Special Announcement – September, 2022:
UTI and Sex. It should come as no surprise that sex is one of the most common triggers for UTIs. But is there anything you do about it, aside from taking antibiotics?
And how do you know whether a sexual partner may be contributing to or causing the issue? Can UTI causing bacteria be passed back and forth between partners? Of course they can. So when should a partner be tested?
Watch the video to learn more, or read the full transcript below.
Jump To Section:
- Video 5 Transcript: UTI And Sex. >>>>
- UTI And Sex: How Infection Can Be Transferred. >>>>
- UTI And Sex: Symptoms To Look Out For. >>>>
- The Mental Health Burden Of UTI And Sex. >>>>
- Other Everyday Risk Factors For UTI. >>>>
Video 5 Transcript, UTI And Sex: Should I Get My Partner Tested?
Melissa: Some of the main questions that we get from our audience are around sex and UTIs. We get a lot of questions about how you can avoid UTIs after sex, whether a partner may be contributing to UTIs after sex and just a whole bunch of questions, and I was hoping to get some insight from you on those.
And so maybe first you can give us an idea of what the current theories are about why sex is a trigger for UTIs?
Dr. Hlavinka: Gosh, sex and UTIs. It kind of seems to go together doesn’t it, unfortunately. And it does for some women, unfortunately, and I will broaden the scope of the discussion to say if you’re not looking at couples you’re not looking at the full spectrum of risk factors for women.
You can’t just isolate women, and so many times I see the partner not involved. And it can be a
same-sex partner, or if a woman has multiple partners, or their partner has multiple partners. And so sometimes you’re talking about a non-monogamous relationship where one of the partners is the person carrying and here is the problem.
And why I can’t get my colleagues to accept this. There are asymptomatic carriers out there. The whole notion of asymptomatic carriers, what does that mean? That means a person who’s got a microorganism living on their body, in their body, in their body cavity, in their prostate, in their vagina, and it’s not causing any symptoms and they can pass that on to somebody else with no symptoms.
Can A UTI Be Transmitted During Sex?
Most people are aware of the classic sexually transmitted infections, Chlamydia, Gonorrhea, Syphilis, and the viruses of Herpes and the Human Condyloma Virus. So the problem is we are aware of asymptomatic carriers in those infections and we have very good public health policies for identifying asymptomatic carriers when somebody comes in for those infections, but we don’t have those for traditional infections or the typical organisms of urinary tract infections.
And that has been my problem, because so many times I find the carrier. I think I’ll illustrate by an example. I had a couple, he was a truck driver here in Texas. It’s hot and he had chronic wetness down there, all right. He had seen two years of doctors, primary care, infectious diseases, dermatologists.
He’d been biopsied and swabbed and poked and prodded and treated with all manner of all kinds of stuff and it just wasn’t working. She got urinary tract infections and chronic vaginal infections. So she had both vaginal infections, vaginitis and cystitis. Bladder infections. Nobody could find the same organism. He didn’t have an infection – they had done everything on him – he didn’t have an infection.
She was getting these chronic infections. She came to me and I said what is your husband experiencing? Well, the dermatologist failed and he’s got this thing. Bring him in. So I have him void into a cup. I swab her vagina, I swab both of his groins because I want to have a control to make sure, and I get the organisms back and guess what?
It is three common coliform urinary tract organisms. It’s E. coli, Klebsiella and Enterococcus on both sides of his groin, in his urine, in her vagina, and in her bladder.
So they had had three microbes they’d been passing back and forth for two years. I gave her two weeks of antibiotics. I gave him two weeks of antibiotics and creams. I’m a hero, they think I’m like you know, the man who landed on the moon. And it was a simple thing to do.
And this is what I believe is the most important thing that we can do, is to recognize that we don’t know what we don’t know, and we have to keep digging for information when presented with a complex patient.
How Often Is The Partner A Contributor To UTI And Sex?
I actually submitted a paper to a meeting that got rejected, so maybe somebody will discover this and decide to publish it, or accept it at a meeting. I’m not bragging, not bragging, just saying hey, this is really important information and I don’t think anybody else is telling you that out there.
