00:00 – People with recurrent UTIs are most likely having
00:05 – a biofilm infection that periodically surfaces. It’s not a re-infection.
00:24 – Melissa: We’re in touch with thousands of people and recurrent and chronic UTI sufferers are
00:29 – constantly told things like wipe from front to back, which is pretty basic information
00:33 – once you get to that point. There has to be more that we can do in order to prevent future
00:37 – UTIs and help the bladder heal, so maybe you can share some some of your thoughts on that?
00:43 – Ruth: Certainly there is more to it than from wiping front to back.
00:52 – Let’s go back to how infections start anyway. Infection equals number of organisms, times
00:59 – virulence of organism, divided by resistance of host. So when they say wipe front to back they’re
01:06 – trying to reduce the number of organisms that can find their way into the urethra and ascend.
01:16 – We’ve all been told as women that we have very short urethras and so somehow by this bad design
01:24 – process we are just always going to get UTIs and just go learn to live with it.
01:32 – But there are some things that can be done that would help prevent bacteria
01:37 – from ascending the urethra and getting into the bladder itself.
01:42 – First of all let’s think a little bit about anatomy.
01:49 – People who are constipated have a mega colon. It gets over stretched and it puts pressure on
01:57 – the bladder neck and that pressure prevents you from completely emptying your bladder.
02:03 – Therefore then too much urine sits there and propagates the growth of the bacteria.
02:12 – So not getting constipated is a very first basic step. You want your bladder to be able to
02:19 – empty completely. The next thing is it takes about three hours for bacteria to colonize the urethra
02:28 – and once it colonizes the urethra it can easily get into the bladder itself.
02:35 – The place where the bladder joins to the urethra is kind of funnel shape
02:42 – or a triangle, and therefore many of us initially were told we had urethritis because we had
02:49 – inflammation, irritation, of the urethra. Then we were told we had trigonitis because that trigone
02:55 – area was inflamed, and then we were diagnosed with interstitial cystitis because the inflammation
03:02 – had now spread to the bladder wall. And and so based on the anatomy of where the infection
03:13 – had slowly but steadily spread we got different diagnoses. Okay so how do you keep the urethra
03:20 – from colonizing? Well first of all if it takes three hours for the bacteria to colonize.
03:27 – We should be emptying our bladders during waking hours at least every three hours.
03:34 – Just very basic. And you should be drinking enough fluids every day that you feel like
03:40 – you do need to empty your bladder at least every three hours and if you
03:44 – don’t have that then you’re not drinking enough fluid. And I know if you drink
03:54 – less you have to urinate less frequently and therefore you might have less pain, if urinating
04:03 – triggers pain at the end of urination, or during urination, and so you tend to avoid it. That’s
04:10 – kind of a bad idea just from the standpoint that if you don’t void frequently enough you are more
04:16 – likely to have more bacteria colonizing and therefore getting into the bladder. We have
04:24 – the opposite problem of people drinking too much, this is seldom discussed. We’re told if you have
04:33 – a urinary tract infection you should drink drink drink drink drink and flush the infection out of
04:38 – your system. Now that may work as an initial step for some people but if you’re on an antibiotic
04:47 – it is possible to over dilute the urine. And once again you’re only getting a sub-therapeutic dose
04:55 – of the antibiotic and it’s not going to work as well. So there needs to be a balance there.
05:03 – You know, we say drinking sufficiently that you need to void every two to three hours
05:09 – is helpful. Let’s talk about intercourse. There are some positions in which the urethra can be
05:17 – more irritated and you and your partner need to find positions that minimize some of that
05:28 – mechanical inflammation. Then
05:36 – simply both partners washing up well
05:39 – before, drinking a lot of fluid before, urinating before, urinating afterwards,
05:46 – is going to also help prevent any ascending bacteria from getting into the bladder.
05:54 – Let’s talk about probiotics. Probiotics are the good guys. They normally live in your
06:01 – gut – they’re an important part of the immune system. They actually produce a small amount
06:07 – of hydrogen peroxide in their life cycle which helps, it has an antiviral and an antibacterial
06:14 – effect. They’re the most important source of your vitamin K that is needed to make some of the
06:27 – TAT complexes that break down extra fibrin.
