BackTable / OBGYN / Podcast / Transcript #42

Podcast Transcript: Recurrent UTIs: Controlling Those Nasty Little Bladder Infections

with Dr. Anne Cameron

In this crossover episode of BackTable OBGYN with Urology, Dr. Suzette Sutherland, Director of Female Urology at the University of Washington, and Dr. Anne Cameron, Professor of Urology at the University of Michigan, share their insights on the prevention and management of urinary tract infections (UTIs). You can read the full transcript below and listen to this episode here on BackTable.com.

(1) Urinary Tract Infections (UTIs) Defined

(2) Understanding Recurrent UTIs: Causes & Risk Factors

(3) UTIs in Patients with Permanent Catheters

(4) The “Urosepsis” Patient: Symptoms, Causes & Incidence

(5) Current Conversations on Antibiotic Resistance

(6) Treatment Guidelines for UTIs

(7) Strategies for UTI Prevention

(8) Can Cranberries Really Prevent UTIs?

(9) Recurrent UTIs: A Clinician’s Key Takeaways

(10) Controlling Bacterial Colonization in Catheterized Patients

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Recurrent UTIs: Controlling Those Nasty Little Bladder Infections with Dr. Anne Cameron on the BackTable OBGYN Podcast)

Ep 42 Recurrent UTIs: Controlling Those Nasty Little Bladder Infections with Dr. Anne Cameron

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[Dr. Mark Hoffman]
Hello, everyone, and welcome to the BackTable OBGYN Podcast, your source for all things obstetrics and gynecology. You can find all previous episodes of our podcast on Spotify, Apple Podcasts, and on backtable.com.

[Dr. Suzette Sutherland]
I'm your host, Dr. Suzette Sutherland from the University of Washington today. I'm excited to have Dr. Anne Cameron as our guest for this special episode discussing the management of urinary tract infections or UTIs. Good morning, Dr. Cameron.

[Dr. Anne Cameron]
Good morning, Dr. Sutherland.

[Dr. Suzette Sutherland]
Of course, I want to introduce you properly. She is professor of urology at the prestigious University of Michigan. She's been there for many years and specializes in pelvic medicine and reconstructive surgery. She has extensive experience in the area of neuro-urology and neurogenic bladder dysfunction. We will cover the idea of basic urinary tract prevention, management in the general population, but also get into some of these more difficult situations, which are often encountered by urologists, and especially with those patients that do have these voiding dysfunction issues.

This population can be associated with very frustrating, sometimes chronic issues and one of those are recurrent UTIs and how we should be handling those today. Again, our topic today, the prevention and management of UTIs. Very excited to have you and have you share your expertise with us here today, Dr. Cameron. All right. Let's just get started with the definitions of UTIs. When you talk to different clinicians, they use these definitions very differently. Let's just look really by the book. What is a clinical UTI?

(1) Urinary Tract Infections (UTIs) Defined

[Dr. Anne Cameron]
A urinary tract infection can be an infection anywhere from the kidneys, all the way down to the bladder. What people often mean when they say, I have a UTI, is they usually mean a bladder infection or cystitis and that's a bacterial infection of the bladder. You can also have a UTI, which is a kidney infection, and a pyelonephritis, but that's a very different and much more severe infection. A UTI, to be truly a UTI, the person who is suffering has to have symptoms.

They have to have the symptoms that are associated with the infection. In terms of the bladder, that is usually urgency, frequency, bladder pain. They might feel like they're going to wet themselves and they might go very, very frequently. On top of that, the person also has to have a test that shows that they have an infection. Either a culture of their urine that proves that they have bacteria in their urine or sometimes we accept a dipstick. This is very much like pool chemicals. You dip the urine and look at the results and the results can show whether there's bacterial activity in the urine. You have to have symptoms and there has to be evidence of bacteria.

[Dr. Suzette Sutherland]
When we're talking about just the general population, how common is it, really, especially among young women or maybe postmenopausal women, how common is it that a woman gets a urinary tract infection?

[Dr. Anne Cameron]
It's unfortunately very common. Half of women in their lifetime will get a urinary tract infection. That's a very, very big problem for women in general since that's half of women. Men don't get infections as often as women do and men are closer to 10% likelihood of getting a urinary tract infection in their lifetime.

[Dr. Suzette Sutherland]
We'd like to think that whoever was responsible for designing our anatomy had everything in mind, but somehow the men have a very long urethra and with that are protected from having urinary tract infections or microbes getting into the bladder, whereas women are much more susceptible just due to normal anatomy. You were also part of, you're on the board of the Society of Urodynamics, Female Urology, and were part of looking at the official guidelines that defined what are recurrent UTIs in women and then how we should be handling that. Can you define that for us? That's a different beast many times when someone has recurrent UTIs.

