“What About Cranberry Juice?” UTI Treatment & Prevention

[Dr. Anne Cameron]
AUA-SUFU says that for uncomplicated urinary tract infections, and I'll explain what that is, that is a female patient who has an uncomplicated bladder, who is not feverish, and is not having flank pain or signs of pyelonephritis. This is a woman who has a typical UTI with typical symptoms and she's otherwise pretty healthy. She doesn't catheterize. She's not immune-suppressed. For that woman, it's appropriate to give her empiric antibiotics without a culture because common things, being common, this is a UTI. She didn't have those symptoms last week and she has them now. It's acute onset and it's very different for her.

In those women, it's perfectly appropriate to give them three days of a narrow-spectrum antibiotic that covers urinary tract infections. One of my first choices is trimethoprim/sulfamethoxazole double strength twice a day for three days. Many people have sulfur allergies. Nitrofurantoin 100 milligrams twice a day for five days is also a great antibiotic and neither of these is very likely to give her a yeast infection. Neither is likely to give her diarrhea because these are not broad-spectrum antibiotics.

[Dr. Suzette Sutherland]
There's so much that's out there. I agree with you completely. I usually end up starting with nitrofurantoin unless there's another reason why I can't And also talk to the patients about that it only goes into the urine. It's good for just a simple urinary tract infection and doesn't wipe out the natural vaginal flora or bowel flora, which is so important to maintaining a good environment to try and prevent urinary tract infections. Then how about if you have more of a complicated situation, what are the guidelines tell us there?

[Dr. Anne Cameron]
For complicated urinary tract infections, that would be an infection in a man in someone who catheterizes, someone who doesn't empty their bladder properly, someone who maybe has had urologic surgery recently, you need to treat those people for seven days. This is not people with a fever or pyelonephritis, but this is a more complicated cystitis. Seven days of antibiotics and a culture is preferred in these cases. I would almost always get a culture in this patient population and treat based on their culture results. Again, it's the same antibiotics that would be given.

I typically do not use nitrofurantoin in men because, as you just pointed out, it doesn't penetrate the tissue. The male prostate is very, very likely to get some bacteria penetrating the spongy nature of the prostate. I try to avoid using that antibiotic in men in particular. In a man, I would start with trimethoprim/sulfamethoxazole twice a day for seven days. Many people also favor fluoroquinolones in the male population, again, because of the penetration in the prostate.

Those antibiotics are very broad spectrum and they also have a lot of risk associated with them. There can be tendon ruptures. You can get acute renal failure from them. Those are very potentially complicated antibiotics to use. Those would be probably one of my last choices. I would probably prefer the cephalexins over the fluoroquinolones in someone who doesn't have an allergy otherwise.

[Dr. Suzette Sutherland]
That's a wonderful algorithm. I would say mine is the same as that while following the guidelines. A good point about the nitrofurantoin in men, my patients are all women, so I don't often have to think about that. When I do think about it is if I think that this simple cystitis is not just a simple cystitis, there might be some pyelonephritis associated with that. Of course, nitrofurantoin won't treat that tissue of the kidney. Now, we're talking about something different.

[Dr. Anne Cameron]
The nitrofurantoin is also really poorly excreted in those patients with chronic renal failure. Your patient with chronic renal failure doesn't excrete it quickly enough to achieve the concentrations to treat the bacteria. In those patients, you really can't use those antibiotics. They're great antibiotics. They're very low toxicity, which is very appealing, but you have to be selective.

[Dr. Suzette Sutherland]
What I also heard you say, and I want to touch on this a little bit further, is you use antibiotics empirically. It sounds like, looks like, smells like a dog. It's not a zebra. I treat it with the low-spectrum antibiotic that I think is going to do it. Then, also, there are situations, how often are you getting a urine culture and then waiting for the urine culture before treating in a symptomatic patient versus starting something empirically and letting the patient know, I might have to change this antibiotic when the culture comes back. What do you do in your practice?

[Dr. Anne Cameron]
For patients who get rare urinary tract infections, you have a patient that is part of your practice. They might have overactive bladder or stress incontinence and they never get urinary tract infections. They call your office on a Friday and they have new burning, new bladder pain. Again, it looks like a urinary tract infection, sounds like a urinary tract infection, and she doesn't have a history of urinary tract infections, then I would empirically treat this person.

On the other hand, I have patients who are getting a urinary tract infection every couple of weeks or every month. Their symptoms can be difficult to differentiate from other bladder conditions like interstitial cystitis or bladder pain syndrome. In those people, I do make them get a urine culture because in my practice, in particular, because we've actually looked into this, 45% of those phone calls where we make someone get a urine culture, the culture ends up coming back negative. If I were to give empiric antibiotics to my recurrent UTI patients every time they call, almost half the time I'm wrong and I'm treating someone with antibiotics incorrectly.

