00:00 – Dr. Kumar: Of course you can have some areas of tissue destruction and inflammation that occurred because
00:04 – of the infection and persist in causing some symptoms even after the infection is treated.
00:25 – Melissa: There’s a question that comes up quite a bit which is, how can I tell if the symptoms I’m
00:30 – experiencing are because of an infection that wasn’t treated properly or because of inflammation that remains after an infection was treated?
00:38 – Dr. Kumar: That’s a great question and that’s something that we see
00:42 – all the time, where people have been, or a woman has been treated for a UTI but she continues
00:49 – to have some irritative symptoms. And I think in that situation we have to look at the
00:57 – trajectory of those symptoms. So if the symptoms are sort of getting gradually worse,
01:03 – where you’re noticing that you’re requiring pyridium every day and it’s keeping you
01:10 – up at night and you’re waking up three or four times, whereas that’s not what you normally do,
01:15 – then I think you have to consider that this may be an infection that wasn’t fully treated.
01:22 – And, you know, now the bacteria since you’ve come off the antibiotics, the bacteria has a chance to
01:29 – emerge and cause another inflammatory response in the bladder. But I think if you notice that, a lot
01:38 – of women will notice that they don’t have symptoms that were as severe as the initial
01:45 – infection but they notice for example that when they have to urinate there’s a greater sense of
01:52 – urgency than there used to be, and so there can be these more mild symptoms which I think are a sign
02:00 – of the bladder number one, being sensitized. So you have nerve endings which normally aren’t
02:07 – active, which become active during the infection and then start responding to bladder stretch,
02:13 – whereas they normally wouldn’t. So you feel a greater degree of urgency, like your
02:18 – bladder doesn’t go completely back to the way it normally was. And then yes of course you can have
02:24 – some areas of tissue destruction and inflammation that occurred because of the infection and
02:31 – persist in causing some symptoms even after the infection is treated. So I think
02:37 – you really have to look at the direction that those symptoms go in. Does it feel like
02:42 – it’s not as severe as that initial infection, but you’re just noticing an increased awareness of
02:48 – your bladder that you didn’t have? And I think it’s always reasonable to retest the urine and if you
02:54 – see clearance of white blood cells and red blood cells and those inflammatory markers,
02:59 – those markers that occur during acute inflammation, and the symptoms are getting
03:06 – better, not worse, then you can assume that your bladder is just sort of healing.
03:12 – bBut I think if the symptoms are getting worse or to the point where you you feel
03:18 – exactly the same as you did at the time of the initial infection,
03:22 – then you have to be really suspicious that maybe it never cleared.
03:27 – Melissa: How long can the post infection inflammation last and what would you do to help relieve those symptoms?
03:33 – Dr. Kumar: I’ve seen it last actually a few months. I’ve seen patients who also get
03:39 – recurrent infections, like three or four times a year where
03:46 – their bladder is almost in a constant state of a little bit of a low-grade inflammation,
03:52 – when we’re almost to the point where we might even diagnose
03:56 – overactive bladder and then when we’ve put those patients on a good prophylactic regimen.
04:02 – And I always think if I can get them a good sort of like six months without getting a UTI,
04:07 – their symptoms seem to get better, so meaning that they say, oh actually
04:13 – I don’t have an overactive bladder anymore, my bladder just feels normal now. So I do think
04:19 – that being vigilant about prevention and really trying to make sure that you don’t get
04:26 – another infection is important in that healing process, because every time that inflammatory
04:31 – process starts you’re going through that same phase of tissue destruction and inflammation
04:37 – all over again. And you really want to be able to give your bladder that time to heal. So I’ve
04:42 – seen it last a few weeks to months and we certainly use things like pyridium,
04:49 – Urobel, Tylenol, ibuprofen, things that essentially help to ameliorate the symptoms.
05:00 – But I do think it’s really important when I see women who have had these symptoms because of a UTI,
05:06 – I also really want to get them on a good preventive regimen because I know that if
05:10 – they get another infection it’s a step backward in terms of their inflammatory symptoms.
05:19 – Melissa: And what does a preventive regimen entail from your perspective?
05:24 – Dr. Kumar: Typically a preventive regimen would be things like a very good quality high PAC product. I like to use Ellura in my patients, or
05:35 – Utiva is another brand that makes a good quality product. And those products typically have 36
05:43 – milligrams of PACs which is proanthocyanidin. And that’s the active ingredient in cranberry
05:49 – that prevents bacteria from adhering to the lining of the urinary tract which is
05:54 – the primary mechanism that bacteria use to ascend into the urethra and cause an infection.
06:02 – And so that’s why we talk about cranberry. In UTIs the problem is when people
06:08 – drink cranberry juice, often they’re not getting enough of that enzyme and the studies that
06:15 – have been done on cranberry have been somewhat equivocal but that’s also because there’s been a
06:20 – a large heterogeneity in the types of products that were used. Now, in this country the supplement
06:26 – industry is not regulated so you know anybody can put anything in a jar and call it whatever
06:32 – they want and sell it as whatever they want, so when we recommend supplements it’s
06:38 – hard to know what is a good quality brand. So Ellura and Utiva are brands that
06:44 – i recommend because the concentration of PAC is actually tested in a third-party lab.