06:31 – So having enough probiotics in your GI tract can actually help you break down the biofilms.
06:41 – So the probiotics are really important. Now we also know that they help prevent urinary
06:46 – tract infections. There was a study done, oh gosh, way back in the early 1980s, in which they had
06:54 – a group of postmenopausal chronic UTI women douching with probiotics once a week.
07:00 – Messy, messy, but there was a 76% reduction of chronic UTIs in that population.
07:09 – Well to my knowledge nobody ever followed up on that study. But it’s always stuck in my head.
07:16 – I didn’t understand how it worked until recently. I watched a webinar put
07:21 – on by Pathnostics lab in which Dr. Alan Wolf, who was instrumental with the urinary biome project,
07:30 – shared some of the findings. And it turns out that some of the probiotics
07:37 – such as Lactobacillus crispatus were found in a higher percentage of women without any urinary symptoms,
07:46 – and Lactobacillus gasseri was found in a higher population of women with overactive bladders. Now
07:56 – they didn’t have any data on chronic UTIs, they didn’t have any data on interstitial cystitis,
08:04 – but I will tell you that when he showed what bacteria they did find in small
08:10 – percentages it was totally different than what i’m finding in my chronic UTI and IC population.
08:21 – So just because seven percent of the women had Enterococcus in their urine
08:31 – doesn’t mean that if your test comes back with Enterococcus, which is the most prevalent
08:37 – organism that both Dr. Fugazzotto found with his broth cultures and I’m finding with DNA testing,
08:45 – just because it comes back within Enterococcus, doesn’t mean that this is a normal
08:50 – urinary pathogen to be found. So we have to be careful how some of that data gets interpreted.
08:57 – Not only that but when I treat and eradicate that pathogen, the bladder symptoms go away
09:04 – and resolve as long as we don’t have other pathogens there as well. So you have to be
09:10 – careful how you use some of that urinary biome data but it does inform us that some of these
09:17 – healthy bacteria probably have a role in preventing some of the other pathogens
09:24 – from colonizing the bladder. You see this in the nasal passage, so there are a number of bacteria
09:32 – that are normal and healthy there and actually prevent people from getting MRSA or prevent them
09:38 – from getting the flu or prevent them from getting other known infections that are circulating. And
09:45 – those bacteria are healthy and appropriate. So when you take a probiotic either orally or vaginally
09:54 – those should help protect the urinary tract from ascending infections.
10:02 – Melissa: Do you think one works better than the other? The oral or the vaginal suppository probiotic?
10:09 – Ruth: They kind of all find their way to the right place eventually. I will say that because so many patients have been
10:16 – on so many oral antibiotics and have just disrupted their vaginal environment that is
10:27 – a helpful test to do. Along with the urine, MicrogenDX does the vaginal testing, Pathnostics does not. And
10:36 – by testing the vaginal environment you can see if you’re seeding bad bacteria into the bladder
10:46 – on an ongoing basis. I’ve had many patients that until we addressed the dysbiosis or the
10:54 – bad balance of bacteria in the vaginal tract, we were not able to stop the urinary tract infections.
11:03 – This is particularly true of postmenopausal women because that vaginal tissue that should be moist
11:11 – and have healthy little hills and valleys called rugae, where the good guys like to hang out, due to
11:18 – the lack of estrogen those tissues become thin and dry and don’t support good bacterial growth.
11:26 – Instead they support the growth of pathogens and so sometimes some vaginal estrogen will restore
11:35 – that healthy environment so the healthy bacteria the Lactobacillus and Bifidus can colonize and
11:44 – therefore continue to protect the urinary tract.
11:49 – Melissa: okay that kind of leads us into the question of how to break the cycle of recurrent UTI. You’ve mentioned balancing an imbalanced vaginal
11:55 – microbiome. Are there other ways that we can try to break the cycle or to prevent the next UTI?
12:04 – Ruth: I think this is a good chance to
12:08 – dispel a myth someone with a recurrent UTI is getting re-infected each time. The most likely
12:18 – scenario is that you have a biofilm problem, that the bacteria have never been fully eradicated
12:26 – and that periodically, like any biofilm when it reaches a certain size, pieces of it
12:34 – break off to go form a new colony somewhere else and are free-floating in the urine.
