00:00 – We have to diminish the infectious
00:03 – load sufficiently that the bladder wall can do its repair job.
00:20 – Melissa: Now that we’ve talked about antibiotic resistance maybe you can tell us a little
00:23 – bit more about your general approach to treatment for chronic infection.
00:31 – Ruth: A while back I mentioned that things have causes and if you don’t address the root cause and eliminate it
00:39 – then you will never get rid of the problem. And so when we have bacteria that
00:49 – are not just free floating in the urine, they’re not just attached to the bladder wall, they have
00:57 – invaded the bladder wall. If they’re in the interstitial spaces, which is the space between
01:05 – the cells, that’s bathed with lymphatic fluid and I have seen pathology slides
01:14 – of bladder wall biopsies in which you can see the bacteria, so we know it gets there.
01:20 – And when it’s in the interstitial spaces it causes swelling, inflammation,
01:28 – pressure on the nerves and pain. And that’s where the definition interstitial cystitis
01:37 – came from, was the was the inflammation in those interstitial spaces. When you see that
01:47 – you have a lot of work to do. We have to
01:51 – diminish the infectious load sufficiently that the bladder wall can do its repair job.
01:57 – It takes about four month months for damaged bladder wall tissue to regenerate after you’ve
02:04 – reduced the infectious load sufficiently that it can seriously start the healing and repair process.
02:13 – So we know that this problem didn’t start
02:18 – as a one time, out of the blue thing, and then go away. It’s been there for
02:26 – some time whether you’re talking months or years. The longer the process has gone on
02:34 – pretty much the more damage there is and the longer it’s going to
02:38 – take to eliminate the infections and then begin the healing and repair process.
02:48 – My approach is to see who is the big player – which infection is
02:55 – the highest amount on one of these reports and target the biggest part of the problem.
03:05 – Now bacteria kind of are classified in a couple different categories: Gram-positive,
03:10 – which has to do with the type of stain they take when you put it on a microbiology slide and look
03:17 – at it under a microscope, or Gram-negative. And most antibiotics address either Gram-positive
03:27 – or Gram-negative bacteria. There’s only a few that will kind of do an okay job with both.
03:36 – By selecting which antibiotic is the best one for the majority of the infection
03:44 – that’s come out of the biofilm currently, is going to knock back the most infection.
03:51 – And when we knock that one back, because the biofilms have lots of inhabitants, lots of
03:58 – different bacteria, then we retest and see who’s the next biggest player that’s now causing the
04:06 – most problem and we go after that one. And this necessitates that you treat each infection that
04:14 – comes out. And I like to do, most protocols are two weeks long. It’s a little bit
04:23 – longer than you’d routinely be given for an acute infection because the acute infections haven’t
04:30 – gotten as embedded. And yet it’s not long term because if you give only one antibiotic long term
04:41 – and the other infections aren’t covered by that one antibiotic you’re given long term then
04:48 – it’s not going to work. It’s only going to take care of some of the infection
04:52 – that happened to come out of the biofilm at that point in time. And they’re left with a
04:57 – lot of infections still in the bladder wall, still doing their damage.
05:02 – Melissa: We do have some other questions about long-term antibiotics but I wanted to go back briefly to the infection embedded in the
05:08 – bladder wall. I wanted to ask if that is what you believe is the cause for the ulcers that
05:13 – are sometimes referred to as Hunner’s lesions, and if so, can those then be treated in the same way?
05:21 – Ruth: Well Hunner’s ulcers remind me of stomach ulcers. In the stomach you have H. pylori
05:31 – as a causative agent. It gets embedded in the lining and if it goes for a long time untreated
05:39 – the lining ulcerates. I think it’s the same process in the bladder wall. Hunner’s ulcers
05:46 – are infection and I have had several patients that we have successfully healed by treating
05:57 – the bacteria that are responsible for damaging the bladder wall in that location to that extent.
06:03 – Now some people have procedures in which they go in with a laser and they actually
06:14 – treat that area and that resolves a lot of the pain issues a whole lot faster.
06:22 – So that is an option but I think that
06:30 – that’s only a temporary solution because if there’s still a lot of infection
06:34 – throughout the bladder wall the propensity is going to be to form more ulcers down the
06:40 – road if you fail to treat the infections that’s responsible in the first place.