[Dr. Anne Cameron]
Recurrent UTIs are when someone gets infections over and over again. The formal definition is someone who gets three urinary tract infections in a year or two within a six-month period. This is actually not rare. Of all the women who get a urinary tract infection, around 30% will have a recurrent urinary tract infection definition. This is not a rare problem or an uncommon event. It affects a lot of people, especially women.

(2) Understanding Recurrent UTIs: Causes & Risk Factors

[Dr. Suzette Sutherland]
Then when we think about recurrent UTIs, I think it's always helpful clinically for me to think about three buckets. Is a woman really getting a recurrent infection? In other words, it gets treated appropriately, some time elapses, and then they just get another infection from an outside source? Was it actually inappropriately treated? Maybe they didn't get the right antibiotic. Nobody got a culture to know that she grew a multidrug-resistant organism or didn't get the antibiotic for a long enough period of time? The third category is what we call persistence of a urinary tract infection.

In other words, you have a culture. You see what the organism is, what's the right antibiotic to use. You treat it appropriately. The woman feels better, but then after a very short period of time, the infection seems to come back with the same organism. In that category, this sense of persistence, what we normally do to treat it isn't enough. We think about other higher-level urological problems that might be coming into play here that's plaguing the woman and why you can't manage these recurrent UTIs. Can you talk about that a little bit? What things as a urologist then are we really responsible for looking for?

[Dr. Anne Cameron]
This is actually a really complicated problem. This is not something that can be solved very easily. It often requires a lot of investigating and a lot of discussion with your patient to figure out. Some women get an infection, or men, and they get prescribed antibiotics. Sometimes, as you said, it's the wrong antibiotic. It was an antibiotic that did not kill or eliminate the bacteria that they have growing in their urine and that's often because they didn't get a culture. A urine culture takes the urine and grows it on a culture plate and they actually treat that culture plate with different antibiotics. They know if the organisms are sensitive to a specific antibiotic or not.

If you get a urinary tract infection treated with a random antibiotic, one that we don't know is sensitive or not, you may be using the right antibiotic and that's great, but you also might be using an antibiotic that has no ability to kill that bacteria or is only weakly able to kill that bacteria, which is an intermediate sensitivity. You may take your antibiotic and it may make you feel a little better, but your symptoms come back very quickly because the bacteria was never really gotten rid of. That's really a recurrent urinary tract infection, but it's more of a persistent variety, meaning the bacteria never really went away.

Also, some people don't take their antibiotics as prescribed. If you're given three days of antibiotics twice a day, you really need to take those antibiotics twice a day for three days. If you're skipping doses and not finishing your course, you're not getting enough antibiotic to truly get rid of the bacteria that's been bothering you and you'll get a rapid recurrence of your symptoms.

The other thing that happens is that some people don't always absorb the antibiotics correctly. Some women who have kidney problems and kidney dysfunction don't excrete the antibiotics correctly and some people who've had gastric bypass surgery sometimes don't absorb antibiotics correctly. There are a lot of different reasons that the UTI might not have been treated properly.

[Dr. Suzette Sutherland]
That's a really good point. I just want to stop right there. That's a fabulous point to make because sometimes we are treating the patient with the right antibiotic, but because of other factors that are inherent with them, it doesn't get absorbed well. That's a wonderful point to make. Thank you.

[Dr. Anne Cameron]
The other problem is that some women are just very at risk for getting infections. They may have things about their anatomy. They may not urinate properly. They may have a residual urine, meaning they don't empty their bladder well. They may have had surgery that changes the way they urinate and some women catheterize their bladder to empty their bladder. Those are all very high-risk situations. You might get reinfected very quickly because of these risk factors and a new bacteria gets introduced into your bladder.

It can be really hard to figure out because E. coli is the most common urinary tract infection, 90% of all UTIs, and someone having two E. coli UTIs back to back doesn't really mean that it's a persistent infection. It could be just two brand new different E. coli infections. It can be a little hard to figure out, but it's really important to get cultures so at least we can compare infections and know if they're the same organism or if they're a different organism.

[Dr. Suzette Sutherland]
Right. When we're thinking about then recurrent UTIs, you did mention some things here that we're looking for as a urologist to say, "Why would there be a persistence?" We're looking, as you already mentioned, are they emptying their bladder okay? Is there something wrong anatomically that they're not draining well? Maybe they have hydronephrosis for some reason or do they have a kidney stone? Those are the main things that we might get some imaging or otherwise look inside the bladder with a cystoscope. I wanted to ask, though, too, if we look at this other population of patients who have some more complicated things that might be neurogenic bladder and have to have a catheter, what's the rate of UTIs with a catheter? Can you speak a little bit more to this idea of chronic colonization and what we should be doing with that?

(3) UTIs in Patients with Permanent Catheters

[Dr. Anne Cameron]
People who have indwelling permanent catheters, those patients are invariably colonized with bacteria. The common wisdom in that 5% of people with a catheter get colonized per day so that at three months, virtually 100% of indwelling catheters have a colonized bladder. There is really nothing you can do about that. It is the expectation that a urine culture from a Foley catheter, even a new Foley catheter will be positive.

