00:00 – Dr. Hsieh: I have had several pediatric patients who, very clearly, had culture negative
00:06 – infections. And I knew they had infections not only because of symptoms.
00:23 – Melissa: When it comes to someone that comes to see you with their first or second UTI, does your
00:27 – testing and treatment approach differ, as opposed to someone who has had this problem of recurrence
00:32 – for a long period of time? Dr. Hsieh: It does. I will say, however, that there’s significant referral
00:41 – bias, as it’s called. I see very very few patients who’ve only had one UTI before.
00:49 – I’ve had a handful that have had two UTIs and I’ve had quite a few who’ve perhaps had
00:54 – three but, yes, I will, generally speaking, manage those patients with lower intensity regimens,
01:04 – with the hopes that that will be sufficient for them. Melissa: Okay, and is there anything people can do
01:11 – when they are at that early stage of the recurrent UTI journey that can help? That is not the obvious
01:18 – kind of advice that everybody gets which is: from front to back, pee after sex, drink more water.
01:23 – Obviously, people in that situation have tried those things. Is there something else that you
01:28 – would suggest that might help them to break that cycle before it gets too bad?
01:38 – Dr. Hsieh: That’s a difficult one. I will say that seeking prompt treatment is important.
01:47 – Some patients try to just let their immune system fight off the infections, and it often can, but
01:56 – in a number of patients, allowing the infection to really take hold I think triggers some
02:02 – severe bladder inflammation and injury that can take a long time to recover from. And, also,
02:11 – there’s very good evidence that prior bladder injury from infection sets the stage for
02:18 – increased risk of subsequent infections. Melissa: Okay and for people that have taken frequent or
02:24 – long-term antibiotics, does this have a long-term effect on their overall health?
02:31 – Dr. Hsieh: At least in terms of the gut microbiome, which is one of the most studied areas
02:37 – with regards to longer term antibiotic use,
02:42 – the bad news is, yes, the microbiome is altered while you’re on antibiotics. And that should not
02:48 – be surprising, I mean, that is what antibiotics do. They kill bacteria. The good news is that,
02:57 – in the limited data that is out there, the gut microbiome does
03:01 – normalize after stopping antibiotics, but it can take up to six months. Melissa: Okay, that was going to be
03:08 – one of my questions as well. And given the link between the gut microbiome and the immune system.
03:14 – After you’ve taken antibiotics, are you then more vulnerable to other kinds of disease?
03:21 – Dr. Hsieh: For sure. Of course. C. difficile infections, clustering difficile infections of the gut,
03:32 – after antibiotic therapy is one of the most feared complications of being on antibiotics.
03:41 – And being on antibiotics also, paradoxically, seems to sometimes increase risk of subsequent
03:49 – UTIs. Now, that may also be because of altering the gut microbiome, and allowing
03:55 – your pathogenic bacteria to overgrow as a potential future source of UTIs.
04:02 – Melissa: Okay, do you think there’s anything that we can do to help that re-establishment of good
04:07 – bacteria in the bladder, but also in the vagina, and the gut, after antibiotic? Dr. Hsieh: Yeah, for sure.
04:15 – In the gut, there are probiotics that have very good evidence for helping restore
04:25 – gut homeostasis after oral antibiotics. A few of the products include Culturelle,
04:34 – and Align. And this is based on quite a few clinical trials. The evidence is strongest for
04:38 – probiotics, as well as a yeast probiotic, interestingly. It’s known as brewer’s yeast,
04:49 – saccharomyces boulardii. The evidence is very strong in terms of these probiotics
04:56 – preventing anabolic associate diarrhea. Melissa: Okay, that’s good to know. And there’s a few other
05:02 – questions that aren’t quite related but also to prevention or possible cause of UTI.
05:07 – One is around oxalates and whether a high oxalate diet or an issue with oxalates might
05:14 – be the cause of recurrent UTI in some people. Dr. Hsieh: I would say there’s no direct evidence for that.
05:22 – Indirectly, high oxalates in your urine from diet could
05:28 – contribute to UTIs in a sense that some patients are prone to forming infection
05:34 – stones, which are stones that contain not only calcium oxalate, which is one of the most common
05:44 – substances in stones, but also bacteria. And, in these patients, their stones will
05:50 – intermittently shed bacteria into the urine which, conceivably, could contribute to UTIs.
05:56 – Melissa: Okay ,and what about whether you can make your urine more acidic or more alkaline? Is either of
06:01 – those likely to help or cause an issue? Dr. Hsieh: There is evidence that patients with more alkaline
06:09 – urine are more susceptible to infections, by certain bacteria, of their urinary tract.
06:19 – Urinary acidification in most patients is not an issue but some patients do have to be careful.
06:27 – Bladder injury caused by prior UTIs, I’ve noted, can increase susceptibility to
06:37 – acidic ph in the urine. Melissa: Okay, that’s interesting. We had a few questions about how much fluid you
06:46 – should drink. There’s this notion that drinking more fluid will help with
06:51 – UTI symptoms. I know it’s not a good idea to drink too much fluid but if it is helping relieve the
06:56 – symptoms… Someone wanted to know if they should be drinking fluid at night as well as during the day.
07:04 – Dr. Hsieh: There was a very good clinical trial in JAMA Internal Medicine a number years ago.
07:11 – It examined women of reproductive age who are prone to UTIs
07:16 – and if, normally, these women drank a liter and a half of water a day or less,
07:23 – and then they took half of these women and had them drink three liters of water a day,
07:29 – the group that drank three liters of water a day instead of their normal amount
07:33 – had about half as many UTIs. So, very significant therapeutic effect.
07:40 – Now, three liters of water a day is a lot for most people depending, of course, on how big of
07:45 – a person you are. And that will, by definition, probably cause you to urinate more often.
