Urinary Tract Infections in Teens and Adults
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This topic is about urinary tract infections in teens and adults. For information about infections in babies and young children, see the topic Urinary Tract Infections in Children.
What is a urinary tract infection?
Your urinary tract is the system that makes urine and carries it out of your body. It includes your bladder and kidneys and the tubes that connect them. When germs get into this system, they can cause an infection.
Most urinary tract infections are bladder infections. A bladder infection usually is not serious if it is treated right away. If you do not take care of a bladder infection, it can spread to your kidneys. A kidney infection is serious and can cause permanent damage.
What causes urinary tract infections?
Usually, germs get into your system through your urethra, the tube that carries urine from your bladder to the outside of your body. The germs that usually cause these infections live in your large intestine and are found in your stool. If these germs get inside your urethra, they can travel up into your bladder and kidneys and cause an infection.
Women tend to get more bladder infections than men. This is probably because women have shorter urethras, so it is easier for the germs to move up to their bladders. Having sex can make it easier for germs to get into your urethra.
You may be more likely to get an infection if you do not drink enough fluids, you have diabetes, or you are pregnant. The chance that you will get a bladder infection is higher if you have any problem that blocks the flow of urine from your bladder. Examples include having kidney stones or an enlarged prostate gland.
For reasons that are not well understood, some women get bladder infections again and again.
What are the symptoms?
You may have an infection if you have any of these symptoms:
- You feel pain or burning when you urinate.
- You feel like you have to urinate often, but not much urine comes out when you do.
- Your belly feels tender or heavy.
- Your urine is cloudy or smells bad.
- You have pain on one side of your back under your ribs. This is where your kidneys are.
- You have fever and chills.
- You have nausea and vomiting.
Call your doctor right away if you think you have an infection and:
- You have a fever, nausea and vomiting, or pain in one side of your back under your ribs.
- You have diabetes, kidney problems, or a weak immune system.
- You are older than 65.
- You are pregnant.
How are urinary tract infections diagnosed?
Your doctor will ask for a sample of your urine. It is tested to see if it has germs that cause bladder infections.
If you have infections often, you may need extra testing to find out why.
How are they treated?
Antibiotics prescribed by your doctor will usually cure a bladder infection. It may help to drink lots of water and other fluids and to urinate often, emptying your bladder each time.
If your doctor prescribes antibiotics, take the pills exactly as you are told. Do not stop taking them just because you feel better. You need to finish taking them all so that you do not get sick again.
Can urinary tract infections be prevented?
You can help prevent these infections.
- Drink lots of water every day.
- Try drinking cranberry juice or taking cranberry pills.
- Urinate often. Do not try to hold it.
- If you are a woman, urinate right after having sex.
Frequently Asked Questions
Learning about urinary tract infections:
Living with infections that keep coming back:
Bacteria that enter the urethra and travel up the urinary tract are the usual cause of urinary tract infections (UTIs). Bacteria that normally live in the large intestine and are present in feces (stool) are the most common source of infection. Sexual intercourse may introduce bacteria into the urinary tract, especially in women. Catheters, which are small, flexible tubes inserted into the bladder to allow urine to drain, are a common source of bacterial infection in people who are hospitalized or live in long-term care facilities.
Sometimes bacteria traveling through the blood or lymph system cause kidney or bladder infections.
Symptoms of a urinary tract infection (UTI) may include:
- Pain or burning when you urinate.
- An urge to urinate frequently but usually passing only small amounts of urine.
- Dribbling (inability to control urine release).
- Pain or a feeling of heaviness in your lower abdomen.
- Reddish or pinkish urine.
- Foul-smelling urine.
- Cloudy urine.
- Pain in your back just below the rib cage, on one side of your body (flank pain).
- Fever and chills.
- Nausea and vomiting.
Some people have bacteria in their urinary tract without having any symptoms. This condition is called asymptomatic bacteriuria. It requires attention in certain situations, such as during pregnancy or before surgery involving the urinary tract. But it usually can be left alone if symptoms do not develop.
Several other conditions, such as vaginal infections or irritable bladder, cause symptoms similar to those of a UTI. Your doctor may evaluate your health for one or more of these if you have urinary symptoms, depending on your medical history and how well you respond to treatment for a UTI.
