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Urine infection in third trimester: UTIs During Pregnancy: Symptoms, Treatment, Common Questions

UTIs During Pregnancy: Symptoms, Treatment, Common Questions

Urinary tract infections (UTIs), also known as bladder infections, are the most common type of bacterial infection diagnosed today, according to research published in the American Journal of Medicine. Roughly 31 percent of pregnant women will have either a symptomatic or an asymptomatic (without symptoms) UTI during pregnancy, research suggests. UTIs occur when bacteria enters into the usually sterile urinary tract and multiplies, causing painful urination and other symptoms. Certain factors during pregnancy make this occurrence more likely to happen. Here’s what you need to know to keep you and your baby healthy.

RELATED: 8 Home Remedies for Urinary Tract Infection (UTI) Symptoms

Why Are UTIs Common in Pregnant Women?

When you’re pregnant, the anatomy of your urinary tract actually changes. For instance, your kidneys become larger and your growing uterus can compress your ureters and bladder. Because of this compression, fully emptying your bladder during pregnancy becomes more difficult. In addition, your progesterone and estrogen levels increase during pregnancy, which can weaken your bladder and ureters. Pregnancy also alters the makeup of your urine, reducing the acidity and increasing the amount of protein, hormones, and sugar in your urine. That excess sugar, for one, can encourage bacterial growth. All of the above contribute to a heightened chance of developing a UTI in pregnancy. And that is why it’s recommended that all pregnant women receive a urinalysis and urine culture at 12 to 16 weeks or during the first prenatal visit.

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UTIs by Pregnancy Trimester

Your risk of UTI goes up beginning at week 6 of your pregnancy; the chances you’ll have a UTI vary by trimester.

First Trimester

About 41 percent of UTIs are diagnosed during the first trimester. Because getting a UTI during the first trimester is so common, the U.S. Preventive Services Task Force recommends that your healthcare provider obtain a urinalysis and urine culture at your first prenatal visit. That recommendation holds whether you present with UTI symptoms or not.

Second Trimester

According to the Centers for Disease Control and Prevention, about half as many pregnant women are diagnosed with a UTI during their second trimester compared with the first trimester.

Third Trimester

Compared with the second trimester, the number of women who experience a UTI during the third trimester is almost halved. However, 80 to 90 percent of acute kidney infections in pregnancy (many caused by the progression of an untreated UTI) occur in the second and third trimesters, according to research published in the Archives of Medical Science. Thus, it’s recommended to do a repeat urine culture during the third trimester, too.

Common UTI Symptoms in Pregnant Women

“While mildly painful urination during pregnancy can often mean a yeast infection, not a UTI, it’s always best to see your healthcare provider if you experience any symptoms,” says Heather Bartos, MD, an ob-gyn in Cross Roads, Texas. After all, research suggests that about 18 percent of UTIs that occur during pregnancy are symptomatic UTIs, meaning the telltale UTI signs and symptoms are present:

  • Strong and frequent urge to use the bathroom
  • Burning while urinating
  • Regularly passing only small amounts of urine
  • Cloudy, red, pink or cola-colored urine
  • Foul-smelling urine
  • Pelvic pain, usually in the center of the pelvis

In pregnancy, women are also more susceptible to asymptomatic UTIs, meaning you have significant bacteria in your urine but your urinary tract is free of signs and symptoms. Experiencing no symptoms, however, does not mean that asymptomatic UTIs are benign. “An asymptomatic UTI can lead to a symptomatic UTI or even a kidney infection,” says Dr. Bartos. In fact, research shows that if asymptomatic UTIs are left untreated, 30 percent of pregnant women will go on to develop a symptomatic UTI, and half of those women will eventually be diagnosed with acute pyelonephritis (a kidney infection). Up to 23 percent will have a kidney infection recurrence during the same pregnancy. It’s important to note that classic UTI signs, like frequent and painful urination, may or may not occur with a kidney infection. Here, some signs to look out for:

Typical Signs of a Symptomatic UTI

  • High-grade fever
  • Chills and rigors (sudden feeling of cold with shivering)
  • Headache
  • Nausea or vomiting
  • Lower back pain
  • Flank pain (often right side)
  • Possible reduced urine output

Are UTIs Dangerous During Pregnancy?

