Type 2 diabetes mellitus (T2DM) is a chronic metabolic disorder in which the level of blood glucose is constantly elevated, due to insulin resistance and progressive failure of insulin secretion. Diabetes patients are more likely to develop infections, as well as microvascular and macrovascular complications. Urinary tract infection (UTI) is one of the commonest infections that occur in T2DM and can be lower UTI (cystitis) or upper UTI (pyelonephritis) [1]. In addition to more frequent UTIs, diabetes is also linked to more severe infections, more frequent UTI, failure to treat UTIs, and hospitalisation for complications from UTI [2]. There are several mechanisms that make patients with T2DM more susceptible to UTI. Chronic hyperglycemia may cause impaired function of neutrophils, cellular immunity, and other host-defense mechanisms [3]. Glycosuria may create a favorable environment for the growth of bacteria and diabetic autonomic neuropathy may affect bladder emptying and lead to urinary stasis. Other factors that may make someone more susceptible to infection are diabetic

nephropathy, vascular changes, advanced age, long duration of diabetes, and poor glycemic control. This is because these factors predispose the urinary tract to colonization and infection by bacteria in people with diabetes [4].

The incidence of UTI in T2DM patients is significant. Overall, 11.5% (95% CI: 7.8–16.7%) of patients with type 2 diabetes had a UTI in a recent systematic review and meta-analysis of 15 studies and 827,948 patients. A large study with 456,586 patients with T2DM found an overall UTI event rate of 87.3 events per 1,000 patient-years [5]. This was significantly higher in women compared with men (111.8 vs. 55.8 events per 1,000 patient-years, respectively). The risk of infection was higher in those older in age, female, with a history of UTI, a higher number of comorbidities, HbA1c level above 9.5%, and impaired renal function. Women seem to be especially susceptible to the risks of diabetes. Of 589 women with diabetes followed in a prospective, multicenter study for 18 months, 20% (115) had a symptomatic UTI. Of the women with T2DM specifically, 81 (23%) of them had a symptomatic infection. Asymptomatic bacteriuria at baseline was an important predictor and symptomatic UTI was more likely to develop in women with baseline bacteriuria [6,7]. Asymptomatic bacteriuria was also prevalent in women with T2DM (29%) in a separate study of the same multicenter cohort, yet more, indicating urinary bacterial colonization in these women. UTI may present in diabetic patients as asymptomatic bacteriuria, uncomplicated cystitis, acute pyelonephritis, urosepsis and severe renal complications [8]. Complicated infections as emphysematous pyelonephritis, renal and perinephric abscesses and papillary necrosis have been associated with diabetes. Additionally, infections by antimicrobial-resistant organisms may complicate empirical treatment and mean more people will use health care services in diabetic patients. In a retrospective study of 3652 type 2 diabetes patients, 409 patients (11.2%) experienced UTI, and the factors associated with UTI were gender, age, blood glucose level and renal involvement [9-11].

Objective

The purpose of this study is to establish the prevalence of UTI in T2DM patients and to generate local data that can help guide doctors to identify persons with higher risk and minimize the complications of UTI.

