MANAGEMENT OF URINARY TRACT INFECTIONS: HISTORICAL PERSPECTIVE AND CURRENT STRATEGIES: PART 1—BEFORE ANTIBIOTICS

Abstract

Urinary tract infections (UTIs) have plagued mankind long before bacteria were recognized as the causative agents of disease and before urology became an established medical specialty. To our knowledge a comprehensive review of the recorded medical history of UTI from its first description in ancient Egyptian papyri through today has not been attempted until now. Numerous resources were used to collect the information described in this review. Older textbooks from the school of medicine library at our institution were used to collect information on UTI in ancient times. Medical texts from the 19th century contains information regarding the treatment of UTI during that era. Early volumes of the Journal of Urology from the beginning of the 20th century are rich with information on the first attempts at chemotherapy for UTI. MEDLINE searches were used to collect appropriate information after 1969. The Ebers papyrus from ancient Egypt recommended herbal treatments to ameliorate urinary symptoms without providing insight into pathological mechanisms. Hippocrates believed that disease was caused by disharmony of the 4 humors and accordingly diagnosed urinary disorders. Roman medicine further expanded the conservative approach (bed rest, diet, narcotics and herbs) advocated by Greek physicians, while also improving invasive techniques (surgical lithotomy for stones and catheterization for retention). The Arabian physician Aetius refined uroscopy and created a detailed classification and interpretation of urinary disease based on this technique. During the Middle Ages no major advances occurred, although existing therapies were refined and treatments for gonococcal urethritis were well described. The early 19th century provided vivid and detailed descriptions of UTIs without the knowledge that they were caused by microorganisms. Management included hospitalization, bed rest, attention to diet, plasters, narcotics, herbal enemas and douches, judicious bleeding (direct bleeding, cupping and leeches), and surgery for stones, abscess and retention. The discovery of microorganisms as the etiological agents of infectious diseases in general and inflammation associated with urinary diseases in particular provided an impetus for physicians critically to examine management approaches and develop evidence based strategies for UTI treatment. Various antibacterial agents, such as hexamine, mercurochrome and others (hexylresorcinol, methylene blue, pyridium, acriflavin and mandelic acid), showed promise in laboratory studies but their efficacy in clinical investigations was disappointing. Treatments for UTI until the discovery of antibiotics were largely palliative because the bacterial origin of UTI was not recognized and no specific antimicrobial therapies were available.