“UTIs can rapidly progress to a kidney infection in pregnancy, which can be much more dangerous than a kidney infection in nonpregnant women,” says Bartos. “Severe infections can lead to respiratory problems and sepsis, which can then lead to preterm labor or even the need to urgently deliver the baby.” Beyond a kidney infection, simply having a UTI during pregnancy appears to possibly be a contributing factor to low birth weight. Women who have a UTI in pregnancy also have a 1.31-fold higher risk of developing preeclampsia, a pregnancy complication characterized by high blood pressure, according to a meta-analysis published in September 2018 in the journal Medicine. It’s thought that a UTI may alter a pregnant woman’s inflammatory response, which can spur preeclampsia.

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Can Having a UTI While Pregnant Hurt the Baby?

Possibly. “A UTI itself doesn’t hurt the baby directly,” says Bartos. “It’s the failure to treat a UTI that can cause things like preterm birth or, rarely, infection of the amniotic sac. ” For example, research published in American Family Physician shows that treating pregnant women who have asymptomatic UTIs decreases the incidence of preterm birth and low-birth-weight infants. That’s why screening and prompt treatment are important.

Can a UTI Cause Contractions During Pregnancy?

Urinary tract infections are not associated with preterm labor, according to research published in the Journal of the Chinese Medical Association. However, if a urinary tract infection is left untreated, it can progress to a kidney infection. And a kidney infection (pyelonephritis) during pregnancy can modestly increase your chances of early contractions and delivery. Research published in the American Journal of Obstetrics & Gynecology notes that women diagnosed with acute pyelonephritis in pregnancy have a 10.3 percent chance of preterm delivery compared with the 7.9 percent chance among women without a kidney infection during pregnancy.

RELATED: Common Types of Vaginal Infections

Do UTIs Differ by Trimester?

At week 6, UTI risk starts to go up, with two-fifths of UTIs occurring during the first trimester. Because of the likelihood of getting a UTI during the first trimester, the U.S. Preventive Services Task Force recommends that pregnant women have a urinalysis and urine culture at their first prenatal visit — whether they have UTI symptoms or not. In the second trimester, about half as many pregnant women are diagnosed with a UTI as in the first trimester, according to the Centers for Disease Control and Prevention, and that number is almost halved again for the third trimester. However, 80 to 90 percent of acute kidney infections in pregnancy (many caused by the progression of an untreated UTI) occur in the second and third trimesters, according to data published in the Archives of Medical Science, so pregnant women should have a repeat urine culture during the third trimester.

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What Are Pregnancy-Safe UTI Treatment Options?

How do you treat a UTI when pregnant? It’s similar to how you treat a UTI when not pregnant — with a few key differences. A short-course of antibiotics is the standard treatment for asymptomatic and symptomatic urinary tract infections that occur during pregnancy. There are, however, two important contrasts in treating UTIs in pregnant women versus nonpregnant women. First, asymptomatic UTIs diagnosed during the first trimester are treated with antibiotics, whereas nonpregnant women’s infections are often not treated in this manner. (Outside of pregnancy, asymptomatic bacteriuria is usually not treated with antibiotics.) Also, the preferred antibiotic drugs used to treat UTI in pregnancy often differ than what would be used while not pregnant. For instance, the following antibiotics have not been associated with any birth defects, thus are likely safe to use at any point during pregnancy:

  • Penicillins Amoxicillin, ampicillin, and augmentin are in this group.
  • Erythromycin Some of the brand names include Ery-Tab, Akne-Mycin, E.E.S. Eryc, and Pediamycin.
  • Cephalosporins Keflex (cephalexin) is a cephalosporin.

UTI history and resistance patterns must be considered before prescribing any of these drugs.

Because certain antibiotics pose a potential risk for birth defects (anencephaly, heart defects, and cleft palate) when taken during the first trimester, they are only considered a first-line treatment for UTIs occurring during the second and third trimesters, according to the American College of Obstetricians and Gynecologists. Prescribing the antibiotics listed below during the first trimester is considered appropriate only when no other suitable alternative treatments are available:

  • Nitrofurantoin Macrobid, Furadantin, and Macrodantin are in this category.
  • Sulfonamides Bactrim (trimethoprim-sulfamethoxazole) is part of this class.

Be sure to double-check what your healthcare provider is prescribing, since despite the warnings, nitrofurantoin remains the most frequently prescribed antibiotic during the first trimester.