06:46 – Melissa: Okay, thanks. So back to long-term antibiotics. Do you see any risks in this type of treatment aside
06:52 – from what you already mentioned with the potential mis-targeting of the antibiotics over time?
06:59 – Ruth: We know that long-term antibiotics have other consequences for the gut flora
07:07 – and yeast issues
07:12 – and other long-term side effects. Now do the benefits outweigh the
07:19 – risks? We have that problem with with every decision we make.
07:25 – By treating long term I have a concern that you’re not treating all
07:31 – the bacteria that’s there in a biofilm community and I have a concern about
07:41 – the long-term effects. When you test and treat and retest and treat you are essentially giving
07:52 – your body an antibiotic holiday and the gut flora does have a chance to repopulate.
08:03 – Fun fact – they finally found a purpose for an appendix.
08:08 – It turns out that that’s a reservoir for the healthy bacteria so if you have a GI bug or
08:14 – you’ve been on an antibiotic and you’ve wiped out a considerable percentage of your normal gut flora,
08:23 – the role of the appendix is to repopulate that in your GI tract. So taking drug holidays or
08:31 – antibiotic holidays does allow that repopulation to take place in a healthier way than to be on
08:38 – one antibiotic continuously month after month after month after month.
08:44 – Melissa: Okay so that was more on the the long term high dose antibiotics but what about prophylactic doses – so low doses that
08:50 – are just used preventatively either after sex or on a daily basis or after other triggers?
08:58 – Ruth: I have had a number of patients who have been put on those protocols
09:02 – and pretty universally they say it helped for some period of months and then it quit working.
09:09 – And the reason it quit working is because you have successfully given your bacteria enough exposure
09:17 – to a sub-therapeutic dose of an antibiotic that it now has developed drug resistance.
09:24 – And so I think it’s important that just like they advocate that you take a full course of
09:31 – an antibiotic for other infections such as sinus infections or throat infections or
09:38 – kids and ear infections, lest you produce drug resistant strains, that the same
09:44 – principle applies to bladder infections. You want to take a full course of a therapeutic
09:52 – level and so to do sub-therapeutic quote-unquote prophylactic dosages
10:00 – doesn’t make sense to me. Because number one, you don’t know what you’re treating
10:06 – and number two you’re ensuring that you will get drug-resistant strains.
10:12 – Melissa: Do you always use oral antibiotics for treatment or do you take other approaches for some patients?
10:19 – Ruth: I do have concerns about only using oral antibiotics, particularly
10:27 – when we have someone whose infections are deeply embedded long term. I’m not naive
10:34 – to think that they’re harmless. I know that there are consequences, but we come back to the benefit
10:39 – risk problem. If your body has been unsuccessful in getting rid of these infections on their own
10:50 – and your body needs some help then the benefit of the antibiotics becomes a quality of life issue.
10:59 – If you can get rid of the infections, let the bladder wall heal and have a normal healthy
11:04 – life, which I consider I have for the past 30 years, I know that bladder walls can be
11:12 – healed. I was told I had one of the most damaged ones and most severe cases of IC the chief of
11:18 – urology at this prestigious university hospital declared. My claim to fame back then I guess.
11:27 – And so I do know that this can be successfully treated with antibiotics. Now
11:33 – how do you do this? Well we mentioned earlier that you need to look at what infection
11:39 – is the predominant player at that time. But there are alternatives to oral antibiotics.
11:48 – I’ve been working with a compounding pharmacy for about eight years now in having them
11:54 – compound IV antibiotics into bladder instillations. And instead of the one size fits all Gentamicin
12:07 – bladder instillation, which is assuming that what you have is Gram-negative like E. coli,
12:15 – and only doing it once a week which once again is another recipe for developing drug resistance.
12:24 – These bladder instillations are instilled by the patient through a small pediatric
12:30 – catheter. It’s pre-lubricated into the bladder twice a day for a period of
12:38 – nine days to two weeks and there are certain issues that determine how long of course you need.
12:47 – These antibiotics are ones that generally the bacteria have never seen before. They’re
12:53 – put in the bladder so we don’t have to have the risks of disrupting the normal gut flora
13:00 – and we generally don’t have to worry about the side effects of any medication because
13:06 – very little if any of the antibiotic is absorbed systemically from the bladder. Although if you have
13:13 – a significantly damaged bladder wall you will have more leakage into the general circulation.