I have a series of ten couples and these are heterosexual, monogamous couples and who had been passing an organism back and forth. And they were like that couple for two years and they also were those for which one member was asymptomatic.
In other words, of these couples, in six of them one of the members was asymptomatic, right. So under those circumstances that person had no idea. I did traditional cultures – absolutely worthless. These are 20 human beings right, 10 males, 10 females and 10 different couples, monogamous couples.
Why Standard Urine Culture Should Not Be Used
And traditional cultures only show four organisms in the whole 20 people, all right. PCR showed the correct organism in only six people out of the 20. Next generation sequencing showed the
organism in both members of the couple in all 10 couples, so in all 20 people NGS showed the culprit in all of them.
That is how worthless traditional cultures are, and PCR is when you’re coming, and I can’t say that, I have to be a scientist. And I can’t say that is the case otherwise, but what I am seeing in couples passing things back and forth – we’re missing the boat. And we’re missing the
boat because our detection techniques are wrong.
Number one, we’re not looking for the partner. Number two, we’re looking at the wrong techniques. So it’s very important to recognize that there’s a whole heck of a lot more sexually transmitted infections.
UTI And Sex: How Infection Can Be Transferred
And I want to say that STI, sexually transmitted infections, the classic ones that we think are bad, and the ones that aren’t the problem, is that there’s a whole lot of infections that people are giving to each other.
However you want to call those, I like to call them sexually related infections because they take
away from the stigma of the STIs that we’re all familiar with. So if you have a sexually related infection then you need to find, you need to look for the partner, and you don’t know what you don’t know, if you don’t look at the partner. So that’s part of the problem.
UTI And Sex: Where Do The Organisms Come From
The next part of the issue is the fact that intercourse and all of its, let’s just say, perturbations can cause an infection. And so when we kind of typically think of the penal vaginal intercourse, well that’s one set of risk factors, but if there’s anal intercourse or even anal contact happening then that can happen.
For instance, I have seen over my career the organisms, and this certainly accelerated after we got next generation sequencing, the organisms go toward more mouth organisms as people are having more oral sex.
For instance, Beta strep you used to never see in the urinary tract. But now, I will tell you that when I started doing next generation sequencing about 30% of the infections and a big reason why people were not getting cured was that Beta strep from the mouth was the organism. And it’s actually pretty easy to eradicate.
Beta strep is a common organism that causes tonsillitis in adults and kids. Most adults are carriers, are asymptomatic. You’d have to swab their tonsils or their throat, the back of their throat, to find this organism. But they can sure pass it on during oral sex.
And so that’s why I think it’s very important to look for these. So those are the mechanisms of how that can happen. Again if there’s an abnormality, if someone has say, for instance, incontinence or they have fecal incontinence or they have an oral infection, you know they have a gum infection, all of that can increase what’s been discovered in the urinary tract as infections.
Now let me just say that the organisms that are considered sexually related in my book has advanced markedly since I started doing NGS three years ago.
UTI And Sex: Symptoms To Look Out For
Melissa: Okay. So are there things that someone should look for around this topic if they’re trying to discover whether their partner may be a contributing factor? Should they be trying to monitor their positions? Whether they have oral sex? Whether their symptoms come on a certain amount of time after sex? How would they know that it might be something to do with their partner?
Dr. Hlavinka: Absolutely. And that can be something as subtle and immediate as what you’re saying, Melissa, that if they notice burning or irritation afterwards, increase in frequency, odor, change in vaginal discharge, all those things can be subtle signs that there’s been an insult by a microbe.
And even more subtle symptoms, like for the man a lot of times the woman will notice, and again again I’m talking about heterosexual, monogamous couples. I can go off on homosexual couples in non-traditional coupling, but it just kind of gets a little bit more in the details so I am going to focus on heterosexual, male-female sexual encounters again, because most of my database is on that to be quite honest. Not that I’m not sensitive to those issues, but the more I learn the more I’ll share.