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Your Pregnancy Matters

September 20, 2021

Your Pregnancy Matters

Robyn Horsager-Boehrer, M. D.

Obstetrics and Gynecology

A UTI during pregnancy is no cause for alarm – unless it’s left untreated. If you experience symptoms, tell your doctor right away. Drinking plenty of water during pregnancy can help prevent UTIs.

As you adjust to new changes in your body during pregnancy, it can be easy to overlook symptoms of everyday health conditions, such as urinary tract infections (UTIs). UTIs are equally common in pregnant and non-pregnant patients and usually require medication to clear the infection.

But if left untreated during pregnancy, a UTI can progress to s serious infection that can lead to preterm labor, premature delivery, or even fetal loss.

UTIs occur when bacteria enter and grow in the urinary tract. During pregnancy, your bladder – which is in the lower part of your urinary tract – is less likely to empty entirely when you urinate, thanks to pressure from your expanding uterus and an increase in hormones that relax the muscles in your uterus. The longer urine stays in your body, the higher the chances that you’ll grow too much bacteria.

We watch for three types of UTIs during pregnancy:

  • Asymptomatic: Approximately 7% of pregnant women may have a UTI that doesn’t cause symptoms. An untreated asymptomatic infection has a 25% chance of advancing to the next level of UTI – your bladder and then your kidney.
  • Cystitis: Localized to the bladder, this infection will cause symptoms typically associated with UTIs, such as frequent but small amounts of urine, painful urination, and strong urges to urinate immediately.
  • Pyelonephritis: This kidney infection can lead to serious issues such as septic shock, anemia, excess lung fluid, and pre-term labor. It typically includes the symptoms of cystitis, plus nausea, fever, chills, and pain in your lower back and sides.

Because UTIs are prevalent during pregnancy, we request a urine sample to conduct a culture test as part of your prenatal care. The test looks for specific types of bacteria in your urine that can cause an infection.

We will likely test your urine multiple times throughout your pregnancy. But don’t assume we’re looking for a UTI every time; this is a common misconception. It’s important to talk with your doctor if you experience UTI symptoms to make sure you get the right test. The earlier we diagnose a UTI, the sooner we can treat you and prevent a more dangerous condition.

UTI treatment: What to expect

UTI treatments during pregnancy are safe and easy, usually involving a short course (3-7 days) of oral antibiotics. There are two exceptions:

  • If you continue to have UTIs after we treat the first one, we may recommend suppressive therapy. You will take a lower dose of antibiotics every day of your pregnancy instead of larger doses for just a few days.
  • If you have pyelonephritis (kidney infection), you will need to receive antibiotics through an IV at a hospital.

For most patients, receiving antibiotic treatment is much safer than risking a kidney infection. We will discuss all your health conditions and pregnancy symptoms to determine the best type of antibiotic for you, depending on what will work effectively against the bacteria in your urine.

Not all urine tests are the same

In the third trimester, we’ll likely test your urine for the presence of protein or glucose, which can indicate high blood pressure or gestational diabetes. Around this time, we also test urine for sexually transmittable diseases such as chlamydia and gonorrhea, which can be transferred to your baby.

Neither of these tests will tell us whether you have a UTI. If you’re experiencing UTI symptoms, please tell us so we can perform the appropriate test and begin treatment.

What increases or reduces risk of UTIs during pregnancy?

Women who have or carry the trait for sickle cell disease are at increased risk for UTIs. We test these patients monthly to ensure we detect an infection as soon as possible.

If you have diabetes, you’re also at a higher risk. We might not test you as frequently, but we will consistently look for symptoms. Both conditions make it harder for the body to fight infections.

Just as when you’re not pregnant, you can take specific actions to lower your chances of getting a UTI, such as:

  • Wiping front to back in the bathroom
  • Urinating before and after sex
  • Wearing cotton underwear
  • Avoiding tight and wet clothing
  • Drinking more water

Prepare for possible postpartum UTIs

In some cases, the risks of developing a UTI increase after you give birth.

Patients who have a C-section or receive an epidural during labor have a catheter inserted into their bladder. This ensures a safer delivery by keeping your bladder empty. But a catheter increases your risk of infection the longer it stays in your body, and its placement provides the perfect track for bacteria to enter your bladder.