Urinary tract infections (UTIs) typically occur when bacteria from the rectal area enter through the urethra, which is a tube that carries urine, and travel up the urinary tract to the bladder or kidneys.
When a bacterial UTI is present but does not cause symptoms, it is called asymptomatic bacteriuria. These types of infections often affect pregnant women and older adults or those who require a catheter to urinate. Pregnant women are screened for asymptomatic bacteriuria, because it can cause preterm labor and other problems if not treated. Asymptomatic bacteriuria may lead to infections that cause symptoms, but in many cases it does not. It usually goes away without treatment.
Typically, UTIs cause urinary symptoms, such as pain or burning during urination. Some mild bladder infections may go away on their own within a couple of days. Most UTIs clear up quickly with antibiotics and home treatment, which includes drinking plenty of water and urinating frequently. The amount of time required to cure the infection and the need for urine tests will vary with the location (bladder or kidneys), frequency, and seriousness of the infection. Kidney infections and UTIs that are complicated by other factors require longer treatment.
Complications of UTIs are not common but do occur. Serious complications can include permanent kidney damage and widespread infection (sepsis), which can be life-threatening. The risk is greater if the infection is not treated or if the infection does not respond to antibiotics.
Although it is possible to have a relapse of the same infection, most recurrent UTIs are caused by new infections. About 20% to 30% of women have recurrent infections.1 A rapid relapse usually means that treatment failed or there is another problem affecting the urinary tract (not just the infection). But recurrent UTIs in women usually aren't serious.
UTIs in men
Men sometimes develop uncomplicated urinary tract infections.
UTIs in older men are more often related to prostate problems. This can make them more difficult to treat. Having an enlarged prostate, which is common in older men, can limit the body's ability to pass urine. Repeated UTIs may indicate prostatitis, epididymitis, or another urinary tract problem. For more information, see the topic Benign Prostatic Hyperplasia, Epididymitis, or Prostatitis.
What Increases Your Risk
Risk factors in women
- Sexual activity, which pushes bacteria into the urethra. Sexual activity with the use of a diaphragm and spermicide raises the risk.
- Pregnancy. Pregnant women are at risk of developing asymptomatic bacteriuria, which in turn increases the risk of infections that cause symptoms. It also increases the risk of preterm labor.
- Previous UTIs.
- Use of feminine hygiene products that contain deodorant.
- Lack of estrogen, which allows bacteria that can cause UTIs to grow more easily in the vagina or urethra. Women who have gone through menopause are at increased risk for UTIs.
Risk factors in men
Things that increase a man's risk of UTIs include:
- Problems with the prostate gland. Men become increasingly prone to UTIs as they get older because of prostate problems, such as enlarged prostate (benign prostatic hyperplasia) and prostatitis.
- An uncircumcised penis.
- Anal intercourse.
- Unprotected sex with a woman who has a vaginal infection.
- HIV infection .
Risk factors in both women and men
Certain risk factors apply to both women and men. These include:
- Not drinking enough fluids. Drinking more fluids causes increased urination, reducing bacteria in the urinary tract and bladder.
- Having a catheter in place. A catheter is a small, flexible tube inserted through the urethra and into the bladder. It allows urine to drain. Bacteria can enter the catheter and start an infection. Most at risk are older adults who are in hospitals or who live in long-term care facilities. Catheterization also greatly increases the risk for asymptomatic bacteriuria.
- Kidney stones and other obstructions in the urinary tract. These may block the flow of urine, raising the risk of bacterial infection.
- Diabetes . People with diabetes are at greater risk for UTIs because their immune systems are weakened. Also, long-term high blood sugar can damage the kidneys' filtering system (diabetic nephropathy).
- Structural problems of the urinary tract. These may be present at birth or develop later in life.
When To Call a Doctor
Call your doctor immediately if painful urination or other symptoms of a urinary tract infection (UTI) occur with:
- Nausea and vomiting.
- Fever and chills.
- Pain in the back just below the rib cage, on one side of your body (flank pain).
Call a doctor if you:
- Have had UTI symptoms previously and have those symptoms again.
- Have minor symptoms of a UTI that do not clear up in 1 to 2 days, such as pain or burning when you urinate, foul-smelling urine, or the urge to urinate frequently while passing only small amounts of urine.
