Recurrent uncomplicated urinary tract infection: A review of psychological factors

Jourrwl of Psychosomatic Printed in Great Britain.

Research,

Vol. 37, No. 4, pp. 313-323,

1993

oln-3999/93 %?4.00+.00 Pergamon Press Ltd

INVITED REVIEW RECURRENT UNCOMPLICATED

URINARY TRACT INFECTION:

A REVIEW OF PSYCHOLOGICAL JEN

HUNT

and GLENN

FACTORS

WALLER

Abstract-Urinary tract infection (UTI) is a very common medical disorder among women, and is a chronic, recurrent problem for a cluster of sufferers. The factors involved in the aetiology of recurrent UT1 are not adequately understood. Most research and treatment has focused on the influence of medical factors, although clinical impressions suggest that psychological factors (behavioural and personality variables) may play an important role. Evidence is reviewed for the involvement of psychological factors in the aetiology and treatment of recurrent UT1 in women. It is difficult to draw any clear conclusions concerning the role of such factors in recurrent UTI, given the relatively small amount of research to date and a number of methodological issues. Suggestions for appropriate methodology and research concerning the interplay of physical and psychological factors are made. THE IMPORTANCE of psychological factors in the aetiology and maintenance of physical illness is now widely accepted. Levels of psychological distress in primary care settings are consistently high [ 1 ] . There is a growing interest in the role of psychological factors in disorders of urination [ 21. In a genito-urinary clinic, a diagnosable psychiatric disorder was found in 3 1% of the clinic population [3 ] . However, the current literature is notable for its lack of clarity regarding both the diagnosis of distinct disorders of urination and the specific psychological mechanisms that are involved. The current paper reviews the evidence for the characteristic, persistent psychological factors that are associated with recurrent uncomplicated urinary tract infection (UTI). It is not intended to discuss levels of psychiatric morbidity or symptomatology in women with urinary disorders, although this is a current topic of debate [4-61 . Such psychiatric symptoms in patients with chronic medical disorders tend to recede with symptom resolution [ 71, suggesting that they are consequential upon the medical disorder. It is intended that clarifying these psychological characteristics should assist in developing more effective treatment of recurrent UTI, simultaneously reducing organic and psychological risk factors. Urinary tract infection is amongst the commonest infections encountered in medical practice [ 81. Recurrent infections in a cluster of patients lead to problems of accurate diagnosis and effective management. Success in explaining and preventing recurrent UT1 depends on understanding in three broad areas. First, it is important to define UTI, in terms of pathological mechanisms, accurate diagnosis, and prevalence and incidence in the population. Second, it is necessary to establish a clear definition of recurrent UTI, including information concerning the skewed distribution of such infections in the population. Third, an understanding of the factors that affect this University of Manchester and University of Birmingham. Address for correspondence to: Jen Hunt, Rawnsley Building, Road, Manchester Ml3 9WL, U.K. 313

Manchester

Royal

Infirmary,

Oxford

314

3. HUNT and G. WALLER

skewed distribution of infection frequency is needed, to allow the development of more effective and efficient preventative treatment approaches. There is a considerable amount of evidence regarding the nature, diagnosis and treatment of UT1 and recurrent UTI, and that evidence will be briefly outlined. However, there is a relative dearth of information concerning factors explaining the distribution of recurrent infection. The majority of the evidence that does exist relates to intraspecific factors, such as bacterial adherence. There is a small amount of research evidence and a good deal of popular belief suggesting that psychological factors (behavioural and personality) play a part in explaining this medical condition. The current review goes on to consider this evidence in detail, describes research strategies to elaborate on these findings, and examines potential psychotherapeutic approaches to preventing and managing recurrent UTI. DEFINING UT1