For recurrent UTI patients, and again this is based on the guideline, I do get a urine culture and wait for that result before treating them. Now, there are exceptions to that rule. Someone calls my office and they're just about to board a plane to go to Cancun for their annual vacation and they have classic symptoms. Again, there are always exceptions to the rule, but the best practice is to wait for the culture. You can often get a preliminary culture in 24 hours and you'll get the final culture at 48 hours. At that 24-hour preliminary culture result, I'll start treating them.

[Dr. Suzette Sutherland]
Where do you draw the line with maybe using self-start antibiotic therapy, allowing the woman to treat herself, give her a prescription for an antibody with maybe a few refills? Do you have any recommendations or cutoffs for that? I know I do that in well-established patients. Again, we have established that when you have these symptoms, we got urine cultures and it's a run-of-the-mill E. coli. It's not some big superbug. When you have a UTI, there's no confusion. If they had a few in a year or when they travel, allow them to have something on hand, they treat themselves. What kind of things do you do for that situation?

[Dr. Anne Cameron]
I think my practice is similar to yours, the female patient who has infrequent urinary tract infections and has classic symptoms when she gets them and has been able to identify UTI in the past. Your patient who gets one UTI a year and is always at the worst time imaginable, again, she's boarding a plane and going to Paris tomorrow and she has a UTI today. In those patients, I will give them to have on hand a single course of antibiotics.

I tend not to give refills. I'll tend to give them one empiric antibiotic prescription because if they're getting another UTI soon thereafter, then they're falling into the recurrent UTI definition. Again, those people that are very reliable and are part of my regular practice, I will give them some empiric antibiotics and with clear instructions and that person understands why we don't want to overuse antibiotics. I feel very comfortable with that.

[Dr. Suzette Sutherland]
I think that the keyword here, really, is reliable, reliable with respect to symptoms and it equates to a true UTI and we've been able to document that. That's really what I also try to educate primary care providers or even ED providers who are giving women sometimes antibiotics repeatedly, repeatedly, or to be able to do self-treatment or even this idea around the time of sexual activity. They've been doing this for 20 years, having to take antibiotics around sexual activity every time.

I think having that reliability gives you the assurance that they know when they have a UTI and here's how they can help themselves. If I do that, they usually will get enough antibiotics for two, maybe three UTIs in a year, depending on how much travel they do and how often they go to Cancun. That weighs into it as well. The convenience factor. That's something I think we really need to stress to primary care providers as urologists.

[Dr. Anne Cameron]
Because what we don't want is people having multiple kinds of antibiotics on hand and they take two or three days of the trimethoprim and they feel that doesn't work. Then they start taking some of their fluoroquinolones and then they don't feel like they're getting better. Again, they're delaying proper care because if they have access to too many antibiotics, then things get confusing and they're not taking a complete course and they're shifting antibiotics, and then by the time they end up in the ER feeling unwell, no one can interpret their urine culture either.

I think the reliable patient who has a clear understanding of what they're treating is the ideal person to do this with. I have a lot of those patients in my practice and they get it and they do a great job of self-management.

[Dr. Suzette Sutherland]
Let's move into the preventive arena now. We've talked about some things that we think are also risk factors for UTI. We peppered them in here, but some common things are just not drinking enough fluids, maybe having issues with your bowels, chronic constipation or diarrhea, maybe not emptying your bladder well, maybe in a post-menopausal woman because of vaginal flora. That's where we look at these categories and think about, "What can we do to help prevent the urinary tract infections by influencing some of these categories?" Why don't we look at each one of these? What do you recommend with respect to fluids? I know you've done a lot of research in this area too, as far as fluids for women. How much should we be drinking a day in order to help prevent UTIs?

[Dr. Anne Cameron]
In people who do have recurrent UTIs, I'm recommending that they're drinking at least 2 to 3 liters per day. Being dehydrated, being chronically dehydrated is a risk factor for recurrent UTIs. There is level one evidence that having someone who has recurrent UTIs achieve a normal urine output. The study I'm referencing is where they mailed a large cohort of women, a liter and a half of bottled water extra per day, and it reduced their UTI rate by half. That's a very low-risk endeavor just staying well hydrated. Now you don't need to drink 6 liters a day because there's diminishing return.

Achieving a normal hydration, 2 to 3 liters, that's perfectly reasonable. Drinking more and more and more is just going to aggravate your overactive bladder symptoms. Staying normally hydrated is important, but also toileting when you have the urge. Urine-holding habits are also part of this. If you're holding your urine and not urinating often enough, you're also creating more problems. The purpose of the water is to urinate more frequently so that you will empty your bladder and flush out the urethra eight, nine times per day, not three times per day.

