Become a Creator today!Start creating today - Share your story with the world!
Start for free
00:00:00
00:00:01
7. Urinary Tract Infections (UTIs) with Dr. David Sheyn
114 Plays1 year ago
Urinary tract infections (UTIs) are a common health issue that affect millions of people each year. These infections can spread through any part of the urinary tract, including the kidneys, ureters, bladder, and urethra. Recurrent UTIs are especially troublesome and are more common in post-menopausal women.
In this episode of Our Womanity, I am joined by my colleague Female Pelvic Medicine Division Chief at University Hospitals, Cleveland, and Associate Professor of Urology and Reproductive Biology at School of Medicine, Dr. David Sheyn. We answer two questions submitted by our listeners about UTIs:
Question 1: “I have been having recurring UTIs for the last 4 years and get about 6-8 a year. I just had a vaginal swab that shows the same bacteria in my urine. Could the bacteria be causing the UTIs without causing severe vaginal symptoms? I get dryness and mild itching at times but no obvious discharge so how do you treat in these situations?”
Question 2: “How do I treat Aerobic Vaginitis? My doctors brush over it and don’t seem to know what to do. I get recurring UTIs and now I think they’re connected. I tried Metrogel (metronidazole) but Google tells me that it will not fight the bacteria. I also tried Boric acid for 14 days.”
Featured in this episode:
- UTI causes and symptoms
- Antibiotics, vaginal estrogen, and other UTI treatments
- Pelvic floor hypertonicity
- Condoms, spermicides, and genetics can cause infections
- Drug resistant bacteria
Are you 60 years of age or older? Help Univesirty Hospitals find a way to prevent infections in the blood. A clinical research study to evaluate an investigational vaccine in adults 60 years of age or older is now enrolling: https://en-us.embracevaccinestudy.com/
Submit your questions on anything and everything women's health-related and we will answer them in one of our episodes.
Want more from Our Womanity?
If you enjoyed this episode of Womanity, please subscribe, rate, and leave a review. Your feedback helps us continue to bring you engaging and empowering content.
Follow us on social media:
- Instagram: @drrpope
- TikTok: @vulvadoctor
- Twitter: @drrpope
Recommended
Transcript
Introduction: Dr. David Shane and the Topic of Female Sexual Health
00:00:00
Speaker
Okay, everybody, welcome back to Arwell Manatee. I have Dr. David Shane on with us. He is a urogynecologist and associate professor in the Urology Institute, a colleague of mine at University Hospital's Cleveland Medical Center. We have worked together for a very long time, but he did go on and do his fellowship in urogynecology. So he's got expertise in gynecology and urology, the bladder and vaginal health.
00:00:23
Speaker
which
Listener Questions: Recurring UTIs
00:00:24
Speaker
is why I brought him on today to answer these questions that I got from our website. And just a reminder, if you have questions about female sexual health, any sort of gynecological health, you can go to ourwomanity.com and put in a question and submit and we will actually answer them. So I have Dr. David Shane here. Welcome Dr. Shane. Thanks so much for your time. Thank you for inviting me to be here, Dr. Pope. I'm excited to talk about UTIs.
00:00:48
Speaker
Yay, UTIs! So we hate them, but they are an interesting thing to study, and this is one of the things that Dr. Shane has spent a lot of time researching. So let me read these questions. There's two of them, so I'm going to start with the first one. It says, I've been having recurring UTIs for the last four years and get about six to eight per year. That's awful.
00:01:07
Speaker
Just had a vaginal swab that showed two of the same bacteria I get in my urine. Could the vaginal bacteria be causing the UTIs without having severe vaginal symptoms? I get dryness and mild itching at times, but no obvious discharge. So how do you treat in these situations? Thank you. That is a great question. She did not mention her age, but I am assuming she might be postmenopausal. That's not always a safe assumption, but postmenopausal women are typically more prone to frequent infections.
00:01:35
Speaker
And certainly eight infections a year sounds like a lot.