The symptoms of UT1 are widely acknowledged to be dysuria (pain on urination), accompanied by urgency and frequency of urination. There may also be fever and haematuria (blood in the urine). In terms of pathological mechanisms, the colonization of the bladder by E. coli is the single most common cause of UT1 [ 91. Levels of bacteria greater than lo5 organisms/ml of urine comprise the accepted criteria for significant infection. Women are 30 times more likely to suffer UT1 than men, since bacteria enter the bladder via the urethra, which is short and presents little barrier in women [lo]. Sexual intercourse is a major precipitating event for UT1 [ 111, probably because of the effects of urethral trauma, encouraging bacteria from the nearby bowel flora to enter the bladder [ 101. In fact, intercourse frequently causes raised bacteria levels in the urine of women subjects, but these increases are normally transient [ 121. Despite the fact that this mechanism is responsible for the majority of infections [9], diagnosis is not a simple matter. A spectrum of diseases with different aetiologies, and with different diagnostic and therapeutic requirements can also cause the same presentation of symptoms [ 131. A further problem of diagnosis is caused by the presence of symptoms at levels of bacteria significantly less than lo5 bacteria/ml. Symptoms have been found at levels as low as lo* bacteria/ml [ 91 . Additionally, around a third of women thought to have symptomatic UT1 in general practice actually have ‘sterile’ bladder urine. This phenomenon, often described as Acute Urethral Syndrome [ 141 may be caused by infection confined to the urethra or surrounding glands and may be due to a variety of infecting agents [ 151. It is clear that patients presenting with the symptoms of UT1 can only be accurately diagnosed with appropriate bacteriological investigation. Clinicians are rather poor at predicting the outcome of urine analyses of women presenting with dysuria and frequency [ 161. Immediate microscopic examination of urine samples in the surgery can make diagnosis easier and more rapid [ 171. Women presenting with chronic dysuria and frequency who do not have recurrent urinary tract infections are often said to have the urethral syndrome. These women should be fully investigated for other infecting agents [ 41 and also other abnormalities of the urinary tract, such as detrusor instability [ 181. Psychological factors associated with idiopathic detrusor instability and other functional voiding disorders also merit further investigation,

Invited Review

315

but are beyond the scope of this paper. In terms of prevalence, dysuria is experienced by large numbers of women at some time in their lives. Studies indicate that 20% of women will experience symptoms of UT1 during any year and that about half of these women will consult a physician [ 191. Based on patient visits to primary care physicians in Great Britain, Fry and colleagues [20] demonstrated that the incidence of UT1 was 90 visits per 1000 patients per year in the 20-yr-old age group. DEFINING

RECURRENT

UT1

Evidence suggests that a sub-group of women suffer frequent re-infections of the urinary tract. About one sixth of women with UT1 infections account for around 70% of all recurrences. These women suffer recurrences at approximately 2.6 per patient yr, in comparison with 0.32 recurrences per patient yr in the remaining group [ 211. The probability of recurrence increases with the number of previous infections. The recurrence of symptoms after treatment is due to re-infection in virtually all instances [ 221. Since recurrent UT1 is almost exclusively seen in women, this review will not consider infection in men. For practical and research purposes, recurrent UT1 has been defined as three or more episodes of significant bacteriuria per patient year. This definition, based on Mabeck’s findings [ 211, is used to introduce consistency, which is generally lacking in papers on this subject. However simply and effectively acute infection of the urinary tract can be treated, recurrent re-infections will inevitably lead to substantial costs at the medical, personal and social levels. The significant morbidity and expense of recurrent UT1 constitute a major health care concern [23] . It is estimated that women with the symptoms of urinary tract infection account for some seven million office visits per year in the U.S.A. [ 241. Since a significant proportion of these visits will be attributable to those women with recurrent infections making multiple visits, effective preventative programmes would have considerable resource implications. The personal costs of recurrent infections, both practically and emotionally, are also high. One study [ 25 ] found that each episode of infection involves an average of 6.1 ‘symptom’ d, 2.4 restricted activity d, and 0.4 bed d. Total days completely lost as an average of 1.2, including doctor visits and urine tests. Although the development of renal damage is rare, suffering regular painful and disruptive infections will no doubt have a significant impact on general health and psychological well-being. There are no studies on the psychological effects of suffering recurrent UTI, but there is some evidence that it can have a disruptive effect on sexual functioning [26] . Since the presence of bacteria in the bladders of most women is not unusual, particularly after intercourse, why do some women go on to develop significant levels of infection? Furthermore, why do a small sub-group of women suffer recurrent infections? The answer clearly depends on understanding the underlying pathological mechanisms. MEDICAL

FACTORS

IN RECURRENT

UT1

The majority of research to date on mechanisms explaining recurrent UT1 has investigated physical factors. Recent literature focuses on the increased susceptibility in recurrent sufferers to bacterial colonization of the vagina and surrounding area.