12:43 – Or your own thrombin / anti-thrombin complexes have been successful in breaking down a piece of
12:50 – the biofilm or you’re taking a biofilm disruptor. Certain things like Xylitol,
12:57 – which is a natural sweetener, is known to have good biofilm disruption properties.
13:05 – So just through the normal life cycle of the bacteria they will shed
13:14 – anyway. So people with recurrent UTIs are most likely having a biofilm infection that
13:24 – periodically surfaces, it’s not a re-infection. So taking a biofilm disruptor, and hopefully you
13:33 – can get the testing to tell you which one is the best one for you based on your genetics,
13:41 – and breaking down the biofilm so that the infections found can be adequately treated
13:49 – and the bladder wall can heal, so you don’t have an environment that fosters the continuation of these
13:57 – biofilm communities, will ultimately prevent recurrent UTIs. And
14:04 – getting the sexual partner tested also could be a part of this. I will say that about
14:11 – 50% of my patients tell me that they flare after intercourse and of those 50% percent,
14:22 – when we check the sexual partner and we check the male’s semen (not the urine),
14:29 – are coming back with the same infections that the female IC or recurrent UTI patient has.
14:38 – Whether they are symptomatic or not, many men have a low-grade chronic prostatitis.
14:45 – They may not have any symptoms but for the sake of the one they love
14:52 – they will get treated and for some women that is the way to break that cycle.
14:58 – Melissa: Are there certain things to look for to know when you should think about testing your partner?
15:04 – Ruth: Probably the biggest sign is that you flare after intercourse. If you have symptoms within
15:10 – the first couple hours it’s probably just the mechanics and the physical contact.
15:17 – If you have a significant flare 24 to 48 hours afterwards that almost certainly is reinfection.
15:27 – Melissa: Okay that’s good to know. When it comes to healing the bladder are there things that
15:32 – we can actually actively do to help rebuild or is it more a matter of eradicating infection?
15:39 – Ruth: The body’s going to repair itself. That’s a given. Now I want to sidetrack just a tiny bit
15:47 – because I think this is a good time to talk about some of the other factors that are ongoing
15:52 – irritants that may prevent some of this repair taking place. The biggest one that I’m finding
16:00 – is mold toxins. Mold toxins are not the same as finding fungal infections in the urine itself.
16:08 – These are chemical substances put out by mold that a person environmentally
16:16 – has been subjected to. It could have been years ago. It could be their current work or housing
16:22 – situation, they may not have even realized that they were being subjected, because sometimes
16:29 – these mold toxins are behind a wall where there’s been a leak in a pipe or in a roof that leaked.
16:38 – And these molds are still in places that are not visible but
16:44 – they’re still producing toxins that get into the environment. Mold toxins depress the immune system,
16:51 – they are huge bladder irritants and I’m finding them about 10% of the time. A pretty significant
16:59 – number of my patients, particularly those where we’ve cleared up the infections and
17:06 – that doesn’t seem to be a player anymore but they’re still experiencing urinary tract symptoms.
17:13 – Mold toxins also get into the nerves, so sometimes when people have
17:22 – other symptoms like the vulvodynia or their symptoms don’t tend to wax and wane
17:29 – like they would with the bladder wall infection, but the nerves going to the bladder are inflamed,
17:36 – their symptoms tend to be more consistent 24/7, they’re not diet dependent and no matter what
17:43 – they do it doesn’t seem to make any difference – those are people that I would very much suspect
17:50 – could have a mold toxin issue. There’s a way of detoxing those mold toxins. It takes six
17:58 – months, nine months usually, occasionally as long as a year. But people are noticing great improvements
18:06 – in their urinary symptoms just when they start, just from dealing with the mold to begin with.
