00:00 – Hi. Welcome back to the channel. My name is Molly, and today at Live UTI Free, we’re chatting with Dr.
00:06 – Elizabeth Kavaler about her approach to recurrent and chronic UTI. If you’re new to our channel, be
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00:27 – that, we hope these videos provide the insight you need to take the next step on your UTI recovery
00:33 – journey. So today on our Clinician Insight Series, we’re talking with Dr. Elizabeth Kavaler. Welcome
00:54 – and thank you for joining us. Thank you for having me. Thank you, so first can you tell our community
01:01 – a bit about yourself, including where you’re based and what you do? Okay yes, so I am a
01:07 – urologist, I was trained as a urologist and I have a special focus on female pelvic medicine, which
01:14 – includes recurrent urinary tract infections. I’m board certified, both as a urologist and in Uro
01:20 – Gynecology. My practice is in Midtown Manhattan. I opened it eight years ago, it’s a private practice
01:26 – and it’s across the street from Rockefeller Center and I opened it with the vision of
01:31 – having a practice that would make patients feel comfortable and safe and we can manage a lot of
01:37 – the major concerns that they have, especially as it relates to urinary tract infections. Amazing, so
01:44 – what sort of patients do you generally see? So I see all sorts of urological issues, I see both
01:51 – men and women, and on the female side, one of the major areas of focus is recurrent
01:58 – urinary tract infections which I see because as a woman urologist, that’s the sort of patient that
02:05 – is sort of, seeks us out and seeks me out as a female provider and so my practice sort of
02:12 – naturally evolved into focusing a lot on recurrent urinary tract infections, which I think a lot of providers
02:19 – finds a little bit challenging and not always so pleasant to treat, but we have you know sort of
02:25 – built our practice around this patient population to help them because a, it’s an unserved population
02:33 – of women, and because it’s the focus of what I do as a female urologist. Okay, so what is your typical
02:41 – approach to diagnosis when you see a new patient who experiences recurrent urinary symptoms? Most
02:47 – of the women that I see have been through a lot of trauma, as it relates to these infections. They’ve
02:53 – had many infections, they’ve been to many different providers, urgent cares, emergency rooms, primary
02:58 – care doctors, they’ve seen gynaecologists and by the time they come to see me, they’ve often been
03:07 – extremely frustrated and they’re very emotional about this situation that they’re in and so
03:11 – the first thing I do is listen to them, I listen to the story that they present with
03:17 – and I think it’s very important from a therapeutic standpoint, that they be able to tell their story.
03:22 – I also think it helps them feel heard and then when I’m able to provide them with what I think
03:29 – should be done, they’re more willing to accept it because I’ve listened to them and I’ve heard
03:34 – their story. Of course the stories are very similar and most women who I see have the same story and
03:40 – every one of them thinks they’re the only one who has this experience, and I say, you know, I hear this all
03:45 – the time all day, you’re like really, I thought I was the only one. It’s like no you are definitely
03:50 – not the only one. So once I hear what is happening, I ask questions relating
03:56 – to the condition that they’re experiencing and just general, their health habits, sexual habits,
04:01 – the things that will pertain to urinary tract infections. I often provide sonograms so
04:07 – that we do non-invasive testing with your kidneys, and your bladder, ovaries, uterus, most patients are
04:12 – very concerned about how the infections and the antibiotics that they’ve been on have affected
04:18 – their organs and they want to know like is there some kind of pathology that we’re missing or
04:22 – is there some kind of consequence of all the treatments that I’ve gotten, and so I can give them the reassurance that they in fact
04:32 – have very healthy organs and nothing is being impacted in a negative way. I think that’s a really
04:39 – nice point about the patients being listened and heard to because I feel like in a lot of instances
