Urologist gives you the best advice for preventing and managing urinary tract infections
Much of my adolescence has been characterised by recurring urinary tract infections. In the 90s, I had more infections than I can count, and I took more antibiotics than I really dare to think about. For years, I took many different tests, but I never got a proper explanation. Eventually, I learnt what the risks were and how to prevent them. I quickly learnt that not peeing after intercourse was a 100% guarantee of getting a UTI. It's been almost three decades since I had recurrent UTIs, but peeing after intercourse is still a rule without exception - because who dares to take the risk? Today, we know a little more about the causes of UTIs than we did when I was in my 20s, and with hindsight and more knowledge, I can see several potential reasons why I suffered from these infections for so many years. That's why it's great to be able to present this interview with Tareq Alsaody, Chief Physician and Specialist in Urology, with whom I had a long conversation about just that - UTIs!
Question: What are the main reasons why some women experience persistent urinary tract infections?
Tareq: The main reason why women are more prone to urinary tract infections has to do with anatomy. Women have a shorter urethra, which is close to the rectum and vagina, making it easier for bacteria from the gut to migrate to the urethra. The majority of UTIs are caused by bacteria from the faeces. Urine tests show that the most common bacteria in UTIs are gram-negative bacilli, which are part of the intestinal flora. This means that the bacteria usually come from the gut.
While urine was previously thought to be a sterile environment, there is now evidence that bacteria are normally present in urine and that there is a bacterial flora in the bladder and lower urinary tract that lives in harmony with the body. This is called the microbiome. I think more evidence is needed, but it is logical that there can be bacteria with which we live in symbiosis and harmony. When this harmony is disturbed, especially in the lower urinary tract, for example by bowel dysfunction, sexual intercourse, from the vagina for some reason, or when the immune system is weakened, both locally and in general, these bacteria can cause infections. It's much like the microbial balance in the vagina. A simple UTI may only need to be treated with a course of antibiotics, but if it becomes a more complicated story, it's never a bad idea to see a GP or an intestinal specialist, as several different diagnoses can affect the immune system in the urinary tract.
Question: What is the difference between urinary tract infection, urethritis and chronic urinary tract infection?
Tareq: A urinary tract infection means that there is an infection in a part of the urinary tract. It can be in the upper urinary tract, such as the kidneys and renal pelvis, or in the bladder itself. The word inflammation is different from infection. Inflammation is the body's reaction to an irritation or an irritant. If this inflammation, or tissue reaction, is focussed and concentrated in the urethra, it is called urethritis. Often, however, urethritis is part of an inflammation of the bladder, urethra or even both vagina and urethra.
Purely urethral inflammation is rare and there are not many statistics on it. It can be part of an inflammation that has subsided in the bladder but is still present in part of the urethra. In the urethra, there are small glands where bacteria can sometimes develop, form colonies and cause a reaction. In many cases of what is known as urethritis, no bacteria can be found, which may mean that there has been previous inflammation that has left a hypersensitive tissue.
Question: So, is it a hypersensitive tissue that can be the cause of several urinary tract infections in a row?
Tareq: Perhaps, if you never find bacteria. However, if you do find bacteria and they turn out to be different types of bacteria in different cultures, it means that each infection is a new infection. This could mean that the problem is a lowered local defence in the person's urinary tract, making it easier for the bacteria to gain a foothold and cause an infection. It is still common to have multiple cultures, ultrasound or CT scans of the bladder and even cystoscopy (examination of the bladder under local anaesthetic) without finding anything visibly abnormal. It is likely that there are one or more factors that we have not yet identified. The concept of a microbiome and a bacteria-rich environment living in harmony may be one explanation.
Question: What is considered a chronic urinary tract infection?
Tareq: There are mixed opinions on this, but they say that if you get three or more UTIs within six months, it counts as a recurrent UTI. I think the choice of words is also important. If you get several UTIs, but with the same bacteria, would you call them recurrent UTIs or new ones? When you say chronic, it sounds like it will never go away, that you think you're sick forever. Are the same bacteria showing up in each sample, or are they different bacteria? If it's different bacteria, you need to look at the bigger picture and perhaps consult other specialities and take a closer look at the woman's immune system, general condition, other medications, previous operations, trauma, lifestyle, eating and drinking habits, sexual habits and toilet habits. A chronic infection sounds like you're sick forever, and that's not the case with a urinary tract infection.
Question: Is there a genetic cause for recurrent urinary tract infections?
Tareq: It can't be ruled out. Research has been conducted on genetic markers, and there appears to be a basis for a genetic tendency to urinary tract infection, where some individuals have reduced local immunity. However, a distinction must be made between anatomical and genetic factors. If an individual has an abnormal development that affects the urinary tract, there is often an increased risk. When it comes to non-visible genetic factors, the immune system can play a crucial role.
Even if you are genetically predisposed, it is not a fateful situation. Approximately 20-30% of the risk can be linked to genetic factors, while 70-80% can potentially be influenced by changes in lifestyle. It is common to ask about urinary tract infections in the family, and it can sometimes turn out that other factors such as bowel dysfunction or habits such as infrequent visits to the toilet can increase the risk through stagnation in the urine and thus bacterial growth.