I also want to emphasize if you are going to get a culture in someone with a Foley catheter, you need to change that Foley catheter at the time of the culture because otherwise, you're culturing the catheter itself rather than the contents of the bladder. Invariably these people have a positive culture. Now, if they have no symptoms, that's called asymptomatic bacteriuria. It's expected, it's well-known and it's not harmful. Now, if they do have symptoms of a UTI, then we can actually use the culture data to help guide their care.

[Dr. Suzette Sutherland]
Oftentimes I know your patient population, you see a lot of this. You've cared for a lot of these types of patients over the years. This idea of making sure that the patient is actually having symptoms and not just a positive urine culture, as you said, this is something that we talk to primary care physicians all the time and even sometimes rehab physicians. Many are educated about this concept, but others not.

Every time somebody with a catheter goes into the emergency room, has to go in for some reason, grandma's not thinking very well. Has a change in mental status. Then they check her urine and they say, "Oh, you have a UTI, we'll give you antibiotics and send you home." How many times has that happened to patients of yours, Dr. Cameron?

[Dr. Anne Cameron]
I think it's happening all the time, unfortunately. Again, if someone has a catheter in place, you can guarantee that the culture is going to be positive. Having a positive culture really doesn't help you figure out what's going on with this person. Asymptomatic bacteriuria is really classically presenting with smelly urine and cloudy urine. Those aren't UTI symptoms. Those are symptoms of just bacteria being present.

The things that we worry about are when those bacteria are actually affecting the person. They're actually affecting their bladder, affecting their kidneys. Those are very different symptoms. Those patients have dysuria. Those patients have bladder pain. They have urgency, frequency. They might have new onset incontinence. They could have fever, flank pain. Those are all symptoms of the bacteria in the urinary tract actually impacting the patient rather than just brewing in the urine, which is asymptomatic bacteriuria.

The concept of cognitive decline or mental cloudiness occurring all alone causing a urinary tract infection has been proven to be not reliable. Older adults who have dementia and have cognitive decline can have cognitive decline whether or not they have bacteria in their urine. What is really making this person better when they get admitted to the hospital and treated for a UTI is actually the supportive care and hydration. Most of these people are dehydrated and they need reorientation and better care and the antibiotics you gave them are not really accomplishing anything. Cognitive changes all by themselves are not a symptom of a urinary tract infection. If someone has new incontinence and bladder pain and cognitive decline or a fever, certainly that is a UTI. Cognitive decline or confusion all by itself is not a urinary tract infection. This has actually been very well studied in the infectious disease literature.

(4) The “Urosepsis” Patient: Symptoms, Causes & Incidence

[Dr. Suzette Sutherland]
They are having symptoms especially elevating to fever. It's the fever causing the cognitive decline, not really just the urine culture. Along that same line, certainly in that patient population, but also in just general patient populations, we've had some newsworthy events where someone got urosepsis and then died pretty quickly and that hit the mainstream a few years ago. Can you speak to this a little bit? What's the incidence of somebody getting a routine what we call population-acquired or community-acquired UTI and if you don't treat it, this idea that it can develop into sepsis and you can die? How common is that?

[Dr. Anne Cameron]
That is actually quite rare and it's rare because it's different bacteria. Someone getting a bladder infection, a cystitis, and that being left untreated for a day or two turning into urosepsis pyelonephritis is less than 1%. The reason that is because the bacteria that because cystitis are different than the bacteria that because pyelonephritis. They're completely different bacteria and they may all be E.coli, but they have different pili and different fimbriae on the bacteria. People who have pyelonephritis, they don't present with bladder pain, urgency, frequency, and then get a fever and then get flank pain. These people present with fever, flank pain, and they're feeling terrible, nausea, vomiting, they feel absolutely awful. Most of them have no lower urinary tract symptoms. The bacteria basically bypassed the bladder and went straight to the kidneys. Those people are very different. They present clinically very differently.

The people who do get a cystitis that turns into pyelonephritis often have some anatomic abnormality. Those are people who've had kidney transplants and kidney transplant patients all have reflux into their transplant kidney. That's how a transplanted kidney is placed into the bladder. That's normal to have reflux, but it puts them at high risk of pyelo. Also, some people have reflux congenitally or have had some bladder surgery. They might have outlet obstruction, they may be catheterizing, and their bladder functions differently. Those people, a cystitis can turn into a pyelonephritis. In the general population with a normal bladder, cystitis really does not cause pyelonephritis.

[Dr. Suzette Sutherland]
Again, in your practice, how many times have you had a patient referred to you from the emergency room who had urosepsis and the whole family comes in with them and says, "I had urosepsis." Let's define what urosepsis is, even separate from pyelonephritis, and what the incidence of that really is.