18:13 – The other thing that can cause some of the chronic symptoms
18:19 – that need to be thought about are tick-borne infections. Once again, in 10-15% of my patients,
18:28 – whether they can remember ever getting a tick bite or not, I am finding Lyme and some of the other
18:34 – infections that ticks carry, particular Babesia, are getting into the bladder wall. And we did have
18:41 – some patients with bladder biopsy specimens – two different labs tested them for the tick-borne
18:47 – infections – and all three came back positive for Lyme and two of the three came back with Babesia,
18:54 – identified with DNA testing. And being in the bladder wall,
18:57 – that will continue to cause bladder destruction. The DNA testing won’t find it because
19:06 – the tick borne infections stay embedded in the bladder wall and don’t spill out into the urine.
19:11 – So sometimes being able to address some of the other reasons as to why the bladder
1916 – wall is not happy and that the nerves have become infected with either tick-borne infections or
19:25 – have mold toxins, can resolve some of the things that seem to linger on, symptom-wise for some people, not everybody.
19:37 – Melissa: That also leads us to another question on other possible
19:42 – irritants, so things like bath bombs or washes or diet, coffee, alcohol. What are your thoughts on those?
19:48 – Ruth: Oh absolutely, if it bothers your bladder don’t do it. There
19:59 – are known irritants. I mean I remember when I worked pediatrics. Little girls and bubble
20:06 – baths we’re not good friends. And so anything that’s going to add to that. Hot tubs are
20:13 – particularly nasty, and a lot of people picking up infections from hot tubs – I don’t trust them.
20:23 – So anything that’s going to add to the infectious load or chemical irritation,
20:28 – some of the fresheners and washes, you have to be very careful of. If they alter the pH
20:34 – they destroy some of the normal skin bacteria that should should be there.
20:42 – Your genital area is not sterile and there are healthy bacteria that should be there. When someone
20:48 – gets diagnosed with interstitial cystitis they are handed a sheet of paper called an IC diet.
20:56 – I have to give Dr. Larrian Gillespie credit for listening to her patients and believing them that
21:03 – there were certain foods that made their symptoms worse. I remember presenting it to my doctor and
21:09 – he said oh I believe people should eat anything they want and you shouldn’t be restricted
21:15 – by a diet and my thought was if it keeps me out of pain I will never eat one of these foods again.
21:25 – And so some people are more diet sensitive than others. Some people say that the big irritants like
21:30 – alcohol and caffeine bother them but other foods don’t. Other people have one grape and they can be up
21:37 – all week long. I was one of those. It took me a while before I could eat a grape again
21:47 – without panicking that it was going to send me off the edge. But I think it’s
21:53 – a symptom management tool and there’s nothing magic about it. It’s not going to fix the problem.
22:00 – If you eat something that’s on that diet and your bladder complains about it you have
22:07 – bought yourself another day or two of misery but it’s not like you’ve set back your progress
22:12 – by months at a time and the world is going to come to an end. And I think you also need to try
22:20 – various things to see what is your problem or not. I had things on the IC diet that gave my bladder
22:27 – no problem at all and I had other foods that were not on the diet that would send me off the planet
22:33 – with pain and and urgency and frequency. And I would be up most of the night and get out the ice
22:40 – packs and any other tools I had in my arsenal to manage the flare. I just simply took a piece
22:48 – of paper put it on the refrigerator, drew a line down the middle with a smiley face on one side
22:53 – and frowning face on the other. And as I discovered which foods i could and couldn’t have I developed
22:59 – my own list. And so if you are diet sensitive you might want to do that and you might be surprised
23:07 – there would be foods that you’ve been avoiding that you don’t have to and you might also discover
23:13 – some foods that maybe you shouldn’t be eating because your bladder thinks it’s a bad idea.
23:19 – Melissa: Do you have patients that have been able to go back to eating whatever they want after treating the infection?
23:23 – Ruth: Absolutely everybody. Matter of fact, that’s one of the early signs. People, when they
23:30 – start treating the infections, depending upon how much is there and how much damage to the bladder
23:35 – wall, start noticing some very small but definitive progress. I will talk to them and they’ll say
23:45 – well I used to get up four times a night and now I only get up once or twice.
23:50 – They might say I didn’t used to be able to eat this food but now I can tolerate small amounts.
23:59 – I’m going a little bit longer between my flares and when they do
24:03 – happen they aren’t as bad as they used to be and they don’t last as long.
