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When To Go To A Doctor For UTI: Dr Michael Hsieh On Recurrent Urinary Symptoms

Melissa Kramer
When to go to a doctor for UTI

When to go to a doctor for UTI? What doctor to see for UTI? Should I see a urologist for recurrent UTI?

We get so many of these types of questions. Part of our mission at Live UTI Free is to provide information about testing and treatment options, so recurrent UTI sufferers can make their own decisions about their journey to recovery.

As part of our series on recurrent UTI treatment approaches, we spoke with Michael Hsieh MD, PhD.

Dr Hsieh, a urologist that specializes in both pediatric and adult urology, is based in Washington DC. He has extensive experience in laparoscopic and robotic surgery for urologic conditions, but also runs a bladder biology research group.

Everything you read below is based on our interview with Dr Hsieh.

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When To Go To A Doctor For UTI?

When should you see a doctor for UTI? The safest answer to this question is: as soon as you have symptoms.

For people who experience recurrent UTI, this can be a time consuming, expensive and frustrating exercise, particularly when their personal history has shown that the symptoms will eventually subside.

But the fact that UTI symptoms do recur, and are always painful, could be a good enough reason to see a doctor for UTI.

Perhaps a more important consideration is this: Do you know that your urinary symptoms are caused by an infection?

There are many different illnesses and conditions that can cause symptoms similar to a UTI. Some are more serious than others. The upshot is, if you haven’t looked into the cause of your recurrent UTI, it could be time to see a doctor.

In our interview with Dr Hsieh, we discussed other potential causes for recurrent UTI symptoms. This list is by no means exhaustive, but will hopefully provide some insight on why seeing a doctor for UTI is a good idea.

Possible causes for urinary symptoms (other than infection):

“Occasionally patients are just drinking way too much water. And so if I get that sense, sometimes I ask patients to keep a bladder diary where they record their intake and outtake. And then you realize they’re drinking two gallons of water a day, and only weigh 100 pounds. And I point out to them that that's not typical, and that if they have excessive urine output and urinary symptoms because of that, that's not so surprising."

Dr Michael Hsieh, MD, PhD

Because your UTI symptoms may not actually be caused by a UTI, there’s a strong argument for considering seeing a gynecologist, urologist or urogynecologist early on. This is particularly important for patients who have had pelvic surgery or any pelvic injuries or treatment in the past.

If you’re wondering when to go to a doctor for UTI, and you’ve never considered other causes, the time could be now.

When To Go To A Doctor For Recurrent UTI

In addition to deciding when to go to a doctor for UTI, you need to decide what type of doctor may be most helpful.

How To Find A Doctor For Recurrent UTI

If you are seeking the help of a urologist, there are a few things to keep in mind. In reality, most urologists specialize in male urology, and they are primarily surgeons. In many cases, a urologist may not be helpful for recurrent UTI.

Some urologists, however, have a specific interest in female recurrent and chronic urinary tract infections. It’s important to locate one of these specialists.

“I think unfortunately, some urologists, and I'd like to think it's a minority, get frustrated with recurrent UTI, partly because they feel like they don't have much to offer. They feel even more helpless when the urine cultures are coming out negative. I'm all about patient empowerment, and I encourage patients in that situation to seek out providers who are comfortable managing patients who do get culture negative UTIs, particularly providers who are willing to do enhanced quantitative cultures, or microbiome testing and are open at the very minimum to discussing the literature on non-antibiotic approaches to UTIs."

Dr Michael Hsieh, MD, PhD

The Link Between Recurrent UTI And Interstitial Cystitis

With the rise in the availability of more advanced UTI testing techniques, the possible link between recurrent UTI and Interstitial Cystitis (IC) has once again come under the spotlight.

Many whom have been previously diagnosed with IC have been able to identify urinary pathogens via newer testing methods.

And with the identification of these pathogens, appropriate treatment has followed, resulting in a resolution of symptoms that were once assumed to be untreatable.

If you’ve been diagnosed with IC after previous negative urine culture tests, you may now have an opportunity to reassess your diagnosis.

Science has provided new ways to look at chronic urinary tract conditions. In the case of Interstitial Cystitis, where standard urine culturing has been unable to pinpoint the cause, DNA sequencing has identified infection in thousands of IC patients.

Dr Hsieh uses these testing techniques that look at the urinary microbiome, rather than relying solely on the standard urine culture, which has been shown to be very inaccurate.

“I've seen patients who have been labeled as having IC, and in my opinion, they didn't even have sufficient diagnostic interrogation. And on top of that, microbiome analysis clearly shows pathogens in their urine. Then you treat it, and their symptoms go away. So pretty clearly it wasn't any kind of IC in that situation."

