We sat down with Dr. Angelish Kumar, a certified menopause practitioner and urologist in NYC, to discuss how hormones can impact the development of UTI. She gave us insight into the importance of estrogen and tips on how to treat and prevent UTI when hormones are playing a role.
Watch the full interviews on YouTube or browse the summaries below to learn more.
- Testing and What To Treat >>>>
- Antibiotics and The Urinary Microbiome >>>>
- Menopause and UTI >>>>
- Cystoscopy and Fulguration >>>>
- Inflammation vs. Infection >>>>
- Pelvic Floor Dysfunction >>>>
Testing And What To Treat
Dr. Kumar: Standard urine culture (SUC) has limitations, and it’s not uncommon for my patients who are experiencing lower urinary tract symptoms (LUTS) to receive negative culture results.
SUC is based on a technique where you take very small amounts of urine and you drop it on different plates that have certain nutrient media. One could be chocolate agar, one blood agar and a couple things can happen.
First, you may not have enough quantity of urine to accurately reflect the bacterial population in the urine. Two is that you may not grow it for long enough. The bacteria may take a much longer time to grow than you’re actually observing those plates. And three, the composition of nutrients on the plate just may not accurately reflect the composition in the bladder and so the bacteria, while it’s thriving in the bladder, may not grow on the plate.
Studies that show a technique of expanded urine culture testing, where they actually use higher quantities of urine volume on the plate, more types of nutrient media, and a longer time to observe the growth, are shown to be more sensitive than the standard cultures that are typically used by the labs that we send the urine.
Testing Restrictions for Urologists in NYC
Because Dr. Kumar is a urologist in NYC, when she has patients who she strongly suspect that they do have a urinary tract infection and their standard culture is coming back negative, she finds there is benefit in using the urine PCR testing or the urine DNA testing.
Dr. Kumar: Shockingly in New York, the labs which offer that testing are not approved. These labs don’t have something called New York state approval, so we are the only state in the country where it’s difficult to order the tests.
Some of my colleagues have actually set up urine PCR labs in their office, so my patients can get it done in New York. Other than that, I have to rely on using a urologist who’s in New Jersey or Connecticut in order to order something like the MicrogenDX or Pathnostics.
Because of the demand for these DNA tests from urologists in NYC, I think more offices will be able to set up their own PCR labs.
For patients who receive a negative SUC but are experiencing urinary symptoms or pelvic pain, I believe they can benefit from these tests.
“It’s important to keep in mind that our goal with treatment is not to sterilize the urine, but to ameliorate symptoms and prevent complications from UTI.”Dr. Kumar, urologist in NYC
How to Test for Skene’s Glands Infection
One thing that can be missed when testing for bacteria is the involvement of Skene’s glands. The Skene’s glands sit on the outside of the urethra and are comparable to the male prostate.
That’s a situation where you have a patient who’s complaining mostly of painful urination but the culture is negative. Sometimes you can detect tenderness on exam at the mid to distal urethra, where those glands are.
Infection in this location is difficult to detect because the organisms are sequestered in the gland. In these situations, I will give the patient a longer course of an antibiotic which has good tissue penetration. This is the same way we treat male prostatitis.
Aside from infection, those glands can be irritated hormonally and are actually testosterone sensitive. One thing we sometimes see, especially in women who are on the birth control pill for a long period of time, those glands are kind of irritated and inflamed even in the absence of infection.
Antibiotics And The Urinary Microbiome
Dr. Kumar: We certainly suspect that antibiotic exposure does alter the urinary microbiome
and it does make women more prone to getting another infection by reducing the amount of protective bacteria. But I think there are no conclusive studies that I know of right now.
When this occurs, the targeted bacteria may be treated with an antibiotic the other organisms are not sensitive to. Those organisms may flourish as their competitor is diminished.
So I think number one, you can get overgrowth of competing pathogens and then you can get a decrease in the population of protective bacteria. There is also a risk of other non-targeted bacteria developing resistance.