[Dr. Anne Cameron]
Urosepsis or just sepsis in general is someone has a proven infection. Either there's a clinical finding of bacteria or there's a culture finding bacteria and they have something called SIRS criteria, which is systemic inflammatory responses syndrome. Those people either have a fever, so a temperature above 38 degrees Celsius, or sometimes they can have a low body temperature because that can be a sign of overwhelming infection. They have to have an elevated heart rate or an elevated respiratory rate or have an elevated white count.

They need to have at least two of those criteria plus evidence of an infection for that to be sepsis. Because you can have sepsis from multiple sources. You can have a bloodstream infection, you can have pneumonia, all of those things can cause sepsis. Urosepsis is when you have a positive urine culture with at least two of those SIRS criteria.

[Dr. Suzette Sutherland]
Then we think that systemic process started or was initiated by what's happening in the urine, right?

[Dr. Anne Cameron]
Right.

[Dr. Suzette Sutherland]
By definition then, that's urosepsis. When I break it down even for patients or even do some educational things for primary care providers, we look at cystitis, that's the bladder. We look at pyelonephritis, that's the kidney. Then sepsis is more of that goes beyond those two organs into the systemic system causing all of the kinds of systemic things that we think about that are associated with a standard sepsis. It's extremely rare, especially in the general population to get a community-acquired urinary tract infection. If it's untreated, "I'm so worried to not treat it with these antibiotics because I'm afraid I'm going to get sepsis and die." We just need to dispel that myth.

[Dr. Anne Cameron]
That's correct. Cystitis or a bladder infection, it's exquisitely rare for that to cause urosepsis, a pyelonephritis, or a kidney infection. Because the kidneys are so intimately related with the bloodstream, it's very easy for a pyelonephritis to turn into sepsis, but not a cystitis in and of itself. It's really pyelonephritis that leads to urosepsis.

The people that are at risk of urosepsis are those who are immune suppressed, your transplant patient, your patient taking immune suppression for rheumatologic conditions, and people who've been in the hospital. Urosepsis in the hospital happens not rarely and that's because these people have catheters in, they're systemically unwell, their immune system is being challenged by whatever process is going on. An outpatient ambulatory person in the community getting urosepsis is very rare.

[Dr. Suzette Sutherland]
Let's switch gears just a little bit and before we get into talking about some preventive measures that we all can be doing and recommending to our patients, let's talk about antimicrobial resistance. It's just such a big problem today and how we can best be stewards of the resources, the antibiotic resources that we have. First of all, let's just talk about, I know some of the history about antibiotic development and where are we today with what new antibiotics are coming down the pike, if any, that you're aware of, and where are we with this idea of limited resources?

(5) Current Conversations on Antibiotic Resistance

[Dr. Anne Cameron]
Unfortunately, antibiotic drug development has really stalled. There are currently no big developments in the antibiotic creation in the world at this time. There were some low-hanging fruit. For example, the penicillins were developed, the fluoroquinolones, and these all happened in the 1970s, '80s, '90s, and they were developing antibiotics every year or so. The resources put towards antibiotic development are not there and it's not very profitable for companies to develop antibiotics, so there's actually very little work being done on the development of new antibiotics. It's mostly just variants of antibiotics we already have. They extend the spectrum a little bit, but there's not been any breakthroughs in decades.

[Dr. Suzette Sutherland]
Therein lies the problem. There's more multidrug-resistant organisms that are happening every day. These organisms are getting smarter when they see these antibiotics and build their own armor against these antibiotics, and yet, there aren't new antibiotics being developed that can penetrate these organisms. It becomes a very scary reality here that we have, not just in the area of urology, but just overall in the area of infectious disease.

That's why we are so adamant about being really good stewards of our antibiotic resources, using them judiciously, using them appropriately, right? Then educating not only practitioners about that, but the patients so they understand too. Are you aware of any new antibiotic drug classes that are coming down the pike? I know there was an oral, maybe, another fluoroquinolone, possibly, but I'm not up on where that research is today and I wondered if you had more insight. Is there anything that you're aware of?

[Dr. Anne Cameron]
I'm not aware of any new classes of antibiotics. They're constantly working on slight variations on what is already out there. The biggest development in antibiotics lately has been the resuscitation of old antibiotics that used to be in the archives. Phosphomycin, for example, that was rarely used up until recently because it's a historic antibiotic that now we realize has very little resistance because it's not been used for so long, whereas the antibiotic resistance that bacteria are developing is accelerating at a logarithmic pace. Antibiotic resistance is different than it was five years ago. It's worse than it was five years ago. The bacteria that were classically resistant to classes of antibiotics are now so resistant that you can't use those antibiotics as empiric therapy.

[Dr. Suzette Sutherland]
Then when we do look at a UTI, we're presented with a patient with a UTI, let's say a community-acquired classic lower urinary tract symptoms, maybe develops into or are coming with pyelo, but this is a general urinary tract infection. What are the treatment guidelines now from the AUA-SUFU?