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This level of susceptibility has been attributed to increased adherence properties of the epithelial cells of sufferers in comparison with non-sufferers. However, it is not yet clear to what extent bacterial adherence is a consistent physical feature (for example, determined by genetic factors [ 27 ] ), or how much it is affected by acquired factors (such as method of contraception). There is some evidence that habitual behaviours may be the most effective ‘host’ defence mechanism against UTI. For example, the flushing effect of bladder emptying helps prevent the adherence of bacteria to the epithelium [ 281. The understanding of medical factors in UT1 is increasing, but broader mechanisms connecting these factors are not yet clearly understood. There have been two effective approaches in the medical treatment of simple UTI. First, efforts have been made to relieve the symptoms and signs of acute infection. Secondly, prophylaxis has been used to prevent recurring infections. The appropriate use of antimicrobial therapy can rapidly achieve sterilization of the urinary tract the main goal in treatment of UT1 [ 211. In fact, treatment can be as simple as a single large dose of the appropriate drug [ 221. Given the ease of treating simple infections, the main therapeutic problem with uncomplicated recurrent UT1 lies not so much in eliminating bacteriuria as in detecting and treating the recurrence [ 2 1 ] . Various prophylactic regimens have been suggested. Most involve continual antimicrobial therapy, such as single-dosage night prophylaxis. Another approach consists of early post-coital prophylaxis with a single dose of antibiotic [29] . These approaches have generally proved effective in preventing infections for the duration of treatment. However, there is some indication that in the long-term such treatment may lead to a higher recurrence rate due to the development of resistant strains of bacteria in the patient’s flora [ 15,291. A further approach is that of self-administered therapy for acute symptoms, which avoids the long-term use of antibiotics and has proved relatively successful [ 301. Other approaches to prophylaxis such as antibacterial perineal washing and intravaginal instillation of lactobacilli have proven generally ineffective [ 3 1,321 . A BEHAVIOURAL

MEDICINE

APPROACH

TO UT1

A better understanding of the mechanisms involved in the chronic development of bacteriuria in recurrent UT1 would lead to more effective forms of prophylaxis by preventing the risk of bacterial colonization of the bladder. What additional factors can be invoked to inform this debate? Other fields of medical enquiry have enjoyed a rapid development of understanding when taken into the domain of behavioural medicine [ 33,341 . That understanding has involved productive research, leading to effective programmes of prevention and rehabilitation. Even where there is clear physical pathology, such as in the case of coronary artery disease, it has been possible to design psychological and behavioural interventions which alter to a significant degree the predicted rate of recurrent disease [ 351. More of the variance in the skewed distribution of recurrent UT1 could be accounted for by investigating behavioural and personality factors, as is the case in other diseases. Particular behaviours (such as voiding and sexual habits) could be clearly linked to already established precipitating medical factors (such as bacterial adherence and urethral trauma). In addition, the effects of behavioural and personality

317

Invited Review

factors upon the frequency of infection may be mediated by the immune system. There is evidence that immunity is adversely affected by stress [ 361 . Existing studies which relate to the possible contribution of psychological factors to the disease process will be reviewed in the next section and implications for future research and treatment will be outlined. PSYCHOLOGICAL

