00:00 – Dr. Kumar: The goal is not to get a test back that says zero bacteria. The goal is to
00:05 – ameliorate symptoms and prevent complications from urinary tract infections.
00:24 – Melissa: Today we’re talking with Dr. Kumar, who’s based in New York and is a women’s urology specialist.
00:29 – She has a special interest in hormone treatment, recurrent UTI and IC. So thank you so much for taking the time to speak with us today.
00:38 – Dr. Kumar: Thank you so much for having me, I appreciate it.
00:42 – Melissa: Maybe first you can just tell us a little bit more about your background so people have some context for your work.
00:45 – Dr. Kumar: Sure. I went to medical school at Tufts from 2002 to 2006 and that’s where I became very
00:55 – interested in urology. I did my residency at NYU Langone medical center here in New York from 2006
01:05 – to 2011, and when I came into practice I was seeing about 75 percent female patients. And certainly
01:14 – recurrent urinary tract infection was a big part of my practice. And I always felt that
01:22 – what we were doing wasn’t enough, and there were so many frustrated patients dealing
01:27 – with this issue. So I really wanted to learn as much as I could and and focus my
01:32 – practice as much as I could on helping women who suffer from recurrent infections as well as
01:40 – other irritative lower urinary tract symptoms which can arise from things like
01:47 – interstitial cystitis or also what we call the genital urinary syndrome of menopause,
01:53 – which you know not only affects the the vaginal tissue but the bladder, urethra and pelvic floor.
02:00 – So you know as I continued to focus my practice I also decided to learn more about
02:07 – menopause and estrogen and I became a certified menopause practitioner by the North American
02:13 – Menopause Society. Then at that point I decided to focus my practice exclusively on
02:20 – treating women and I decided to set the whole practice up as a practice that is by women and
02:27 – for women. That led me to open up my practice where I am now, which is called Women’s Urology in New York
02:36 – Melissa: I think there’s definitely a need for that kind of practice. There
02:39 – are so many people that we hear from in that position. I want to start with something basic,
02:43 – with the questions that we’ve received, which is just around testing. So maybe you can give us a bit
02:48 – of insight into the limitations of standard urine culture and why so many seem to come back negative even though people still have symptoms?
02:54 – Dr. Kumar: Sure. So that’s a great question. Standard urine culture
03:01 – is based on a technique where you take very small amounts of urine and you drop it on different
03:10 – plates that have certain nutrient media. So one could be chocolate agar one could be blood
03:17 – agar and a couple things can happen. One is that you may not have enough quantity of urine
03:23 – to accurately reflect the bacterial population in the urine. Two is that you may
03:33 – not grow it for long enough. The bacteria may take a much longer time to grow than you’re
03:39 – actually observing those plates. And three, the composition of nutrients on the plate just may
03:47 – not accurately reflect the composition in the bladder and so the bacteria, while it’s thriving
03:54 – in the bladder, may not grow on the plate. And studies that show a technique of
04:01 – expanded urine culture testing, where they actually use higher quantities of bacteria,
04:08 – I’m sorry, they use higher quantities of urine volume on the plate, they use
04:13 – more types of nutrient media, and they use a longer time where they observe the growth,
04:19 – are shown to be more sensitive than the standard cultures that are typically used by the labs that we send the urine to.
04:27 – Melissa: And do you access that kind of expanded culture
04:31 – through your practice or do you use something else for testing?
04:38 – Dr. Kumar: In our practice, what I actually like to do when I have patients where I really strongly suspect that they do have
04:43 – a urinary tract infection and their standard culture is coming back negative, then I do find
04:49 – there is utility in using the urine PCR testing or the urine DNA testing. Shockingly in New York,
04:58 – the labs which offer that testing are not approved. I actually just had this
05:06 – conversation with someone from Pathnostics last week. These labs don’t have something called New York
05:12 – state approval and so we are the only state in the country where it’s difficult to order the
05:17 – tests. Some of my colleagues have actually set up urine PCR labs in their office and so
05:23 – now I have colleagues who I can refer to, to get it done in New York. And then other than that
05:29 – I have to rely on using a urologist who’s in New Jersey or Connecticut in order to
05:36 – order something like the MicrogenDX.
05:39 – Melissa: I see. We do hear from a lot of patients in New York, that they’re having difficulty accessing anything but a standard culture.