13:20 – The bladder instillations oftentimes can be combined with a biofilm disruptor
13:28 – and that makes the antibiotic work better. And faster, because you’re not only breaking down
13:35 – biofilms right where they are but the antibiotic is able to get in a higher concentration
13:41 – directly where the infection is present in the bladder wall versus having to be
13:46 – systemically absorbed, metabolized, cleared through the bladder and then whatever
13:54 – gets to the bladder is the part that can work.
13:58 – Melissa: I imagine for some people it’s difficult to hold the instillation in their bladder when they have urgency, frequency symptoms. Is it still helpful if
14:06 – they can just hold it in for a little bit of time? And what’s the ideal amount of time to hold it in?
14:15 – Ruth: Longer is better. I have many patients who can’t hold it very long but as we
14:23 – reduce the amount of infection and get the bladder wall to start healing they become more
14:31 – and more successful holding it for more periods of time. This is done twice a day,
14:37 – so of course in the morning when you’re drinking and you have more fluid in your bladder
14:45 – you don’t hold it as long as you can overnight. Many patients may make it three to four hours or
14:52 – even sometimes all night long and the more you can get the antibiotic to have come in contact
15:00 – with the bladder wall of course it’s going to work better.
15:03 – Melissa: Is this a type of treatment approach that a patient can ask their own doctor to work with the compounding pharmacy on and access?
15:13 – Ruth: A little bit harder at this point in time.
15:17 – The compounding pharmacy that I work with has
15:23 – determined what concentration of antibiotic is appropriate for the bladder bladder wall
15:29 – tissue and that isn’t information that most compounding pharmacies have access to.
15:37 – And likewise, this is sterile compounding which many compounding pharmacies aren’t equipped to do.
15:45 – Melissa: So they really need to work with a specialist compounding pharmacist that has this experience.
15:51 – Ruth: It needs to be a compounding pharmacy that does sterile compounding.
15:59 – I’m in the process of doing training modules for other practitioners
16:04 – and then those trained practitioners will have access
16:09 – to those concentrations and are able to work with more local compounding pharmacies.
16:16 – Melissa: For people that are unable to continue taking antibiotics for one reason or another
16:20 – are there other non-antibiotic treatment approaches that they could consider?
16:26 – Ruth: I wish we had more. I’ve had a number of people try herbal treatments. I know that that Stephen
16:34 – Buhner’s book on herbal antibiotics is something that many people have looked to as a reference.
16:41 – I’ve had a number of patients try his protocols based on which bacteria the
16:46 – DNA testing was identifying and we’ve not had terribly good success in reducing the infectious
16:54 – load of those those organisms. I don’t know whether it’s because the urine dilutes
17:02 – the herbals. I don’t know if it’s because they just need to do it longer and haven’t. I don’t know
17:12 – what those variables are. That being said, there are some alternatives that are more promising
17:21 – on the horizon. I know that people have been given and have tried Hiprex
17:28 – and I have to say I am less than enthusiastic about that one because the Hiprex itself
17:35 – interacts with the urine and produces formaldehyde. And formaldehyde, if you’ve ever
17:42 – seen the pictures of labs with brains and other organs floating in a jar, they’re floating in jars
17:50 – of formaldehyde. It basically pickles the organ. Formaldehyde is also known to be carcinogenic
17:57 – and I could not find any studies looking at the long-term effect of formaldehyde being
18:04 – produced by a person’s body in the bladder and then remaining there for months at a time.
18:13 – And because I know that some of the antibiotics when we give them in the bladder by instillation
18:20 – do have some small amount that gets into the systemic circulation I am concerned
18:26 – that particularly someone with a damaged bladder wall will be absorbing some of that formaldehyde.
18:35 – In place of that I’ve recently started using some methylene blue. It’s an old urinary
18:42 – tract infection remedy that does not disrupt normal gut flora and give people yeast issues.
18:51 – And we’re starting to see some good success on eradication of multi-drug resistant pathogens
18:58 – in several of my patients. But i don’t have enough data on it yet to say that it’s the new answer to antibiotics.
