00:00 – Dr. Hlavinka: If you’re not looking at couples you’re not looking at the full spectrum of risk factors
00:07 – for women. You can’t just isolate women, and so many times I see the partner not involved.
00:24 – Melissa: Some of the main questions that we get from our audience are around sex
00:28 – and UTIs. We get a lot of questions about how you can avoid UTIs after sex, whether a partner may be
00:34 – contributing to UTIs after sex and just a whole bunch of questions, and I was hoping to get some
00:39 – insight from you on those. And so maybe first you can give us an idea of what the current
00:44 – theories are about why sex is a trigger for UTIs?
00:47 – Dr. Hlavinka: Gosh, sex and UTIs. It kind of seems to go together doesn’t it, unfortunately. And it does for some women, unfortunately, and I will broaden
00:57 – the scope of the discussion to say if you’re not looking at couples you’re not looking at
01:05 – the full spectrum of risk factors for women. You can’t just isolate women, and so many times I see
01:11 – the partner not involved. And it can be a same-sex partner, or if a woman has multiple
01:16 – partners, or their partner has multiple partners. And so sometimes you’re talking about
01:21 – a non-monogamous relationship where one of the partners is the person carrying and here is
01:30 – the problem. And why I can’t get my colleagues to accept this. There are asymptomatic carriers out
01:38 – there. The whole notion of asymptomatic carriers, what does that mean? That means a person who’s got
01:43 – a microorganism living on their body, in their body, in their body cavity, in their prostate, in their
01:48 – vagina, and it’s not causing any symptoms and they can pass that on to somebody else with no symptoms.
01:54 – Most people are aware of the classic sexually transmitted infections, Chlamydia,
01:58 – Gonorrhea, Syphilis, and the viruses of Herpes and the Human Condyloma Virus. So the problem is
02:09 – we are aware of asymptomatic carriers in those infections and we have very good public health
02:16 – policies for identifying asymptomatic carriers when somebody comes in for those infections, but
02:22 – we don’t have those for traditional infections or the typical organisms of urinary tract infections.
02:29 – And that has been my problem, because so many times I find the carrier. I think I’ll illustrate by an
02:35 – example. I had a couple, he was a truck driver here in Texas. It’s hot and he had chronic
02:42 – wetness down there, all right. He had seen two years of doctors, primary care, infectious diseases,
02:50 – dermatologists. He’d been biopsied and swabbed and poked and prodded and treated with all manner of
02:55 – all kinds of stuff and it just wasn’t working. She got urinary tract infections and
03:02 – and chronic vaginal infections. So she had both vaginal infections, vaginitis and cystitis. Bladder
03:08 – infections. Nobody could find the same organism. He didn’t have an infection – they had done everything
03:13 – on him – he didn’t have an infection. She was getting these chronic infections. She came to me
03:19 – and I said what is your husband experiencing? Well, the dermatologist failed and he’s got this thing.
03:24 – Bring him in. So I have him void into a cup. I swab her vagina, I swab both of his groins because I
03:32 – want to have a control to make sure, and I get the organisms back and guess what? It is three
03:41 – common coliform urinary tract organisms. It’s E. coli, Klebsiella and Enterococcus
03:46 – on both sides of his groin, in his urine, in her vagina, and in her bladder. So they had had three
03:54 – microbes they’d been passing back and forth for two years. I gave her two weeks of antibiotics. I
03:59 – gave him two weeks of antibiotics and creams. I’m a hero, they think I’m like you know,
04:06 – the man who landed on the moon. And and it was a simple thing to do. And this is
04:11 – what I believe is the most important thing that we can do, is to recognize that we don’t know
04:17 – what we don’t know, and we have to keep digging for information when presented with a complex patient.
04:22 – I actually submitted a paper to a meeting that got rejected, so maybe somebody will discover
04:29 – this and decide to publish it, or accept it at a meeting. I’m not bragging, not bragging, just saying
04:36 – hey, this is really important information and I don’t think anybody else is is telling you that
04:41 – out there. I have a series of ten couples and these are heterosexual, monogamous couples and who had
04:49 – been passing an organism back and forth. And they were like that couple for two years and they also
04:58 – were those for which one member was asymptomatic. In other words, of these couples, in six of them one of
05:07 – the members was asymptomatic, right. So under those circumstances that person had no idea.
