00:00 – Dr. Hsieh: There are very few parasites that are known to infect the urinary tract just
00:06 – a handful so one of course as you mentioned is Schistosoma haematobium
00:23 – Melissa: Today, we’re talking with Dr. Michael Hsieh who’s a recurrent UTI specialist and urinary microbiome
00:28 – researcher, but you also have a various other areas of expertise. Thanks so much for joining us.
00:33 – for this interview today. Dr. Hsieh: My pleasure. I had the privilege of having trained
00:40 – as not just a urologist and fellowship trained in pediatric urology, even though I see adult patients as well,
00:51 – especially those of recurrent UTIs, I also have a PhD in immunology and
00:59 – have tried to integrate those backgrounds to assist in the care of patients with recurrent UTIs.
01:08 – Because of my background, I’ve also focused in part my research on urogenital schistosomiasis,
01:14 – which is a parasitic worm infection that affects the urinary tract.
01:19 – Melissa: We definitely got a bunch of questions about that, which we can get to a little bit later. I thought, given we are
01:26 – going to be talking about some of the less common causes of urinary symptoms, maybe first we could talk
01:31 – about some of the more common causes that are not your typical UTI. Can you list some of those for us?
01:37 – Dr. Hsieh: Of course. Overactive bladder, as well as pelvic organ prolapse, in particular
01:48 – of the bladder, are some common causes. Benign prostatic enlargement in the case of men,
01:58 – and then bladder stones, of course, can also cause urinary symptoms.
02:03 – Melissa: One of the things that came up quite a few times in the questions you received was lichen sclerosus.
02:10 – Can you explain what that is and what the symptoms of this are?
02:15 – Dr. Hsieh: Lichen sclerosus as it pertains to
02:20 – urinary symptoms is atrophy, a sort of regression of normal maintenance of development
02:32 – of the vaginal lining and it’s often associated with menopause. Lichen sclerosus is interesting
02:42 – because not only is it associated with atrophy, it’s also associated with chronic inflammation. Clearly,
02:49 – the body’s homeostasis in that part of the of the urinary tract has gone awry and
02:56 – it’s thought that patients of lichen sclerosus often have improvement with topical estrogen cream
03:05 – for instance, because estrogen helps restore on a more normal lining of the vagina that’s lost
03:13 – frequently in menopause. Melissa: You mentioned that it happens often after
03:18 – menopause and in patients with chronic inflammation. Are there other patient populations that it’s more common in?
03:26 – Dr. Hsieh: Not so much. Again, it is really a reflection of lower estrogen, at least in
03:37 – post-menopausal patients, and estrogen has multiple effects on the vaginal
03:43 – lining as well as the lower urinary tract. First of all, it promotes growth of lactic acid bacteria—
03:50 – so-called good bacteria—that most of the time help prevent overgrowth of potential UTI-causing
03:58 – organisms that could infect the urinary tract. Estrogen also
04:06 – restores more normal lubrication of the vagina.
04:10 – Without that lubrication, many patients have significant discomfort in the vaginal region.
04:18 – And then more interesting data has indicated that estrogen affects the local immune system
04:25 – in the lower urinary tract and that loss of this estrogen can
04:31 – result in relative immunosuppression and, perhaps, increase susceptibility to UTIs.
04:38 – Melissa: Speaking of the immune system, someone asked if lichen sclerosus is an autoimmune issue or is it
04:43 – just related in the way that you just mentioned? Dr. Hsieh: It’s not a traditional autoimmune disease
04:51 – where you have an antigen. (An antigen is a protein recognized by the immune system.)
04:57 – You don’t have an auto antigen, an antigen from the body that seems to be triggering the inflammation.
05:04 – Melissa: What type of specialist should someone see for this type of diagnosis? Is a urologist the
05:10 – right person? Dr. Hsieh: I would say on average gynecologists see more
05:15 – lichen sclerosus of the vagina, certainly urologists that see many patients with recurrent UTIs
05:25 – or do female reconstructive urology for instance are probably more likely to be familiar with these
05:33 – issues, as well as urogynecologists. Melissa: Is it something that you can actually see on a
05:38 – physical examination or do you have to test for it? Dr. Hsieh: Yes, well, you usually can see it on physical exam
05:46 – but, of course, if a biopsy was done, which is usually not necessary, it’s also readily identifiable.
05:54 – Melissa: Is it possible to actually cure this condition or is long-term management really what you’re aiming for?
06:01 – Dr. Hsieh: Lichen sclerosus can often be reversed, at least while on treatments. For
06:11 – example, lichen sclerosus is often also treated with steroid creams, besides estrogen therapy
06:23 – if it’s a post-menopausal issue. Melissa: How is it specifically related to UTI symptoms?
06:31 – Can it actually directly cause an infection or is it more that the symptoms might be mistaken for a UTI?
06:41 – Dr. Hsieh: Many of the symptoms associated with lichen sclerosus can mimic
06:47 – urinary tract infections and, in fact, there is a term which refers to symptoms
06:59 – associated with menopause: the “genitourinary syndrome of menopause” is an umbrella term
07:09 – that can refer to symptoms such as urinary urgency and frequency that in some cases are due to
07:18 – post-menopausal changes in the vagina and urethra, such as lichen sclerosus, but not
07:24 – limited to just that. Melissa: Are there skin conditions of the genitals that could
07:26 – also mimic UTI symptoms? Dr. Hsieh: Many patients have vestibulo vulvodynia
07:40 – that can also contribute to urinary symptoms. Many of those patients, of course, have classic
07:49 – symptoms of pain with intercourse or pain with what seems like very minimal
07:57 – touching for example of the external genitals. Melissa: Is that kind of a diagnosis of exclusion type
08:05 – syndrome or is it something that you can actually identify with a test and then
08:09 – treat? Dr. Hsieh: It’s dependent on history and physical exam.