(6) Treatment Guidelines for UTIs

[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.

(7) Strategies for UTI Prevention

[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?

[Dr. Anne Cameron]
Oral prevention strategies for recurrent UTIs are all the rage right now. If you've listened to the radio or watched television, there are ads all over the place right now, which I think is actually a good thing because this is raising awareness of the problem of recurrent UTIs that exists in the population. There is varying data on the success of some of these strategies.

Although many of these agents are not harmful, if they're not helpful, I wouldn't recommend something to someone because they're paying for this and many of them are very expensive. I think that we need to have data to support their use, but also only recommend things that are useful. Although something's not harmful, there might be financial toxicity with recommendations of some products.

D-mannose is a sugar, it's present in our food. It is present in many fruits and vegetables. The D-mannose supplements are simply a sugar, just the concentrated form of D-mannose. The data is pretty weak on D-mannose in the prevention of recurrent UTIs. In the neurogenic population, it has almost zero effectiveness. In the female population that is voiding, it has pretty minimal effectiveness. The effects are so small that it's not one of the therapies that I recommend to my patients. It's also very expensive. It's one of the more expensive supplements for the urinary tract. D-mannose is not on my list of regular recommendations.

[Dr. Suzette Sutherland]
It is interesting. I do want to stop there quickly because it has been used for, gosh, Dr. Cameron, I don't know how many years, right? It is on the list, primary care providers recommended all the time. We have patients coming in who've been on it for 20 years and they're still getting recurrent UTIs. It's interesting that something has been so widely used without having good data behind it, right? It's almost like a mainstay in this prevention of recurrent UTIs in the general population out there.

I'm glad you made that point that as we educated physicians, scientists look at what data is available, it really doesn't support the use of D-mannose.

[Dr. Anne Cameron]
That's correct. That's why the AUA did not put it on its list of UTI prevention mechanisms. D-mannose is not on the AUA guideline, and I agree with that decision.

[Dr. Suzette Sutherland]
There are some other ones. Talk about cranberries, talk about hiprex and other kinds of things that are available out there.

(8) Can Cranberries Really Prevent UTIs?

[Dr. Anne Cameron]
Sure. Cranberry supplements are on the AUA guideline since there is good quality evidence to suggest that they work to prevent UTIs, particularly in the voiding female population. There's also some studies in children's recurrent UTIs that show that a good quality cranberry product taken every day can reduce your risk of urinary tract infections with minimal side effects. Cranberry supplements can cause a little bit of GI upset, but by and large, they are pretty easy to take, pretty well tolerated and if you get a good quality cranberry product, that is one where they have removed much of the acid from the product. Then those are safe to take with anticoagulants like warfarin and those are safe to take in people who are recurrent stone formers because the acids in cranberries are pro-stone forming and we don't want to be causing new problems.

[Dr. Suzette Sutherland]
When we look at the cranberry supplements, then, well first of all, let's look at patients say, "Well, what should I be looking for if I'm looking at a cranberry supplement?" There's so many that are out there. Are there certain ones that work better than others?

[Dr. Anne Cameron]
Some cranberry supplements are simply powdered cranberries. They take cranberries, they powder them, and they put them in a capsule. That is a very simplistic approach to cranberry supplementation. Again, those cranberry supplements have interactions with warfarin and they can cause kidney stones and they also have a lot of acid present in them, which can irritate your bladder. That's not a high-quality cranberry product.

What we like to see are soluble PAC, and you want it at a high enough concentration that it's going to be effective. The products that I recommend to my patients are Ellura, which is the company that has really led the stage in the studies on cranberry supplements. Most of the literature out there actually used their products when they're making recommendations about cranberry. Many of the other companies have used their data and said, oh, we have the same product.

Again, it's not quite that simple. The supplements and the way that they're processed can be different. I recommend Ellura and I also recommend Theracran based on available literature that supports use of those specific products. As we all know, nutraceuticals are not regulated by the FDA, so you have to be really careful about which ones you use and which ones you buy because you need to ensure that you're actually getting what's on the label. The only way you can do that is by using a trusted product.

[Dr. Suzette Sutherland]
The two buzzwords that I use to talk to patients about cranberry supplements is the, you mentioned PAC, Proanthocyanidins, that's what that stands for. That is the active compound in the cranberry, whether you eat a cranberry or take a cranberry supplement. That's the active compound that needs to be in the cranberry supplement. You need to have enough of that active compound for it to be effective, just like anything.

The dose that seems to be effective is 36 milligrams and that's what's in one tablet of the product that I often recommend is Ellura for the same reasons that you mentioned them. That has 36 milligrams. We find one to maybe two at a time. If you're having some symptoms you think might being UTI like, but more than that at a time has not been proven to be affective. The usual dose is one, once a day around the time of susceptible events such as sexual activity or things like that.

