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 – David Kaufman about recurrent and chronic UTI testing methods. If you’re new to our Channel
00:12 – be sure to check out the description below as we linked other resources that you might find helpful.
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00:28 – that we hope these videos provide the insights you need to take the next step on your UTI recovery.
00:40 – Welcome Dr David Kaufman and thank you for taking the time to join this clinician insight
00:52 – series in recurrent UTI. Thank you Molly good morning to you. Good morning, firstly for our
01:01 – listeners would you like to tell us a little bit about yourself perhaps including how you got into
01:06 – the role and where you’re based. Sure so my name is David Kaufman, I’m a urologist in New York City.
01:13 – I trained in urology at Colombia in New York and have really never left New York. I practiced
01:24 – first in one of the big hospital systems here and then went into a private practice, a solo private
01:30 – practice where I practiced Urology for about 25 years and more recently I’ve been involved in
01:37 – a multi specialty group where I am the Chief Urologist. The group is known as Maiden Lane
01:44 – Medical. We have about seven sites in New York City and the immediate environment and you know I
01:53 – big part of my practice is taking care of men and women with urinary tract infections. Great and
02:01 – how long have you been working with recurrent UTI patients? Well it’s a that’s a interesting story
02:09 – I actually first trained in urology and then I fellowshipped in male infertility. So your
02:17 – your listeners and viewers might be wondering how I got involved in this field, well the way
02:23 – it works in the states is when you come on to a new practice, which I did when I finish my
02:30 – residency I worked for a hospital system, you kind of take care of all the patients that nobody else in
02:35 – the in the urology practice was really interested in and I was referred a young woman who
02:44 – had terrible urinary symptoms you know. Her life was in shambles, her
02:53 – boyfriend dumped her, her job fired her and we really didn’t understand what was going on and
02:59 – to make a long story short, I eventually diagnosed her with Interstitial cystitis and
03:07 – I that put me in the world of IC at the very beginning this was 1990 perhaps and
03:16 – we didn’t know a lot about Interstitial Cystitis back then, we know a lot more about it now and we
03:23 – know that there’s a very direct connection between IC and chronic urinary tract infection and just to
03:31 – kind of jump to the chase I think most of us who have been working with IC patients over the past
03:38 – 25 30 years recognize that whereas in the past we thought that those patients were for many years
03:48 – misdiagnosed with chronic urinary tract infections and as a result the the true diagnosis of
03:55 – Interstitial cystitis was missed, in fact we’re now realising that they did have chronic urinary
04:01 – tract infections and many of us believe that it is the chronic urinary tract infection that
04:09 – eventually causes the damage to the lining of the bladder that leads to Interstitial cystitis where
04:16 – the infection is no longer the issue, excuse me, but it’s the deficient bladder lining that
04:25 – causes these very very severe symptoms but you know there’s a very direct correlation between
04:32 – women who are not adequately treated for urinary tract infections and who may eventually develop
04:41 – Interstitial cystitis years later. So that’s how I got into the field of female pelvic pain and
04:52 – that’s how I became very aggressive in treating my chronic UTI patients with antibiotics because I
05:01 – knew that I would be preventing many of them from developing this much more awful condition known
05:09 – as Interstitial cystitis where there really isn’t a easy fix for. Yeah no that’s really interesting.
05:18 – So to help provide our audience with some more details about your practice, what type of testing
05:23 – do you utilize when investigating recurrent UTI and in what situations would you do so?