- Notice blood or pus in your urine.
- Have symptoms of a UTI and you have diabetes.
- Have been taking antibiotics for a UTI but your symptoms do not improve or they come back (recur) after improving temporarily.
Watchful waiting is a wait-and-see approach. If you get better on your own, you won't need treatment. If you get worse, you and your doctor will decide what to do next.
In adults, home treatment for minor urinary tract infections (UTIs) often resolves the problem. Home treatment includes drinking plenty of water and urinating often, emptying the bladder each time.
- Try home treatment for 1 to 2 days if your symptoms are minor.
- If your symptoms last longer than 1 to 2 days or are severe, seek medical help.
Watchful waiting is not appropriate if you:
- Have diabetes or an impaired immune system.
- Are pregnant.
- Are older than 65.
Who To See
The following health professionals can treat urinary tract infections (UTIs):
- Nurse practitioner
- Physician assistant
- General practitioner
- Family medicine physician
To prepare for your appointment, see the topic Making the Most of Your Appointment.
Exams and Tests
If you have symptoms of a urinary tract infection (UTI), your first evaluation by a doctor will likely include:
Your doctor may order a urine culture to confirm the diagnosis of a suspected UTI. But if your symptoms, medical history, and urinalysis make the presence of an uncomplicated urinary tract infection likely, your doctor may have you begin treatment with antibiotics without waiting for the results of a urine culture.
A doctor may order a urine culture:
- For women with unusual UTI symptoms, such as symptoms that last longer than 7 days, or symptoms of a kidney infection (pyelonephritis).
- For men before and after treatment for a UTI.
- For anyone older than 65 with UTI symptoms.
- If you have diabetes, an impaired immune system, or structural problems in your urinary tract.
- If your UTI symptoms return after 3 days of treatment. A urine culture can identify what type of bacteria is causing the infection, so that the most effective antibiotic for that bacteria can be used.
- After treatment for a UTI in people who have kidney infections (pyelonephritis), to make sure the infection is cured.
- To screen young girls for asymptomatic bacteriuria.
If you are pregnant, your doctor may order a urine culture:
- If you have UTI symptoms.
- After treatment for a UTI.
- To screen for asymptomatic bacteriuria.
Tests used less frequently
If the infection does not respond to treatment with antibiotics or recurs rapidly, if the infection may be complicated by other factors, or, in some cases, if the kidneys are infected, your doctor may order other tests to:
- Look for the cause of recurrent or chronic infections.
- Check for other kidney problems.
- Diagnose structural problems of the urinary tract that might make you more likely to get UTIs.
- Find out whether the infection is caused by unusual bacteria.
- Find out whether you have an impaired immune system.
Tests may include:
- Abdominal ultrasound, which uses reflected sound waves to produce a picture of the upper abdomen.
- Pelvic ultrasound, which uses reflected sound waves to produce a picture of the lower abdomen.
- Voiding cystourethrogram, which is an X-ray test that takes pictures of your bladder and urethra while you are urinating.
- Cystometry, which measures your bladder's ability to hold in and push out water or gas.
- Cystoscopy, which allows your doctor to look at the interior lining of the bladder and the urethra.
- Intravenous pyelogram (IVP), an X-ray test that provides pictures of the size, shape, and position of the kidneys, bladder, ureters, and urethra.
- Spiral (helical) CT urogram, a high-speed (about 90 seconds) scanner that provides detailed pictures of the area scanned.
If you get UTIs often, your doctor may write you a standing prescription for antibiotics that you can fill without a doctor's appointment. Then when you first have symptoms of a UTI, you can start taking medicine right away. You may want to use a home test for UTI to make sure you have an infection before you start antibiotics.
Experts disagree about the value and cost-effectiveness of screening people who are at high risk for urinary tract infections. Factors that increase the risk for UTIs include previous UTIs, using condoms coated with spermicide, and prostate problems.
All pregnant women should receive screening for asymptomatic bacteriuria.
Antibiotics can treat most urinary tract infections (UTIs) successfully. The goals of treatment for UTIs are to relieve symptoms, eliminate the infection and prevent recurrence, and prevent unlikely but serious complications such as kidney damage and sepsis. In pregnant women, treatment protects the woman and the fetus. The number of days your doctor will have you take antibiotics depends on your infection and the type of antibiotic medicine.
