It’s one of the most common misdiagnoses in American medicine, and it usually happens like this: An old and frail person gets confused, tired, or a little dizzy. Maybe she just doesn’t feel like eating. Or she stumbles.
These are classic geriatric syndromes that usually receive a classic medical response: the senior is ordered to pee in a cup for testing. The leading suspect is a urinary tract infection.
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Too often, it’s the wrong suspect.
The urinary tract infection (UTI), has become the medical bogeyman that will not go away, a default but often incorrect diagnosis that seems to come up every time an older person has some ill-defined health presentation but still lacks the most reliable symptom of painful urination. As a career geriatrician, I don’t enjoy calling out colleagues, but health professionals need to spend less time ordering people to pee in a cup and more time figuring out the true causes of the problem.
UTIs are one of the world’s most commonly reported health problems. More than 400 million cases are diagnosed globally every year. In the U.S., UTIs are responsible for 10.5 million office visits and 3 million hospital emergency department treatments per year. More than half of all women in their lifetimes will be diagnosed with at least one UTI. The frequency of UTI diagnosis increases dramatically as people age, especially after they reach 65 years old.
At the same time, many studies around the world have confirmed the systemic overdiagnosis of UTIs, including three of four patients in a 43-hospital study in 2020; 28 % of all cases at 46 hospitals in Michigan and up to 85% of diagnosed patients in California in two separate studies published in 2022.
The problem with the wrong diagnosis of UTIs is that we put people, especially people with advanced age, on antibiotics they don’t need. That heightens the risk for three bad outcomes: Unwarranted gut infections from using an unneeded antibiotic. Increased antibiotic resistance that makes it harder to treat actual infections. Overlooking and failing to treat the serious root causes of geriatric syndromes.
Read More: 7 Things Every Woman Should Know About UTIs
Why do medical professionals get it so wrong so often? One of the biggest reasons, I’m convinced, is the shortage of geriatric training. Aging baby boomers mean America is older than ever, but somehow the number of board-certified geriatricians has plunged 25% over the past two decades. Fewer health professionals are experts on what to look for in our senior population.
Most physicians in family practice or internal medicine don’t even receive training on the unique challenges of treating older people. Only 10% of medical schools require a rotation in geriatric care, compared to 96% that require a rotation in pediatric care, according to a 2024 John A. Hartford Foundation study of the U.S. health care workforce. Too many doctors just don’t know where the pitfalls are when working with older people. In fact, a 2022 online survey of 1,700 doctors and nurses in New Hampshire found they improperly diagnosed UTIs 34% of the time.
There are technical medical reasons for the misdiagnoses, too. It’s rare for a frail older person to be able to pee in a cup in a sterile way. To collect a urine sample free of contamination, you have to clean the labia and the urethra. You have to place the cup without touching any skin; start and stop urinating; and then put a sterile cap on the sample. It’s not an easy thing to do for a 30-year-old nurse, but it may be impossible for an 80-year-old incontinent person with mobility issues who is wearing an adult diaper. In my own professional experience, I’d say most of these urine samples are contaminated and therefore yield undependable results.
Another complicating factor is that many older people have complex conditions and are colonized with bacteria in their bladders in a way that is normal for them. This is called “asymptomatic bacteriuria. “And people with urinary catheters have this 100% of the time. Most people with asymptomatic bacteriuria won’t develop symptomatic UTIs, but too many are treated anyway with antibiotics, a case of the “cure” truly being worse than the “condition.”
The upshot is that too many urine samples are either contaminated or testing positive for reasons other than UTIs.
Let’s be clear: There’s no question that legitimate UTIs do exist, and that elderly people are at risk for a potentially lethal complication of UTIs called sepsis. Nobody wants to miss that. But medical professionals and caregivers should avoid jumping to conclusions and assuming that UTI is the default diagnosis. Taking a good medical history, paying attention to vital signs, performing an examination, ordering pertinent bloodwork, considering other possible causes for the symptoms, and doing close follow-up monitoring are good ways to avoid missing serious infections.
A urine test is easy to order—but that doesn’t mean it’s always the right thing to do.