How to Replenish the Urinary Microbiome
Dr. Kumar: I think that there is a role for both estrogen and probiotics in repairing and replenishing the microbiome. One of the most important bacteria that we have in the vagina and also in the bladder is Lactobacillus.
There are some studies to show that when we take oral Lactobacillus, the Lactobacillus actually does populate in the vagina. We have vaginal probiotics on the market now which have good strains of Lactobacillus, like Lactobacillus crispatus, which you can use directly in the vagina.
When you have those strains of Lactobacillus in the vagina, it’s from there that they can repopulate inside the bladder.
The other important aspect of that is estrogen. When we replace estrogen in the vagina, we have growth of healthy lactobacilli strains and again that can help with repopulation of healthy bacteria in the urethra and the bladder as well.
You have to be very careful because there are a lot of women who have symptoms from genitourinary syndrome of menopause. That can really mimic the symptoms of a urinary tract infection where it’s that burning, that irritation, the increased frequency, and the pressure.
Hiprex as an Antibiotic Alternative
We’re uncertain if other non-antibiotic urinary antiseptics, like Hiprex (or methenamine), contribute to depletion of a healthy urinary microbiome. Hiprex works by basically making ammonia and formaldehyde in the bladder.
I think if you have a large amount of bacteria, the Hiprex is essentially working to prevent it from being able to replicate because the formaldehyde is bacteriostatic. So unless the bacteria is attempting to be active, then I don’t know that having Hiprex is going to make a difference.
How the Immune System can Contribute to UTI
A person’s immune system also has an important role in both clearing infections and repairing the bladder. The first response of the immune system to get rid of bacteria. The second response is to repair the damaged tissue.
I think you’re going to get women where their immune system gets in very quickly and is very efficient at clearing the bacteria. When they take ibuprofen for the symptoms and let their immune system do the rest, it works.
In other women, by only treating an infection with ibuprofen, that bacteria is going to hang around for a longer period of time. That’s where you may start getting these intracellular reservoirs.
If the immune system’s response is to switch from bacterial clearance to tissue repair too quickly, you actually get bacteria embedded in a deeper layer of the mucosa in the bladder. The tissue starts to repair before the bacteria is fully cleared.
When this mechanism between the immune system and bladder occurs, the body may be encouraging bacteria embedding into a deeper layer of bladder tissue.
Menopause And UTI
Dr. Kumar: In the 10 years prior to menopause you go through something called perimenopause. During that time, estrogen levels surge as well as drop low.
A lot of women aren’t expecting symptoms before they actually go through menopause, but they may start experiencing some of the manifestations of the fluctuations in estrogen.
Genitourinary syndrome in post-menopaual women also occurs. When it comes to the genitourinary syndrome of menopause, that actually progresses over time.
Vaginal dryness, vaginal irritation, itching, or severe pain with intercourse, like razor blades can all occur post-menopause. Intimacy is very difficult. It’s important to recognize that the vagina needs estrogen.
Unfortunately, when the Women’s Health Initiative study came out in 2002, everyone became afraid of estrogen. It’s important to recognize that using local estrogen is not the same as taking hormone replacement therapy. This is like your multivitamin for the vagina.
When you take hormone replacement therapy, you’re increasing your blood levels of estrogen. Hormone replacement therapy is beneficial in many ways for appropriately selected people, but using vaginal estrogen is extremely safe.
“I think it’s really important to recognize that local estrogen is very safe, and there are no studies that show that it increases your risk of cancer or thromboembolic events.”Dr. Kumar, urologist in NYC
Why Does Menstruation Affect Urinary Tract Symptoms?
Some people describe developing a UTI every time they menstruate, just before or after their period, or during ovulation. What is the link between the fluctuations in the menstrual cycle and UTI?
Dr. Kumar: A lot of women develop urinary symptoms which are cyclical. You can get overgrowth of bacteria when there’s a lot of blood, which is nutrient-rich, in the vagina.