Dr Michael Hsieh, MD, PhD

Dr Hsieh’s Personal Interest In Recurrent UTI And Interstitial Cystitis

Michael Hsieh has studied the immune system and infections for more than 25 years. Around 16 years ago, as a urology resident, he became interested in researching and treating chronic UTI. Since then, his research has been supported by grants from the NIH.

Throughout his research, Hsieh has studied the naturally occurring microbiome, and how the presence of non-pathogenic bacteria may prevent urinary tract infections. He also headed a research group focussed on bladder inflammation, UTI and bladder cancer.

When To Go To A Doctor For UTI: Dr Hsieh’s Experience

Most patients that see Dr Hsieh for urinary tract infections have suffered from multiple episodes and are desperate for something that works. His investigative approach has enabled him to assist patients with previously unidentified urinary pathogens.

“I am very careful about labelling patients with Interstitial Cystitis, I think a lot have occult UTI with difficult to culture organisms. By utilizing more accurate testing methods we are able to identify pathogens in many cases, and develop appropriate treatment."

Dr Michael Hsieh, MD, PhD

Dr Hsieh takes a multi-pronged approach to UTI diagnosis, treatment, and prevention. In order to reach a diagnosis, he supplements conventional urine testing (which has significant limitations) with microbiome-based techniques. Learn more on that below.

Why Some Urinary Tract Infections Are So Hard To Test For

People who experience recurrent UTI or IC often describe frequent individual episodes of flaring symptoms. It is possible that these seemingly individual infections are actually a single infection that has never been properly treated.

With this type of chronic infection, UTI symptoms may ebb and flow, or they may be continuously present.

A chronic infection like this is caused by pathogens living within your bladder wall, or in structures called biofilms.

"Dans le cas d'une infection urinaire chronique, un biofilm peut être défini comme une colonie de bactéries : elles se regroupent et se collent à la paroi de la vessie. Ces bactéries produisent un film protecteur qui les isole des antibiotiques et des attaques du système immunitaire."

Your body naturally flushes out free-floating pathogens in your urine, but biofilms and pathogens within the bladder wall remain intact…

Biofilms and intracellular communities make diagnosis and treatment very difficult as the pathogens contained within them may not pass into your urine, and will therefore not be detected by testing.

“I think biofilms play a major role. Although a number of practitioners are reluctant to embrace the concept, in my opinion, it's pretty clear that it's a true phenomenon. It would explain why a given patient can get what seems like an appropriate antibiotic based on antibiotic susceptibility testing from cultured bacteria. Then as soon they stop taking the antibiotic, even if they've taken it for a week or two, the same exact bacterial isolate comes roaring back, with the same antibiotic susceptibility. Why wasn’t it wiped out? Well, I think sometimes it's intracellular bacterial communities, or biofilms."

Dr Michael Hsieh, MD, PhD

Can You Test For Biofilms Or Chronic Infection?

While standard urine culture is unlikely to identify pathogens within epithelial cells, or pieces of biofilms that are shed into the urine, microbiome test methods should be able to.

In this case, you’re not testing to see whether a biofilm is present per se. Instead, genetic sequencing techniques are able to pick up the DNA of bacteria present, regardless of whether or not they would grow on a culture plate.

The limitations of the standard urine culture mean we know very little about what should and should not be in the urinary tract. This also makes it difficult to know what to treat.

Microbiome testing is helping scientists find organisms in the urinary tract that were never considered possible. For recurrent UTI sufferers who receive negative urine culture results, this newer type of testing could provide answers.

“With Microbiome testing, you don't often get one bacteria. Certainly, I have found the usual suspects like E. coli. I’ve even detected some STIs, and anaerobes that can’t be grown by culture. Sometimes, you get long lists of bacteria that we know very little about, and I'll do extensive literature searches and sometimes barely come up with one or two papers. And so what I generally do in that situation is to try and figure out which are likely to be pathogenic, and treat those. This is a really different way of prescribing antibiotics compared to when I was trained."

Dr Michael Hsieh, MD, PhD

For those considering when to go to a doctor for UTI, there is another layer to be taken into account. Is your doctor open to using more advanced testing techniques to help you find answers?

Dr Hsieh’s Recurrent UTI And Interstitial Cystitis Treatment Approach

The key to Dr Hsieh’s approach to recurrent UTI treatment is to evaluate each patient’s case individually. He also makes a point not to dismiss patient symptoms. In Dr Hsieh’s own words:

“UTIs are caused by interactions between our bodies and bacteria that are perceived as harmful by our immune system. How these interactions play out are different not only for every person, but also every infection. We are all unique genetically, including genes that determine how our immune systems react to infections, and properties like how “sticky” the lining of our urinary tracts are for bacteria.