The first buzzword is really the potency, right? Is it strong enough to be effective? The other is, is it soluble? The body able to utilize it? To your point, you take a supplement, if it doesn't get absorbed well, then it doesn't matter if it was potent when it wasn't absorbed because it's not absorbed and it's not helping you. We know that soluble PAC is very bioavailable. It's readily used by the system and you're getting then what the pill is meant to deliver.

That again, is that product Ellura, where they've done a lot of basic science research in this area. I believe Theracran has also done some research and another product out there, Utiva is hitting the market, their marketing campaigns. I'm not as familiar personally with the Utiva data and how soluble that compound is. Those are the two things to look at. When you look at a lot of these other products that you can get online or over the counter, they don't even mention PAC, let alone anything about their solubility. I loved what you mentioned, you used that term financial toxicity, right? Of course, if you're buying expensive supplements that aren't even going to be working, then what's the point?

[Dr. Anne Cameron]
Yes. The other, sorry to interrupt, Dr. Sutherland, but the other comment I get from patients is, "Oh, well, I drink cranberry juice." Drinking cranberry juice to treat recurrent UTIs is a full-time job if that's what you're doing because you do need to drink the cranberry concentrate. You actually have to drink quite a bit of it. Even the unsweetened version, you're probably getting close to 600 or 700 calories of juice per day just to get enough to reach that level of PAC concentration. If you're drinking the cranberry cocktail, then we're really talking about liters of cranberry cocktail a day. That is really not a good strategy.

No one wants to consume an extra 700 calories per day. In your diabetic patients, now we're really getting into trouble where they're drinking simple sugars and their diabetes being poorly controlled is probably going to lead to more UTIs. I really don't recommend the juice to any patients. Although you can achieve the dosage, it's just not sustainable.

[Dr. Suzette Sutherland]
Yes. It also can be very expensive, the pure cranberry. They have a sugar-free one at Trader Joe's, but it can be very expensive. Again, so back to the financial toxicity. Those are great points. Thank you. Let's look at the Hyprex and vitamin C. Can you speak to that? If the cranberries aren't working, the other things you've done and when do you-- That's something that's been available for so many years and it's coming back a little bit I think into modern practices. Why don't you speak to that a bit?

[Dr. Anne Cameron]
Methanamine hypurate is an old medication. It's been around for a really long time. It is metabolized and converted into something similar to formalin. It's not formalin, but it's basically an antiseptic that when it's excreted and concentrated in the urine, it will kill bacteria. The methanamine literature from 20 years ago was relatively poor, poorly controlled studies. They didn't have great control groups. They didn't report their outcomes very well. People really poo-pooed the results of the methanamine literature.

In the last five years, and this didn't hit the AUA guideline, in the last five years, there have been several really well done, large randomized control trials with a placebo arm comparing methanamine to other things. The results were very good. The results showed very little toxicity and showed a significant decrease in recurrent UTIs. Based on this new literature, which in my mind is going to get incorporated in the next guideline version because it is such high quality, I do definitely recommend the methanamine.

If you prescribe the methanamine hypurate, you don't actually need to combine this with vitamin C because it is already acidified. The medication needs to be acidified to work and the vitamin C will do that. The methanamine hypurate version of it will acidify itself. I'm a big believer in this medication and I have many patients who do take it. Again, it's a non-antibiotic strategy. You can't get resistance to an antiseptic because it's not an antibiotic.

[Dr. Suzette Sutherland]
Yes, that's such a great point that you can't develop a resistant organism on it. Therein lies why it's beneficial. Let's just look overall. I want to touch two other areas here really quickly in the time that we have remaining. Let's just look first of all, wrap this up. What's your overall strategy when you talk to a woman, a young woman, or postmenopausal woman having some issues with recurrent UTIs? What's your package that you just recommend?

(9) Recurrent UTIs: A Clinician’s Key Takeaways

[Dr. Anne Cameron]
At the start, I make sure that she really is having urinary tract infections because interstitial cystitis and other bladder conditions can mimic this. If I'm convinced that these really are urinary tract infections, we have positive cultures, then I make sure that she is emptying her bladder. I do that with a post-void residual. That's easy. I will do a vaginal exam because I want to assess the estrogen status of her vagina. I want to look for things like a cystic seal that might be impairing voiding. I also check for a urethral diverticulum that can be a source of recurrent UTIs and also assess her voiding habits with a history.

How often is she going? Is she emptying her bladder after sexual intercourse? You don't need to urinate before you have sex, but you do need to pee afterwards. I often ask them about their bowel habits and their wiping habits as well as their hygiene habits because many women, although they won't tell you this upfront, are doing very aggressive hygiene measures that are really not helpful. I really emphasize here that I also try to de-stigmatize recurrent UTIs. Many of these women think that they are doing something wrong. They think that they are dirty, that they are themselves the because of these UTIs because that's what's out there in the lay press. I really try to reassure these women that the more they wash, the more they douche, the more they soap, the more UTIs they are going to get. This is not their fault. They have a risk factor, whether it be a genetic risk factor or hormonal risk factor that's causing these UTIs, and I really try to take the blame away from them. It's not the way they're wiping. It's not the way they're urinating. This is just bad luck for that poor woman.