To decrease your UTI risk, our goal is to remove your catheter no more than six to eight hours after surgery and even sooner after an epidural. An infection can take days to appear, so watch for symptoms after you leave the hospital and tell your doctor right away if you experience them. We don’t perform routine UTI tests after delivery, so it’s important to alert us to abnormal pain or discomfort.

Related reading: Tips to prevent involuntary urine leakage (incontinence) during and after pregnancy

With so many new tasks to complete and emotions to experience after bringing your newborn home, it can feel overwhelming to keep track of one more thing – but your health remains a priority after the birth of your baby. The more you tell us about how you feel, the more we can do to help you stay healthy.

To visit with an Ob/Gyn, call 214-645-8300 or request an appointment online.

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Urinary tract infections vs pregnancy: treatment and prevention

Summary. Urinary tract infections are one of the most common complications in pregnant women, which can lead to serious consequences not only for the expectant mother, but also for the child. When managing pregnant women with diseases of the urinary system, it is extremely important to choose the right and, most importantly, safe therapeutic tactics. What drugs are safe during pregnancy? What obstetric and therapeutic tactics are most effective for kidney diseases in pregnant women? What diagnostic methods are best used for asymptomatic bacteriuria, acute cystitis and pyelonephritis? Professor 9 spoke about this in her speech0003 Olga Grishchenko , Head of the Department of Perinatology, Obstetrics and Gynecology of the Kharkiv Medical Academy of Postgraduate Education during a training workshop for gynecologists “Actual Guidelines of Gynecology, Reproductology, Obstetrics”, held on March 29, 2019 in Kharkiv. The event was organized by the MedExpert Group of Companies together with the National Medical University named after A.A. Bogomolets and National Medical Academy of Postgraduate Education named after P.L. Shupyk.

Urgency of the problem

Urinary tract infections (UTIs) are the most common bacterial infections in outpatient practice, they take the 2nd place, second only to respiratory tract infections. According to statistics, 50% of women in the world have an episode of UTI at least once in their lives, of which 25–40% experience a relapse of the disease within 6–12 months. Every year, about 10% of women develop acute cystitis, and pyelonephritis remains the leading cause of hospitalization during pregnancy for non-obstetric indications.

In the presence of UTI in pregnant women, the risk of preterm labor and rupture of amniotic fluid, chorioamnionitis increases, premature or functionally immature children are born, and the level of perinatal mortality increases.

In the structure of UTI, asymptomatic bacteriuria is observed in 4-9.5% of pregnant women, acute pyelonephritis – in 12-25%, chronic pyelonephritis – in 33%, glomerulonephritis, urolithiasis – in 0.1-0.2%.

Risk factors and pregnancy

As a rule, infections, self-medication or improper treatment, asymptomatic bacteriuria, frequent UTIs in combination with inflammatory diseases (colpitis), lifestyle and nutrition can affect the occurrence of pathology of the urinary system.

Pregnant women have an increased risk of diseases of the urogenital tract. A high level of progesterone leads to the development of hypotension, hypokinesia, dyskinesia of the ureters and pyelocaliceal system. In turn, the uterus compresses the ureter, high intra-abdominal pressure occurs, especially in primiparas. During pregnancy, the renal pelvis enlarges, the growing uterus squeezes the ureter more and more, the outflow of urine from the kidneys becomes difficult, the urine stagnates, bacteria multiply in it, and inflammation easily occurs.

Infectious agents can enter the bladder by ascending (with inflammatory diseases of the urethra), descending (most often with tuberculous kidney damage), hematogenous (if there is a purulent focus in other parts of the body) and lymphogenic (with diseases of the genital organs) by.

Classification of UTIs in pregnant women

UTIs in pregnant women include asymptomatic bacteriuria, lower urinary tract infections (acute and recurrent cystitis) and upper urinary tract infections (acute pyelonephritis, chronic pyelonephritis in remission, exacerbation, latent course).

Cystitis in pregnancy: course, diagnosis

Cystitis is an inflammation of the bladder wall, one of the most common urological diseases, as a rule, its cause is an infection. Symptoms of cystitis in women are manifested in the form of frequent urination, cramps and pain when urinating, pulling sensations in the lower abdomen, weakness, fatigue, irritability, blood in the urine, cloudy urine, pus or yellow spots on the underwear.