FACTORS

IN RECURRENT

UT1

For the purpose of methodological and conceptual clarity, psychological factors will be divided into those studies relating to behaviours and those relating to personality. It is hypothesized that behavioural factors, such as voiding habits have a direct effect on identified medical risk factors (such as adherence). In contrast, the effect of personality factors on the development of infection is hypothesized to be indirect. That indirect effect would involve mediation by other factors, such as specific behaviours or physiological differences (e.g. the stress response). Understanding of recurrent UT1 may well depend on an understanding of the links between particular behaviours and specific physiological mechanisms. The number of papers reporting research into psychological factors in UT1 is relatively small. The studies described below represent the cohort of papers relating the two factors that were available using computerized literature searches (Medline and Psychlit) for the period 1970-1990. Behavioural

factors

There are widely-held assumptions that behavioural factors play a vital role in the aetiology of UTIs. For example, the ‘post-coital flush’ (voiding after intercourse) is thought to expel bacteria from the bladder that have entered during sexual activity. However, such assertions are often backed by little more than subjective clinical evidence [ 371. In particular, it is commonly assumed that voiding habits play a large part in recurrent UTI, but it is still unclear to what extent sufferers differ consistently in this respect to comparison groups. Table I details the existing studies of behaviours that are related to the presence of UTI. The identified risk factors include: failing to void post-coitally; voluntarily retaining urine for some time after the urge to urinate is felt; drinking less fluid; and voiding less frequently than comparison groups. Diaphragm use and intercourse are consistently suggested to be risk factors [ 431. However, it is unclear whether recurrent UT1 sufferers differ from non-sufferers in terms of these behaviours (e.g. intercourse frequency). Evidence for substantial differences in behaviours must be regarded as weak in light of the methodology used in the studies. First, the population studied is likely to be a confounding factor. For example, it is possible that the differences between student and general medical populations are entirely due to their consistent age differences. Second, the measures used will introduce further variance. For example, the reliability of questionnaires cannot be assumed when measuring variables such as volume of liquids consumed or frequency of voiding. In fact, it is likely that recurrent UT1 sufferers monitor such habits differently to controls. The nature of questions used in such questionnaires also varies across studies. For example, one study [ 391 examines voiding within 10 min of intercourse and retention of

318

J. TABLE

HUNTand G. WALLER

I.-BEHAVIOURAL

RISK FACTORS IN RECURRENT

UT1

Ref.

Samples

Measures

Findings

[381

84 female students (median age 21 yr) all history of 3+ UT1 No comparison group

Interview: diet, hygiene, and sexual habits Urine culture (Advice given: urination and hydration, hygiene)

Risks: sex and retention of urine (Reduced UT1 rate following advice)

[391

84 female students (no UTI) - comparison for [ 381 (median age 22 yr)

As above

Risks: retention of urine

I401

23 females with current (mean age 33 yr)

UT1

Questionnaire/ interview re behaviour; urination hydration hygiene

Risks: less fluid voiding less

[411

34 females - recurrent (age not given) Treatment study: randomly assigned education or control

UT1

Questionnaire: voiding, hygiene, sex

Significant reduction in rate of UTIs in treated group

[25,421

44 female students (mean age 21.5 yr) current UT1 18 1 comparison women no history of UT1

Questionnaire: diet, voiding, sexual, birth, control Specimen

Risks: sex, diaphragm, voiding, habits

[431

172 female students current UT1 (mean age 23 yr) 665 comparison women with no UT1 (mean age 22 yr)

Questionnaire: symptoms, sex, hygiene, birth control habits Specimen

Risks: sex, diaphragm, prior UTI, post-coital urinary

urine for more than 1 hr after the urge is felt. In contrast, another study [40] considers voiding within 1 hr of intercourse and retention of urine for more than 2 hr. Third, studies’ definitions of UT1 and recurrent UT1 are vague or absent. Studies often involve heterogeneous groups of women suffering the symptoms of unconfirmed UTI. The urological histories of subjects and comparison groups (where these exist) are rarely reported. Recurrent UT1 is rarely operationally defined, if recurrent sufferers are discussed separately at all, thus precluding description of specific factors in recurrent UTI. Finally, issues of causality are unclear. Behavioural differences between groups may be a result of infection rather than a cause. Given the issues of methodology raised, which of the findings concerning behamentioned, there is vioural factors can be regarded as robust ? As previously evidence to suggest that some risk factors (e.g. intercourse and diaphragm use) are consistent. However, it is not clear if recurrent sufferers differ consistently in such habits from non-sufferers. Evidence concerning the nature of the influence of other

