A few weeks back, I had a 450 pound woman lumber into one of the back rooms of the Emergency Department. To be honest, I'm not quite sure how she got around on a daily basis, but kudos to her for not caving to the electric scooter craze.
Before I went in the room, I looked up her records. Multiple UTI's - in fact, 7 in the past 6 months - with every antibiotic under the sun thrown at her. Chronic diarrhea, probably secondary to the antibiotics. Diabetes with extreme insulin resistance. Hypertension resistant to treatment. The list goes on.
She was an overwhelmingly nice woman, and said that for the past 6 months it "burned down there" on and off whenever she peed. 7 different courses of antibiotics, no cure yet. Multiple workups for gonorrhea, chlamydia, trichomonas... all negative.
Lo and behold, she had another UTI. Bacteria were swarming all over her urine sample. I sat there, scratching my head; all my antibiotic tricks had already been used with no cure.
And then I thought to myself: I wonder if this was a clean specimen?
I did a pelvic exam. It took myself and 3 other people to physically lift her pannus to the point where I could get a clean, catheterized specimen. It was actually the most physically taxing thing I did all week. We were all sweating by the time we finished, but I finally, successfully, got a clean urine sample directly from her bladder. Along the way, I noticed that she had a wicked yeast infection.
Lo and behold, her urine came back crystal clear. Not a single bacteria. The special KOH slide I tested, on the other hand, showed copious amounts of yeast.
I went in and talked with her for quite a while afterwards. "You don't have a urinary tract infection," I explained, "and probably never did. All the antibiotics you were given predisposed you to your diarrhea and this yeast infection. You need to know - and this isn't an easy thing to hear - the reason you've been diagnosed with UTI's so many times is that you are physically unable to give a clean urine specimen because of your morbid obesity."
"I know it's causing me problems," she said, "but I sure didn't know it could do that. Thank you for your kindness. I know I need to lose weight, maybe this will be the reason."
I hope she does, but statistically she is mandated to undergo gastric bypass; the incidence of complications from the surgery is actually less than that of simply being so obese. I wonder... should we add frequently misdiagnosed UTI's to the known complications of morbid obesity?