My first education piece is hydration. If she has a low estrogen state in her vagina, my first step is to introduce vaginal estrogen either via the cream, the ring, or the tablets because this has excellent evidence to support its prevention of recurrent UTIs and restoration of the normal vaginal flora. This also has positive side effects such as vaginal comfort, decreased vaginal symptoms, and better comfort with sexual activity. This is a win-win strategy. In other women who prefer to avoid estrogen products, I will then discuss the supplements and that would be either the cranberry supplements or the methanamine. Those would be my starting point for those patients. That's where I start and I go over good practices. Good hygiene practices are things like urinating after sexual activity, after having a bowel movement, using a different piece of tissue in the front and in the back, but there's front to back to front wiping really doesn't matter. That's been proven to not really be impactful and I really just try to de-stigmatize it at this point in time.

[Dr. Suzette Sutherland]
Yes, those are all great recommendations and that's a similar strategy I would say that I would use as well. Again, going back to what I said previously, I like that especially speaking with women, reminding them that they do have three compartments down in the perineal area and the pelvic area and attention needs to be paid to all three of those compartments, the bladder, the vagina, and the bowel.

Let's switch gears a little bit again and talk about more of this a little more problematic or urological patients, that patients that have chronic catheters, that have neurogenic bladders, especially the chronic catheter patient that has a lot of clogging with the catheters where they have colonization of course, when to treat when they are colonized versus a UTI and then how to keep that colonization as best we can under control or certainly the clinical UTIs under control. I know you've done some work and some creative things in this area at the University of Michigan. Can you share with us some of the catheter management things you've developed?

(10) Controlling Bacterial Colonization in Catheterized Patients

[Dr. Anne Cameron]
Indwelling catheters are very problematic in those patients who get either recurrent UTIs or catheter clogging and catheter clogging is just another way of saying colonization of the urine because the catheter clogging is due to bacterial colonization causing precipitate in the urine. They're both the same thing. Those patients can be extremely difficult to treat because the biofilm that's present on the catheter and even if you change their catheter frequently, that biofilm just reforms within hours. These patients are often in a difficult position because they're dependent on the catheter, they can't get rid of the catheter, but the catheter itself is the source of the urinary tract infections.

I try to get those patients treated with a suprapubic tube rather than a urethral catheter and not because they have a different infection rate, but because I can put a bigger catheter in someone's suprapubically. You shouldn't put anything bigger than a 16 French in the urethra, but you can put a 20 or a 22 French suprapubically. The lumen of that catheter is much bigger and it drains better so it's less likely to get clogged.

I also have those patients learn how to irrigate their own catheter with some saline and a tumi syringe. This will keep them out of the emergency department. They get a little clog, a little mucus in their catheter and instead of this being crisis, they can manage this themselves or their caregivers can help them. This is invaluable because these people otherwise have nowhere else to turn for help and that ends up being the emergency department.

For recurrent UTIs, there is really robust literature on daily oral prophylaxis and how it absolutely does not work. If you give these people daily Bactrim, daily Cipro, daily Keflex, daily whatever you want, it does not reduce the risk of UTI 1 iota. It's a zero efficacy. It doesn't do anything at all. Please don't do that. All you're doing is causing harm, changing their gut flora and making them resistant. This is actually contraindicated. In the Neurogenic Lower Urinary Tract Dysfunction Guidelines, we address that and say, please don't do this. Do not give them daily oral antibiotics because they don't work in people with indwelling catheters.

Novel strategies that you were alluding to when we were speaking a little earlier are to do gentamicin bladder installations. This is gentamicin, which is an antibiotic that is quite historical and is somewhat toxic when given IV because it can impair kidney function, it can because autotoxicity. Given intravesically, so basically diluted in saline and squirted into the bladder through a catheter, it's not absorbed through the urinary tract at all. We have serum studies to prove that doesn't happen. Even in those patients who've had bladder augments, they don't absorb it. That's why we don't ever use gentamicin orally, right?

If you swallow gentamicin, you absorb none of it. That's why we know it really isn't absorbed anywhere through any mucosal layer. You leave that indwelling in the bladder for 30 minutes. I often have them use a catheter plug for 30 minutes and then drain the bladder. This works pretty well. I have many patients who are getting consistent catheter clogging, recurrent UTIs.

When they have gentamicin bladder installations, they can self-manage either when they're getting a little infected, so when they notice their urine gets smellier or cloudier, they self-treat for a week at that time. Most of my patients actually just do it every day as a preventative. The rate of UTI in that population when they go from just the way they were to the gentamicin, so the before and after, the UTI rate usually goes down by around 60 or 70%. You're not going to get rid of all their UTIs, but that's a big improvement.

