Episode 12: The Return of the UTI-Linda's Revenge

In this episode, Linda V returns...and so do her urinary tract infections...again and again. We'll explore Recurrent UTIs and what we can do to prevent them.

Transcript

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This podcast is not intended to be a substitute for professional medical advice, diagnosis, or treatment. It is for informational purposes only. Always consult with a qualified healthcare professional for any health concerns or before making any decisions related to your health. Thank you.

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Hello there, and welcome back to You're in Luck Now Streaming, the podcast where we talk about all things people whisper about in doctors' offices but loudly complain about at family dinners. I'm your host, David Miller, physician assistant, and today we're bringing back one of our most popular guests, Linda V from New Jersey. Thank you, um, Mr. Miller. Although I gotta tell you, if I keep coming back here this often, I'm gonna start asking for employee benefits. All right, we'll get you a parking spot first. Good, because the last time I came here, I parked so far away, I almost got another urinary tract infection, just trying to find the office. So Linda, what's been happening since our last visit? Mr. Miller, it's been a disaster. Three urinary tract infections in nine months. Three at this point, I know the pharmacist better than I know my grandchildren. Three infections in nine months? That definitely gets our intention. Every time I start feeling normal, boom. Burning, urinary urgency, running to the bathroom every ten minutes. I I haven't run this much since the Bruce Springsteen concert in 1984. And you know, Linda, that is very important because according to the American Urological Association, recurrent urinary tract infections are generally defined as either two culture-proven infections within six months or three within one year. So you qualify. Wonderful! I finally qualify for something. You know, many people think that recurrent urinary tract infection means something terrible is happening. Most of the time it's not the case. A UTI happens when bacteria gets into the bladder and multiplies. A recurrent urinary tract infection simply means that it keeps happening over time. Like my cousin Sal showing up at Thanksgiving. Nobody invited him, nobody knows how he got there, but every year he's back. Exactly. Except bacteria don't bring potato salad. Uh listen, one thing I want to point out is that you have never had euroscepsis. That's the thing where the infection gets into the bloodstream. Correct. You've had uncomfortable infections, but you've never become seriously ill from them. That's reassuring. Good. Because every time I Google something, I end up planning my own funeral. And that's why doctors keep telling people not to use Dr. Google as their primary physician. Google always thinks you're dying. Linda, how old are you now? 68. Although, if anybody asks, 53 with excellent lighting. Fair enough. One of the big risk factors for recurrent UTIs in women after menopause is the loss of estrogen. Wait a minute. You are telling me menopause is still finding ways to annoy me 20 years later? Unfortunately, yes. Estrogen helps keep the tissues around the vagina and the urethra healthy. It also helps maintain the normal protective bacteria that live there. So when estrogen levels decline, harmful bacteria can gain an advantage. The tissue becomes thinner and more vulnerable. So the neighborhood security system got laid off. That's exactly a pretty good way to think about it. One of the strongest recommendations from the American Urological Association guidelines is vaginal estrogen therapy for postmenopausal women who have recurrent urinary tract infections, assuming there isn't a reason that they can't use it. You mean I'm not taking estrogen now, and I probably should be? Um, it's definitely something we should discuss. We're talking about low-dose vaginal estrogen and not just vaginal estrogen. I always recommend that my patients put the estrogen around the urethra as well as in the vagina. It's not the same thing as taking systemic hormone replacement pills. This treatment helps restore the health of the tissues around the vagina and the urethra, and it really can significantly reduce the risk of future infections. So you are telling me that there might be a treatment that doesn't involve swallowing antibiotics every few months? Exactly. And that's one reason the guidelines support it. I like this plan already. Mr. Miller, every friend I have has an opinion. One says I need a CT scan, one says I need a camera in my bladder, one says I need crystals from Sedona. Who should I listen to? Well, generally speaking, probably not the crystals, though Sedona is a beautiful place to visit. Um, the AUA guidelines tell us that women with uncomplicated recurrent urinary tract infections usually do not need extensive imaging or cystoscopy. So we reserve those tests for specific situations. Thank God, because if you're putting a camera in my bladder, I want popcorn and a narrator. All right, let's talk prevention. People often hear all kinds of advice, some good, some questionable. Here are a few reasonable strategies. First, you have to stay hydrated. Don't hold urine for long periods of time if you can avoid it. And next, you really have to treat constipation if you have it. You have to maintain good hygiene habits. That means wiping front to back, making sure that you pee after you have sex. You need to use the vaginal estrogen when it's appropriate, and you have to make sure that infections are actually confirmed with urine testing. You mean not every weird sensation means I need antibiotics? Exactly. Burning in urgency can have other causes. We want to confirm infections whenever possible. So, Mr. Miller, here's my real problem. Vinny and I booked a cruise to the Bahamas, and now I'm terrified I'm going to get a UTI in the middle of the ocean. This may be the first time in history that somebody was worried about a UTI ruining a cruise more than the buffet. Have you seen those buffets? Nothing ruins unlimited shrimp. Nothing. All right, here's what I'm going to tell you. Three infections in nine months doesn't mean that you're destined to get another one during your trip, but we really need to make a prevention plan. First, you need to stay hydrated. You have to avoid getting dehydrated in the sun. Next, you really should consider starting vaginal estrogen before the