05:13 – I did traditional cultures – absolutely worthless. These are 20 human beings right, 10 males, 10 females
05:19 – and 10 different couples, monogamous couples. And traditional cultures only show four organisms in
05:26 – the whole 20 people, all right. PCR showed the correct organism in only six people out of the
05:36 – 20. Next generation sequencing showed the organism in both members of the couple in all 10
05:46 – couples, so in all 20 people NGS showed the culprit in all of them. That is how worthless traditional
05:53 – cultures are, and PCR is when you’re coming, and I can’t say that, I have to be a scientist. And
05:59 – I can’t say that is the case otherwise, but what I am seeing in couples passing things back and forth –
06:07 – we’re missing the boat. And we’re missing the boat because our detection techniques are wrong.
06:11 – Number one, we’re not looking for the partner. Number two, we’re looking at the wrong
06:15 – techniques. So it’s very important to recognize that there’s a whole heck of a lot more sexually
06:20 – transmitted infections. And I want to say that STI, sexually transmitted infections, the classic
06:27 – ones that we think are bad, and the ones that aren’t the problem, is that there’s a whole lot
06:34 – of infections that people are giving to each other. However you want to call those, I like to call them
06:39 – sexually related infections because they take away from the stigma of the STIs that we’re all
06:44 – familiar with. So if you have a sexually related infection then you need to find, you need to look
06:50 – for the partner, and you don’t know what you don’t know, if you don’t look at the partner. So that’s
06:55 – part of the problem. The next part of the issue is the fact that intercourse and all of its, let’s
07:02 – just say, perturbations can cause an infection. And so when we kind of typically think of the penal
07:08 – vaginal intercourse, well that’s one set of risk factors, but if there’s anal intercourse or even
07:14 – anal contact happening then that can happen. For instance, I have seen over my career
07:21 – the organisms, and this certainly accelerated after we got next generation sequencing, the organisms go
07:28 – toward more mouth organisms as people are having more oral sex. For instance, Beta strep you used
07:33 – to never see in the urinary tract. But now, I will tell you that when I started doing next
07:38 – generation sequencing about 30% of the infections and a big reason why people were not getting
07:45 – cured was that Beta strep from the mouth was the organism. And it’s actually pretty easy to
07:52 – to eradicate. Beta strep is a common organism that causes tonsillitis in adults and kids.
08:00 – Most adults are carriers, are asymptomatic. You’d have to swab their tonsils or their throat, the
08:07 – back of their throat, to find this organism. But they can sure pass it on during oral sex.
08:12 – And so that’s why I think it’s very important to look for these.
08:17 – So those are the mechanisms of how that can happen. Again if there’s an abnormality, if
08:25 – someone has say, for instance, incontinence or they have fecal incontinence or they
08:30 – have an oral infection, you know they have a gum infection, all of that can increase what’s been
08:36 – discovered in the urinary tract as infections. Now let me just say that the organisms that
08:42 – are considered sexually related in my book has advanced markedly since I started doing NGS three years ago.
08:49 – Melissa: Okay. So are there things that someone should look for around this topic if they’re
08:55 – trying to discover whether their partner may be a contributing factor? Should they be trying to
08:59 – monitor their positions? Whether they have oral sex? Whether their symptoms come on a certain
09:04 – amount of time after sex? How would they know that it might be something to do with their partner?
09:10 – Dr. Hlavinka: Absolutely. And that can be something as subtle and immediate as what you’re saying,
09:16 – Melissa, that if they notice burning or irritation afterwards, increase in
09:24 – frequency, odor, change in vaginal discharge, all those things can be subtle signs that there’s been
09:31 – an insult by a microbe. And even more subtle symptoms, like for the man a lot of times the
09:39 – woman will notice, and again again I’m talking about heterosexual, monogamous
09:43 – couples. I can go off on homosexual couples in non-traditional coupling,
09:54 – but it just kind of gets a little bit more in the details so I am going to focus on heterosexual,
10:00 – male-female sexual encounters again, because most of my database is on that to be quite
10:06 – honest. Not that I’m not sensitive to those issues, but the more I learn the more I’ll share.