08:19 – Again, pain with intercourse, if on exam with very light touch the patient expresses pain
08:27 – upon contact with the vulva or the vestibule of the vagina those are all very suggestive of that
08:33 – diagnosis. Melissa: Let’s move on to parasites, because I know this is
08:40 – one of your specialties and you mentioned Schistosoma. Are there other parasites that can exist in the bladder or
08:46 – known or documented to be in the bladder? Dr. Hsieh: There are very few parasites that are known to
08:55 – infect the urinary tract—just a handful. One, of course, as you mentioned, is Schistosoma haematobium,
09:04 – which is the cause of urogenital schistosomiasis. It is true that occasionally you will see patients
09:10 – with amoeba infections of the urinary tract—amoebiasis. Echinococcus, which is a sheep transmitted
09:23 – parasitic infection, sometimes affects the kidneys, and you can see parasite life stages in the urine.
09:32 – But on the whole, it’s exceedingly rare to see parasites in the urinary tract itself.
09:39 – Melissa: Is that the same for the vagina or are there other things that could reside there?
09:44 – Dr. Hsieh: Interestingly, S. haematobium, the cause of urogenital schistosomiasis, can
09:50 – cause infection of the vagina and I’ve seen several cases of female patients
09:59 – that have visited endemic regions for S. haemitobium infection
10:05 – unknowingly contracted infection and then upon return to the U.S. had symptoms of vaginal pain
10:13 – and they had extensive testing for sexually transmitted diseases which was negative, until
10:18 – finally a biopsy demonstrated parasite eggs in the vagina. But I would again emphasize that outside of
10:27 – endemic areas it’s a very rare diagnosis. Melissa: Can you name some of the endemic areas?
10:33 – Dr. Hsieh: S. haematobium is endemic in portions of Sub-Saharan Africa and the Middle East.
10:41 – Melissa: How did you come to do research on this topic? I can’t imagine it’s very common. Was
10:47 – this something that you came across in your own practice or you just came across research on it?
10:53 – Dr. Hsieh: The reason that I became interested in urogenital schistosomiasis
11:00 – actually dates all the way back to graduate school. One of my classmates and good friends is an
11:05 – immunoparasitologist and for many years while we were both in training we discussed how there were
11:12 – not good models of urogenital schistosomiasis and that that may have been a major reason
11:19 – why research lagged in that field. When I completed my training in immunology urology
11:29 – I decided to embark on developing models of this infection, which were quite successful.
11:36 – It’s been really a nice melding of my interest in the immunology of the urinary
11:43 – tract and infection. Melissa: What are the symptoms of bladder
11:50 – schistosomiasis? Is it similar to UTI symptoms or is there something else that you would look for?
11:55 – Dr. Hsieh: A classic sign of urogenital schistosomiasis is hematuria, also known as bloody urine.
12:03 – Patients with bacterial UTIs can also have blood in their urine—that’s not uncommon.
12:10 – Other urinary symptoms can include frequency and urgency.
12:14 – Again, that is similar to what many patients with bacterial UTIs will have.
12:21 – Melissa: Do you know how the parasites get to the bladder in the first place? Are they coming
12:26 – from the digestive tract or could they enter the urethra directly from a water source for instance?
12:32 – Dr. Hsieh: This parasite is very interesting. It’s transmitted by a snail and what happens is
12:39 – the larvae emerge from the snail in water and the larvae actually can sense human skin products
12:49 – dissolved in the water. They follow that gradient to find humans and they burrow through
12:55 – the skin directly to cause infection. Once the larvae are in the body, they develop into worms
13:03 – and the worms can live for years (individual worm pairs) and they’ll lay thousands of eggs
13:09 – a day, often in the bladder. Melissa: That’s really horrible to think about. Is the
13:16 – treatment for bladder schistosomiasis the same as it would be if it was elsewhere in the body?
13:23 – Dr. Hsieh: The mainstay of treatment for your urogenital schistosomiasis is an anti-parasitic medication,
13:28 – called praziquantel. There are a few other drugs that don’t work as
13:34 – well, but really the only WHO-approved drug is praziquantel and it’s used regardless of any
13:43 – ectopic, unusual sites of infection. Melissa: Is it 100% effective or is there often a case of a
13:51 – relapse? Dr. Hsieh: The biggest issue is that patients can get
13:53 – reinfected, even after appropriate treatment with praziquantel. But even in those that are not reinfected there
14:00 – is some evidence that a single dose of praziquantel probably does not kill all worms. Conversely, there is
14:11 – an opinion that eliminating the vast majority of worms may be good enough in suppressing any urinary pathology.
14:23 – Melissa: Is there anywhere in the USA that this parasite is found?
14:30 – Dr. Hsieh: No the the only site outside of Sub-Saharan Africa and the Middle East that this parasite is found is the
14:36 – island of Corsica, which is Europe and that focus of infection was actually the first
14:48 – site of European infestation for over a century. Melissa: Interesting. If you are in an area where this
14:58 – parasite is known to be, should you preemptively take treatment?
15:04 – Dr. Hsieh: It’s not uncommon for visitors to endemic regions, such as peace corps volunteers returning
15:13 – to the United States, to be tested and often treated for common parasites such as S. haematobium.