05:30 – Okay so you know I mean I think that the vast majority of women who come to me are ones who
05:38 – just simply fail first line therapy, they’re treated by their PCP, they’re treated by their
05:44 – gynecologists, they’re sometimes treated in Urgent Care Centers and I don’t know what happens in the
05:50 – UK but typically patients are treated based on symptoms in these scenarios. They are you know
06:01 – they they give a good story for a UTI, they get a dipstick urine analysis at the time if we’re
06:09 – lucky the facility sends their urine out for a urine culture so we get a real true result
06:17 – in a few days but more often than not that doesn’t even happen, they’re treated empirically almost
06:23 – based on a urinary, a urine analysis and symptoms. In this country they’re almost as a knee-jerk response
06:32 – they’re put on Nitrofurantoin, the brand name is Macrobid for five to seven days and
06:42 – admittedly many of them get better and move on but there’s certainly a sizeable minority who
06:48 – don’t respond to Nitrofurantoin and perhaps it’s that’s patient that eventually finds their way to
06:56 – my practice. A few words about Nitrofurantoin, to it’s a lousy antibiotic I mean it’s really it’s
07:03 – not a bactericidal antibiotic, it doesn’t kill bacteria, it’s a bacteria static it kind of wounds
07:09 – it. It’s the antibiotic of choice in these types of facilities because very few people
07:19 – are allergic to it so they don’t have to deal with allergic reactions. Very few bacteria are
07:26 – truly resistant to it so it’s kind of an easy antibiotic to use and again it probably works
07:33 – in a majority of cases, except when it doesn’t so I’ll see those failures in my practice
07:43 – I, if they’re not absolutely miserable I prefer not to treat them with antibiotics until I get
07:50 – the results of a regular culture and sensitivity back. If they’re absolutely miserable I’ll put them
07:57 – on something with the acknowledgement on their part that they might hear from me in three or
08:01 – four days and I might change that antibiotic to something better and again that works out for
08:09 – most patients we get a culture back we confirm that the antibiotic that they’re on was the best
08:16 – antibiotic and they get in touch with me in 7 to 10 days if they’re not feeling better and most of
08:24 – them are feeling better except for those who don’t and then that kind of brings us into the world of
08:32 – what patients don’t really respond to that sort of, you know average term therapy of seven days
08:40 – of a decent and culture specific antibiotic and typically those are patients who fall into
08:48 – the chronic UTI realm where I will ask them, you know, when you have been getting antibiotics in the
08:56 – past at the end of the course of of the antibiotic do you feel 100% back to normal and most of these
09:05 – women say, you know I definitely was feeling better and I didn’t feel like I needed to be treated
09:12 – anymore but I really wasn’t perfect and that’s how this chronic UTI issue begins and once the
09:23 – bacteria kind of take hold to the lining of the bladder and into the mural wall of
09:31 – the bladder it becomes a much difficult a much different animal in terms of treatment. A
09:38 – 5-day course or 7-day course of even the right antibiotic doesn’t necessarily wipe it out because
09:45 – these bacterias are embedded into the wall of the bladder and you know it’s partially the fault of
09:52 – the patient that they really didn’t jump on it and they accepted you know partial treatment and
09:58 – and better but not perfect kinds of symptoms, and it’s partially the fault of the doctor who
10:06 – typically treated them with an antibiotic that wasn’t culture specific they felt better from it
10:12 – but they weren’t really cured of the infection and these symptoms typically stretch for months and
10:20 – months and months by the time I see them and the unfortunate thing is that at that point when we
10:28 – do culturism on them the cultures are typically either negative or low colony count, right less
10:35 – than 10K bacteria. Your viewers aren’t going to like hearing this but I do try to convince
10:43 – the patient to allow me to do a catheterised urine sample, it’s not the most comfortable experience
10:51 – but you know urologists who take care of patients like this, we’re really good at it and we know how
10:56 – to make patients feel as comfortable as possible and the test we’re talking about a catheterisation
11:03 – that takes you know under 30 seconds to do but the advantage of that, it’s a huge advantage, is
11:10 – that we don’t have to worry about bacteria on the labia of the vagina and in the vaginal vault
11:19 – contaminating the urine sample. So that when I get a less than 10K bacteria on a catheterised
11:28 – sample you know we both know, the patient and I both know that this is a real infection that’s
11:33 – in the bladder and probably represents a embedded low grade smoldering urinary tract infection that