Diagnosing UTIs: Importance of Urine Cultures
00:01:41
Speaker
I would be curious to know how these infections are diagnosed. The current diagnostic criteria from the CDC and treatment is when many women report UTI symptoms, they will get empiric antibiotics, meaning they can just be treated without any sort of evaluation.
00:01:57
Speaker
right typically holds true for one infection and maybe a second infection but not when you have six to eight then we want to start looking for other things that may mimic a urinary tract infection so the first thing i would start with would be how are these infections being diagnosed are they being diagnosed with a urine culture.
00:02:16
Speaker
And what is the culture showing is it showing that it's normal and you're still having the symptoms and you could still have an infection because cultures can be negative up to one out of three times, which is kind of terrible. That is kind of terrible. But if you've had six to eight episodes and cultures are negative every time it is unlikely to be an infection.
00:02:37
Speaker
That being said, the criteria for frequent infections is only two in six months or three in a year, so the bar is pretty low. Right. Let's assume that the cultures are negative or we're still waiting to kind of diagnose you for that. I would want to evaluate you for other things. One of
Evaluating Frequent UTI Symptoms and Genital Urinary Syndrome
00:02:53
Speaker
the most common things that kind of goes in line with this podcast and our humanity is Genital Urinary Syndrome of menopause.
00:02:59
Speaker
that can often mimic symptoms of a frequent infection and it's also a risk factor for frequent infections and typically symptoms of bother. It's gynosin mild itching. Gynosin mild itching typically is a more of a symptom of genital urinary syndrome and menopause although UTIs especially as we get older both men and women tend to present kind of weird they're not always going to present weird
00:03:19
Speaker
urgency and frequency and worsening incontinence and burning and what i usually tell especially my older patients is if you constantly get the same symptom whether it's a headache or your right hand hurts or you have dryness and itching and then you have a positive infection and when you check other times you have a negative infection and that's your uti symptom and that's what i want you to go after
00:03:37
Speaker
and check a culture. Even if your cultures are positive, I would want to figure out why because that's an unusual number. Some people have visionatic predisposition. Some people might have prolapse. We even want to do a vaginal exam. A lot of times I will do a cystoscopy, which is when we put a little tube inside the bladder to look around, make sure there are no growths or bladder stones. Or if you've had previous surgery, especially mesh surgery, we'd want to make sure there's no mesh in there.
00:04:01
Speaker
And sometimes I'll get a CAT scan because, again, also they're looking for growths in stones and stones are very common source of infections. They're like little planets that the bacteria can live on and they sort of occasionally seed or colonize the urinary tract and then you'll get growth of this bacteria and then you'll get an infection.
00:04:20
Speaker
Unless you said if you're having more than two UTIs in six months, that might be the path that you are taken down. If you see a urogynecologist, a gynecologist, or a urologist, someone who's going to try to investigate what's the source of these UTIs, right? Right. At this point, it doesn't matter whether or not you have real infections. The point is you have symptoms six to eight times a year, and that's abnormal, so a lot of the evaluation would be very similar.
00:04:44
Speaker
If somebody has come in for like two infections in six months and they're really just hitting the mark, I don't do any really additional testing. I would start to do treatment. And if they have breakthrough infections through this treatment or if they're coming in with a lot of these infections, I would still do the same workup because even somebody with a diagnosis of frequent infection, that's a rather high number.
00:05:03
Speaker
So let's talk hypothetically. So we don't know exactly the age. We're assuming she's postmenopausal. What kind of
Prevention Strategies: Vaginal Estrogen and Antibiotics
00:05:09
Speaker
treatment are you going to start talking to her about? So I always focus on prevention. And even if somebody doesn't meet criteria for infections yet, I can still do a lot of prevention. So the mainstay is vaginal estrogen.
00:05:21
Speaker
National estrogen is great. It's now pretty cheap and we have ways that you agent getting into people who might have a hard time obtaining it financially. It works in several ways, not all of which we know about. But one thing it does is it thickens the urethra in a process called co-optation. So I usually compare it to like an inner tube at a water park. So I heard you say that before I realized.