04:43 – they don’t know where to go, so being listened to, that’s a really great point and patients knowing
04:48 – that they’re not the only one that experiences this and there’s a lot of other people in the
04:57 – same situation. Right right. Yeah okay, so it would be great to learn more about your approach
05:01 – to UTI testing and how you’ve implemented your own lab for this process, can you tell us
05:08 – a little bit about this? Yes so once I started doing more and more of this I realized that one of
05:15 – the challenges we have is that we don’t have great testing. So in many cases patients will be seen
05:21 – somewhere where there’s no followup, they don’t get their test results, the tests get lost, the lab
05:28 – data doesn’t make sense, a culture isn’t done, just a urine analysis and it’s all over the place and
05:34 – it’s really hard to get a good sense of what we’re doing, what we’re treating and how we’re treating
05:40 – it without having some kind of data that will help us. And so we decided that we were going to open a
05:46 – PCR lab in our office. And a PCR lab is different than a regular, what we call Reference Lab, where
05:53 – a culture is done, so when a urine is left in the office it can be plated and the bacteria
05:59 – are grown, and sensitivities can be tested with various types of antibiotic dips and that’ll take
06:05 – three, two, two days, three days, four days, depending on the lab but there’s a lot of processing
06:09 – that’s involved which means the specimen has to get to the lab, it has to be put at the right
06:14 – temperature, it has to be properly handled, and it has to be properly plated, and there’s a lot of
06:19 – error potentially within that process, especially now with so many specimens being processed because
06:25 – of viral issues and all the stuff that’s going on now with COVID and the flu. So we opened a lab where
06:33 – two things are, we’ve kind of overcome, one is the quote unquote chain of custody, it goes from
06:38 – the bathroom and it goes two feet into our lab, so we know the specimen is being properly handled, it
06:44 – belongs to the patient who’s left it, and it’s getting into the lab as we want it to. And secondly,
06:49 – we can get results within six hours because it’s a PCR lab. It actually takes about three or four
06:55 – hours to run it, but by the time you know get all our specimens together, patient leaves it in the
06:59 – morning, by 4:30 in the afternoon we’ll know which organisms are involved, we know which antibiotic
07:04 – options are available, and so patients are going to get rapid results that are reliable, that they
07:10 – can then or we can use to treat appropriately so smaller amounts of medication are needed
07:15 – to get rid of the symptoms. Wow so that’s the same day turn around, that’s really quick for
07:20 – patients especially if they’re in pain, to know what antibiotics to take. Right, that’s right, so
07:26 – what often what they’ll do is if they drop off a specimen, they’re really miserable, we’ll give them
07:31 – an Azo or over the counter medication, we can give them one antibiotic pill that we have here just to
07:36 – see, get things going, but then later in the day when they’re ready for their second pill, because
07:40 – all these antibiotics are twice a day, we won’t have to give them something that’s incorrect, so
07:44 – the one we gave the morning, it’s only the right one we’ve only lost one, you know one antibiotic pill
07:49 – has been sacrificed, but it’s not four or five days of having been on something that’s going to be
07:54 – completely ineffective. So, in your experience what are some of the common difficulties or obstacles
08:01 – that those living with recurrent or chronic UTI face? So, I think that one of the main obstacles is just
08:07 – being taken seriously, for patients to recognise when they have something, they have something. If
08:12 – they, if they’ve gotten infections you know, their whole adult life, since they’re you know 16, 17, 18
08:20 – years old and they go into an you know a facility to get tested, a lot of times doctors will be
08:25 – like oh well, the urine doesn’t show anything, so you don’t have an infection, and they do,
08:29 – and they know they do, then they wonder maybe they don’t, or after a series of infections, the
08:34 – doctors are like well you know maybe you don’t have infections, because they get frustrated.