The present study is descriptive cross sectional study that was carried out in the department of Medicine, Saidu Group of Teaching Hospital, Swat, Pakistan for the duration from November 2025 to April 2026. There were 178 patients in total. Sample size was determined by using the WHO formula for the estimation of single population proportion. Urinary tract infection (UTI) was recently found by a cross sectional study in Pakistan at Gulab Devi Hospital, Lahore, in 63.1% of the Diabetic patients, culture confirmed. Based on 63.1% expected frequency, 95% confidence level and 7.1% absolute precision, a sample size of 178 patients was calculated. A consecutive sampling technique was employed, that is non-probability sampling. Patients aged 18-70 years of either gender who have been diagnosed with type 2 diabetes mellitus for at least six months were included. Patients with and without clinical signs of UTI were all recruited in order to establish the incidence of UTI among the study population. Patients were excluded if they had type 1 diabetes mellitus, were pregnant, had a urinary catheter in situ, a known congenital or structural abnormality of the urinary tract, renal or ureteric stones, chronic kidney disease on dialysis, recent urological intervention, or use of antibiotics in the preceding 2 weeks. Patients who were not consented were also excluded. Data Collection Procedure All participants gave their written informed consent after approval from the Institutional Research and Ethics Committee. The demographic and clinical data were collected on a proforma which included age, gender, diabetes treatment, history of diabetes, urinary symptoms, previous UTI history and other co-morbidities. Symptoms suggestive of UTI: dysuria, frequency, urgency, suprapubic discomfort, flank pain and fever. All of the participants had a clean-catch midstream urine collected before antibiotic treatment. Pyuria, leukocyte esterase and nitrites were tested in the urine. Standard microbiological methods were used for culturing urine specimens. The diagnosis of UTI was made if a patient presented with matching urinary symptoms with culture of 1 or more uropathogens with a count of 10⁵ or more colony forming units/mL. The isolated microorganism is also noted. Fasting blood glucose and glycated hemoglobin (HbA1c) were drawn. The distribution of glycemic control, duration of diabetes, age and gender were documented to evaluate their distribution between patients with and without UTI. The main outcome was the incidence of UTI in type 2 diabetes mellitus (T2DM) patients. The following secondary observations were made: Age, gender, the duration of diabetes, glycemic control, clinical presentation, and the different microorganisms were all observed. Data Analysis An IBM SPSS Statistics version 26.0 was used for data entry and analysis. The quantitative variables (age, duration of diabetes, fasting blood glucose and HbA1C) were reported as mean ± standard deviation or median with interquartile range as appropriate. Qualitative variables such as gender, urinary symptoms, presence or absence of UTI and isolation of microorganisms were presented as frequencies and percentages. UTI was divided into four subgroups based on age, gender, a duration of diabetes and glycemic control. Where appropriate, a post-stratification chi-square test or Fisher's exact test was used to determine p-value and a p value < 0.05 was deemed statistically significant.

The mean age of the 178 patients was 54.2 ± 10.9 years. There were 80 (44.9%) males and 98 (55.1%) females. The mean duration of diabetes was 9.1 ± 5.8 years, while the mean fasting blood glucose was 176.4 ± 58.2 mg/dL and mean HbA1c was 8.7 ± 1.8%. A previous history of urinary tract infection was reported by 31 (17.4%) patients.

Table 1. Baseline Characteristics of the Study Population

Data are presented as mean ± SD or n (%).

Urinary tract infection was present in 62 (34.8%) of the 178 patients with type 2 diabetes mellitus, whereas 116 (65.2%) patients had no UTI. Thus, approximately one-third of the study population had urinary tract infection.

Table 2. Frequency of Urinary Tract Infection Among Patients with Type 2 Diabetes Mellitus

Figure 1. Frequency of urinary tract infection among patients with type 2 diabetes mellitus.

Among the 62 patients with UTI, dysuria was reported by 43 (69.4%), increased urinary frequency by 38 (61.3%), urgency by 29 (46.8%), suprapubic pain by 22 (35.5%), fever by 17 (27.4%), and flank pain by 12 (19.4%). On laboratory assessment, pyuria was present in 52 (83.9%), leukocyte esterase was positive in 47 (75.8%), and nitrites were positive in 36 (58.1%) patients.

Table 3. Clinical and Laboratory Findings among Patients with UTI

Escherichia coli was the most frequently isolated organism, identified in 39 (62.9%) of the 62 positive urine cultures. This was followed by Klebsiella species in 10 (16.1%), Enterococcus species in 5 (8.1%), Proteus species in 4 (6.5%), and Pseudomonas aeruginosa in 2 (3.2%) patients. Other organisms accounted for 2 (3.2%) isolates.

Table 4. Distribution of Microorganisms Isolated from Urine Cultures

Figure 2. Clinical and laboratory findings among patients with UTI.

UTI was significantly more frequent among females than males, occurring in 42 (42.9%) females compared with 20 (25.0%) males (p=0.013). Patients aged ≥50 years had a higher UTI frequency than those aged <50 years, 39.3% versus 27.3%, although the difference was not statistically significant (p=0.104). UTI was significantly more common in patients with diabetes duration >10 years than ≤10 years, 46.8% versus 25.3% (p=0.003). Its frequency also increased with worsening glycemic control, from 17.1% in patients with HbA1c <7% to 31.6% with HbA1c 7–8.9% and 48.4% with HbA1c ≥9% (p=0.006).