00:05:43
Speaker
It's a deflated energy is what happens when the urethra doesn't have estrogen so it kind of the wall isn't very thick. The middle hole is a little bit more open versus a thicker tube formed with full of air after estrogen. It will help prevent bladder infections just because bacteria have a harder time crawling up.
00:06:00
Speaker
that you rethought to invade into the bladder. It also brings back healthy bacteria like lactobacilli and changes the vaginal pH. That's sort of your militia, your home guard that protects you against foreign invaders of the bacteria. And as far as the vaginal swab, again, I would have to know how the swab was obtained. Certainly, you could be colonized with certain bacteria, but a lot of bacteria that we have can be uropathogenic. That could be just a variant. There are some normal bacteria. There's even kind of normal non-pathogenic
00:06:28
Speaker
pathogenic, E. coli pathogenic being that's something that causes disease. There's only bacteria in the vagina. That's one of the things I spend a lot of time talking to my patients about. There's going to be bacteria in the vagina. It's not necessarily a harmful thing unless it's a pathogen that's getting into the bladder and causing an infection.
00:06:45
Speaker
Exactly. So going back to treatment. So estrogen is a big part of what I do. Some women may not be candidates for it. It tends to be rather rare, usually with active cancers that are estrogen dependent. But even somebody who's had cancer before, that's fairly far away. I'll check with their oncologist, but usually it's such a low dose and it only works in the vagina.
00:07:02
Speaker
Then if you do meet the criteria for infections, we usually start you on a low dose of an antibiotic, which is one of the three that we use that are relatively low risk, have a lower risk of developing resistance. And we do that for three to six months. And the reason we have this really strict criteria, and this is why I spend a lot
00:07:20
Speaker
probably a lot more time than my colleagues talking about what an infection is, is we don't want to give everybody an antibiotic even though they're safe. It's because it's only a matter of time before you can get drug resistance. So we have to balance that against treating people's symptoms and I actually manage my infections very closely just so they don't think I'm blowing them off.
00:07:43
Speaker
If they don't meet the criteria, I put in a standing culture so that means you can go to the lab at your convenience. You don't have to go to the doctor. A lot of people think they have to go to the doctor first. But if you set the standing culture order and people can go as often as they want and always check if they're feeling unsure. One thing that I strongly dislike are the ASO strips.
00:08:00
Speaker
Oh, you do? I do. All right, listeners, why? I don't like them because if they're normal, you could have an infection. And if they're abnormal, you could not have an infection. And one of the most common treatments also made by the ASO people, the ASO, will turn the ASO strip positive. I always tell people, just save your money and let us build the insurance for the culture. This is my new thing. I've been, I've been using this hashtag, save your money for vacation.
00:08:26
Speaker
but it can be misleading. It's misleading in both directions, which is why I don't like it. The emergency department, I know we always discuss with them the best way to diagnose infections, they've gone away from the healthcare equivalent of an ASO strip. They use something called a microscopic care analysis, which somebody actually sits down and counts to sell because that ASO test is so unreliable.
00:08:48
Speaker
And there's so many women that I see who are resistant to everything except for an IV antibiotic. Right. And to get to that point is that's a tough thing to have to go in for IV antibiotics for a urinary tract infection. Yes. And there is a little bit of good news with that is there is some data that if you stop the exposure to certain antibiotics, you might go back to having sensitivities to that. That's cool.
00:09:14
Speaker
There's some actually I'll have to share with you later. There's another
Exploring Viking Cures and Antibiotic Resistance
00:09:17
Speaker
podcast about two women. One's a microbiologist and one's a historian and they have opposite hobbies. The microbiologist is really into history and the other one is really into microbiology. There's some old Viking cures for Staphylococcus that work again. Is this all about the nun and how she had discovered an antibiotic? I didn't hear about it. I mean, I heard about it. I didn't listen to it.