10:11 – The bottom line is that it can be as subtle as a change in semen color. So if the
10:17 – woman is wiping herself afterwards and she notices that the normal white, pearly semen color in her
10:22 – husband is sort of a dark yellow or something, or a yellow brown, that can be all you need. Or
10:27 – the odor, it’s a different odor, a different taste if its oral sex. Same for him if he is
10:32 – doing oral sex and he notices a different taste or an odor, that can be a subtle sign that
10:37 – there’s been a change in the vaginal microbiome. So everything from something that you see
10:43 – immediately, to something that’s a change in a body chemistry, is something that you can find as
10:49 – as subtle clues that this may be happening.
10:52 – Melissa: Do you have any advice about mentally disassociating UTIs and sex? It’s very difficult to enjoy sex if it’s constantly a trigger for UTI. Or maybe
11:01 – you have advice on how to minimize the chances of it happening, but also on the mental aspect.
11:09 – Dr. Hlavinka: That’s a very good question.
11:12 – So being someone that’s a sexual health provider for both men and women and have been for 20 years,
11:19 – understanding that the negatives of a sexual encounter are so important
11:27 – and they are something that need to be accounted for, and so I believe that
11:35 – is also a place where I can be very much instructive to the partner and be helpful.
11:41 – Because I know for a lot of my patients a sexual encounter is the last thing they
11:45 – want to hear about when they’re getting over an infection. Particularly when it happens every time.
11:50 – And I’ll take a little of an aside here, how I got into this, all right? So I’m early 40s right,
11:58 – smart urologist, I know everything. Yeah right. So a 71 year old lady came to see me. I think I was
12:04 – in my early 40s and she’d been getting recurrent urinary tract infections and she’d been seen by
12:08 – primary care and OBGYN. And of course now you get to go to the urologist and see if the urologist
12:12 – is going to take care of you. We didn’t even know about menopausal related infections and vaginal
12:19 – atrophy and estrogen deficiency. We didn’t know any of that stuff at this time in the late 90s.
12:24 – All we knew was that I had a patient on my hands that I couldn’t help. So
12:31 – I started to walk out saying there’s nothing I can do for you. And she start crying she said doctor
12:35 – you don’t understand. Stop and listen to me. She says I love my husband. I get an infection every
12:40 – time I have sex with him. She says, I want to make love to my husband. You have to help me be able to
12:46 – make love to my husband without getting infection. That’s actually when the lightning bulb went off,
12:50 – Melissa. And that was you know 22 years ago. So then I said I’m going to help you. And then I went
12:57 – back and I did all the research. Of course, then you had to go to the library. You couldn’t Google.
13:01 – So I went to the library, and big books, big books, nothing, you know. There was nothing there.
13:06 – So that’s when I started getting into hormone replacement therapy and women’s sexual health
13:11 – courses and just educating myself on all these. So I believe that there is a way to continue to
13:19 – maintain intimacy. What I don’t want is for couples to lose intimacy while this is happening. So fear
13:27 – should not supplant the capacity to have intimacy. So many times there’s genital sexual touch that
13:34 – you can do. You can do mutual masturbation. You can do clitoral touch for a woman to orgasm,
13:41 – to avoid penetrative sex and still have satisfying sexual encounters. But the main thing to do is to
13:47 – make sure that you’ve done everything you can to treat the infection, eradicate it, find the partner
13:52 – who may be contributing. Now if, let’s just face it, I’m a guy so I can say this: If the guy’s a clod,
13:59 – well then he needs to be educated, all right. And sometimes educating him in the right way,
14:04 – let’s just say, abstinence is always a choice, then that can be something that gets him quite
14:12 – motivated. And again it’s a process of education, recognition that intimacy should not be sacrificed,
14:19 – finding the organism that needs to be treated, and then trying to do my best to let the patients know
14:25 – that there’s an understanding and empathetic provider that’s going to do everything I can
14:31 – to help you get through this.
14:32 – Melissa: With sex being a risk factor we actually received a lot of other questions about specific things that people have
14:38 – associated with onset of their UTIs and I wanted to kind of run down the list and see if you had any thoughts on whether these items are also risk factors.
14:47 – First is swimming – in public pools, in lakes in the ocean?
14:53 – Dr. Hlavinka: So it should be very safe to swim. Public pools typically have high enough levels of chlorination
15:02 – or non-chlorinating bacterial microbe diminishment. Obviously if it’s been not treated properly then
15:10 – that is possible to get E. coli for instance because obviously other things
15:16 – come out too. A properly maintained pool should not do that. And the same thing with
15:23 – a hot tub. Now hot tubs because of the heat, and also I don’t know about having sex in a hot tub.