Normally, urination is not accompanied by pain. In women, painful urination can be caused by diseases of the bladder, urethra, or vagina. So, pain in the bladder, as a rule, is felt in the area of ​​the womb, it can increase during urination or, conversely, decrease when the bladder is empty. Urethral pain associated with urination is felt by the patient directly in the urethra and is usually aggravated by urination. Urine entering the vaginal opening can cause pain if it is inflamed. Inflammation of the urethra is most often characterized by a bacterial nature and requires additional examination and treatment.

Primary diagnosis of cystitis involves an examination by specialized specialists (urologist, nephrologist, gynecologist), as well as taking an anamnesis and establishing possible causes of the disease (hypothermia, unprotected intercourse, taking medications, the presence of concomitant diseases).

Laboratory tests include a urinalysis for Nechiporenko cultures (helps identify the pathogen), a general urinalysis (allows you to identify erythrocytes, leukocytes, protein in the urine; the urine itself may be cloudy with an admixture of blood or pus), a general blood test (allows you to identify a picture inflammatory process, it is possible to increase the erythrocyte sedimentation rate (ESR), leukocytosis). Among instrumental methods, ultrasound examination (ultrasound) of the bladder, ureteroscopy and cystoscopy (in case of violation of the passage of urine) are used.

Asymptomatic bacteriuria during pregnancy

Asymptomatic bacteriuria during pregnancy is dangerous for both mother and fetus, against its background, 25% of women develop acute pyelonephritis. According to the World Health Organization, about 8% of women report asymptomatic bacteriuria, 15-57% of women with untreated asymptomatic bacteriuria develop symptoms of a UTI (acute cystitis or pyelonephritis). Therapy of this disease during pregnancy reduces the risk of developing acute UTIs, preterm birth, and low birth weight.

Diagnosis of asymptomatic bacteriuria can be established by detecting 10 5 CFU / ml of one bacterial strain or 10 2 CFU / ml of uropathogen Escherichia coli in 2 urine samples taken at intervals > 4 hours and containing >10 leukocytes per field of view in the absence of clinical manifestations of UTI.

It should be remembered that the risk of this pathology is most real from the 9th to the 17th week of pregnancy. The only reliable method for diagnosing asymptomatic bacteriuria is the method of urine culture.

In accordance with Ukrainian and international recommendations for asymptomatic bacteriuria, oral antibiotic therapy with a single dose of fosfomycin trometamol is recommended.

Pyelonephritis: diagnosis

Pyelonephritis is an infectious and inflammatory disease of the kidneys of bacterial etiology with a primary and predominant lesion of the interstitium and tubular apparatus. The incidence of pyelonephritis during pregnancy reaches 33%, mortality – 3.5%, maternal mortality from kidney disease in the structure of extragenital pathology is 8-10%, the incidence of gestational pyelonephritis is 11.5%.

Primary pyelonephritis in pregnant women is difficult to treat, may be accompanied by fever, chills, nausea, vomiting, pain in the lumbar region, the appearance of pyuria, bacteriuria. As a rule, the right kidney is affected more often than the left one, with expansion of the pelvicalyceal system (according to ultrasound).

In acute pyelonephritis, the mandatory research methods are a general urinalysis (in 2 portions) 1 time in 7 days, a Nechiporenko urinalysis, a general and biochemical blood test, a bacteriological urinalysis, ultrasound of the kidneys and bladder, daily proteinuria, a biochemical blood test , blood pressure monitoring, urologist consultation. Additional research methods – computed tomography without contrast or excretory urogram, nuclear magnetic resonance imaging – are carried out exclusively for strict, sometimes vital, indications.

It should be remembered that dysuria in primary acute cystitis with a body temperature of 38 ° C and chills may indicate acute ascending pyelonephritis. A sharp dysuric syndrome is characteristic of the associated cystitis during exacerbation of chronic pyelonephritis. Urinary syndrome (proteinuria, leukocyturia, hematuria, etc.) may periodically disappear with a unilateral process and ureter occlusion; therefore, serial urine tests are necessary. The degree of leukocyturia does not always correspond to the severity of the inflammatory process. A single urine culture gives at least 20% false positive results. Bacteriuria appears and can be detected 2 days earlier than pyuria.

Choice of drugs for the treatment of pregnant women with UTIs

There are certain requirements for antibiotics for the treatment of UTIs in pregnant women. In particular, they must be effective against most pathogenic pathogens, have the ability to create a high concentration in organs – foci of infection, have a long half-life sufficient to maintain a high concentration of the antibiotic in the blood, not have toxic and allergic effects, be well tolerated by patients, be harmless to mother and fetus.