I think bladder symptoms can certainly be cyclical, and if it turns out that it actually is a UTI, then it most likely has to do with changes in the vaginal microbiome at that time that are making you more susceptible.
For women who tend to have more pelvic pain urinary symptoms and show no white blood cells on the urinalysis, even with the limitations of SUC, then I think that’s an indication that it’s not necessarily an infection. It could be something like endometriosis.
Cystoscopy And Fulguration with Dr. Kumar, Urologist in NYC
Dr. Kumar: Cystoscopy is when we take a look inside the bladder to evaluate the lining. I’ve seen in patients with recurrent urinary tract infections, someone who’s had chronic infections, we often see something called cystitis cystica. This the bladder’s response to chronic inflammation.
The cells just sort of heap up on top of each other and form tiny nodules. I’ve had some patients where I’ve seen that and we’ve done a low-dose nitrofurantoin, like a daily nitrofurantoin to prevent UTIs for six months, and then I re-scope them and it clears. It’s pretty amazing.
I’ve also seen a discrete area of inflammation and the tissue looks very ragged and has almost formed a plaque. I had a patient where I biopsied the tissue and I actually demonstrated the growth of bacteria in the tissue.
I think that our ability to demonstrate the areas of embedded UTI cystoscopically would be wonderful. Additionally, we always want to look inside if we have a patient who has irritative bladder symptoms and they’re not responding to antibiotics.
You have to make sure there’s no cancer in the bladder. Sometimes you may even find endometriosis on the inside of the bladder. It’s pretty rare, but that has certainly been found as well.
Dr. Kumar’s Cystoscopy Procedure
When we perform a cystoscopy, we use a very strong numbing jelly in the urethra. I often will dilate the urethra a little bit very gently so that when the scope goes in it’s not traumatic.
I’ve had a lot of patients who’ve seen other urologists and they’ve been really traumatized by the cysto experience. I think it just has to be done right. The risk of getting a UTI from the cystoscopy is about 1-2%. In our office, we are very meticulous about sterile technique and numbing and things like that.
Most people will have a little inflammation at the trigone or something that we call squamous metaplasia, or they’ll have some area where you can tell they’ve had a UTI and there’s some inflammation of the tissue.
In about 60 to 70 percent of patients we find something on cystoscopy that we wouldn’t have otherwise seen. Occasionally, I have a patient who’s symptomatic and I don’t see a single thing that I would biopsy or cauterize. It looks pristine.
In these instances, I’m more prone to believe that their symptoms are from genitourinary syndrome of menopause.
Bladder trabeculation is when there is a thickening of the muscle fibers in the bladder wall. It’s usually seen in men. We often see it when the prostate is obstructing and creating an outflow obstruction so that the bladder muscle actually has to work harder to get urine out.
In women, we actually tend to see it in women with overactive bladder. On the cystoscopy you’ll see where it looks like there are bands underneath the mucosa and those bands are just actually areas where the muscular layer of the bladder and muscle fibers are just thickened.
Sometimes it can be a manifestation of a disease which is neurologically affecting the bladder, but in most patients it’s mild and there’s nothing to treat aside from overactive bladder or an outlet obstruction.
Often in women who have had urinary tract infections, we can see areas where the bladder tissue has reacted to inflammation. Sometimes small, raised nodules will be visible. It’s felt that these nodules may be areas where the bacteria can reside.
You can use a very small instrument to cauterize these nodules, which means you’re essentially gently burning them. This can be compared to zapping off a skin tag in a dermatologist’s office.
Fulguration is basically the same thing. We’re very gently cauterizing the nodules.
Dr. Philippe Zimmern out of UT Southwestern, has done studies showing that while it doesn’t help 100% of recurrent UTI patients, about 50-60% of women have had less urinary tract infections.
There’s not a lot of risk in gently cauterizing these lesions. I think that the risk is high when you are resecting deeper pieces of tissue in the bladder and if you’re doing it in multiple areas, throughout the bladder. There is a greater risk of scarring and fibrosis.