05:46 – Do you think in the near future that might change or is this likely to be a long-term issue?
05:51 – Dr. Kumar: I do think it will change. I think that given the demand for the testing,
05:58 – more offices will be able to set it up. I know that Dr. Kavaler, who is one of
06:04 – my colleagues, she has set up a a urine PCR lab in her office. It’s
06:11 – taken her over a year – you have to get CLIA certified, you have to have a lab director. So
06:17 – there’s a lot that goes into it. I think other practices will follow and I also think that
06:24 – those companies are actively pursuing New York state regulatory approval. So I think
06:29 – they’ll be available here and hopefully that happens sooner rather than later.
06:35 – Melissa: That would be great. So for people that have had negative standard urine culture and
06:41 – do have pelvic pain of some kind, do you think they could benefit from these other kinds of tests?
06:47 – Dr. Kumar: Yes I do. I think that certainly in the patient who shows on the urinalysis some white blood
06:56 – cells, leukoesterase, certainly the patient who is showing that there are signs of inflammation
07:02 – in the bladder you know, and the culture is coming back negative. In that patient I’m
07:07 – very suspicious that they do have a urinary tract infection and you know they are falling into that
07:13 – 30% of patients who are getting a false negative standard culture. The other situation
07:20 – that I think it’s very useful is that some of the tests are actually able to detect resistance genes
07:26 – and I think if you have a patient who you know has a positive urinalysis, has a positive culture
07:33 – and they’re not responding to the antibiotic you have them on, then it’s helpful. Because
07:39 – your standard culture, the way the resistance is determined is also a fairly crude
07:44 – technique and you may be getting a more accurate characterization of the sensitivity and
07:50 – resistance profile with the PCR or DNA testing. So I think there’s
07:59 – various ways in which that testing is useful. But you know I think that I would,
08:06 – as a first measure still send a standard urinalysis and culture and then if I
08:12 – find it’s necessary beyond that, then I would use the DNA testing. Because I mean there’s a large
08:18 – percentage of women who come in with UTI symptoms, we do the standard test, it comes back positive, we
08:24 – treat them and they feel better. So I think that [DNA testing] is useful in the
08:30 – population of patients where their symptoms are persistent and we think that
08:37 – the standard test just isn’t correlating with what we’re seeing clinically. Given
08:42 – what we are starting to understand about the urinary microbiome, our goal with treatment is
08:48 – not to sterilize the urine. And I think that was one of the questions, you know is
08:55 – what is our end point with this? Our goal is to ameliorate symptoms and our goal is to prevent
09:02 – complications from urinary tract infections. Complications can include things like
09:08 – pyelonephritis, where the infection ascends up to the kidney, although very few people actually
09:13 – get pyelonephritis from urinary tract infections, or urosepsis, which is when the
09:20 – bacteria actually enter the bloodstream. So that’s our goal. Our goal is not to
09:27 – sterilize the urine. And I think from what I’ve seen, multiple patients who’ve been on so many
09:32 – different rounds of antibiotics, both orally and intravesically and they’re still having symptoms,
09:38 – those are the patients who you really need to consider, you know, that this 20 000
09:45 – colony count or this presence of a little bit of E. coli or enterococcus, or
09:52 – a variety of different organisms in the bladder, or I shouldn’t even say in
09:58 – the bladder because we don’t know if it’s coming from the bladder, it might just be perimeatal.
10:01 – You know, it may not be the cause of of their symptoms and I think
10:06 – because infection is so common in the female bladder, I like to actually
10:13 – do a very thorough job in ruling that out. So I don’t think there’s anything wrong with
10:18 – making an attempt to treat it but if your patient is not getting better then you need to
10:25 – rethink whether this is actually infection or you’re just detecting
10:29 – some bacteria from around the urethral opening or the vagina that’s not really causing the problem.
10:35 – Melissa: The ability of these other kinds of tests to pick up more organisms means that patients
10:40 – also often get a long list of things and their doctor might tell them that certain organisms
10:45 – are just normal, they’re meant to be there, and therefore they won’t treat them. Do you think
10:49 – there are times when organisms like ureaplasma or lactobacillus could be pathogenic and then therefore should be treated?