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Review

319

habits such as voiding patterns remains to be confirmed. Contrary to popular belief, there appears to be little evidence concerning the role of hygiene or clothing habits in the aetiology of UTI. To summarize, although the role of certain behaviours (intercourse and diaphragm use) as risk factors in UT1 has been demonstrated, the role of voiding and hygiene habits is less consistent and awaits more sophisticated studies. Furthermore, the influence of these factors has not been detailed with respect to recurrent and non-recurrent infection. Personality

factors

As previously suggested, personality factors are likely to play an aetiological role in UT1 indirectly via behavioural factors or via physiological mechanisms. Therefore, clinically significant personality factors should include traits that increase risky behaviours (such as deferring micturation) and traits increasing levels of stress or susceptibility. Table II details the few existing studies that have attempted to examine these factors. TABLE

H.-PERSONALITY

FACTORS ASSOCIATED WITH

RECURRENT

UT1

Ref.

Samples

Measures

Findings

1441

31 females with urgency/frequency (18-65 yr)

Middlesex Hospital Questionnaire Eysenck Personality Inventory

High neuroticism

1451

50 females with recurrent dysuria (mean age 34 yr)

Psychiatric interview Eysenck Personality Questionnaire Morbid Anxiety Inventory

High anxiety and obsessionality

1461

56 females with dysuria/frequency (mean age 34 yr)

Minnesota Multiphasic Personality Inventory

High hysteria and hypochondriasis

As with the relationship between behavioural factors and UTI, there is some consensus that personality traits relate to UT1 symptoms. However, the evidence for this link is poor. One study emphasized the importance of neuroticism as a factor of recurrent presentation [ 441, another the importance of anxiety [ 45 ] _ However, once again the studies reviewed have serious methodological shortcomings. Populations used are poorly defined and are mostly compared to normative data for the questionnaires used, rather than being matched to specific comparison groups. Subjects appear to have been suffering from a variety of urological problems or were often suffering symptoms in the absence of positive bacteriological or physical findings. To summarize, there is currently no satisfactory evidence of mechanisms that may link personality factors and UTI, nor any physiological studies. fie

association

of behavioural

and personality

factors

Until recently, there had been no attempt to study the association between these two groups of factors. However, a small scale study [ 471 examined that association

320

J. HUNT and G. WALLER

between behavioural and personality factors in recurrent UTI. It also addressed some of the problems of methodology identified in previous studies. The study consisted of a clearly defined clinical group and age-matched controls. The clinical group had all suffered at least three confirmed episodes of UT1 in the previous year. In contrast, the control group had never consulted their doctor with UTI, but were recruited when they attended with a minor infection (e.g. of the respiratory tract). Data regarding relevant habits were collected using a questionnaire of relevant habits [42], and standardized measures of personality [48] were administered. The findings of this study [ 47 ] indicate the importance of neuroticism and specific ‘risky’ behaviours. For example, urination and hygiene habits were associated with the diagnosis of UTI. They were also related to the frequency of infection in recurrent sufferers. Important behaviours were voiding prior to intercourse (presumably reducing the efficiency of the post-coital flush) and bathing less frequently. Furthermore, neuroticism and certain ‘risky’ behaviours (urinating before intercourse and infrequent bathing) were associated. These results await replication with a larger sample and perhaps even more accurate forms of monitoring (e.g. fluid intake). PSYCHOLOGICAL