15:28 – That’s obviously a risk factor because of the heat, the chlorine and everything – I just don’t think it’s
15:33 – a good idea. Have sex on the corner, on the edge of the hot tub how, about that? But the hot
15:39 – tubs are probably more just because of the heat. I think there’s a potential to create, you have to
15:44 – be more careful. But again, a well-maintained hot tub should be okay. So lakes oceans.
15:55 – Theoretically, the vagina is closed and water shouldn’t get in. And water, if it has you know a
16:03 – contaminant, it could theoretically, but most women should not have problems with swimming, the usual,
16:11 – bathing. Now, as part of my career there is a SeaWorld in San Antonio, Texas, where I live. SeaWorld
16:19 – is the park, the nature park that talks about marine life. And so SeaWorld had some
16:27 – fun acts, and one of the fun acts they used to have was a water ski team. And the water ski
16:32 – team was five boys and five girls. Teenagers that were basically in swimsuits eight hours a day
16:39 – for the whole summer. And I used to see so much in those poor people, and they yes, they made me wrong.
16:46 – And they were in so much water for so long I think it altered all their skin, their vaginal
16:52 – environment, their prostate, and everything their bladders, and they got lots of infections. So I
16:57 – would say if you’re like a real swimmer, like if you’re like a triathlon type swimmer, all of that
17:02 – goes out the window. That’s different and you would have to treat according to symptoms.
17:08 – So obesity is another one you have listed here. Obesity is as we found with COVID, a risk factor for many, many
17:15 – things and it’s independent of all other factors. Any other comorbidities. But obesity, because of the
17:21 – potential to have a lowered immune system also, and to increase amounts of different types of flora
17:32 – that live in the skin folds and the perineum, with the chronic wetness and
17:38 – things like that. Yes, I mean I can see that. My patient was obese, the truck driver that had this
17:45 – moisture in his groin because of being a truck driver in Texas. Yes that was a risk
17:51 – factor, an obese man. And losing the weight may not have cured him but it sure set him up for the
17:56 – infection that he ultimately transmitted to his wife. So the digestive disorders or acid reflux.
18:06 – Anything that can alter the normal gut microbiome can predispose to infection. Any alteration in
18:15 – that downstream causes issues with what lives on the bottom, what lives in the
18:21 – vagina, can cause increased risk of infection.
18:24 – Melissa: We had a really specific one: Horseback riding.
18:27 – Dr. Hlavinka: I’m going to say no… Now I think horseback riding does have some risk factors for perineal trauma.
18:38 – I know that men and women can have issues with perineal trauma and the capacity to cause
18:46 – alteration and blood flow with trauma is an alteration in the immune system locally and
18:53 – thus you can change. And also, if it’s hot and you’re riding in pants for a long period of
18:58 – time, same thing. So same thing as with the swimming.
19:01 – Melissa: Okay, right. And urinary or fecal incontinence?
19:05 – Dr. Hlavinka: Fecal incontinence, absolutely, simply because fecal incontinence creates a lot more organisms
19:12 – that live on the perineum. The perineum is a space between the vagina and the anus,
19:17 – and perineal organisms become vaginal organisms by and by depending on their
19:22 – amounts. The bottom line is that fecal incontinence is a real risk factor always. Urinary
19:28 – incontinence, I can’t get my colleagues to recognize that the older ladies that
19:33 – have significant urinary incontinence and are wearing pads that are chronically moist, just a
19:39 – rich breeding ground for bacteria and a setup for infection, and it’s so costly to change these pads.
19:46 – There’s a lot of data and this is another one I don’t want to go off into the weeds on, but there’s
19:50 – a lot of data to show that the complications of urinary incontinence are much more vast
19:57 – than what we recognize. And being such an under-treated condition and predominantly
20:01 – in women, again that’s why it gets ignored. But UTIs being a very significant one of those complicating factors of chronic urinary incontinence.
20:11 – Melissa: Okay, good to know. How about pH of urine?