These genes are subject to changing their activity by epigenetic alterations, which are reversible ‘marks’ that our bodies place on DNA in response to environmental factors, such as stress and prior infection exposures.

Layered on top of all of this is our microbiome, the community of thousands of bacteria living in and on our bodies, including in the urinary tract. Bacterial members of the microbiome can differ significantly from one another, even when of the same species. Thus, how these highly unique bacterial strains interact with our epigenetically modified genes can result in very different UTI symptoms and patterns for each patient.”

There are two main differences between the approach of Dr Hsieh, and the approaches of many other practitioners. First, is testing.

Dr Hsieh uses microbiome analysis to supplement testing of patients, especially if they have culture negative infections. He also uses Expanded Quantitative Urine Culture (EQUC), which has been shown to be much more accurate than a standard urine culture.

Second, there is a difference in Dr Hsieh’s therapeutic approach. While antibiotics are still a mainstay for treatment and prevention, he also tends to recommend non-antibiotic alternatives that have reasonable data in favor of them. These include certain probiotics and certain cranberry products.

How Long Does Recurrent UTI Treatment Take?

Occasionally, Dr Hsieh sees his patients turn around very quickly. Some patients who have had multiple UTI episodes in a three to six month period, have changed their regimen and quickly become symptom free.

Unfortunately, this is not typical. Most patients require six months or longer of management, before a resolution of their symptoms. Dr Hsieh reports that around 80% of his recurrent UTI patients do recover completely.

It isn’t easy to know when to go to a doctor for UTI, particularly when you’ve experienced symptoms on a recurring basis. If you are thinking about trying again, it pays to do your homework. Find a doctor that is aware of new research and treatment approaches.

Bladder Instillations For Recurrent UTI Treatment

Dr Hsieh typically starts patients on an oral antibiotic, along with probiotics and other supplements. If this approach does not prevent breakthrough symptoms, bladder instillations may be the next step.

Bladder instillations enable the delivery of high concentration antibiotics directly to the bladder, via a very small, pre-lubricated pediatric catheter.

Of course, this method is technically more invasive, requiring the insertion of a catheter through the urethra, but it’s likely it reduces any impact of antibiotics on the gut.

For recurrent UTI patients who have taken numerous rounds of antibiotics, this can be an important consideration.

Patients are trained to administer bladder instillations themselves, usually once or twice per day for various periods of time. The ideal treatment regimen for bladder instillations is still unknown.

[Insert catheter instillation image…]

The antibiotic is placed into the catheter, which is then inserted through the urethra. The medication is delivered into the bladder, and ‘held in’ for as long as possible, before it is passed as urine normally would.

Dr Hsieh often recommends delivering the instillation right before bed time, to maximize the time the antibiotics are in the bladder.

Of the patients treated with bladder instillations, Dr Hsieh has seen good responses in many. The response is not necessarily immediate, but this approach does appear to be a good option for certain patient populations.

Is It Important To Restore The Bladder Lining?

A healthy bladder is lined with a mucus-like, protective layer that prevents potentially harmful substances from the urine from entering deeper layers of the bladder wall.

This protective bladder lining (the urothelium) has a high density of glycosaminoglycans, also known as GAG. And this is where the name GAG layer comes from.

Chronic infection may cause damage to the GAG layer, making it more difficult for the bladder to heal, and impacting normal bladder function.

Because of this, the restoration of the urothelium GAG layer has been adopted as a therapy for Interstitial Cystitis and recurrent UTI.

A review of the studies around restorative therapy showed that patients participating in various clinical trials were likely to experience an improvement of one type or another.

Dr Hsieh considers this type of therapy a last resort.

“The GAG layer is basically a slime that helps protect the urothelium. I do think that there are treatments that can help restore a normal, more normal gag layer on the urothelium, which would hopefully be more biofilm resistant."

Dr Michael Hsieh, MD, PhD

Is Antibiotic Treatment Necessary For UTI?

It was long thought that urine is sterile. This mistaken belief is based on old studies that relied upon the ability to grow bacteria in the laboratory.

These studies failed to grow bacteria out of the urine of most healthy individuals, and this led scientists to believe that the urine is typically sterile.

However, the advent of molecular, non-culture-based methods to detect the bacteria in and on our bodies (the microbiome), has revealed that the urine may never be sterile, even in healthy people.

“Even as a physician who has conducted microbiome research for a number of years, I was initially skeptical of urine microbiome testing as a means to diagnose UTI. However, I have had multiple patients who had standard urine cultures that lined up exactly with their microbiome testing, and quite a few patients who had “positive” microbiome testing followed by a subsequent UTI. This strongly suggests that microbiome testing is not only accurate in the right setting, but also may predict imminent UTI in some patients."