The bottom line is that it can be as subtle as a change in semen color. So if the woman is wiping herself afterwards and she notices that the normal white, pearly semen color in her husband is sort of a dark yellow or something, or a yellow brown, that can be all you need. Or the odor, it’s a different odor, a different taste if its oral sex.
Same for him if he is doing oral sex and he notices a different taste or an odor, that can be a subtle sign that there’s been a change in the vaginal microbiome. So everything from something that you see immediately, to something that’s a change in a body chemistry, is something that you can find as subtle clues that this may be happening.
The Mental Health Burden Of UTI And Sex
Melissa: Do you have any advice about mentally disassociating UTIs and sex? It’s very difficult to enjoy sex if it’s constantly a trigger for UTI. Or maybe you have advice on how to minimize the chances of it happening, but also on the mental aspect.
Dr. Hlavinka: That’s a very good question. So being someone that’s a sexual health provider for both men and women and have been for 20 years, understanding that the negatives of a sexual encounter are so important and they are something that need to be accounted for, and so I believe that is also a place where I can be very much instructive to the partner and be helpful.
Because I know for a lot of my patients a sexual encounter is the last thing they want to hear about when they’re getting over an infection. Particularly when it happens every time.
And I’ll take a little of an aside here, how I got into this, all right? So I’m early 40s right, smart urologist, I know everything. Yeah right. So a 71 year old lady came to see me. I think I was in my early 40s and she’d been getting recurrent urinary tract infections and she’d been seen by primary care and OBGYN.
And of course now you get to go to the urologist and see if the urologist is going to take care of you. We didn’t even know about menopausal related infections and vaginal atrophy and estrogen deficiency. We didn’t know any of that stuff at this time in the late 90s.
All we knew was that I had a patient on my hands that I couldn’t help. So I started to walk out saying there’s nothing I can do for you. And she start crying she said doctor you don’t understand. Stop and listen to me.
She says I love my husband. I get an infection every time I have sex with him. She says, I want to make love to my husband. You have to help me be able to make love to my husband without getting infection.
Changing The Way Patients Are Treated
That’s actually when the lightning bulb went off, Melissa. And that was you know 22 years ago. So then I said I’m going to help you. And then I went back and I did all the research. Of course, then you had to go to the library. You couldn’t Google.
So I went to the library, and big books, big books, nothing, you know. There was nothing there. So that’s when I started getting into hormone replacement therapy and women’s sexual health courses and just educating myself on all these.
So I believe that there is a way to continue to maintain intimacy. What I don’t want is for couples to lose intimacy while this is happening. So fear should not supplant the capacity to have intimacy. So many times there’s genital sexual touch that you can do. You can do mutual masturbation. You can do clitoral touch for a woman to orgasm, to avoid penetrative sex and still have satisfying sexual encounters.
But the main thing to do is to make sure that you’ve done everything you can to treat the infection, eradicate it, find the partner who may be contributing. Now if, let’s just face it, I’m a guy so I can say this: If the guy’s a clod, well then he needs to be educated, all right.
And sometimes educating him in the right way, let’s just say, abstinence is always a choice, then that can be something that gets him quite motivated. And again it’s a process of education, recognition that intimacy should not be sacrificed, finding the organism that needs to be treated, and then trying to do my best to let the patients know that there’s an understanding and empathetic provider that’s going to do everything I can to help you get through this.
Other Everyday Risk Factors For UTI
Melissa: With sex being a risk factor we actually received a lot of other questions about specific things that people have associated with onset of their UTIs and I wanted to kind of run down the list and see if you had any thoughts on whether these items are also risk factors.
First is swimming – in public pools, in lakes in the ocean?
Dr. Hlavinka: So it should be very safe to swim. Public pools typically have high enough levels of chlorination or non-chlorinating bacterial microbe diminishment. Obviously if it’s been not treated properly then that is possible to get E. coli for instance because obviously other things come out too.
