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Many women are unsure how to take a urine sample when they have a suspected urinary tract infection, research has found. Better information could improve the diagnosis and treatment of the condition.

Infections of the urinary tract (bladder or kidney) are common. They are diagnosed by tests which use a urine sample collected by the woman. The first part of a stream of urine can be contaminated by bacteria from the skin so women need to take a midstream sample. However, this can be challenging for doctors to explain and for women to perform.

Not much is known about women’s understanding of how urine samples should be collected, or of how urine tests guide treatment. In this study, women who had previously had a suspected urinary tract infection were interviewed about their experience and understanding of urine tests.

The study found a general lack of awareness among women of the need for a midstream urine sample. Many did not know how the tests of their sample related to decisions about treatment such as antibiotics. The research concluded that better communication between doctors and women about test results and the need to produce uncontaminated samples could improve the management of urinary tract infections.

For more information about urinary tract infections visit the NHS website.

What’s the issue?

The urinary tract (the organs involved in peeing) includes the bladder and kidneys. Both men and women experience urinary tract infections, but they are much more common in women. One in 10 women have a urinary tract infection every year; half of all women will have one in their lifetime. They are often treated with antibiotics.

Urinary tract infections are caused by bacteria. The most reliable test for urinary infections involves growing bacteria found in urine in the lab (urine culture). If bacteria grow, they can be identified and an appropriate antibiotic chosen (one which will kill the bacteria). The urine culture can take up to 3 days to produce a result. However, about 1 in 3 urine samples are contaminated by bacteria which live on the skin or in the back passage. That means the test cannot establish whether there is a urinary tract infection. These samples waste time (because another sample is needed) and money (because tests must be run twice).   

To avoid contamination, women are advised to collect a midstream sample. However, this can be difficult for clinicians to explain and for women to do. Women’s views on and understanding of sampling are not well understood.

A test called a urine dipstick involves dipping a colour changing strip into a urine sample. This takes 2 minutes and can be performed immediately, before antibiotics are prescribed. However, guidance differs even within the UK as to whether this test should be performed. It is not accurate at ruling in or ruling out infection.

In this study, women with a suspected urinary tract infection were interviewed about their experience and understanding of collecting urine samples for testing.  

What’s new?

Researchers interviewed 29 women who were consulting their GP about a suspected urinary tract infection. They were aged 20 to 88 and were from a variety of backgrounds and locations. All had taken part in a trial comparing 2 urine sample collection devices (CONDUCT).

The women outlined their understanding of urine samples in key areas.

On why to take a midstream sample:

  • some but not all women knew about the need to collect a midstream sample; many wanted more information, repeat instructions, or information sheets from clinicians
  • others said that it can be hard to produce a midstream sample when you have a urinary tract infection (which can promote the urge to pee frequently, even if there is no urine): “If you haven’t got any [urine], then you can’t do midstream because there is no midstream.”

On contamination of urine samples: 

  • most women did not know their sample could be contaminated: “I hadn’t been appreciating the fact about contamination, I was really surprised
  • even among women who knew a midstream sample was needed, many did not know that it was to avoid contamination; one woman knew that bacteria on the body was a source of contamination
  • other women wrongly related contamination to the collection containers: "I did know that [about contamination] but that’s why I use a very clean mug."

On how tests relate to treatment:

  • a few women knew that the dipstick test could rule out urinary tract infections; some said the dipstick test, carried out in front of them, overcame their reluctance to take antibiotics: “I’d rather know that you need them before taking them… I don’t mind taking tablets, but I don’t take them for the sake of it
  • some women said that lab tests had checked whether they were receiving the correct antibiotic or needed to switch; other women did not remember receiving the results: "You don’t always get that bit of information back …I don’t know what came of it, did they find something or not."
  • some women were not aware of how tests could inform their treatment; one did not believe the results of her negative dipstick.

Why is this important?

The amount, quality, and timing of information given to women varied. Some would have welcomed more verbal and written information from healthcare professionals about urine samples and tests.

Few women had sufficient knowledge about contamination. More information could help avoid contamination and – potentially – reduce the number of tests that need to be repeated.  

A thorough explanation of how test results relate to treatment could encourage more women to take their prescribed medication. Better communication about antibiotics between doctors and women could improve shared decision-making. Some women might prefer to wait until their lab tests are confirmed before taking antibiotics. This, again, could avoid unnecessary prescribing.   

What’s next?

A new information booklet for women with a suspected urinary tract infection covers the diagnosis and treatment of urinary tract infections, including why and how to collect a midstream urine sample. Clinicians could share this booklet with women to increase their understanding. As yet, no research has been done to see whether this booklet reduces contamination rates.

The women in this study had already taken part in a trial about urinary tract infections. Further research could explore whether awareness of urinary tract infections is different in the general population.

You may be interested to read

This Alert was based on: Glogowska M, and others. Women’s information needs around urine testing for urinary tract infections: a qualitative study. British Journal of General Practice 2022;72:e244–e251.

Information from the NHS on the collection and storage of urine samples.

More information on urinary tract infections is available on the NHS website.

A patient information booklet on the diagnosis and management of urinary tract infections.

Bladder Health UK's factsheet on how to take a midstream urine sample.

Funding: The study was funded by the NIHR Research for Patient Benefit Programme.

Conflicts of Interest: The study authors declare no conflicts of interest.

Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care.


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