19:05 – Melissa: Right, and is that an over-the-counter compound or prescription?
19:11 – Ruth: Unfortunately not. It gets compounded by compounding pharmacies into capsules
19:17 – that you take twice a day and it does make your urine blue. It’s not known to have any
19:27 – side effects in particular. If any of you have used Uribel
19:32 – for pain management, it does have a small amount of methylene blue in it. Once again I don’t
19:39 – think it’s enough to go after some of the pathogens that we’ve been finding.
19:48 – It may help discourage the growth of them but it doesn’t seem to eradicate them the way the higher doses do.
19:55 – Melissa: We’ve received a lot of questions from people on different UTI products like Uqora,
20:00 – uva ursi products, Utiva, Marshmallow root and other natural products for UTIs. People want to
20:07 – know your thoughts on those, but also on ozone instillations as another non-antibiotic approach.
20:14 – Melissa: Some of those actually have some good merit, some of them may not be well tolerated
20:21 – with a damaged bladder wall and some of them have very limited application.
20:30 – The Marshmallow root and aloe vera may give good symptom management but I do have some concerns
20:39 – about that because they’re mucilaginous. They put sort of an artificial coating on the bladder wall
20:46 – which was the goal of Elmiron. They are for symptom management. They’re not going to heal
20:52 – or cure anything as long as the infection is still embedded in the bladder wall.
20:59 – So all of those products should be stopped a week before you send off any
21:03 – testing by DNA. Patients who’ve been on those products and send off a specimen oftentimes
21:14 – get negative or no pathogens found on the DNA test. So that tells me that basically those are
21:24 – effective barriers but they also prevent good diagnosis and treatment.
21:34 – D-mannose is really stunningly brilliant. It comes from mannitol which is a plasma
21:42 – volume expander, and some brilliant person observed that when it was being given
21:49 – it would attract Gram-negative bacteria, particularly E. coli, and like a magnet link
21:57 – up with it. And then basically that infection would be cleared out of the urinary tract.
22:03 – It is not effective for Gram-positive organisms and therefore you may find
22:10 – that D-mannose works for one person and not for another person. D-mannose
22:15 – is fairly effective when it’s a low level of E. coli but I have been unsuccessful in making it
22:25 – work well for people with a medium or a high load of that pathogen. If you look at the Uqora
22:34 – product it does have some D-mannose in it. It has some vitamin C in it, which if it’s ascorbic
22:41 – acid could be a further bladder irritant. However, they do buffer it with some magnesium
22:48 – which may or may not be enough. Natural lemon and potassium and citric acid which is in
22:58 – that product could potentially be an irritant as well, so I think it depends upon how damaged your
23:06 – bladder wall is as to whether that product would be helpful or a further irritant. The uva ursi
23:16 – is interesting because it actually does go after Gram-positive pathogens and may be more effective
23:24 – than D-mannose if the Gram-positives are what infections you tend to be harboring primarily. The
23:34 – ozone treatment is becoming more and more popular. We’ve noticed on the Microgen report
23:43 – they have a little category that says respiration. And it will talk about aerobic –
23:52 – needing oxygen, anaerobic – not needing oxygen and something called FAN – facultative
24:00 – anaerobic, meaning that it’s a very smart bug that can live with or without oxygen.
24:08 – And so when you’re talking about putting ozone or free oxygen into someone’s bladder,
24:15 – some of the bacteria, if they can only live as an anaerobe
24:23 – and you give them oxygen, may not like that, curl up and die. But if you have bacteria
24:32 – that thrive in oxygen or have the capability of thriving in oxygen they may just laugh
24:41 – and say, you know, I’m going to party, thank you for the extra oxygen. So I don’t know
24:49 – at what concentrations the oxygen would help the bacteria grow or discourage its growth. I
24:57 – do have a number of patients who have done it and I guess my warning is you need to be very careful
25:04 – and go at much lower concentrations than what is typically given if you have chronic urinary tract
25:12 – infections or have been diagnosed with IC and there’s a significant damage to the bladder wall.
25:19 – I have had a number of patients who said that it made their bladder worse so I’m
25:26 – not saying not to try it. I’m for anything that will help people get rid of infections.
25:32 – I’m just not seeing it deliver consistently for my patients who have tried it.