10:56 – Dr. Kumar: Ureaplasma, yes. This was actually part of Dr. Ackermann’s talk,
11:03 – where they actually found that treating ureaplasma in patients in the absence of pyuria did
11:10 – not make a difference in symptoms. Ureaplasma is a very interesting organism because
11:18 – that is a test that you can order in the office and that is a DNA based test.
11:25 – I have had patients certainly where treating it has improved their symptoms and
11:33 – when they’ve seen other doctors they keep getting a standard urinalysis and culture and they’re not
11:38 – testing for mycoplasma, ureaplasma. I’ve seen where I’ve treated with the one
11:44 – dose of Azithromycin and the symptoms didn’t clear but when I treated with a longer course of
11:50 – Azithromycin that the patient totally felt better afterwards. I think if i see ureaplasma
11:58 – in a patient who has irritative bladder and urethral symptoms I am going to treat it.
12:05 – It is a commensal organism. I’ve seen women who’ve had urinary tract infection
12:13 – with E. coli and then we’ve also detected ureaplasma and their symptoms have cleared just with
12:18 – the treatment of the E. coli. So I think, again, you really have to take into
12:24 – consideration the information that you have and then you have to use clinical judgment in order to
12:30 – to determine what you’re going to treat because you do want to minimize
12:36 – antibiotic exposure to the extent you can. And as we discussed, the goal
12:42 – is not to sterilize the urine, the goal is not to get a test back that says zero bacteria. The
12:47 – goal is to ameliorate symptoms and prevent complications from urinary tract infections.
12:55 – Melissa: That is kind of a difficulty with the switch from the standard culture to these other kinds
12:59 – of tests because patients and clinicians, I think, are expecting it to be positive or negative,
13:04 – but the tests that are actually looking more at the urinary microbiome – surely we’re not trying
13:09 – to eradicate everything, now that we know that there are things that should be there.
13:13 – So how do you kind of draw the line when you’re doing treatment like that and decide which one
13:19 – should stay, is it all just about how the patient feels?
13:27 – Dr. Kumar: I think there are certain known uropathogens, and so if we’re seeing that there’s a predominance of those
13:34 – and the patient’s having symptoms… Let’s say there are two bacteria, like
13:40 – E. coli and pseudomonas, and in that situation I’m, I think,
13:47 – apt to treat both. Especially if let’s say the patient has done a standard culture before
13:53 – and we’ve been treating the E. coli that grew on that and they’re not responding to it.
13:59 – I would go based on what we know to be the organisms
14:04 – we know to cause urinary tract infections and I think that if the patient has
14:12 – been on antibiotics and you know they’re not getting better and it’s something that
14:18 – these bacteria should be sensitive to, I think then and especially if they’re doing a voided specimen,
14:25 – then we have to say, look, these bacteria, they live around the
14:32 – meatal opening they live in the pair the perineal skin. These are commensal bacteria and we
14:39 – shouldn’t be treating it. So the other thing is, I think if I’m doing that test I really favor doing
14:44 – a catheterized specimen because I think if we’re doing voided specimens for that type of testing
14:50 – then it’s very similar to doing a vaginal swab.
14:54 – Melissa: A question I have is, if they are using a catheter sample, what if the infection is in the urethra? Do they not just miss the problem then?
15:01 – Dr. Kumar: No. You still can get bacteria. If it’s in the urethra you still can detect it in the
15:10 – catheterized sample and in fact, catheterized samples don’t do as good a job as we think in
15:17 – avoiding vaginal contamination. I see that all the time in my office where I check a catheterized
15:22 – specimen in a woman, and she’s totally asymptomatic and I might be
15:29 – checking it just to see how well she empties her bladder, or for other complaints
15:34 – than UTI complaints. And I see it all the time where we detect like fifty thousand
15:41 – E. coli, twenty thousand enterococcus, strep viridans. So catheterized specimens
15:50 – can often give you bacteria that are perimeatal and from the urethra. The only
15:58 – way of checking a true bladder specimen is by doing a suprapubic aspirate,
16:06 – which would be invasive in most people, so we don’t routinely do that. But so I
16:15 – do think that trying to limit the amount of contamination by doing a catheterized specimen,
16:20 – if you’re going to do something like a MicrogenDX test, I think it is wise.