It has been shown that for the treatment of pregnant women with acute cystitis, asymptomatic bacteriuria, acute pyelonephritis, it is advisable to use antibacterial uroseptics. In particular, fosfomycin trometamol has a bactericidal effect associated with blocking the bacterial enzyme involved in the synthesis of the cell wall, as well as an anti-adhesive effect (it destroys the fimbria of Escherichia coli, preventing it from fixing on the wall of the urothelium and contributing to leaching from the urinary tract). After a single dose of the drug, the therapeutic concentration is observed for 48 hours (this is enough to sterilize urine and recover).

An alternative to antibiotics are phytoneering preparations with anti-adhesive and antibacterial activity, as well as anti-inflammatory, antispasmodic, nephroprotective properties.

Organization of care for pregnant women with UTI and prevention

Delivery of pregnant women with UTI (without obstetric pathology) is carried out through the natural birth canal, taking into account the obstetric situation.

There are degrees of risk of pyelonephritis:

  • I degree – uncomplicated pyelonephritis that occurred during pregnancy;
  • II degree – chronic uncomplicated pyelonephritis, noted before pregnancy;
  • III degree – pyelonephritis with hypertension, azotemia, pyelonephritis of a single kidney.

They must be taken into account when managing pregnant women. So, at I-II degree of risk, pregnancy can be prolonged, but at III degree (creatinine> 265 μmol / l, glomerular filtration rate < 30 ml / min), pregnancy should be terminated.

Prevention of UTIs in pregnant women should include sanitation of the vagina in case of violation of its microflora and other sources of infection (teeth, pharynx, etc.), normalization of bowel function, optimal water regime.

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Marina Kolesnik,
photo of the author

Asymptomatic bacteriuria – articles from specialists of the clinic “Mother and Child”

Agranovskaya Anna Valerievna


Lapino-1 Clinical Hospital “Mother and Child”

During pregnancy, this problem requires special attention!

It should be noted that the kidneys of a pregnant woman experience increased stress. The smooth muscle of the urinary system is affected by the hormone progesterone, which has a relaxing effect on it.

From the second trimester the gradually enlarging uterus begins to compress the abdominal organs, including the ureters, kidneys, and bladder. As a result, the pyelocaliceal system of the kidneys expands, which contributes to some stagnation of urine. Such urine is a favorable environment for the reproduction of bacteria.

During pregnancy, the presence of bacteria is found in urine tests, but the woman does not present any complaints, nothing bothers her. This is regarded as asymptomatic bacteriuria. A similar phenomenon occurs on average in 6% of cases.

Asymptomatic bacteriuria in pregnant women significantly increases the risk of urinary tract infections – inflammation of the bladder / cystitis / and inflammation of the kidneys / pyelonephritis /. And urinary tract infections can cause a number of serious complications of pregnancy and childbirth – a decrease in hemoglobin, an increase in blood pressure, premature birth, the birth of children with a low body weight of less than 2500 g.

When bacteria are isolated in a general urinalysis, an additional examination is recommended – seeding for flora and sensitivity to antibiotics to identify bacteria and determine their sensitivity to antibacterial drugs.

Based on the results of sowing, the doctor prescribes an effective and safe treatment for a pregnant woman. The duration of the course of treatment depends on the severity of changes in the culture. After treatment, urine culture control is prescribed, not earlier than 5 days after the end of treatment.

Prevention! In order to prevent exacerbations, it is necessary to follow the recommendations to ensure an improvement in the outflow of urine and prevent stagnation and reproduction of bacteria in the organs of the urinary system:

  • diet with restriction of spicy, salty, smoked
  • sweets should be limited – glucose is a favorable environment for the development of microorganisms
  • drinking regime not less than 1.5–2.0 liters per day. A sufficient volume of liquid contributes to the free removal of waste substances and toxins from the body. Among drinks, preference should be given to mineral non-carbonated water, compotes, cranberry and lingonberry fruit drinks
  • knee-elbow position for 5-10 minutes 3-5 times a day. In the knee-elbow position, the load is redistributed. The uterus, under the force of gravity, shifts forward and down, freeing the ureters, kidneys, and bladder from compression.