[Dr. Suzette Sutherland]
This idea oftentimes gets translated. Also, I go to the bathroom every time I feel at all like I might have to go because I don't want to get a UTI and then they're peeing every hour. We also need to be careful of that one. I think just as you said, if you're drinking the appropriate amount, then going to the bathroom about every three to four hours during the course of a day is pretty much normal. Having a nice, large, satisfying void, not a tiny little trickle because you have something to work with since you're drinking the fluids. Those are real practical recommendations. How about the bowels?

[Dr. Anne Cameron]
In adults, there's actually pretty poor literature on the impact of the bowel on the bladder. There's a lot more literature in the pediatric population where constipation is very much associated with recurrent UTIs. In adults who have fecal incontinence, you can clearly see how having fecal incontinence would predispose to urinary tract infections. Also, having your bowels work properly makes your bladder feel better. Pooping once a week does not make your pelvis feel better, does not make your bladder feel good.

It might be confusing to figure out when you have a UTI because your pelvis feels so poorly. It just makes sense. Empty your bowels once a day, don't have diarrhea. Having prebiotic foods in your diet normalizes your fecal flora. As we all know, urinary tract infections are directly related to your fecal flora. If you have a healthier fecal flora, you're going to get less urinary tract infections.

[Dr. Suzette Sutherland]
Having regular bowel movements every day, every other also evacuates that fecal flora. We're all colonized, of course, but I think there's something to this very large bacterial load when there's so much constipation going on and just keeping things moving is beneficial as well.

[Dr. Anne Cameron]
Exactly.

[Dr. Suzette Sutherland]
Then the third category, especially in women, not in men, but is that vaginal space. What happens there that predisposes us to urinary tract infections and how do we prevent that?

[Dr. Anne Cameron]
Women who are still menstruating have a good level of estrogen and their vaginal epithelium makes a ton of glycogen. That's naturally present and that glycogen actually feeds lactobacilli and lactobacilli are healthy vaginal flora. You want all lactobacilli in your vagina. Lactobacilli make a lot of acid and an acidic vaginal environment really tamps down all that fecal flora. Your E. coli can't survive there, your pseudomonas, all the awful bacteria that can cause a urinary tract infection.

The lactobacilli also outcompete those bacteria for space. Those bacteria can't reproduce because the lactobacilli have the right environment and they've made it so acidic. Now, what happens when people are washing excessively? They're douching, they're using tons of soap, they're irrigating their vagina, they're flushing out those healthy bacteria.

[Dr. Suzette Sutherland]
Antimicrobial, using antimicrobial soap. I can't tell you how many times I get a question about using antimicrobial soap in the perineal area.

[Dr. Anne Cameron]
Dial soap has no place on your bottom. Again, your lactobacilli are protecting that area from having those urinary colonizers from adhering to the mucosa. Your fecal flora adheres to your perineum and they stick there and they wait until they can make it into your urethra. Having an acidic vagina full of lactobacilli is the way to go. Now, there are many times in a woman's life when she does not have a estrogen-rich situation for example, a woman who is breastfeeding your vaginal estrogen levels go very low when you're breastfeeding.

Also when a woman becomes peri and postmenopausal, the vagina changes. Now it takes a very long time, which is why most breastfeeding women don't suffer from recurrent UTIs because it can take a couple of years for the vaginal epithelium to completely change over to a postmenopausal status. That postmenopausal status is very thinner. It doesn't have glycogen in it, and the cell layer is very thin and is not exfoliating itself as often.

Premenopausal women's vaginas are exfoliating constantly. Even if a bacteria was stuck on the outside, it gets shed many times per day. Whereas a thinner vagina, it doesn't shed, and that vagina does not have lactobacilli because the lactobacilli don't have anything to thrive on. The postmenopausal vagina tends to be more colonized with fecal flora and the fecal flora are there and they're just waiting to get into your urinary tract.

[Dr. Suzette Sutherland]
When I talk to women about their recurrent UTIs and then prevention, I talk about a woman has three compartments down there, right? [laughs] We have the bladder, that's where the urine is, and we need to make sure that that milieu is healthy and where it needs to be with fluids. We have the vagina and that milieu, just as you spoke, needs to be healthy. Then we have the bowel, right?

Those three compartments, you need to do what you can to keep all three of those milieus happy so that the colonization is where it needs to be and it doesn't overgrow and cause problems. Let's start with the bladder compartment then. What are some things that we can do besides drinking lots of fluid, right? When I say lots, I mean two to three liters. That's my recommendation as well. Again, to your point, you drink more and you can run into other problems, even hyponatremia, right?

Having lots of problems with low electrolytes and things like that, especially in the elderly population. We do need to be careful with those recommendations of drinking more water. It should be about two to three liters a day. What other things can we add if needed that will help in that bladder compartment?