24:08 – So all of those are encouraging signs that you’re on the right track. And it’s not going to be
24:16 – a straight line progress. It’s a little dance, two steps forward, one step back, occasionally one step
24:22 – forward and two steps back. But if you take the long view that if you look at where you are now
24:29 – and you look at where you were three months ago or six months ago or a year ago
24:35 – it’s very rare for people not to be able to see
24:38 – progress. And whether or not you believe that interstitial cystitis is an infection or not,
24:47 – your body cannot appreciate the infections being there. So if you find infection there is no compelling reason to not treat it.
24:57 – Melissa: The setbacks can be one of the things that makes it so
25:00 – hard to keep going with treatment and most people do tend to experience that from what we’ve heard.
25:05 – In your opinion, how long does treatment take on average?
25:10 – Ruth: Oh goodness, everybody’s different. If I can start working with a patient within the first couple months
25:18 – usually we can turn around in a couple of months. If it’s been a couple of years
25:23 – it’s probably going to take longer. And this is really important – if someone has mold or tick-borne
25:32 – infections it’ll take longer. If somebody has one of those genetic hypercoagulation mutations
25:42 – in which they don’t break down biofilms as well as other people and those include Leiden factor V
25:51 – PAI-1, which stands for plasminogen activator inhibitor one, which
25:58 – is the one I find most commonly by the way, or Lipoprotein A, which is a form of bad LDL
26:06 – cholesterol that isn’t generally tested for on a lipid panel, then we’re talking about a longer
26:16 – course because we have more biofilms to break down. And generally they have more infection.
26:28 – Melissa: That makes sense. So the longer you’ve been suffering,
26:30 – the longer treatment might take in general?
26:34 – Ruth: In general, but it also depends on how fast we can move.
26:42 – People who are able to do bladder instillations with the biofilm disruptor directly in the bladder
26:49 – tend to move faster than people who can’t and are depending upon the oral course.
26:56 – People who are following the test, treat, retest, retreat,
27:07 – make faster progress than people who maybe feel good after they’ve treated, don’t retest, allow
27:15 – the remaining infections to wall back off in the biofilm, go back to square one where their
27:22 – symptoms are really bad before they retest and then retreat. So if you if you get the bugs on
27:31 – the run, you get the biofilms broken down and you keep hitting it, with the infections that are there,
27:39 – of course you’re going to make faster progress and you can get through it sooner than if you only
27:47 – test based on when your symptoms have returned a month or two later. They’re so bad that you say oh I guess I better retest.
27:52 – Melissa: It’s a compelling reason to retest, that’s for sure.
27:59 – Ruth: I know that it’s hard to get your mind around
28:04 – that I should test when I’m not having symptoms but that also will be helpful especially if
28:12 – you take a biofilm disruptor. If you’re not staying on one because of your genetics, take a biofilm
28:18 – disruptor for a couple, for a week, a couple of days before you retest and see what else you can
28:25 – chase out of that biofilm to be found and treat it.
28:30 – Melissa: If someone has recovered from a recurrent or chronic UTI and then years later they experience another UTI, what steps should they take then?
28:40 – Ruth: Treat it as if you would treat an acute UTI, unless you have the genetics that make you
28:48 – prone to making really extravagant biofilms.
28:53 – I think if you have those genetics you need to stay on a biofilm disruptor the rest of your
29:01 – life because that’s going to prevent any infection you get, whether it’s urinary or anywhere else in
29:09 – your body, from walling off in a biofilm. The second compelling reason is that if you are making extra
29:17 – fibrin in response to inflammation, and we all get it from lots of sources on ongoing basis,
29:25 – that extra fibrin will be deposited in your blood vessels, particularly the arteries
29:33 – and start narrowing them and set you up in the long term for cardiovascular disease. And
29:42 – most of you who have those genetics have family members, parents, grandparents,
29:50 – aunts and uncles who have cardiovascular disease. And so that’s one indication
29:57 – that you might be prone to having one of those genetic issues and to take a biofilm disruptor
30:06 – geared to which genetics are involved, because they aren’t all the same, will prevent you from getting
30:13 – another chronic infection as well as reduce your risk in the long term of cardiovascular disease.