A properly maintained pool should not do that. And the same thing with a hot tub. Now hot tubs because of the heat, and also I don’t know about having sex in a hot tub.
That’s obviously a risk factor because of the heat, the chlorine and everything – I just don’t think it’s a good idea. Have sex on the corner, on the edge of the hot tub how, about that? But the hot tubs are probably more just because of the heat. I think there’s a potential to create, you have to be more careful. But again, a well-maintained hot tub should be okay.
So lakes, oceans.
Theoretically, the vagina is closed and water shouldn’t get in. And water, if it has you know a contaminant, it could theoretically, but most women should not have problems with swimming, the usual, bathing.
Does Spending Too Much Time In Water Cause UTIs?
Now, as part of my career there is a SeaWorld in San Antonio, Texas, where I live. SeaWorld is the park, the nature park that talks about marine life. And so SeaWorld had some fun acts, and one of the fun acts they used to have was a water ski team. And the water ski team was five boys and five girls. Teenagers that were basically in swimsuits eight hours a day for the whole summer.
And I used to see so much in those poor people, and they yes, they made me wrong. And they were in so much water for so long I think it altered all their skin, their vaginal environment, their prostate, and everything their bladders, and they got lots of infections.
So I would say if you’re like a real swimmer, like if you’re like a triathlon type swimmer, all of that goes out the window. That’s different and you would have to treat according to symptoms.
Obesity And UTIs
So obesity is another one you have listed here. Obesity is as we found with COVID, a risk factor for many, many things and it’s independent of all other factors. Any other comorbidities. But obesity, because of the potential to have a lowered immune system also, and to increase amounts of different types of flora that live in the skin folds and the perineum, with the chronic wetness and things like that.
Yes, I mean I can see that. My patient was obese, the truck driver that had this moisture in his groin because of being a truck driver in Texas. Yes that was a risk factor, an obese man. And losing the weight may not have cured him but it sure set him up for the infection that he ultimately transmitted to his wife.
So the digestive disorders or acid reflux. Anything that can alter the normal gut microbiome can predispose to infection. Any alteration in that downstream causes issues with what lives on the bottom, what lives in the vagina, can cause increased risk of infection.
Horseback Riding, Fecal And Urinary Incontinence
Melissa: We had a really specific one: Horseback riding.
Dr. Hlavinka: I’m going to say no… Now I think horseback riding does have some risk factors for perineal trauma. I know that men and women can have issues with perineal trauma and the capacity to cause alteration and blood flow with trauma is an alteration in the immune system locally and thus you can change. And also, if it’s hot and you’re riding in pants for a long period of time, same thing. So same thing as with the swimming.
Melissa: Okay, right. And urinary or fecal incontinence?
Dr. Hlavinka: Fecal incontinence, absolutely, simply because fecal incontinence creates a lot more organisms that live on the perineum. The perineum is a space between the vagina and the anus, and perineal organisms become vaginal organisms by and by depending on their amounts. The bottom line is that fecal incontinence is a real risk factor always.
Urinary incontinence, I can’t get my colleagues to recognize that the older ladies that have significant urinary incontinence and are wearing pads that are chronically moist, just a rich breeding ground for bacteria and a setup for infection, and it’s so costly to change these pads.
There’s a lot of data and this is another one I don’t want to go off into the weeds on, but there’s a lot of data to show that the complications of urinary incontinence are much more vast than what we recognize.
And being such an under-treated condition and predominantly in women, again that’s why it gets ignored. But UTIs being a very significant one of those complicating factors of chronic urinary incontinence.
Can Urine pH Cause UTIs?
Melissa: Okay, good to know. How about pH of urine?
Dr. Hlavinka: So as I said earlier, for those who are listening, the change of one pH point can vastly change the environment of the vagina.
The chemical environment, the microbial environment, the way receptors work, for anything that may stick to the vaginal lining layer, read that invade, or cause a chemical reaction, so all of those things can be – for instance the normal premenopausal healthy vagina vaginal pH is very acidic it’s 4.5. So a pH of 6.5 is almost pathognomonic, almost diagnostic of the problem of a vaginitis. Now, what it comes from depends on what you find in the vagina.