11:42 – needs to be treated aggressively and we’ll talk about that later I guess. The problem is that
11:51 – we don’t typically get sensitivities on these low colony count bacterias because you know it
11:57 – just can’t be done practically, there’s not enough bacteria to really tell us which antibiotic works
12:04 – better than another so then we’re kind of winging it a little bit and that’s really how I practiced
12:10 – and treated patients in this situation for the for up until about five years ago and you probably
12:18 – know Molly that there’s been a seismic shift in our testing capability over about the past five
12:26 – years. First it began with DNA PCR work which was a dramatic improvement over cultures because
12:35 – we were able to identify maybe 70% of the DNA of bacteria so we were able to identify the specific
12:45 – bacterias 70 or so percent of the time and again and we were able to find resistance genes
12:54 – in these genomes of the bacteria so we didn’t know which
13:02 – antibiotics worked but we had a historical perspective on that and but we did know which
13:08 – antibiotics we shouldn’t choose to work and then that eventually evolved shortly afterwards with
13:17 – NGS testing, which are you guys familiar with that in the UK? Yeah. So that stands for
13:23 – Next Generation sequencing and that looked at the 16s ribosomal RNA which of the bacteria
13:34 – which we had very good a very good library on identifying the the the RNA of different
13:43 – bacteria on the 16s ribosome so our identification capability improved to about 98.5% and we still
13:55 – had the advantage of having resistance gene. So that’s kind of where I am right now I
14:05 – don’t do this on everybody to make it clear I do this on people who have that history of chronic
14:11 – cystitis who’ve been on short-term antibiotics and who have failed that, who don’t feel completely
14:18 – better and I will tell your viewers that it’s worthless almost worthless to do a an NGS
14:29 – PCR study on a voided sample this it’s going to pick up everything and if it’s a voided sample
14:36 – there is going to be contaminating bacteria that wasn’t even picked up on the regular culture it’s
14:42 – going to be picked up by by the NGS markers so you know I can’t convince everybody to let
14:52 – me catheterise them but it’s almost a waste of their money because most insurance is at least in
14:58 – the in America don’t pay for this, although it’s not terribly expensive and I would
15:06 – I just hate for my patients to waste their money and end up getting like you know eight different
15:11 – bacteria that show off and that just muddy the waters it just confuses the issue so I do
15:17 – try to get convince them to allow me uh to catheterise them so then we do know that every bacteria that’s
15:25 – being identified is coming from bladder urine. I’ll also send you know you only really need to
15:31 – send a small amount of urine to for this PCR NGS testing so the remainder of the catheterised sample
15:39 – I send for regular culture and sensitivity we get those results back in about four or five days
15:46 – usually they’re negative, that’s why we’re doing this other test. We get the PCR tests back in
15:52 – about five days and we get the NGS test back in about 10 days so you know these are patients who
16:00 – typically aren’t miserable they’re just you know uncomfortable and we’re usually able to just wait
16:07 – until we get all that data in and then we can make a really good educated choice on what antibiotic to
16:15 – put them on. But there’s one more facet to this treatment regimen that’s really really important.
16:22 – At this point and I’m sure most of your viewers recognise this at this point, you know 5 days of
16:29 – antibiotics 7 days of antibiotics 10 days of antibiotics just ain’t going to cut it, patients
16:34 – don’t get better from that and so you know at a minimum I’ll treat for three weeks, see them
16:42 – again in three weeks and if they’re not perfect and there’s one other thing I want to go back to
16:48 – if they’re not perfect treat them for another three weeks so what I said in the past
16:54 – on this on this broadcast that I was aggressive with antibiotics, that’s what I mean by being
16:58 – aggressive you know, if they don’t feel a big difference in 3 weeks you know a lot of doctors
17:06 – might just quit and go on to something else or maybe maybe treat them for Interstitial cystitis
17:12 – which is going totally down the wrong path. You need to kind of hang in there as a physician and
17:19 – just keep on going because invariably the majority of patients by the time you’re on the second round
17:27 – of antibiotics do start feeling better and can be made 100% better. The one thing I wanted
17:37 – to go back to and I’m sure that you have questions for me that would that would have asked me these
17:43 – questions but since I’m on a roll right now let me just address that. Physical examination really