TREATMENTS

The obvious implication of the behavioural medicine approach to understanding recurrent UT1 would be to recommend treatment programmes to reduce behavioural and personality risk factors. However, there are few such studies. This dearth is perhaps due to the poor understanding of the specific psychological factors important in the aetiology of recurrent UTI. There appears to be only one controlled intervention study of behavioural factors in recurrent UT1 [ 4 1 ] . Recurrent UT1 sufferers were assigned to either an educational programme (concerning ‘risky’ behaviours and alternatives) or a comparison group receiving routine treatment. The results of this study were promising. There was a reduction of reported symptoms in the experimental group at follow-up. However, their methodology suffers in the way outlined above (e.g. use of selfreported measures of habit change and symptoms as outcome measures). This study requires replication with more reliable and valid measures. In a further intervention study [ 441, it is suggested that one third of the clinical group improved with individual therapy. However, the criteria for improvement and the nature of the intervention used were not made clear in this study. To summarize, there is a lack of well-controlled studies examining psychological factors and mechanisms in recurrent UTI. As a consequence, the design of intervention studies to date has not been theory-led or data-led. Reliance upon those studies that do exist is likely to result in further conceptual confusion. FUTURE

In the light work in this as guidelines UTI. First, it is

RESEARCH

of studies reviewed, it is possible to make recommendations for future area of behavioural medicine. A number of suggestions will be made for consistent research, both in the aetiology and treatment of recurrent important

that a common

approach

to definition

is adopted.

Diagnostic

Invited Review

321

criteria for UT1 and recurrent UT1 should be clearly stated, and should relate to current medical opinion. Currently, l@ organisms/ml can be said to represent significant bacteriuria, and it is suggested that recurrent UT1 be defined as three or more infections at this level of bacteriuria per patient year. Subjects presenting with symptoms only or with symptoms caused by rare pathogenic agents should be excluded from studies of this sort, although they may merit separate attention. In addition, chronic symptoms in the absence of bacteriological findings need to be closely investigated. Such ‘pathogen-free’ disorders may be found to be psychogenic in nature, and again would merit separate attention. Second, the measures of behaviour and personality need to be standardized, and should have clinical validity as well as reliability. On the basis of existing studies, it is suggested that such research should include the following behaviours: frequency and timing of voiding; frequency of intercourse; frequency and nature of hygiene habits; and amount of fluids consumed. Daily recording of some behaviours is probably more reliable than self-report questionnaire measures. In fact, our own research indicates that self-reported fluid intake is only reliable if recorded concurrently. Similarly, other research [ 491 has recommended concurrent recording of urinary frequency. Reliable measurement of other behaviours, such as frequency of sexual intercourse, does not appear to depend on the method of assessment (questionnaires vs diaries). Accurate recording of fluid intake could be improved by the employment of standardized drinking vessels by subjects or, less intrusively, by measuring the capacity of individual’s own vessels. Similarly, personality should be measured through existing reliable and valid measures. It is suggested that the personality dimensions studied should be those with conceptual links to ‘risky’ behaviours, including neuroticism (and associated generalized anxiety) and obsessionality. Newly devised measures should be evaluated for both their clinical validity and their general reliability. Third, it is important to define the sample population under consideration, in order to establish the generalizability of conclusions. Samples should be clearly diagnosed as suffering from recurrent UTI, screening out additional physical or medical complaints that may influence the rate of infection. For example, pregnant women and elderly individuals are known to be more susceptible to frequent infections. Appropriate control groups also need to be selected. Preferably, they should involve both subjects with no urological history and subjects who suffer from recurrent minor infections other than UT1 (such as throat infections). Such comparisons would allow the specific factors behind recurrent UT1 to be studied independently from the general factors associated with recurrent infection. A fourth recommendation is that research should establish causal links between psychological and physical mechanisms. For example, do personality factors relate to physiological measures of stress, and does the stress affect physical factors such as adherence? Similarly, does delaying urination predispose the bladder to bacterial colonization by reducing natural defence mechanisms or by increasing adherence factors? Finally, as this clearer understanding of psychological factors in recurrent UT1 develops, it should be followed by the development of treatment programmes. Such programmes might include: educational components; specific behavioural changes; and perhaps broader psychotherapeutic approaches to modifying neurotic styles of