Inflammation vs. Infection
Dr. Kumar: Something that we see often is a woman who has been treated for a UTI but continues to have irritative symptoms. I think in that situation, we have to look at the trajectory of those symptoms.
If the symptoms are getting gradually worse, where you’re noticing that you’re requiring pyridium every day, and it’s keeping you up at night and you’re waking up three or four times, whereas that’s not what you normally do, then I think you have to consider that this may be an infection that wasn’t fully treated.
For example, when urinary urgency increases, this can be a sign of the bladder being sensitized. The nerve endings which normally aren’t active become active during an infection. They begin responding to the bladder stretching, whereas normally they wouldn’t.
You can also have some areas of tissue destruction and inflammation that occurred because of an infection. This destruction and inflammation can persist and cause some symptoms even after the infection is treated.
It’s always reasonable to retest the urine. If white blood cells, red blood cells, and inflammatory markers have cleared, and symptoms are improving, then you can assume your bladder is in a process of healing.
It’s important to prevent new infections during this time to limit the tissue damage and inflammation and allow the bladder to heal.
Dr. Kumar’s Method to Preventing UTI
Dr. Kumar: As a preventative regimen at our urological clinic in NYC, we use things like PAC, vaginal estrogen, probiotics, and after sex prophylactic antibiotics.
PAC, or proanthocyanidin, is the active ingredient in cranberry. PAC prevents bacteria from adhering to the lining of the urinary tract. Taking PAC differs from taking a cranberry product or juice. Often, those products do not contain a high enough concentration of the PAC enzyme.
In postmenopausal women, I will use vaginal estrogen as a preventative. It’s a very low risk, high reward strategy. The concerns about using estrogen in terms of it being a hormone are more relevant to using estrogen as a hormone replacement therapy.
When it’s used in the vagina, it’s not elevating your blood levels of estrogen to a premenopausal state. When vaginal estrogen has been used in mice, it’s been shown to help the tissue healing process in the bladder after a UTI, and it works by enhancing the healthy vaginal microbiome of the vagina.
Taking a probiotic as part of a preventative regimen is harmless and potentially beneficial. I have found using vaginal probiotics with some patients to be beneficial.
The last thing would be post-coital prophylaxis. I think that’s a very appropriate strategy. You’re better off taking one pill after intercourse than taking a short, therapeutic course of antibiotics.
An additional simple recommendation would be increased fluid intake. There was a study in JAMA about a year and a half ago showing that when women increased their fluid intake by about 1.5 liters, their frequency of UTI decreased.
Pelvic Floor Dysfunction
When pelvic floor dysfunction (PFD) is involved, how can you tell if the PFD caused the UTI or if the UTI caused the PFD?
Dr. Kumar: For patients I’ve seen who have had UTI, I think the pain has caused them to have pelvic floor dysfunction. They may still feel like they have a UTI, but when we treat with additional antibiotics, the pain doesn’t subside, and on exam the muscles are contracted and not relaxing, pelvic floor therapy is more beneficial.
Unless PFD is causing urinary retention, which can cause a UTI, it’s more likely that the pain from a UTI is causing a reactive pelvic floor.
PFD can also be caused by other sources. Pelvic floor laxity can result in a prolapse, or dropped bladder. For these patients, surgery may be an option after pelvic floor therapy has been tried.
In our urological practice in NYC, we have a list of pelvic floor therapists to whom we refer. Unfortunately, many patients are recommended to do pelvic floor strengthening exercises. But when the muscles are already contracted, this is counterproductive. We refer to therapists who work with women to relax those muscles with stretching, myofascial release, and massage.
The hormonal stages that women transition through can affect not only vaginal health, but bladder health as well. We are grateful to Dr. Kumar, a urologist in NYC, for taking the time to answer these important questions around hormones and recurrent and chronic UTI. As Dr. Kumar pointed out, hormonal imbalances can cause urinary tract symptoms. This can be an important consideration when seeking a proper diagnosis.
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