08:38 – Physicians and the nurse practitioners and the PAs managing patients are frustrated, so
08:42 – they blame the patient, then the patient starts to think well maybe I don’t really have one and
08:47 – they second guess themselves and they’re sort of in this whole you know, alternate universe of
08:51 – feeling like they have something that they know they have, but they’re not being validated and so
08:56 – they’re not taking antibiotics. And so the first thing I like to tell patients, especially after
08:59 – they you know they tell me this whole saga, is like if you know you have something, you pretty
09:03 – much have it, and if the doctor tells you you don’t, they’re wrong, you’re not wrong. If
09:08 – the culture says that it’s negative and you have symptoms, there’s something wrong with that
09:13 – culture, you’re the one that knows because you’ve been through this so much. The first one is just
09:17 – giving patients the sense of empowerment to know that they have what they have, and then the second
09:23 – is there’s a lot of false information about hygiene and prevention and sexual practices and there’s
09:28 – a certain blame that goes on to patients, who you know most, all of us are like pretty similar in our
09:33 – in our habits and our practices it’s nothing to do with that and then the third is just the third
09:39 – challenge is for patients to have access to the care they need, so that when they have symptoms,
09:44 – they can actually get resolution quickly so that they’re not on more medication than they need and
09:49 – they’re not suffering needlessly. I think that’s a really great point, especially when you
09:54 – spoke about patients having the power and knowing that they, like they know their own body, we have
09:59 – a lot of patients in our community that come to us because they’ve been told that the test is
10:04 – negative and so that they don’t have UTI, and so they don’t have any symptoms, when in fact it’s
10:09 – almost empowering the patient to know that if you have symptoms you know when you have a UTI,
10:15 – or you know when you have symptoms. Right right. So, typically how long can a patient expect
10:23 – to be in treatment? So the goal of our practice is for patients to have management that they, that they can handle on their own and they’re
10:28 – not dependent on us to treat them or to provide you know medications or intervention that they
10:34 – know what works for them, and there’s a whole spectrum of options for patients to treat. At
10:40 – the most sort of sophisticated end, would be antibiotics right, that’s what is available
10:46 – that I can provide patients but then there are all kinds of over-the-counter things that they
10:51 – can use and that’s all at their disposal, and everybody who gets these infections goes online
10:56 – and they read about these products, and that’s up to them if they want to use them if they have
11:00 – symptoms and they want to use cranberry or one of the other products that’s out there and d-mannose,
11:05 – they can do that. What I can offer them is ways of using antibiotics that will be effective and
11:12 – safe for them, and also to provide them with those antibiotics. But I have no problem if they want to
11:18 – use alternate medicines or herbal medicines or naturopathic products. My role is what happens
11:26 – if none of that is working, what else is there and that’s where I come in. So do patients get
11:32 – given a treatment plan, do they have a plan on how long they’re going to be on the treatment
11:35 – for? So when, so there are three ways that we manage these and they’re with antibiotics. There are three
11:41 – methods of managing urinary tract infections with antibiotics and it depends on where a
11:45 – patient is and sort of the whole experience of infections. The first one is self medication,
11:51 – where an antibiotic is prescribed and they have it available and they can medicate themselves when
11:56 – they feel the symptoms have started and they take whatever antibiotic it is, of which there
12:01 – are many options. It’s twice a day for a maximum of three days so the quicker they get the antibiotic
12:07 – on board, the quicker they feel better, the less medication they have to take, so the goal itself
12:11 – medication is to have control and to be able to take less medication to get resolution much more
12:17 – quickly, so they’re not exposed to too much medication and they’re not calling, right they have
12:22 – all their medicine available, they deal with it on their own, I see those patients once a year,
12:27 – we review how they’re doing, make sure they have medication on hand, sometimes we switch it because
12:31 – one antibiotic doesn’t work as well as it used to, we switch to another one once a year. The second
12:36 – group are the ones that go on what’s called the post coital pill, which is where they take a half
12:40 – dose of an antibiotic, one full pill but a half dose, again many options are available. They can
12:46 – take it before or after intercourse if they feel that their symptoms are related to sexual activity
12:52 – and those patients, I’ll give them their medication and if they feel either that they’re getting an
12:57 – infection without having intercourse or if they feel that they’re ready to stop that, they do it
13:02 – for six months and they feel like, I think I’m sort of better now, I would like to not have to do that
13:06 – anymore, I’ll see them at that point, and then we’ll put them on the self-medication program and that’s
13:11 – up to the patient to decide, when she’s ready to do that. And the last group are the group that go on
13:16 – the daily low dose antibiotic which is a half of a single dose medication every single night for a
13:23 – given period of time, and that’s for women who get so many infections they don’t even know if
13:27 – they have one anymore. So we put them on that and I usually start with a six week course. I have them
13:32 – come back in six weeks and see where they are, some are ready to come off and go on either the self-
13:36 – medication with a post coital pill, some are not ready and they want to continue it a little bit
13:41 – longer depending on what the reason is, some women are on it for longer periods of time especially
13:46 – if they’re on chemotherapy, if they have an immunocompromised system, we may put them on that for
13:51 – longer and that’s a more close sort of, close watch with those patients because we have to sort
13:58 – of monitor where we are with them, when we’re ready to get them off that program. No I think
14:03 – that’s really great the amount of options there, so you can choose with intercourse and things like that.