Treatment for uncomplicated bladder infections is usually a combination of antibiotics and home treatment. Home treatment includes drinking a lot of water and fluids and urinating frequently, emptying your bladder each time. More testing is not needed if your symptoms improve.
Oral antibiotics usually can treat kidney infections (pyelonephritis). But you may need a brief hospital stay and a short course of intravenous (IV) antibiotics if you are too ill or nauseated to take medicine by mouth (oral medicine). Kidney infections tend to make people more severely ill than bladder infections.
You may need more tests before and after treatment if you:
- Are pregnant.
- Are older than 65.
- Have diabetes or an impaired immune system.
- Are a man.
If you have a severe kidney infection, or if a bladder or kidney infection is complicated by other factors, you may need hospital care.
Treatment if the condition gets worse or recurs
If the infection spreads and affects your kidney function or causes widespread infection (sepsis), you will need hospital care. These complications are not common. And they rarely occur in people who are otherwise healthy. People are at higher risk if they have an impaired immune system, diabetes, untreated urinary tract obstruction, and/or other conditions that affect the kidneys or bladder.
A new infection, rather than a relapse of the same infection, usually is the cause of a UTI that keeps coming back (recurs).
- Women with recurrent bladder infections may be treated with preventive antibiotic therapy.
- Recurrent UTIs in men are usually a sign of prostate infection (prostatitis). Chronic prostatitis can be hard to treat. For more information, see the topic Prostatitis. Follow-up checkups are usually necessary in men who have UTIs and are always necessary if the infection recurs.
What To Think About
Your doctor may base treatment decisions for a bladder infection on your symptoms and urinalysis results, without doing a urine culture. If treatment clears up the symptoms, it confirms the diagnosis of a simple, uncomplicated UTI. If the symptoms do not clear up, you will need further testing to look for:
- A kidney infection.
- Structural problems with the kidneys that increase the risk of infection.
- Infection with an uncommon bacteria.
- An impaired immune system.
- A cause for the symptoms that is not an infection.
Many forms of bacteria have become resistant to common antibiotics designed to destroy them. These are called antibiotic-resistant bacteria. Antibiotic resistance among bacteria that cause UTIs has increased steadily in recent decades.
You and your doctor may have to try different antibiotics, and different combinations of antibiotics, to find the right medicine that will kill the bacteria causing the UTI. But in most cases, a urine culture and antibiotic sensitivity test will help find the right antibiotic to use.
You can take steps to prevent new or relapsing urinary tract infections (UTIs).
Prevention steps for men and women
- Drink plenty of water and other liquids each day. This helps ensure that you urinate frequently, which flushes bacteria from your urinary tract.
- Urinate when you have the urge. Don't hold your urine for a long time.
- Avoid constipation.
- Drink cranberry juice or take cranberry pills.
- Ask your doctor about taking methenamine to prevent recurrent UTIs.
- Ask your doctor about taking antibiotics to prevent recurrent UTIs.
Prevention steps for women
- Urinate immediately after sexual intercourse. This is the best protection women have against UTIs, because it helps prevent bacteria from moving into the urethra.
- Avoid using condoms coated with spermicide or a diaphragm for birth control if your doctor believes they are causing you to get UTIs.
- Change sanitary napkins often.
- Avoid douches, feminine hygiene sprays, and other feminine hygiene products with deodorant. These can change the normal balance of organisms that help prevent infection.
- Wipe from front to back after using the toilet to avoid spreading bacteria from your anus to your urinary tract.
- If you get UTIs often, ask your doctor about taking antibiotics right after sexual intercourse to prevent recurrent UTIs.
- Post-menopausal women may want to ask their doctors about using vaginal estrogen to prevent recurrent UTIs.
Prevention step for men
- Keep the tip of your penis clean, especially if you are uncircumcised. The foreskin can trap bacteria, which can then get into the urinary tract and cause infection.
You may be able to cure an early urinary tract infection (UTI) if you act promptly when you have the first symptoms of a UTI, such as pain and burning with urination. Home treatment steps that may stop an infection from getting worse include:
- Drinking lots of water, especially during the first 24 hours after your symptoms appear. This will help make the urine less concentrated and wash out the infection-causing bacteria. This may alter some of your body's normal defense mechanisms. But most doctors recommend drinking a lot of fluids when you have a UTI. Some people also drink cranberry juice.