Table 5. Factors Associated with Urinary Tract Infection

The present study was to find the prevalence of U.T.I in 178 diabetes mellitus type 2 patients. In total, 34.8% of patients (62/180) were identified as having UTI. This study validates the significance of UTI as an infectious complication in the T2DM group. This was also higher than the summed prevalence of 11.5% from a systematic review and meta-analysis of 827,948 T2DM patients. The difference could be due to differences in study population, level of glycemic control, diagnostic criteria, health care system, and access to patients in a tertiary care centre. The Pakistan data also indicate a significant prevalence of urinary infection in diabetics. A previous study of 545 patients of type 2 DM in Pakistan has found that 8.08% had culture-proven asymptomatic urinary infection. The lower frequencies recorded in the present study as compared to the previous study in Pakistan might be attributed to the study conducted among patients with no clinical symptoms or signs of the disease as opposed to symptomatic patients in the current study. Importantly, the same Pakistani study also revealed that female accounted for 77.27% of culture-positive cases, and Escherichia coli was the most common organism with 52.3% of the positive cultures [12]. Among all the studied parameters, female gender was significantly associated with UTI in the present study (p=0.013), with 42.9% of females vs 25.0% of males having UTI. This is in accordance with earlier studies which revealed that diabetic women are more prone to urinary infection than diabetes-free women. In a recent systematic review, the odds of UTI in diabetic females were found to be around 3.77 times more prevalent in females than males. The more frequent incidence in females might be due to anatomical differences (shorter urethra, closer of the opening of the urethra to the perineal region), plus the effects of hyperglycemia and impaired host immunity [13]. Next, duration of diabetes was of great importance. For patients with diabetes >10 years, UTI was recorded in 46.8% of patients and for patients with diabetes ≤10 years, UTI was found in 25.3% of patients (p=0.003). Greater cumulative exposure to hyperglycemia, incomplete bladder emptying, microvascular complications, and progressive immune dysfunction may make people with diabetes more susceptible to infection.Because with the progression of diabetes immune function becomes impaired, and people with diabetes may not empty their bladders properly, microvascular dysfunction and longer duration of diabetes may make them more susceptible to infection [14]. In addition, poor glycemic control was significantly correlated with UTI. The frequency increased from 17.1% among patients with HbA1c <7% to 31.6% among those with HbA1c of 7–8.9% and 48.4% among patients with HbA1c ≥9% (p=0.006). Long-standing hyperglycemia can also affect the function of the neutrophils and cellular immunity, while glycosuria creates a perfect breeding ground for bacteria. The results highlight the need for controlling glycemia in the prevention of infection-related complications among people with T2DM. The strongest association in the current study was with a prior UTI history. In patients having previously had a UTI, 61.3% had infection, while for those that had not had a previous UTI, 29.3% had infection (p<0.001) [15]. Previous studies that found an association between past UTI and an increased risk of future urinary infection among people with diabetes support this finding, reporting that patients who had experienced one UTI had about three times the likelihood of having another one [16]. Systematic reviews have also revealed that recurrent UTIs are common in T2DM patients, especially women, and that E. coli still is the leading cause of the UTIs. Escherichia coli was the most prevalent (62.9%) microorganism, followed by Klebsiella species (16.1%), Enterococcus species (8.1%) and Proteus species (6.5%). Proceeding in line with the evidence of both Pakistan and international studies showing E. coli is the most frequent uropathogen found in Diabetes patients [17]. The predominance of E. coli has clinical significance as elevated levels of resistance to antimicrobial agents could pose difficulties in empirical therapy and necessitate testing of urine by culture and susceptibility testing [18,19]. There were some limitations in this study. First, because of the cross-sectional design, it was possible to measure the prevalence of UTI as well as factors that were associated with it, but not determine cause and effect. Second, this study took place in one tertiary care centre, so the results may not be representative of the overall diabetic population. Thirdly, there is a possibility of selection bias due to the usage of non-probability consecutive sampling method. Fourth, certain potential risk factors for UTI (such as diabetic neuropathy, nephropathy, sexual activity, menopausal status, hydration, and detailed urinary tract abnormalities) were not evaluated. Fifth, urine culture was a single sample, and multiple cultures were not routinely ordered. Lastly, no assessment was made of antimicrobial resistance pattern and long term recurrence of UTI.

The conclusion is that urinary tract infection is a prevalent complication among the patients with type 2 diabetes mellitus in this study at 34.8% of the study population. UTI was much more common in the female, patients with longer duration of diabetes, poor glycemic control, and history of UTI. The most frequent isolate was Escherichia coli. The burden and complications of a UTI may be minimized in patients with type 2 diabetes mellitus by early identification of high-risk patients, improved glycemic control, and treatment based on a urine culture.