trip. And we should discuss whether or not carrying an antibiotic for self-start treatment makes sense for your specific situation. So I don't need to spend the whole cruise hunting for bathrooms and panic buying cranberry juice. No. You should spend the cruise enjoying yourself. Okay, so we got the estrogen thing. What else can I do besides carrying hand sanitizer and saying prayers to St. Anthony? Well, fortunately we have several options. I like to think of recurrent UTI prevention as a menu. We don't necessarily need every item, but we choose the ones that make sense for each patient. Good, because if this was an Italian restaurant, I'd already be ordering appetizers. Alright. Let's start with cranberry. Contrary to popular belief, cranberry doesn't sterilize the bladder. There goes my mother's entire medical education. Well, what cranberry appears to do is make it harder for certain bacteria, especially E. coli, to stick to the bladder wall. Think of bacteria as unwanted party guests. The cranberry makes the floor slippery so they can't get a good grip. So instead of moving into the neighborhood, they slide right out. Exactly. The American Urological Association says cranberry products may be offered to help reduce recurrent UTIs. My neighbor Nancy, she keeps talking about D-manos. She sounds like she's in a commercial. What is it? Well, D-manos is a naturally occurring sugar. It works somewhat similarly to cranberry. Many bacteria have tiny structures that act like velcro. And D-manose can attach to those structures and prevent the bacteria from attaching to the bladder lining. The bacteria essentially grab onto the D manos instead of your bladder. Then they get flushed out when you urinate. So it's basically a decoy. Exactly. It's like giving the bacteria a fake phone number. I wish I had that option in high school. Um What about something that isn't an antibiotic? I feel like I've taken enough antibiotics to qualify as a pharmacist. Ah. So that's where methanamine hippurate can be helpful for some patients. It's not an antibiotic. When it gets into acidic urine, it breaks down into compounds that create an environment that bacteria don't particularly enjoy. Think of it as making the bladder a less welcoming hotel. So we're not killing the bacteria with a flamethrower, we're just making them leave a bad online review. That's surprisingly accurate. For some patients, methanamine can reduce infections while avoiding long-term antibiotic exposure. You keep saying some patients. What about women who, you know, get infections after sex? Excellent question. For women whose UTIs consistently occur after intercourse, a single low-dose antibiotic taken after sexual activity can be very effective. We call that postcoital prophylaxis. I don't think that's my problem. Can we talk about my husband? Because uh Vinny's gonna be mad if I don't mention him. Absolutely. How's he doing? Well, he's got erectile dysfunction, but he's too embarrassed to see a urologist. Every time I bring it up, he changes the subject faster than a politician. Well, he's certainly not alone. Erectile dysfunction is extremely common and it's one of the most treatable conditions we see. Tell him that. He acts like going to a urologist means admitting defeat. Actually, it means asking for help, which is what adults are supposed to do. Can you say that loud as though he hears it from the waiting room? Vinny, if you're listening, make an appointment. We're nice. Thank you. Vinny's erectile dysfunction has turned our romantic schedule into a leap year event. Fair enough, but it's important for you to know that it's an option. All right. What if nothing else works? Well, for patients who continue having frequent infections despite other preventative measures, we sometimes consider a low-dose antibiotic taken for several months. It can be very effective. However, we try to use it thoughtfully because long-term antibiotic use can increase bacterial resistance and may cause side effects. So that's not usually the first thing we reach for. Correct. We often consider vaginal estrogen, adequate hydration, cranberry products, D-manose, proper hygiene, like wiping yourself from front to back, making sure that you pee before and after sex, possibly a post-coital antibiotic, among other strategies. She got a urine test. The doctor told her that she had bacteria in her urine, but she felt completely normal. So then they didn't give her any antibiotics, and then she thought they forgot. Actually, they probably did exactly the right thing. This is something called asymptomatic bacteria. It means bacteria are present in the urine, but the patient has no symptoms. No burning, no urgency, no bladder pain, no infection symptoms. Wait. You can have bacteria in your urine and not need treatment? Absolutely. In most patients, especially in older women, treating asymptomatic bacteria doesn't help and can actually create problems by increasing antibiotic resistance and causing unnecessary side effects. The general rule is simple. If there are no symptoms, we usually don't treat. So just because a urine culture grows bacteria doesn't mean everyone needs antibiotics. Exactly. We treat patients, not laboratory reports. Can you put that on a t-shirt? Because I know at least six people who need to hear it. All right, Linda. Let's summarize your plan. You've had recurrent urinary tract infections. We're going to discuss starting vaginal estrogen therapy. We'll continue obtaining urine cultures when infections occur, and we'll focus on prevention strategies, and we're going to help you enjoy that cruise instead of worrying about every bathroom trip. And maybe get Vinny to a urologist. Alright. One miracle at a time, Linda. You know, I feel better already. That's what we like to hear. And if I make it through the cruise without a UTI, I'm bringing you a souvenir. Please, don't bring me anything collected in a urine specimen cup. No promises. Thanks for listening to Urine Luck. Remember, recurrent urinary tract infections are common, especially after menopause, but there are effective ways to reduce your risk. Make sure that you talk to your healthcare provider about whether vaginal estrogen prevention strategies or other treatments might be right for you. And until next time, stay healthy, stay hydrated, and may your cultures always be negative. Be sure to tell your friends, follow and subscribe. And remember, if you're in trouble and you need help, go to your in luck. Thanks for listening.

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