If it’s a yeast well then it’s a yeast infection, or if it’s a bacterium it’s BV. So can you change the pH of the urine independently and change it? Not enough. You typically have to do this as a part of other therapies. So just changing pH by a refresh or replenish or one of those things, or alkaline if it’s acidic or acid type things, acidic washes, no that’s not enough in my opinion.
Pelvic Floor Dysfunction And UTI
Melissa: Okay, and the next one is pelvic floor dysfunction or pudendal nerve entrapment.
Dr. Hlavinka: Another broad spectrum topic. I feel like, let’s say, how many patients got their pelvic floor dysfunction from a urinary tract infection, or chronic UTIs. So the chronic pain and irritation, frequency and urgency of UTIs, if that makes you contract your pelvic floor to avoid incontinence or because of this urgency, well you can get pelvic floor dysfunction. Or you can get it independent of that mechanism.
But the bottom line is it can be related in so much is that you have a stasis of blood flow. So stasis means static or stagnant. The pathognomonic in the pathogenesis of pelvic floor dysfunction is chronic muscle tension.
So it’s like a Charlie horse in the pelvic floor muscle. What happens when you get a Charlie horse? The lactic acid builds up and it hurts and that’s painful. Well how do you respond to pain signals? Well you clamp down.
So you get this vicious cycle of pain spasm, lactic acid build up, pain spasm, lactic acid buildup, and you can’t break it. So it does affect the pelvic blood flow in my opinion. I see an increased risk of urinary tract infections in patients with pelvic floor dysfunction.
We’re not going to be able to say cause or effect and the problem is the association is very high for that mechanism. And that’s because you’re just impairing pelvic floor blood flow and pelvic blood flow and you have all these terrible reflex mechanisms with pain receptors and what they do to the local immune response and chronic pain.
Running, Dehydration And UTI
So the same thing is true to a smaller degree with pudendal nerve entrapment. And pudendal nerve entrapment is something that’s still a bit controversial but I see it in a lot of female runners.
It certainly is something that can be a part of that. Now is that because they have runners bladder and they get pudendal nerve secondarily, I don’t know. The female runners tend to get more UTIs.
I think it’s multifactorial. I think it’s dehydration, I think it’s a chronic trauma of the roof of the bladder hitting the floor of the bladder, I think it’s probably more chronic moisture in their underclothing. Multiple factors.
Melissa: Right, okay. And one other risk factor, or possibly not: Is it safe to let a UTI go untreated and can it go away on its own?
Dr. Hlavinka: So there was a study that showed that you could drink a gallon of water – what is that four liters? Four liters. We’re terrible. Four liters of water 48 hours, per day, and that’s in addition to your other fluids and your coffee and your tea and things like that.
For two days, for 48 hours, and that you had just as much eradication capacity as you did for an acute UTI treated with antibiotics. In other words at 72 hours the eradication rates were equal and there’s about 50% of each of them were eradicated. Which is dismal for the antibiotic, but again I think they measured that a little bit too early.
So the bottom line is I believe that in young, healthy women who have no risk factors, who have proven that they don’t get complicated UTIs or persistent UTIs, that it’s very safe to use measures to try to get rid of it. Like flushing yourself, apple cider vinegar.
I think apple cider vinegar has worked very well in the right patient, I firmly believe in that and I think that patients can prevent it. There are some other naturopathic treatments for prevention and treatment that I’d like to go into at a later date.
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UTI and sex is one of the most talked about topics around recurrent UTI. Abstaining from sex is not the answer, though many people resort to this in order to minimize UTI symptoms. We need this topic to be taken seriously in future research so better solutions can be developed. We’d like to thank Dr. Tim Hlavinka for generously sharing his time to answer the questions submitted.
More from our expert video series
Watch the rest of our video series with Dr. Tim Hlavinka, or subscribe to Live UTI Free on YouTube.
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- UTI And BV, Yeast Infection And Other Risk Factors