16:27 – And I don’t know that you necessarily miss urethral bacteria. The one thing that you can miss
16:36 – is – I think there’s a population of women who end up with an infection in the skene’s glands,
16:42 – which are the glands which sort of sit on the outside of the urethra and are homologous to the
16:49 – male prostate. And that’s a situation where you have a patient who’s complaining mostly of dysuria
16:56 – and they’ve maybe had a UTI previously but the urine is culturing negative now. And
17:03 – sometimes you can detect some tenderness on exam at the mid to distal urethra,
17:09 – where those glands are. We typically think of the skene’s glands when they
17:14 – form a cystic structure or when they may erupt into the urethra and form urethral diverticulum,
17:21 – but I think that there’s probably a population of women who have infection or inflammation in those
17:26 – glands similar to how men develop prostatitis. And you kind of have this chronic smoldering
17:32 – infection and it would be very difficult because the bacteria is being sequestered in the gland.
17:39 – So it would be very difficult then to culture that.
17:42 – Melissa: There’s a lot of discussion amongst patient groups actually, that urethral syndrome could be skene’s glands being infected, because
17:51 – the symptoms just seem to be around that area. How do you detect whether it is a skene’s gland problem and then how do you treat that?
17:58 – Dr. Kumar: It’s really hard because again you can’t
18:02 – rely on your urine result if you believe that the bacteria is being sequestered in the gland. So
18:09 – that is a situation where I will give the patient, in order to treat it in the same way that we treat
18:15 – male prostatitis, you need a longer course of an antibiotic which has good tissue penetration. So
18:22 – the antibiotic getting excreted into the urine is not enough, you need something like a cipro or
18:27 – a bactrim or an amoxicillin, where you’re actually getting into the tissue and you’re achieving that
18:33 – tissue concentration for a long enough period of time. So I will usually prescribe a
18:39 – four-week course and then I tell the patient, you need to let me know, you know by seven days
18:46 – or so, you know if this is helping you because if you’re feeling no relief in your symptoms
18:51 – then I want you to stop it because then I don’t believe that this is a skene’s gland
18:57 – infection. If you are feeling significant relief with the antibiotics then I think it makes sense to continue.
19:02 – Melissa: Is surgery ever an option for that kind of issue?
19:09 – Dr. Kumar: If the gland forms a cyst, sometimes the gland will actually fill with like pus and if you can
19:16 – palpate a cyst under the urethra, or you can even image and see it on MRI
19:24 – then yes, you can surgically remove it. But unless it’s enlarged, it would be very difficult to
19:32 – actually localize and dissect out the gland. So I think surgery is an option if
19:40 – it presents itself a cystic structure or in the case that it erupts into the
19:45 – urethra, it’s a urethral diverticulum and most women want surgery for that because
19:50 – they’re experiencing dribbling or chronic infection. So that usually will
19:56 – become symptomatic. If it just forms a cyst and it’s not actually communicating with the urethra
20:02 – sometimes women will feel that as a sub-urethral mass or they’ll notice their
20:07 – urinary stream is diverted. Sometimes they don’t feel it at all and we just detect it on exam.
20:12 – And so if it’s enlarged you can excise it but if it’s not then you don’t have anything to find and dissect out and remove.
20:20 – Melissa: When you say the urinary stream is diverted, does that
20:24 – mean it is actually passing through a different piece of anatomy?
20:29 – Dr. Kumar: No, it just means that if there’s a structure that’s sort of pressing on the urethra you may notice that when you urinate
20:36 – your stream is getting diverted. You know you may say my stream always aims to the left and
20:41 – then when we examine you we find a skene’s gland cyst on the right side. Sometimes
20:47 – they can get quite big and so they cause a little bit of compression of the urethral opening.
20:54 – And I think that even in the absence of infections sometimes those glands can
20:59 – be irritated hormonally and those glands are actually testosterone sensitive. And so one
21:04 – thing we sometimes see, especially in women who are on the birth control pill for a long period
21:13 – of time, those glands are kind of irritated and inflamed even in the absence of infection and
21:20 – using a little bit of a compounded cream that has both estrogen and testosterone
21:26 – can actually help to soothe the irritation in the glands and provide symptomatic relief.
21:33 – Melissa: That’s interesting too. I wonder how many clinicians approach it that way,
21:37 – because I think a lot of clinicians don’t consider the skene’s glands.
21:41 – Dr. Kumar: Yeah, it’s a very overlooked, it’s an extremely overlooked structure, certainly.