Dr Michael Hsieh, MD, PhD

There are certain ramifications of the discovery of the urinary microbiome. One is that asymptomatic bacteriuria should not necessarily be treated.

If there is supposed to be bacteria in the urinary tract, why would we try to wipe them out when the patient is not experiencing symptoms?

A caveat to this is pregnancy. It does appear that treatment of asymptomatic bacteriuria may still be important in this patient population.

A second consideration raised by the discovery of the urinary microbiome, is how the use of any antibiotic may impact the balance of bacteria in the urinary tract. It can no longer be assumed that antibiotics do not cause issues in the urinary tract, as much as they may also treat or prevent them.

For these reasons, Dr Hsieh may recommend a non-antibiotic therapy approach, particularly in patients who have had adverse experiences with antibiotics, or who experience very mild UTI symptoms.

When To Go To A Doctor For UTI Caused By Antibiotic Resistant Bacteria

Dr Hsieh has seen, in many patients with antibiotic resistant infection, that if exposure to antibiotics is avoided, the antibiotic resistant strain disappears over time.

In other words, if you have an antibiotic resistant organism at a given time, it does not necessarily mean you’ll always have that. In fact, it will probably be eliminated by your body, or be out-competed by other bacteria.

Possible antibiotic resistance is one of the reasons Dr Hsieh works to support the urinary microbiome, rather than recommend prophylactic antibiotics.

Prophylactic antibiotics refers to the preventative use of antibiotics, at low doses, over an extended timeframe. This may be a daily dose, or a dose taken after sex.

Although prophylactic antibiotic use is common, studies have shown there may be other reasons to avoid it, including antibiotic resistance. We’ve covered this in more detail in our article about recurrent UTI treatment.

How To Make An Appointment With Dr Hsieh

Dr Hsieh currently sees pediatric chronic UTI patients at the Children’s National Health System. You can visit the link for more Information on how to make an appointment.

Appointments with Dr Hsieh are covered by healthcare insurance in most cases. For uninsured patients, Dr Hsieh does his best to make fees reasonable and within their financial means.

What Types Of Patients Can Make An Appointment?

Dr Hsieh’s office is open to all pediatric patients. This includes female and male teenagers and children of any age, including fetuses.

Many of Dr Hsieh’s patients have more complex anatomy due to prior surgery or congenital urologic conditions, however, a significant number of patients are sufferers of recurrent UTI who are otherwise healthy.

When To Go To A Doctor For UTI In Children And Adolescents

The question of when to go to a doctor for UTI may be even more pertinent for infants. In these cases, it’s important to see a pediatric specialist that can help.

Dr Hsieh’s specialty in pediatric urology extends to transitional urology for adolescents. What is transitional urology?

Patients born with congenital genitourinary conditions require complex care early in life, but also as they progress through adulthood.

Transitional urology provides continuity in this care, supporting these patients through childhood, adolescence and adulthood.

“So the best analogy is: kids with congenital heart disease rarely used to make it through childhood, even with the best attempts at care. But both medical and surgical care have improved. Now these patients routinely survive to adulthood. As a result of that, then there was a new adult patient population with congenital heart disease that required adult congenital cardiologists or basically transitional cardiology. The same thing has happened in urology, there are a number of congenital urologic diagnoses that used to routinely, unfortunately, lead to death in childhood. But now almost all these patients survive to adulthood. That's given rise to the field of transitional urology."

Dr Michael Hsieh, MD, PhD

How To Prepare For A Urology Appointment With Dr Hsieh

The more information you can provide regarding your own experience with UTI, the better. Dr Hsieh recommends you prepare as much of the following as you can:

This may seem like a lot, but it’s important for urologists to look at all patient results and imaging. There could be subtleties relevant to UTI that the person who prepared the results may not have commented on.

If you have completed any recent testing and have not received your results before you attend your appointment, it’s important that you grant Dr Hsieh access to the results, prior to your appointment.

“After five years of experiencing recurrent UTI’s and being on antibiotics, finally for the past seven months I have been symptom free of UTIs and most urine tests showed no bacteria. I think that the supplements Doctor Hsieh recommended have helped. In addition, Dr. Hsieh suggested I have a microbiome testing of the urine. The results of this test showed that I had biofilm/intracellular bacterial communities. Which allowed him to treat me accordingly. I could not believe that I was symptom free and felt normal for the first time in many years!” Maria, Patient

As always, if you have any questions or comments, you’re welcome to leave them below.

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