00:09:39
Speaker
But what they show is for staph aureus, which is the most dangerous bacteria, is if you just leave it alone, it'll go back to being sensitive to things that it was resistant to previously. That's really cool. And the other piece of good news is because we don't really have great prevention strategies. I can't leave someone
Potential UTI Vaccines: Current Studies and Trials
00:09:55
Speaker
on an antibiotic forever. Some people are really hesitant of being on estrogen for the rest. If they come in in their 50s and 60s, I want to be on estrogen for 30 or 40 years.
00:10:02
Speaker
There's at least one and maybe two vaccines for UTI that are going to come out soon. And UH, just to plug this a little bit, UH is doing a study for women over age 65 that they're currently recruiting. Anyone that's had an infection proven by culture is eligible for the study. And it's very, very safe. This is what we call a phase three trial, meaning that safety has already been proven and so has efficacy on a smaller scale. So now this is a study right before the FDA approved it. There's also an inhalable vaccine that seems to be pretty
00:10:32
Speaker
There's a sublingual one that's developed in Spain. It's gone through the processes here in the US, but I've not seen, you know, when it's going to come to market, but you have to take it for I think it's 90 days sublingually. Yeah. And it was like a pineapple flavor. It's a little bit funny. But for, for many of my patients who get six to eight UTIs a year, they said they'll do it. Yeah. And they only take antibiotics for 90 days every day. Right.
Preventative Measures: D-manos and Methenamine Hippurate
00:10:57
Speaker
Right.
00:10:58
Speaker
So that's basically it. Then after I do something a little funny, and we're trying to do some research studies after this, is I will occasionally use D-manos. And a lot of people will take it for any infection, but unfortunately, the data that exists is it only works for E. coli. And then the other thing is something called methanamine hyperage, which makes your urine very acidic. There's also some data to suggest that it's a good preventative. But far and above, the only thing that, which I think is another thing that's confusing
00:11:25
Speaker
the community. The only thing that is really treatment for an infection is an antibiotic. There's nothing else.
00:11:33
Speaker
Hi friends, I'm here to remind you to subscribe and like to the podcast. I love doing this. I love bringing people on, but I need to know if you're actually listening to me. I get no feedback out here. So I know things are going out and then suddenly I'll talk to someone and they say, oh yeah, I love your podcast. It's awesome. I'm like, oh, I didn't even know you were listening. So if you want to stay in the know, you want to get notified when new episodes come back, please, please, please subscribe and like go into your podcast and you just
00:12:01
Speaker
upper right corner you press the plus sign and it turns to a check mark and then you're subscribing and then of course you can like it five stars of course right if you can please and if you spotify if you use zencast or whatever you use it's fine just please subscribe and like
00:12:16
Speaker
My policy personally is after your first infection, if you're postmenopausal, you're going to get vaginal estrogen and D-mannose if you're willing to try it out. There's very little harm. Like you said, most people are eligible. I remember back in residency with Dr. Mahajan, how much vaginal estrogen
00:12:34
Speaker
we've used. I feel like maybe as gynecologists, we've done a bad job of explaining to the public, you know, how important it is. Now the word is getting out to primary care physicians as well, like of how helpful vaginal estrogen can be for postmenopausal urinary tract infections. But this is not new. This has been around for a very long time and help keep people out of the hospital and keep people from getting sepsis from urinary tract infections.
00:12:59
Speaker
Right. And we actually, we are about to publish something on hospitalizations for urinary tract infections and death is pretty rare. The most common one was obviously in people over age 80 who were septic, but even that the risk of death was less than 2%. But you do go into hospital a lot. So for most people, UTI is a pretty terrible inconvenience, but it's not
Antibiotics and Lab Processes in UTI Diagnosis
00:13:18
Speaker
life threatening, but it can't be. It's one of the few things that you're a gynecologist treat that can be life threatening. So we try really hard to make sure people don't get them.
00:13:26
Speaker
If this person who sent in the question is postmenopausal, some of the vaginal symptoms make sense that that would be from low estrogen as well. However, if she was not menopausal, is it possible that she's getting other infections? I have another question here, which I'm assuming this person is premenopausal.