- Urinating frequently and completely, to empty your bladder each time.
To relieve pain, take a hot bath or lay a heating pad over your genital area. Never go to sleep with a heating pad in place.
Self-treatment of recurrent UTIs
If you are a woman who has frequent uncomplicated UTIs, your doctor may write a standing prescription for antibiotics to take if you develop symptoms of a UTI. If you and your doctor agree to follow this approach and you develop symptoms that you are certain are caused by a UTI, follow your doctor's instructions for taking the medicine and for watching your symptoms. Be sure to tell your doctor if your symptoms do not improve or if you start having UTIs more often than in the past.
Oral antibiotics can treat most bladder infections and uncomplicated kidney infections successfully. In many cases, if the symptoms and urinalysis suggest a urinary tract infection (UTI), you will start taking antibiotics without waiting for the results of a urine culture.
The number of days your doctor will have you take antibiotics depends on your infection and the type of antibiotic medicine.
Antibiotics for recurrent infections
Doctors sometimes advise that women with repeat infections use preventive antibiotic therapy. This may include taking a small dose of antibiotics daily or on alternate days, taking antibiotics after sexual intercourse (since sex often triggers UTIs in women with recurrent infections), or taking antibiotics only when you develop symptoms. Talk with your doctor about which treatment strategy is right for you.
Medicines used to treat UTIs include:
- Antibiotics to cure the infection. Antibiotics used for UTIs include sulfonamides with trimethoprim (such as Bactrim), nitrofurantoin (such as Macrobid), and fluoroquinolones (such as Cipro).
- Phenazopyridine (such as Pyridium and Uristat) to treat the pain and burning of a UTI. Uristat is an example of phenazopyridine you can buy without a prescription.
- Other nonprescription medicines for pain. These include acetaminophen (Tylenol) and nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Advil, Motrin) and naproxen (Aleve).
Medicines used to prevent recurrent UTIs include:
- Antibiotics, including sulfonamides with trimethoprim (such as Bactrim).
- Methenamine (such as Hiprex).
- Vaginal estrogen (such as Estring, Vagifem, or Premarin) for women who have been through menopause.
Be sure to tell your doctor if you are or think you may be pregnant. Some of these medicines are not safe to use if you are pregnant.
What To Think About
These medicines are often prescribed in a less costly generic form, rather than under a brand name. A pharmacist might also decide to give you a generic instead of a brand name medicine unless the prescription says "no generic."
Take all of the antibiotics your doctor has prescribed. Most people begin to feel better soon after they begin the medicine. But if you stop taking the medicine as soon as you feel better, the infection may return. And not taking the full course of antibiotics encourages the development of bacteria that are resistant to antibiotics. This not only makes antibiotics less effective but also makes bacterial infections harder to treat.
Many forms of bacteria have become resistant to common antibiotics designed to destroy them. These are called antibiotic-resistant bacteria. Antibiotic resistance among bacteria that cause UTIs has increased steadily in recent decades. You and your doctor may have to try different antibiotics, and different combinations of antibiotics, to find the right medicine that will kill the bacteria that is causing your UTI. Before starting you on a new antibiotic, your doctor may get a urine sample from you. Results from tests on this sample will help guide the decision on which antibiotic you take next.
If your doctor prescribes antibiotics, ask whether there are any potential drug interactions you should be aware of. For instance, some antibiotics used to treat UTIs may make birth control pills less effective. Your doctor may recommend a backup form of birth control. Antibiotics can also reduce the effectiveness of warfarin (Coumadin), an anticoagulant (blood thinner) that lowers the risk of heart attack and stroke in people at high risk for these conditions.
Antibiotics for recurrent UTIs
For women who have recurrent UTIs, some doctors may write a standing prescription for antibiotics that a woman can take as soon as she has symptoms of a UTI. This saves the cost and inconvenience of a clinic visit. It also allows a woman familiar with the typical symptoms of a UTI to begin treating the infection without delay. Talk with your doctor about whether this self-treatment strategy is right for you. If you and your doctor have agreed to follow this approach and you start to have symptoms that you are certain are caused by a UTI, follow your doctor's instructions for taking the medicine and for monitoring your symptoms.