Sometimes hygiene measures can also play a role; excessive use of sanitary products in the genital area can cause chemical irritation that affects the immune system or disrupts the intestinal flora, which can increase the risk of UTI. Investigating recurrent UTIs in women often requires more time and attention.
Question: What is the role of diet and lifestyle in the prevention and treatment of chronic urinary tract infections?
Tareq: When it comes to diet, strong spices can sometimes be excreted in the urine and have an irritating effect on the mucous membrane of the bladder, which can disrupt the bacterial flora and the immune system. It's important to be aware of this, especially if you experience symptoms similar to a urinary tract infection despite a negative urine test. The diet also includes other factors such as nicotine and alcohol, which can negatively affect health, including the urinary tract. Avoiding these substances as much as possible can be beneficial for maintaining good overall health and minimising the risk of UTI.
Question: Is there anything else you can tell us about the study on a vaccine to prevent urinary tract infections?
Tareq: The vaccine is called MV140 and is intended for the prevention of recurrent urinary tract infections
The aim of the study was to evaluate whether a sublingual vaccine, MV140, can reduce recurrent urinary tract infections (rUTIs) in women treated for three or six months. The study enrolled 240 women in the UK and Spain, aged 18-75 years, who were required to have had at least five uncomplicated cystitis (urinary tract infections). The study was a randomised, double-blind, placebo-controlled, multi-centre trial in which participants were randomly divided into three groups that received the vaccine for 3 months, 6 months and a placebo group. The evaluation measured the number of urinary tract infections (UTIs) and the proportion of patients who were free of UTIs within nine months. It also assessed perceived quality of life and safety. The results showed the following:
🌸 Urinary tract infections: The median number of urinary tract infections was 3.0 (placebo) compared to 0.0 (MV140 groups).
🌸 Patients without urinary tract infection: 25% for placebo, 56% for 3-month MV140 and 58% for 6-month MV140.
🌸 Side effects: A total of 205 adverse events were reported: 81 (placebo), 76 (3-month MV140) and 48 (6-month MV140).
The conclusion is that MV140 reduces the number of urinary tract infections and increases the proportion of patients who become free of urinary tract infections, but it is still only available as a licensed medicine. Treatment with MV140 has also been shown to be safe for women with recurrent urinary tract infections, but long-term studies are needed to determine whether the effect remains in the body.
Reference: Lorenzo-Gomez, MF., Foley, S., Nickel, C. et al. 2022 Sublingual MV140 for Prevention of Recurrent Urinary Tract Infections. NEJM Evidence 1, 1 (2022). Digital journal, available for subscribers.
Question: How do hormonal changes, such as the menopause, affect the risk of developing a urinary tract infection?
Tareq: Hormones definitely play a crucial role in the environment that can predispose to urinary tract infections. Estrogen has been shown to have a preventive effect against infections, which is known for the vagina and probably also for the urinary tract. Therefore, localised oestrogen therapy is a treatment method often considered for women who experience recurrent UTIs and are no longer menstruating, with presumed good effect.
Question: What other causes can lie behind urinary tract infections?
Tareq: In the case of young girls who have not yet reached puberty and suffer from urinary tract infections, it is unlikely to be due to hormonal factors. However, it may be related to the fact that the bladder is not completely emptied when urinating, limited knowledge of intimate hygiene, improper use of toilet paper, and in some cases constipation. The impact of the bowel on bladder behaviour is also crucial. Just as vaginal health affects the urinary tract, the condition of the skin is important. People with poor skin health, such as untreated diabetes, for example, are at increased risk of urinary tract infections. Sugar in the urine can both irritate the bladder mucosa and act as a nutrient for microorganisms, which can contribute to infections. It is therefore important to take these factors into account when assessing and treating urinary tract infections.
Question: Can the use of contraceptives affect the risk of developing urinary tract infections?
Tareq: A disturbance of hormone balance can affect the urinary tract - this includes the use of contraceptives such as birth control pills. Hormones play an important role in the body as a whole.
Question: A young woman on the contraceptive pill with recurring urinary tract infections - is it acceptable to recommend another form of contraception?
Tareq: When dealing with a young woman with recurrent UTIs and the use of oral contraceptives, it's important to look at the whole picture to address any contributing factors:
- How is her urination, specifically how empty is her bladder? Are there obstacles at work that prevent her from going to the toilet?
- Access to the toilet - is it clean and does she feel comfortable there?
- Bowel function - is it regular?
- Food and drink - is there anything that can affect the immune system and thus urinary health?
- Sexual activities - have the problems started after she got a new partner? What was it like before? It may be relevant to discuss local contraceptives, such as spermicides.
Question: Does sexual intercourse increase the risk of urinary tract infection in women?
