More microbiome news … Urinary Tract Infection

Focus on:

The causes of UTI, why it matters and looking especially at recurrent UTI in postmenopausal women and in men with poor urine flow due to benign prostatic hyperplasia [BPH]. All these lessons are equally applicable to your daughters.

This matters, because…

Urinary infection is dangerous: either in your parents, or if you are 65+ for you, too.

If there is a UTI and delay in diagnosis; or antibiotics are either not prescribed or deferred, then 25-30% [ 5-6 in 200] end up in hospital, about 1 in every 200 have septicaemia and overall 2% [4 in 200] die, but that rises to 5.4% [11 in 200] of the untreated who may not get even get to hospital i. The authors say…

 

Finally, 2.0% (6193/312 896) of the participants older than 65 years who presented to their GP with a UTI died within 60 days; 5.4% (1217/22 534) for no antibiotics, 2.8% (545/19 292) for deferred antibiotics

And, as always, this is preventable and fixable if you take a proactive approach.

Where are you on this?

Specific risk factors

BPH: men with residual urine have a stagnant pool in which [often overnight] any bad bugs that are there can multiply.

Women not on HRT or using local oestrogen: A female gynaecologist wrote in Medscape recently “Vaginal Dryness is killing women, now”.

This is clever use of humour to draw attention to a serious truth. The lack of oestrogen that causes vaginal dryness also damages the protective vaginal microbiome [of mainly lactobacilli]. In their place coliform bacteria colonise the vulval and perineal area surrounding the entrance to the bladder. The risk of these getting into the bladder increases dramatically. Hence vaginal dryness is contributing to UTI and to the morbidity and mortality described above.

Old and infirm: I mention this as many of you have elderly relatives. UTI is a silent and deadly threat. Often in the summer, when the elderly are dehydrated and not flushing urine through, they just - one morning - seem a bit below par. Low appetite, not themselves … no drama and often no temperature or urinary symptoms. UTI is the commonest cause and needs to be checked for, urgently.

Diabetes: UTIs are more common in diabetics. Glycosuria [sugar in the urine] increases the risk of UTI by making the urine a great culture medium for bugs. The SGLT2 inhibitors like dapagliflozin and other -flozin drugs work by making the kidney pump more sugar into urine so they exacerbate this trend ii.

The picture is complex. There is an increased risk if HbA1c control is poor and local female hygiene, often more of a problem in the overweight, or poor flow mechanics and residual urine in men with BPH also contribute. Any cause of diminished immunity increases the risk.

Understanding the Female issues

UTIs are usually caused by E Coli [of other ‘coliform’ bacteria] that come from faecal material. Even using moist wipes after a bowel movement doesn’t completely remove bacteria from the perianal area [though this is a good strategy]. The nature of the female anatomy means that the distance between the anus and vulvo-vaginal area is small and in underwear [and tights or sanitary pads, pantyliners] or with any hygiene issue, those bugs are around the bladder entrance. Any degree of vaginal laxity that has followed childbirth increases vulnerability.

If there are other bladder issues and the bladder is incompletely emptied this increases infection risk.

Sex stirs things up a bit and encourages any bacteria that are in the vulvovaginal area to get into the bladder.

Finally, many women pee then wipe from back to front increasing the risk of coliform bacteria getting into the bladder - this is a habit to change.

Understanding the Male issues

UTIs are most prevalent in those with BPH. Men also need to be careful about local hygiene and if uncircumcised, cleaning under the foreskin. Older men may relax their hygiene!

What does good look like?

Both sexes:

Be aware of the risk. If you think you may have a UTI test yourself with a SureSign urine test stick. [Get these in, in advance], or other brand depending on where in the world you are.

If you are positive then this is an emergency that justifies getting antibiotics immediately, by whatever means are available. Be insistent, don’t delay.

Double void: every time you go to pee then pee- wait - pee again – and maybe another time too. Aim to be fully empty.

Use moist wipes to clean the perianal area after a bowel motion. Wash all the naughty bits every day [just soap and water]

If you are diabetic this is another reason to get your sugars under tight control and to be very alert to UTI risk..

Men

If you have a poor stream, ask your Dr for medication to increase the flow [not anti- androgens!]. Tamsulosin is non-toxic.

Women

Wipe front to back, always

ALL women not taking HRT should consider vaginal oestrogen. It stops any soreness or irritation, allows the lactobacilli to come back, and reduces UTI risk. There are zero risks.

It just means putting a small tablet into the vagina at bedtime. You can buy this over the counter in the UK without a prescription. The instructions tell you to take it for 2 weeks every day and then reduce to 2x weekly. If you do that, 30% of women get no effect. My recommendation is everyday Mon-Fri. There is a vaginal ring that delivers low dose oestrogen that a doctor can prescribe.

Be sure to pee after sex and ideally wash.

What might stop you?

All of this is evidence based – it is not a personal opinion. Any doubts – email me. There is nothing here that is at all difficult, or controversial.

What should you do now?

Tick the boxes, please!

If you have recurrent UTIs that is also fixable – but a discussion for another time.