Be sure to notify your doctor if your symptoms do not improve or if you start having UTIs more often than in the past.
There is no surgical treatment for urinary tract infections (UTIs) at this time. If you have a problem with the structure of your urinary tract that is causing frequent UTIs, you and your doctor may want to consider surgery to correct the problem.
Other Places To Get Help
|National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)|
|Building 31, Room 9A06|
|31 Center Drive, MSC 2560|
|Bethesda, MD 20892-2560|
The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) is part of the U.S. National Institutes of Health. It conducts and supports research on many of the most serious diseases affecting public health, particularly the diseases of internal medicine. NIDDK sponsors the National Kidney and Urologic Diseases Information Clearinghouse (NKUDIC). It has information about diseases of the kidneys and urologic system for people with these diseases and their families, health professionals, and the public.
|National Kidney and Urologic Diseases Information Clearinghouse|
|3 Information Way|
|Bethesda, MD 20892-3580|
The National Kidney and Urologic Diseases Information Clearinghouse (NKUDIC), a federal agency, is a service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). NIDDK is part of the National Institutes of Health under the U.S. Department of Health and Human Services. The clearinghouse provides information about diseases of the kidneys and urologic system to people with kidney and urologic disorders and to their families, to health professionals, and to the public. NKUDIC answers inquiries; develops, reviews, and distributes publications; and works closely with professional and patient organizations and government agencies to coordinate resources about kidney and urologic diseases.
|National Kidney Foundation|
|30 East 33rd Street|
|New York, NY 10016|
The National Kidney Foundation works to prevent kidney and urinary tract diseases and help people affected by these conditions. Its Web site has a lot of information about adult and child conditions. The site has interactive tools, donor information, recipes for kidney disease patients, and message boards for many kidney topics. Free materials, such as brochures and newsletters, are available.
|UrologyHealth.org, American Urological Association|
|1000 Corporate Boulevard|
|Linthicum, MD 21090|
1-866-RING AUA (1-866-746-4282) toll-free
UrologyHealth.org is a Web site written by urologists for patients. Visitors can find specific topics by using the "search" option.
The Web site provides information about adult and pediatric urologic topics, including kidney, bladder, and prostate conditions. You can find a urologist, sign up for a free quarterly newsletter, or click on the Urology Resource Center to find materials about urologic problems.
- Gupta K, Stamm WE (2008). Urinary tract infections. In DC Dale, DD Federman, eds., ACP Medicine, section 7, chap. 23. Hamilton, ON: BC Decker.
- Schrag S, et al. (2002). Prevention of perinatal group B streptococcal disease: Revised guidelines from CDC. MMWR, 51(RR-11): 1–22.
- Sen A (2006). Recurrent cystitis in non-pregnant women. Clinical Evidence (15): 2558–2564.
Other Works Consulted
- Jepson RG, Craig JC (2008). Cranberries for preventing urinary tract infections. Cochrane Database of Systematic Reviews (1).
- Lee BSB, et al. (2007). Methenamine hippurate for preventing urinary tract infections. Cochrane Database of Systematic Reviews (4).
- Neumann I, et al. (2008). Pyelonephritis (acute) in non-pregnant women, search date February 2007. Online version of BMJ Clinical Evidence: http://www.clinicalevidence.com.
- Perrotta C, et al. (2008). Oestrogens for preventing recurrent urinary tract infection in postmenopausal women. Cochrane Database of Systematic Reviews (2).
- Talan DA, et al. (2004). Once daily, extended release ciprofloxacin for complicated urinary tract infections and acute uncomplicated pyelonephritis. Journal of Urology, 171(2, Part 1): 734–739.
- Vogel T, et al. (2004). Optimal duration of antibiotic therapy for uncomplicated urinary tract infection in older women: A double-blind randomized controlled trial. Canadian Medical Association Journal, 170(4): 469–473.
|Editor||Kathleen M. Ariss, MS|
|Associate Editor||Pat Truman, MATC|
|Primary Medical Reviewer||E. Gregory Thompson, MD - Internal Medicine|
|Specialist Medical Reviewer||Avery L. Seifert, MD - Urology|
|Last Updated||June 8, 2009|
Last Updated: June 8, 2009