Park neighborhood of St. Paul, one of five clinics in the Twin Cities metro area.

About 10% of older women will have a UTI in any given year, research shows. The difficulty in diagnosing the infection is that it tends to present differently as women age.

Manco’s patients, whom she characterizes as a “young 65 and older population,” may lack the typical symptoms of “burning pee” or back pain. Instead, she explains, in addition to an urgency to urinate, older women with a UTI may have fallen unexpectedly or become mentally confused — or “something else that you would not normally relate to a UTI.”

A key reason, says Dr. Melissa Urrea, chief medical officer at Herself Health, is overall vaginal health. Progesterone and estrogen levels drop as women enter menopause, often in their late 40s. Loss of hormones results in “thinning, drying and inflammation of the vaginal walls,” according to the Mayo Clinic. This natural part of aging, which the medical establishment has long called vaginal atrophy, can set women up for recurring bladder infections or more serious UTIs.

Urrea balks at the word “atrophy.” She prefers the term GSM, short for genitourinary syndrome of menopause, because it sounds less “blaming” and more inclusive. “A UTI is a symptom of a larger picture,” the Austin, Texas–based physician explains, which may include a weakened pelvic floor, aging tissues, weaker muscles and a changing environment for bacteria.

Whether a woman had children vaginally or through a C-section, had ovarian cancer, ever had radiation or chemotherapy or experienced trauma through sexual assault: All will affect her vaginal health once she is older.

“GSM is a progressive chronic condition,” Urrea says. “If you treat the GSM and not just the UTI, you’re [positively] affecting that person’s quality of life in terms of reducing falls, better sleep, more cognitive health.” In lay terms, that means treating the whole person and taking the time to hear women’s stories. “We are fluid and dynamic creatures,” she explains.

For older women, especially those in nursing homes or other long-term care facilities, UTIs can be fatal if they lead to a stronger infection in the kidneys called urosepsis. “That’s the far end of the spectrum, but it puts an exclamation mark on it,” says Sandy Hart, a certified nurse midwife in the Twin Cities, now retired. She started the Menopause Center of Minnesota in St. Paul when she was middle-aged and became well enough known that a doctor-and-nurse team in St. Joseph, Mo., brought her in to consult on their study of UTIs in older women, especially in care facilities.

“They saw a dramatically high incidence of asymptomatic UTIs in older women,” Hart recalls. “That means the infection is there and can ascend toward your kidneys. As it advances, the infection throws off the balance of electrolytes. Women die, because they’re so sick by the time they exhibit symptoms.”

Her own mother, who lived in Arkansas, was hospitalized with a UTI that antibiotics could not kick. That was reportedly the case for former First Lady Rosalynn Carter, who died two days after entering hospice. Hart’s mother went into a coma and never regained consciousness.

Drinking enough water to avoid a bladder or urinary tract infection — the former is the less serious, most common type of UTI — can be a challenge among older people. Men and women alike may lose their sense of thirst, says Nancy Haugen, president of the board of Minnesota-based Elder Voice Advocates. Haugen is a registered nurse with a master’s degree in mental health nursing.

If the person has dementia — or just the forgetfulness that comes with age — they may not remember when they last drank, Haugen says, or they think: “I don’t need the water because I drank my coffee.” Older women, she adds, may deliberately drink less because they’ve lost bladder control and want to avoid urine leakage — or they’re less mobile and can’t get to the bathroom as easily anymore.

Urrea cautions against avoiding urination. “When you have to go, go,” she says. “That urine is toxic. It needs to get out of your body.”

Men suffer bladder infections, too, though often less severe and in lower numbers. According to WebMD, “about 12% of men will get a UTI at some point,” usually after age 50.

Because women have shorter urethras than men, they’re more prone to have E. coli — the bacteria that live in the intestines — travel up to the bladder and cause infections. Wiping front to back after a bowel movement is the standard recommendation. “This is not something people want to talk about,” Haugen says. Nor is it something that hurried caregivers in a nursing home always pay enough attention to, she adds.

As women age, the advice for avoiding UTIs remains the same tried-and-true reminders that I received four decades ago, when I was in my 20s and dealing with recurring infections from bicycling in jeans with a thick crotch seam:

Many health care professionals recommend pelvic floor exercises, though one physical therapist says that a simple Kegel exercise is oversold as a solution to UTIs. Instead, squats and lunges “activate the pelvic floor more,” says Hannah Strom, a doctor of physical therapy who founded Awake Pelvic Health & Wellness in Woodbury. Strom also swears by yoga poses such as bridge, which double as bone-strengthening exercises, too.

The advice I never heard as a young woman was what Herself Health promotes: Establish a strong relationship with a health care professional who will take the time to listen and learn your history. That becomes more financially possible once women are old enough to be on Medicare, Urrea adds.

“These conditions are not women’s fault,” she says. “You didn’t eat the wrong foods, live on the wrong side of the tracks. Our mantra is this: We want to see you more frequently, so you stay well.”