Tareq: It is likely that sexual intercourse can increase the risk of UTIs in women who are more prone to UTIs. If the bladder is not emptied properly after intercourse, bacteria that have entered the urethra during intercourse can remain and cause infection. That's why it's especially important to urinate after intercourse to flush out any bacteria that may have moved closer to the urinary tract during intercourse. In fact, it's also good to urinate before intercourse. If the bladder is full, it can be uncomfortable and painful to hold it.
Question: Are there any new or ongoing studies that provide insight into the treatment or prevention of chronic urinary tract infections?
Tareq: Absolutely! There are always new studies and systematic reviews that provide valuable insights. It's always exciting to keep up with the research, as new ideas and treatment methods may emerge that can lead to a better understanding and treatment of chronic urinary tract infections.
Question: How effective are natural remedies such as D-mannose and cranberries, as well as home treatments, compared to traditional medical treatment of UTIs?
Tareq: All remedies that alkalise the urine are to be considered. Once the bacteria reach the bladder, they begin to colonise, leading to the formation of a biofilm on the mucous membranes. Biofilms can also form on catheters and are a common cause of recurrent urinary tract infections in catheter users. Natural remedies that are believed to be effective are those that prevent the formation of this biofilm. To do this, you need to change the chemical behaviour of the urine from acidic to alkaline, which D-mannose and cranberries, for example, can help with. There is also a perception that vitamin C can be effective, but there is also concern that high doses can contribute to the formation of urinary stones, which requires caution. Solving one problem while risking creating another is a constant balancing act.
Question: We have many customers who tell us that they no longer get urinary tract infections after they started using VagiVital AktivGel. We don't have our own studies on this, but what do you think about it?
Tareq: This is probably due to the fact that the mucous membranes are moistened and the bacteria no longer have the same opportunity to penetrate. In addition, the gel can almost act as a protective film. There are several speculative explanations. Perhaps the gel protects the mucous membranes. It could also be that it reduces the risk of trauma when wiping with toilet paper or during intercourse, because the mucous membrane is less affected. It is also possible that the gel has a stabilising effect on the bacterial flora. This is an interesting question that needs to be investigated further.
Read more reviews about VagiVital AktivGel here!
Question: What impact does psychological stress have on the frequency or severity of chronic urinary tract infections?
Tareq: Stress definitely has an impact. If we're talking about infections due to bacterial growth, stress is in a way a form of inflammation in the body, a challenge. Especially if the stress is prolonged and negative, it can lower the immune system. It's a fact that the body is a unit. If you study anatomy, tissue science and physiology, you'll see great similarities between different systems, even if they are located in different parts of the body.
Question: What are your recommendations for women with suspected recurrent urinary tract infections?
Tareq: If a woman has a UTI for the third time in six months, it may be time to seek further help, and calling 111 is always a good place to start. Digital health services are also becoming more and more common, allowing you to get a consultation with a healthcare professional wherever you are and start the assessment process. If antibiotic treatment is warranted after a thorough investigation, courses of antibiotics are perfectly acceptable. There is a category of UTIs that respond well to prophylactic antibiotic doses, which is a small dose.
This usually starts with a urine culture to find out which antibiotics are effective against the bacteria, and then selects one of these that the patient can tolerate for treatment for 5-7, sometimes 10 days at full dose. Then 25-30% of the dose can be used over the next 3-6 months to see how it progresses. One drug that is relatively underestimated is Hiprex, which is a urinary tract antiseptic with a bactericidal effect. It is used as an antiseptic in the bladder to hopefully prevent infections. But so far, there is no medicine that I know of that provides 100 per cent efficacy for users.
Question: What are your top three tips for women with recurrent UTIs?
Tareq:
- When faced with recurrent urinary tract infections, it's important first and foremost to reflect on your daily life and lifestyle. This involves identifying patterns, such as when the infection usually occurs and under what circumstances.
- It is crucial to take a urine culture to identify which bacteria are involved. A urine dipstick can give a preliminary indication by showing the presence of red blood cells, glucose, nitrite (a by-product of bacteria), white blood cells and more. If the test is positive for nitrite, it indicates that the bacteria are growing in the urine in significant quantities, making a culture even more valuable to accurately determine the nature of the bacteria.
- After a course of antibiotics has ended, it's also always wise to wait a few days and then take a follow-up culture. If the bacteria continue to grow despite treatment, it may indicate that there are factors that favour recurrent infections and require further investigation.
FINAL WORDS
In my experience, recurrent urinary tract infections can be both complicated and frustrating to deal with, but with the right knowledge and prevention, they can be reduced in frequency and severity. New research is constantly being conducted in this area and there is hope. Urologist Tareq Alsaody also emphasises the importance of understanding the underlying causes, taking thorough urine cultures and reflecting on lifestyle factors. By following this advice, women can hopefully better prevent and manage urinary tract infections, which in turn contributes to a better quality of life ❤️
Take care of yourself & Stay Pussytive ❤️
/Fanny Falkman Grinndal
Business Manager Nordics
Peptonic Medical AB
fanny.falkman-grinndal@peptonicmedical.se