20:16 – Dr. Hlavinka: So as I said earlier, for those who are listening, the change of one pH point
20:21 – can vastly change the environment of the vagina. The chemical environment, the microbial
20:28 – environment, the way receptors work, for anything that may stick to the vaginal lining layer,
20:34 – read that invade, or cause a chemical reaction, so all of those things can be – for instance the normal
20:44 – premenopausal healthy vagina vaginal pH is very acidic it’s 4.5. So a pH of 6.5
20:51 – is almost pathognomonic, almost diagnostic of the problem of a vaginitis. Now, what it comes from
20:57 – depends on what you find in the vagina. If it’s a yeast well then it’s a yeast infection, or if
21:02 – it’s a bacterium it’s BV. So can you change the pH of the urine independently and change it?
21:11 – Not enough. You typically have to do this as a part of other therapies. So just changing pH by a
21:18 – refresh or replenish or one of those things, or alkaline if it’s acidic or acid
21:25 – type things, acidic washes, no that’s not enough in my opinion.
21:31 – Melissa: Okay, and the next one is pelvic floor dysfunction or pudendal nerve entrapment.
21:37 – Dr. Hlavinka: Another broad spectrum topic. I feel like, let’s say, how many patients got their pelvic floor
21:49 – dysfunction from a urinary tract infection, or chronic UTIs. So the chronic pain and irritation,
21:57 – frequency and urgency of UTIs, if that makes you contract your pelvic floor to avoid incontinence
22:03 – or because of this urgency, well you can get pelvic floor dysfunction. Or you can get it
22:10 – independent of that mechanism. But the bottom line is it can be related in so much is that you have
22:16 – a stasis of blood flow. So stasis means static or stagnant. The pathognomonic in the pathogenesis
22:27 – of pelvic floor dysfunction is chronic muscle tension. So it’s like a Charlie horse in the pelvic
22:33 – floor muscle. What happens when you get a Charlie horse? Well the lactic acid builds up and it hurts
22:38 – and that’s painful. Well how do you respond to pain signals? Well you clamp down. So
22:43 – you get this vicious cycle of pain spasm, lactic acid build up, pain spasm, lactic acid buildup,
22:50 – and you can’t break it. So it does affect the pelvic blood flow in my opinion. I see
22:56 – an increased risk of urinary tract infections in patients with pelvic floor dysfunction.
23:02 – We’re not going to be able to say cause or effect and the problem is the association is very high
23:06 – for that mechanism. And that’s because you’re just impairing pelvic floor blood flow and
23:12 – pelvic blood flow and you have all these terrible reflex mechanisms with pain receptors and what
23:18 – they do to the local immune response and chronic pain. And so the same thing is true to a smaller
23:26 – degree with pudendal nerve entrapment. And pudendal nerve entrapment is something that’s still a bit
23:31 – controversial but I see it in a lot of female runners. And it certainly is something that can be
23:39 – a part of that. Now is that because they have runners bladder
23:42 – and they get pudendal nerve secondarily, I don’t know. I mean
23:46 – the female runners tend to get more UTIs. I think it’s multifactorial. I think it’s dehydration,
23:53 – I think it’s a chronic trauma of the roof of the bladder hitting the floor of the bladder,
23:58 – I think it’s probably more chronic moisture in their underclothing. Multiple factors.
24:04 – Melissa: Right, okay. And one other risk factor, or possibly not: Is it safe to let a UTI
24:12 – go untreated and can it go away on its own?
24:15 – Dr. Hlavinka: So there was a study that showed that you could drink a gallon of water – what is that four liters? Four liters. We’re terrible. Four liters of water
24:25 – 48 hours, per day, and that’s in addition to your other fluids and your
24:34 – coffee and your tea and things like that. For two days, for 48 hours,
24:40 – and that you had just as much eradication capacity as you did for an acute UTI treated
24:47 – with antibiotics. In other words at 72 hours the eradication rates were equal and there’s about 50%
24:52 – of each of them were eradicated. Which is dismal for the antibiotic, but again I think they measured
24:57 – that a little bit too early. So the bottom line is I believe that in young, healthy women who have no
25:03 – risk factors, who have proven that they don’t get complicated UTIs or persistent UTIs, that
25:09 – it’s very safe to use measures to try to get rid of it. Like flushing yourself, apple cider vinegar.
25:15 – I think apple cider vinegar has worked very well in the right patient, I firmly believe
25:20 – in that and I think that patients can prevent it. There are some other naturopathic
25:25 – treatments for prevention and treatment that I’d like to go into it at a later date.