14:08 – So, do you have any tips for individuals who have, believe they’ve got recurrent UTIs and don’t know
14:14 – where to turn next? So, the first thing is, these tend to come in clusters, so I think a lot of women
14:20 – feel that it’s an escalating, like a it’s like a linear issue, like goes from bad to worse worse
14:27 – worse and before you know it, like getting so many infections you’re going to wind up you know in
14:30 – the hospital, but it doesn’t work like that. You go through clusters, you have a series of infections
14:35 – one year, then you don’t get as many the next year, and they go in clusters, and most of these, 99% of
14:41 – these are harmless, these are not infections that are going to cause long, they’re not going to get
14:46 – you in the hospital, but even the ones that get you very sick, once they resolve you’re completely
14:50 – healthy, your system recovers, your kidneys, your bladder, your whole body will recover and you’ll
14:55 – be back to your baseline. so there’s a certain catastrophic feeling to this and it, the
15:02 – first thing is like it’s not, it shouldn’t be that way that, they’re miserable when
15:06 – you get them but they’re not going to be like this for your whole life and so I think it’s
15:10 – really important for patients to know that. The second is that the better your health the better
15:15 – your bladder right, so good nutrition, good sleep exercise, sexual activity, keeps us healthy, that’s
15:23 – what keeps us healthy and strong so you want to do the best you can on that front. And then you find
15:27 – somebody, a provider who really cares about this condition and will treat you respectfully and
15:32 – effectively so that you have a way to deal with them, it’s almost like you integrate them into
15:37 – your life, you accept that we don’t know why they happen, we can’t prevent them, we can manage them in
15:43 – a way that would make you a much more calm happy fulfilled person, whose lives are, whose life is not
15:49 – being altered by this, and if you can find somebody who will help you do that, it will definitely make
15:55 – your life much easier. Yeah great, I think that’s some really good points there. So finally, how can
16:02 – patients get in touch with you? So we have a pretty robust website, where you can contact
16:09 – us, ask questions, we do monitor it, we answer your questions, so through the website they can go on
16:16 – they can call, there’s a phone number but the best way is to email us or reach out to us
16:21 – on our website and yeah we welcome questions, we welcome patients, anything that we can do to
16:27 – help, we want to do to help patients. Well thank you for chatting with us today about chronic and
16:34 – recurrent UTI, I will include your information in the description below for those that are
16:39 – interested in learning more. Thank you, thank you for having me. Thanks so much for watching. I hope
16:44 – you found this video helpful, you’re always welcome to reach out to us for more information about
16:49 – clinicians who specialise in recurrent and chronic UTI. Our contact information is in the description. If
16:56 – you’d like to learn more about this or related topics be sure to check out our other videos or head over
17:02 – to liveutifree.com for other articles on recurrent UTI treatment options. Of course if you like what
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17:19 – Insight Series, if you have suggestions for who we should interview next, be sure to drop us a comment.