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coping. In addition to reducing the medical and personal costs of recurrent UTI, those treatments should allow for the testing of further hypotheses about specific mechanisms. For example, it could be hypothesized that an intervention aimed at personality changes will lead to behaviour change. In turn, the change in behaviours should effect change in critical physical factors, which will lead to a lower recurrence rate for infection. Such hypotheses could be tested directly. Furthermore, psychological approaches to treatment should be examined both in conjunction and in comparison with traditional medical approaches to prophylaxis. CONCLUSION

To date, there is little literature in the area of psychological factors and recurrent UTI. However, there are indications from recent studies (e.g. [41,47], that there is much potential in pursuing the role of psychological factors in the aetiology and prevention of recurrent UTI. The present review has made suggestions about how such factors might be studied in a comprehensive, clinically meaningful way. The adoption of a common methodology will do much to clarify the role of various hypothesized factors. In turn, this understanding should lead to the development of effective preventative programmes. Such interventions would yield enormous costbenefits. Costs saved would include consulting times, drug costs and laboratory time. Furthermore, working days lost, personal inconvenience and suffering (both physical and psychological) would be reduced for patients and their families. REFERENCES 1. GOLDBERG D, HUXLEY P. Mental Illness in the Community. London: Tavistock, 1980. 2. MACAULAY AJ, STERN RS, HOLMES DM, STANTON SL. Micturition and the mind: Psychological factors in the aetiology and treatment of urinary symptoms in women. Br Med .I 1987; 294: 541-543. 3. BARCZAK P, KANE N, ANDREWS S, CONGDON AM, CLAY JC, BETTS T. Patterns of psychiatric morbidity in a genito-urinary clinic. Br J Psychiat 1988; 152: 698-700. 4. MASKELL R. Psychiatric aspects of urinary incontinence. Br Med J 1990; 301: 556. 5. NORTON KRW, BHAT AV, STANTON SL. Psychiatric aspects of urinary incontinence in women attending an outpatient urodynamic clinic. Br Med J 1990; 301: 271-272. 6. TURKINCTON D, GRANT J, TOPHILL P, JOHNSTON J. Psychiatric aspects of urinary incontinence. Br Med J 1990; 301: 444-445. 7. MAIN CJ, SPANSWICKCC. Pain: psychological and psychiatric factors. Br Med Bull 1991; 47: 732-742. 8. ANDRIOLE VT. Urinary tract infections: Recent developments. J Infect Dis 1987; 156: 865-869. 9. STAMM WE. Protocol for diagnosis of urinary tract infection: reconsidering the criterion for significant bacteriuria. Urology 1988; 32 suppl 2: 195-208. 10. BRAN JL, LEVISON ME, KAYE D. Entrance of bacteria into the female urinary bladder. N Engl J Med 1972; 286: 626-629. 11. NICOLLE LE, HARDING GKM, PREIKSAITIS J, RONALD AR. The association of urinary tract infection with sexual intercourse. J Infect Dis 1982; 146: 579-583. 12. BUCKLEY MR, MCGUCKIN M, MACGREGOR RR. Urine bacterial counts after sexual intercourse. N Engl J Med 1978; 298: 321-324. 13. CORRIERE JN. Avoiding ‘overkill’ in diagnosis and treatment of lower urinary tract infections. Urology 1988; 33: 17-21. 14. GALLAGHER DJA, MONTCOMERIE JZ, NORTH JDK. Acute infections of the urinary tract and the urethral syndrome in General Practice. Er J Med 1965; 1: 622-626. 15. STAMM WE, WAGNER KF, AMSEL R, ALEXANDER R, TURCK M, COUNTS GW, HOLMES KK. Causes of the acute urethral syndrome in women. N Engl J Med 1980; 303: 409-415. 16. SUMNERS D, KEL~EY M, CHAIT I. Psychological aspects of lower urinary tract infections in women. Br Med J 1992; 304: 17-19. 17. MELLON AF, COULTHARD MG, SHAW J, MILLAR J. Psychological aspects of lower urinary tract infections in women. Br Med J 1992; 304: 384.

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between

clinical

methods

of measure-

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