[Dr. Suzette Sutherland]
Your recommendation then would be for daily bladder washes, as you described, indwelling about 30 minutes. What's the dose that you recommend for the prevention?

[Dr. Anne Cameron]
It's around 15 milligrams to 30 milligrams, but I diluted 480 milligrams of gentamicin diluted in a liter of normal saline, and I have them put either 30 or 60 cc's in their bladder. Some people have too small of a bladder to tolerate the 60 CC's, and I'll have them use 30, but I recommend 60 cc's once a day. In a catheterized patient, that can be any time of day that's convenient. In my self-catheterizing patients, I have them do it just before bed. They would catheterize their bladder, drain it completely, and then squirt the antibody in through the same catheter they did our catheterization, and then leave it indwelling overnight.

[Dr. Suzette Sutherland]
Then if a patient seems to think they're starting to get a urinary tract infection, I think what I understood you say, you're advocating for them to increase the dose a bit for self-treatment. What do you recommend for them if they're increasing the dose to try and treat an early onset UTI?

[Dr. Anne Cameron]
We're talking here about your reliable patient, so your reliable patient with a catheter or reliable self-catheting patient who says, "Ooh, my urine's getting a little yucky today. I'm a little cloudy. It's a little smelly. My bladder's feeling a little pre-infectious." Again, those people, I'll have them increase to twice a day to basically put the gentamicin in twice a day until those symptoms clear. Many of those patients will do this for a week, and then those pre-UTI symptoms go away on their own without them resorting to oral agents.

The freedom that I give them here, it allows them to have some self-efficacy and self-management, but it also doesn't because resistance. As we all know, resistance happens in the gut. When you expose your gut flora to antibiotics, that's when the bacteria get exposed to high doses of antibiotics, and that's where the resistance develops. You don't develop resistance in your bladder. The bacteria aren't there long enough to develop resistance. What we're trying to avoid is gut exposure to antibiotics. People who have recurrent UTIs who are multi-drug resistant, if you treat them with gentamicin, their resistance pattern actually improves because their gut is not being exposed to antibiotics repeatedly.

[Dr. Suzette Sutherland]
That's great. That's very great practical information. Thank you. Especially for those more problematic patients that we have in our urological communities. Thank you. That has been a lot of information. We've covered community-acquired UTIs. What does that mean? How do we prevent them? Moved into some more complicated urological patients, and you provided us with a lot of practical information. Really appreciate that, Dr. Cameron. Are there any other final words that you were hoping to impart with us we haven't touched yet? I want to give you the opportunity.

[Dr. Anne Cameron]
Oh, the one emerging patient population that I'm seeing now with recurrent UTIs are those patients that are using sodium glucose transporter medications, such as Genuvia, where the mechanism of action of those diabetes medications is to make those people excrete sugar in their urine, which is a great way to treat diabetes because you're eliminating sugar, and these patients lose weight, and their glucose control is excellent. However, in your recurrent UTI patients, that glucose is feeding their urinary tract infection.

I've had people where I've gotten their UTIs under control. They start one of these medications, and then their UTIs go crazy, and you have to really talk to their endocrinologist about alternative strategies, although I'm pro-controlling diabetes. If they're going to be getting recurrent UTIs because of all the glucosuria they're having, then we need to find another plan. I've had many patients where their recurrent UTIs have gone back to their healthy normal when we've stopped those medications.

[Dr. Suzette Sutherland]
Yes, that is such a great point. Thanks for bringing that up. I've seen a lot of those types of patients in my clinic, too. Would you work with the diabetes specialists? In other words, are there some things you think we can do to allow them to manage their diabetes with those new agents, but yet we do something different on our end to help prevent the UTIs?

[Dr. Anne Cameron]
If that person is not on maximum antibiotic prevention on my end, again, the woman who's not on vaginal estrogen, who's not taking Cranberry, who is now getting these recurrent UTIs, I would maximize what I could do before changing their diabetes medicine, especially in someone who has now achieved good diabetic control with this medicine. If we can meet in the middle, that would be great. When I've exhausted what I can do and they're still getting these UTIs, then that's when I reach out to their diabetes management team.

[Dr. Suzette Sutherland]
Good point. Yes, it does take a team most of the time. Thank you very much, Dr. Cameron. It's really been a pleasure to have you as our guest. We're very thankful that you have shared with us your expertise and your experience concerning these issues of recurrent urinary tract infections.

[Dr. Anne Cameron]
Thank you very much, Dr. Sutherland.

Podcast Contributors

Dr. Anne Cameron

Dr. Anne Cameron is a urologist and assistant professor with University of Michigan Medical School in Ann Arbor.

Dr. Suzette Sutherland

Dr. Suzette Sutherland is the director of female urology with UW Medicine in Seattle, Washington.

Cite This Podcast

BackTable, LLC (Producer). (2023, December 27). Ep. 42 – Recurrent UTIs: Controlling Those Nasty Little Bladder Infections [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.