17:51 – important, I will not treat a woman with a chronic UTI without examining them first
18:00 – and really what my goal is in the exam is to make sure that nothing else is going on that
18:07 – could be causing similar and overlapping symptoms so the exam takes all of you know three minutes
18:17 – it’s not a big deal I don’t use a speculum in the exam. What I start with is what
18:26 – is known as the Q-tip test, I don’t know if that’s something that you’re familiar with but the Q-tip
18:31 – test just takes a long applicator stick with a little cotton ball at the end of it and I
18:38 – gently stroke the inner labia of the vagina and what I’m looking for is severe sensitivity that
18:48 – we associate with the condition known as vulvodynia and vulvodynia is not a urinary
18:57 – tract infection and patients with vulvodynia have present with urethral burning they think
19:04 – it’s urethral burning that they’re experiencing but it’s not it’s the tissue around the urethra and it’s the tissue
19:11 – along the inner labia that’s exquisitely sensitised for a whole lot of reasons that we don’t have to get into right now
19:21 – but to treat these patients with antibiotics is just
19:24 – an exercise and futility you need to do the exam you need to find out if they have vulvodynia and you
19:31 – need to treat that with its own course of therapy which we don’t have to go into right now because
19:35 – this is a UTI talk but that’s very important but we don’t put the Q-tip down yet. Then we find
19:43 – where the urethra is and on either side of the urethra are two glands which are known by many
19:48 – names one of them is the vestibular glands and what I do is I gently push into those glands on
19:56 – either side and if the patient reacts to that and they say oh yeah that’s where my pain
20:03 – is again, presenting with urethral burning not, they have vulvar vestibulitis, again a condition
20:13 – that’s not going to get better with antibiotics and they’ll tell me that I’ve never felt better
20:17 – from antibiotics I still have urethal burning what’s going on so you know the buck kind of
20:23 – stops in my office that I’m the one, I’m often the first one that’s ever even recognise that this is
20:29 – a possible diagnosis for these patients and again it’s treated totally differently, which
20:37 – is another talk. So we’re not finished with the exam, the next part of the exam is I put the Q-tip
20:46 – down and I put my glove finger my lubricated glove finger into the vagina and I gently can you see my
20:53 – fingers in this picture there you go so I gently lift up there we go I lift up on the floor of the
21:01 – bladder and if you know patients with chronic cystitis will go oh yeah doctor that’s really
21:08 – uncomfortable that’s what I feel and that kind of reinforces the diagnosis that’s made based
21:17 – on just history that’s almost always present, if that sensitivity ain’t there they don’t
21:23 – have chronic cystitis and there’s something go else going on, of course if they react to
21:29 – that finger lift by screaming and jumping off the table that’s not chronic cystitis either, that’s
21:36 – most likely Interstitial cystitis, it’s a it’s a logarithmically greater sensitivity than
21:44 – what we see with embedded urinary tract infections, all right but our fingers are still on the vagina
21:51 – we’re still not finished in there next thing we do and this is probably the most important thing
21:56 – is we swing our fingers laterally and we feel up against we push up against the levator Ani
22:02 – muscles and the pubococcygeus muscles on either side because sometimes it’s only on one side or
22:08 – the other side, most of the time it’s on both sides and of course if they have real tightness of those
22:13 – muscles and it’s uncomfortable when I do that you know they definitely have pelvic
22:23 – floor dysfunction right or pelvic floor hypertonic spasticity right. That’s not going to go away unless
22:31 – it’s addressed specifically with pelvic floor physical therapy, is that something that’s
22:37 – happening in the UK these days? Yeah yeah. Okay crucially important what were you gonna say Molly
22:44 – I was going to say it’s just so interesting how the conditions can overlap like the
22:50 – conditions you’re talking about the symptoms how they overlap between each other and making sure
22:54 – that you do receive the right diagnosis to treat the specific condition. Otherwise you’re spinning
22:59 – your wheels for months. Yeah. Right spinning your wheels for months. So here’s the the kicker though
23:06 – is that you can have not only are they overlapping conditions but they’re also potentially concurrent
23:14 – conditions where you can have vulvodynia and vulvar vestibulitis you almost always have pelvic
23:20 – floor dysfunction and let me make this important point, pelvic floor dysfunction pelvic floor muscle
23:26 – spasticity causes urinary symptoms, it causes urgency, it causes a frequent need to void, it