06:53 – I’ve been using, for example Ellura, I’ve been using it in my practice also
06:57 – now for about five years and I’ve seen that it works really nicely in patients.
07:03 – Sometimes I even have people, they take one a day and one pill has 36 milligrams of PAC and
07:11 – then I’ll have them if they start feeling any symptoms, like starting of a UTI, they’ll take
07:16 – two or they’ll take a second one if they have any sexual activity and that helps to prevent
07:21 – a UTI from coming on. So certainly I use that. I think the only side effect of doing it is
07:29 – potential like GI symptoms. Some people feel it’s a little harsh on their stomach and some
07:35 – patients with IC are concerned about the potential that it’s acidic and it may aggravate
07:40 – their IC symptoms. But I actually always suggest that people try it because most people tolerate
07:47 – it really well. So that’s number one. Number two, in postmenopausal women I definitely use
07:55 – vaginal estrogen. I think that’s also a very low risk, high reward strategy.
08:02 – The concerns about using estrogen in terms of it being a hormone are really more relevant to using
08:10 – estrogen as hormone replacement therapy and so one thing I find it’s really important, is to
08:16 – inform my patients that when you use it in the vagina it’s not elevating your blood levels of
08:21 – estrogen to a premenopausal woman. It is not hormone replacement therapy. And I think
08:28 – in one of our other questions we were talking about the
08:35 – utility of vaginal estrogen and the UTI global um alliance where they just
08:44 – did this fantastic series of lectures from researchers from microbiologists and immunologists.
08:50 – And one of the talks was by a woman from the university of, I’m sorry, from Washington University
08:58 – in St Louis, and they’re actually showing that vaginal estrogen in mice, when they administer
09:05 – it, it actually helps the tissue healing process in the bladder after a urinary tract infection.
09:12 – And I think that that’s an area of really great interest because
09:19 – the healing process and what happens and how that varies from person to person and how that affects
09:25 – the symptoms that you may continue to have after you get a UTI is a really important part of how we
09:32 – are going to clinically approach patients. So vaginal estrogen I think is a very
09:39 – low risk and high reward strategy and also helps with genitourinary syndrome of menopause
09:46 – which can cause UTI-like symptoms. Vaginal estrogen also works by enhancing the
09:54 – healthy vaginal microbiome, enhancing the growth of lactobacillus in the vagina which
10:01 – decreases the prevalence of uropathogenic bacteria that can form reservoirs in the vagina. So I
10:08 – definitely do that. The evidence for probiotics also is equivocal, however,
10:16 – I find taking a probiotic is a harmless and potentially beneficial thing to do.
10:24 – I would love to see more studies on how oral probiotics populate, whether the
10:32 – presence of that bacteria or that probiotic, those strains of lactobacillus that you take orally,
10:38 – if you’re actually able to populate the bacteria in the vagina once it transits through
10:44 – the GI tract. I have used vaginal probiotics in some patients who
10:53 – don’t find it irritating or you know goopy, or who don’t have any issue using something in the vagina.
11:00 – I feel using a probiotics can potentially help and you know can’hurt so I do
11:06 – that as well. And then the last thing would be post-coital prophylaxis. I think that’s a
11:12 – very appropriate strategy and works really well in a lot of patients. You’re certainly
11:17 – better off taking, for example one pill of nitrofurantoin after intercourse
11:23 – than having to take a whole three or five day course of therapeutic dose antibiotics
11:30 – if you get a UTI. So I think there’s a lot of things that women can do which
11:39 – are relatively low risk and can really help to prevent UTIs. And then the other thing of
11:45 – course is fluid intake. There was a study that was in Jama about a year and a
11:50 – half ago showing that when women increased their fluid intake by about one and a half liters
11:56 – their frequency of UTIs decreased. So that’s of course important and generally good for you.
12:03 – Melissa: Is there any concern about antibiotic resistance with the prophylactic treatment?
12:10 – Dr. Kumar: With post-coital prophylaxis, especially with nitrofurantoin we have not seen it. I have seen it
12:17 – when I have used daily low-dose prophylaxis either with nitrofurantoin or particularly with bactrim.
12:26 – You can use either trimethoprim alone or just like one pill of low-dose spectrum
12:33 – or a single-strength bactrim um a day which is trimethoprim combined with sulfamethoxazole.
12:39 – I have seen it with that but for postcoital I have not seen it. And even in women who have
12:46 – said that they took their nitrofurantoin after sexual activity and they still got a UTI,
12:51 – when we do the culture I often see that the bacteria still remains sensitive to nitrofurantoin
12:58 – but they need a treatment course. Just one pill wasn’t enough because they
13:02 – really did get, the bacteria was very successful in causing that infection.