00:13:44
Speaker
I'll read this to you. It says, Hi, how do you treat aerobic vaginosis? My doctors brush over it and don't seem to know what to do. I get recurring UTIs and now I think they're connected. I tried metrogel or flagell, metronidazole gel, but Google tells me that will not fight the bacteria. I also tried boric acid for 14 days. Thank you.
00:14:03
Speaker
starting with the premenopausal patients. And these questions are somewhat related. But again, you would want to make sure that there are not other things going on. So certainly premenopausal women are prone to infections, but typically there is some evident trigger like intercourse is a big risk factor using condoms with spermicide. There could be a genetic component here. Some people just get them for no reason, just like in postmenopausal, a good colleague of mine that I've sort of borrowed her treatment is we'll still give estrogen to people.
00:14:31
Speaker
who are kind of in their 30s, 40s, who are getting true infection just to restore their microbiome. But typically, I've had a good success with treating them with just suppressive antibiotics. The other thing you want to make sure in these patients, again, it's not something else. So younger patients might be more prone to pelvic floor hypertonicity. That is a very common thing that I see. I can almost tell just by talking to someone who's in their 20s, 30s, even early
00:14:54
Speaker
40, I get 12 UTIs. Sometimes they happen right after sex, but they only happen like an hour or so after sex. And I also feel really sore. That is typically a symptom of a pelvic floor problem. Interstitial cystitis is basically a UTI without the bacteria. So the symptoms are exactly the same. And the other word for UTI is cystitis. So it's just inflammation that's due to something. In the case of UTI, it's bacteria. And with interstitial cystitis, it's something that we're not quite sure of, but the symptoms are often the same.
00:15:24
Speaker
Yeah. Other than the estrogen plus or minus in the premenopausal woman, I do everything else to save. So an antibiotic, methanamine, D-manos, and make sure there's nothing else. I will probably do more diagnosis in the premenopausal woman right off the bat, especially if she can't tell me the trigger, just to make sure we're not missing anything.
00:15:42
Speaker
And a lot of people are also worried about cancer with these conditions. So cancer is rare, but it's not a 0% chance. So that's always something we want to look at. Most women that come in with these symptoms don't have cancer. And that's one of their biggest concerns. Yeah. And I'm not aware of any established link between bacterial vaginosis and urinary tract infections.
00:16:03
Speaker
We do see group B strep in the urine, and I think that a lot of women are colonized with GBS. This is why we test for it during pregnancy, to make sure there's no exposure to the neonate during birth. But whether it's always a pathogen or something that's causing an infection, it's not always. Even you can be colonized and it's not causing an infection. Right.
00:16:24
Speaker
where you could have symptoms of infection and if you find it then I would treat it. I don't know what your thoughts are about GDS or any other vaginal flora that's found in the vagina if you don't think it's just a contamination of the urine. I typically if somebody has symptoms and they're consistently symptoms of UTI and then they grow this and I will often when their symptoms go away I will test them again which is not something we don't do test of cures typically for UTIs except in pregnancy.
00:16:52
Speaker
But I will test it just to make sure, because staphylococcus and epiderminis, and we call coagulitis negative staph, and GPS can cause, in large enough numbers, an infection. So I sort of try to link it to their symptoms. And if it does show up as a symptom, each side they have an infection, and otherwise it's absent, then we have to call it an infection. And I would just treat it like I would treat any other infection. But it does become a little bit of a diagnostic dilemma.
00:17:15
Speaker
Right, because otherwise, just to explain it to people listening, otherwise, we assume those organisms are a contamination that means they're just on your skin. And when you gave your urine sample, they happen to kind of fall into the urine sample. But like Dr. Shane saying, if you see a lot of that bacteria or high colony count,
00:17:33
Speaker
They literally, what they do is they take the urine and they put it in a Petri dish and let it sit in a lab and just kind of watch it grow. And so if you see a couple of those things here or there, then they would call it contaminated. But if you see a ton of growth, then we might be more concerned.