23:36 – causes what patients interpret as bladder spasms but they’re not bladder spasms they’re pelvic
23:43 – floor muscle spasms so that’s why it’s perfectly common for a woman to present to me with symptoms
23:51 – that sound like chronic cystitis or even a urinary tract infection where they don’t have it they
24:00 – don’t have bacteria even with NGS testing or PCR testing and what they have is urethal burning from
24:09 – the vulvar vestibulitis and the vulvodynia and urinary urgency and frequency from the
24:14 – pelvic floor spasticity so antibiotics are not the approach here we have to address those two
24:21 – conditions individually. What makes matters even more complicated is somebody could have chronic
24:30 – cystitis with pelvic muscle spasticity because it’s all about the up-regulation of the nerves that
24:38 – go to the bladder and the vagina and when those nerves are irritated for a long time as they are
24:45 – with chronic cystitis and as they are with vulvodynia and vulvar vestibulitis it will cause this windup
24:52 – phenomena of these peripheral nerves that feed back to the nerve roots at the S3 and S4 spinal
25:01 – area of the spinal cord, which also share nerves that go to the pelvic floor muscles, so that wind
25:08 – up phenomena is transferred over to the nerves that go to the pelvic floor and cause the pelvic
25:14 – floor to go into spasm. So if patients have either of these primary conditions of chronic cystitis or
25:23 – vulvar vestibulitis or vulvodynia, they will often develop over time after a few months this pelvic
25:33 – floor muscle spasticity so even with treating with antibiotics properly of chronic cystitis patients
25:43 – still might not feel better because the pelvic floor hasn’t been addressed, so it’s complicated.
25:49 – You need to take your time with these patients, you need to do a physical exam every time they
25:55 – come in because, often at the 3 week mark, when you do that bladder they’ll still have similar
26:04 – symptoms but when you do that bladder lift exam it’ll be remarkably improved over it was when you
26:11 – they first came in but if you haven’t addressed or recognised the pelvic floor dysfunction that’s
26:17 – still there and giving these patients the same symptoms, so as I said before it’s complicated
26:26 – and it’s not as easy is taking out your prescription pad and writing out a prescription
26:31 – for antibiotics for these patients, all right I’ll let you ask another question Molly.
26:37 – One I was going to ask is we often have patients experiencing negative UTI test results, so what
26:43 – advice would you give to someone who suspects that they have a UTI but are testing negative
26:48 – using standard testing methods? Yeah so I think we’ve really covered that but it’s it’s important
26:53 – enough to talk about it again, they need to be examined properly to make sure that even though
27:00 – they have urinary tract symptoms that it is not something else that we just spoke about
27:07 – and then of course you know what I’m going to say, I think they need to be catheterised and
27:11 – have a sample sent for you know a catheterised culture and sensitivity but also if they’re up for
27:19 – it and they’re willing to pay out of pocket for the NGS and the PCR testing and that’s the right
27:25 – move. Yeah no thought a really good summary. So how can recurrent and chronic UTI patients reach
27:32 – out to your practice? Well I have a website you know Maiden Lane Medical, they can just Google
27:42 – Maiden Lane Medical and find me as one of the practitioners there and make an appointment
27:48 – just online, it’s really very easy to just fill out a form and make an appointment online
27:55 – and one of our receptionists will get in touch with you. If you’re in the states our phone
28:02 – number in New York, our trunk line number is area code 6462909560 but online is really
28:11 – easy we’ve got a great staff of receptionists who will get back to them and it really
28:20 – doesn’t take that long to get to see me I see a lot of patients every day and so they should
28:25 – really be able to get in in a week or two weeks probably. Okay amazing, well thank you for providing
28:31 – insights into the testing and treatment methods for use of chronic and recurrent UTIs. We will link
28:37 – down your practice below in the description if anyone is interested but thank you very much for
28:42 – joining this talk. You bet Molly thank you. Thank you.
28:46 – Thanks so much for watching I hope you found
28:49 – this video helpful. You’re always welcome to reach out to us for more information about clinicians
28:54 – who specialise in recurrent and chronic UTI. Our contact is in the description below. If you’d like
29:00 – to learn more about this or related topics be sure to check out our other videos or head over to Live
29:07 – UTI Free.com for other articles on recurrent UTI treatment options. Of course if you like
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