00:17:48
Speaker
I want to sort of underscore this part. A lot of people sometimes will perceive without a good explanation that we don't want to give them antibiotics. And we would much rather give you antibiotics than A, have you be mad at us. Or it's easier to give antibiotics than to have a 10 minute conversation about why antibiotics aren't indicated. So what we're trying to do, and not every doctor or provider does a good job of this, is what we're trying to do is prevent unnecessary treatment that puts you at risk both for side effects and then worse for drug resistance.
00:18:18
Speaker
I don't get scared by much, but I get scared by drug resistant bacteria. We sort of, I don't know how Dr. Pope feels. I feel very much painted into a corner. When I see this because I'm like, oh, this person is not
Innovative Diagnostic Methods to Reduce Overtreatment
00:18:29
Speaker
that sick yet, but they could get really sick and I don't have anything to give them. Fortunately, it's not that common where we live right now. It does pop up once in a while. And most people, I think fewer than one in five will have drug resistance of any sort, which we actually just analyzed the urine cultures and the ER for the last six months. So that's like hot off
00:18:47
Speaker
the presses. But I was joking with people like I can put a little box in your butt cheek that makes you pee normally, but I still can't diagnose an infection correctly. So we are working on a lot of ways to diagnose there's a new genetic test or DNA test rather, that can help differentiate pathogenic from non pathogenic bacteria, including GPS that we're running a study about that now. And it's also comes back a lot quicker urine cultures take up to four to five days and sometimes they're contaminated this test will come back in 18 hours.
00:19:14
Speaker
However, the infectious disease physicians let me know that it also will detect the bacteria that might not be a problem and then also will detect some dead bacteria. Exactly. That's actually why I don't use it outside of a research setting. That's the study. The study is we send both tests. We send the culture and the DNA PCR and we're comparing how concordant, so how much they agree.
00:19:39
Speaker
And then how often in the disagreement when the DNA test is positive, I treat based on that in the study, how often are we actually getting rid of someone's symptoms? And I'm partnering with Dr. Hojat. She's the antibiotic stewardship person at UH. And we're going to work on some studies to improve diagnosis and prevent overtreatment. But yes, the dead bacteria is a big thing because the DNA people really try to sell us on. It's much more sensitive. But the question is how sensitive is too sensitive. You don't want to detect everything.
00:20:08
Speaker
Correct. And so let me just explain again, like, so we were talking about the Petri dish, literally growing the sample of urine that you've given to your physician or your provider, when you have symptoms of UTI, what the lab then does is they take the most common antibiotics that we use to treat UTIs, and they actually put a little bit of each of the antibiotic on the Petri dish. And then
00:20:28
Speaker
And they look to see how much of the bacteria that's growing is actually killed off by which antibiotic. And that's how they can tell. We call it the sensitivities of the antibiotic. And so if we see that you've got bacteria that's growing like crazy in this Petri dish and none of those antibiotics are killing it,
00:20:47
Speaker
then you have a resistance to multiple antibiotics, right? And that's why we can tell in the first maybe 24 hours that there's a bacteria growing and we will call you until you start an antibiotic and then it can be two or three days later when those sensitivities are actually taking effect to see what's happening with the antibiotics to let you know which is the right antibiotic to be on. And then we have to call you again and tell you we're sending a different prescription, throw away the other one. And this is the thing that
00:21:15
Speaker
really irritates people and also requires a lot of work on our side too. So yeah, it's not a great system. It's something I don't know when the whole petri dish sort of process was developed probably 100 years ago. Yeah. I usually tell when somebody comes in, I had a really bad UTI and I was on pre antibiotic. Like it just means we guessed wrong twice.
00:21:37
Speaker
Exactly. Right, right. And I think this is the thing that is not necessarily always well explained. So hopefully everybody out there listening understands it now and why it might take three days to be on the right antibiotic and why you might get changed. So that study sounds amazing. I hope that it's successful. I really appreciate your time. Thank you so much for being here and we'll have you back on when you have new research to share. Yeah, I would love to. My pleasure. Thank you.