07:52 – The best way to try and handle that amount of fluid, in my opinion,
07:58 – is to sip it throughout the day, rather than chug it in large quantities at a time. Because
08:05 – we know that chugging large amounts of fluid at a time will very rapidly fill your bladder,
08:13 – and a major cause of urinary frequency and urgency is when your bladder fills quickly.
08:19 – So, sipping water is probably less likely to exacerbate those types of symptoms. Melissa: Okay, one of
08:26 – the things that comes up with excessive intake of fluid is the possible depletion of minerals.
08:31 – Is that actually a problem or at what point could that be a problem? Dr. Hsieh: It has been reported that,
08:39 – in patients who drink a vast amount of water, and by vast I mean at least five or six liters of water
08:45 – a day, they can drop their blood sodium levels to dangerous levels. But again, it requires
08:54 – an extraordinary consumption of water. Melissa: We hear from many people who have children who experience
08:58 – recurrent UTI, and often we hear reports from them that the only advice they’re offered by
09:04 – their clinician is to make sure that constipation is avoided in the child. Can you fill us
09:11 – in on why constipation is raised so often in pediatric urology and not in adult urology?
09:18 – Dr. Hsieh: Well, first of all, I do think constipation can be a contributor to UTIs for adults as well
09:28 – but there is extensive data showing that constipation in children, in particular,
09:33 – contributes to urinary symptoms and UTI risk. And it may be a little
09:41 – strange-sounding why that may be but there’s at least two theories, which may both be correct,
09:46 – that could explain why there’s this constipation
09:51 – UTI link. So, first of all, it may be a mechanical issue and this mechanical issue can also
09:58 – apply for non-infectious urinary symptoms. So, the mechanical consideration is that if the
10:05 – pelvis of a child is filled up with stool because of constipation, the bladder does not have enough
10:11 – room to work properly. And that dysfunction can not only lead to urinary symptoms but also increase
10:21 – susceptibility to UTI. The other hypothesis as to why constipation may contribute to UTI risk
10:28 – in children, is related to the microbiome. There is evidence that the microbiome is altered in the
10:37 – setting of constipation and, presumably, that is what’s called a dysbiotic adaptation. Meaning that
10:47 – bacteria may be overgrowing in the gut that contribute to UTI risk.
10:54 – Melissa: Okay. If the constipation is not an issue, is it possible that a child can also have an embedded
10:59 – UTI? Dr. Hsieh: Yeah. So, you know, for example, some other
11:05 – common issues in children that increase their risk for recurrent or persistent UTI is infrequent
11:11 – voiding, especially shortly after toilet training. The most common clinical scenario
11:18 – is a young child who loves playing and doesn’t want to be bothered with stopping when
11:25 – their bladder is full, to go to the bathroom. And, not surprisingly, if your bladder is chronically
11:31 – full you have stasis of the urine and if there’s a small amount of bacteria in there it has plenty
11:39 – of time to grow and develop into an infection.
11:44 – Melissa: And when it comes to that for children is your testing and treatment approach
11:49 – the same as it would be in adults, or is there something different that you would do?
11:54 – Dr. Hsieh: Interestingly, for reasons that are unclear to me, children rarely have culture negative UTIs.
12:03 – So, I tend to not perform microbiome testing on children. That being said, I
12:11 – have had several pediatric patients who very clearly had culture negative
12:16 – infections. And I knew they had infections not only because of symptoms but, in a few
12:22 – of those cases, they had x-ray findings that clearly indicated they had kidney infection.
12:29 – Melissa: What does a kidney infection look like on an x-ray? Dr. Hsieh: On an ultrasound you can see enlargement of the
12:37 – kidney and edema. Edema is fluid within the tissues. On a CAT scan, you can see those types
12:45 – of findings as well. And if intravenous contrast is given on the CAT scan, you’ll see some typical
12:53 – striations within the kidney, indicative of kidney infection. Melissa: Okay, do you have any advice for parents,
13:00 – or guardians, who care for children that do have recurrent UTI? Dr. Hsieh: Yes. First of all , make sure the child does not get constipated. So, plenty of water, fruits and vegetables and
13:14 – whole grains, rather than refined grains. In other words, minimize white rice and white bread.
13:22 – And seeing as infrequent voiding is a very common issue in young children, instituting something
13:30 – known as timed voiding can be very helpful. Where you, literally, set a watch and when
13:36 – the alarm goes off every two hours, you send the child to the bathroom even if they don’t want to.
13:41 – Melissa: Okay, and you find those techniques help with a lot of pediatric patients? Dr. Hsieh: It does. It doesn’t
13:48 – help all patients, of course, but it helps many of them. Sometimes, you need to be also treating
13:53 – alongside these behavioral changes, so that they can overcome what’s happening.
13:59 – So many of these patients will require to be on antibiotics, temporarily, while they’re
14:06 – working on their voiding habits, to reduce their risk of a UTI during that period.
14:13 – Melissa: And children that do have frequent UTI, is it likely that they will continue
14:18 – to have that problem into adulthood, or do a lot of kids kind of grow out of this?
14:24 – Dr. Hsieh: Many children who are prone to UTIs, especially girls,
14:31 – sort of retain their susceptibility to infections as they get older, unfortunately.
14:36 – Especially during pregnancy, but some patients seem to outgrow it. Melissa: And why would they outgrow it?
14:46 – Dr. Hsieh: There are some theories that the estrogenization of the vagina, associated with puberty, allows for
14:55 – growth of lactic acid bacteria that prevent overgrowth of potential UTI-causing bacteria. Melissa: Have
15:02 – you seen any research into that for pre-menopausal women? The estrogen link, I mean, for pre-menopausal
15:09 – women? Dr. Hsieh: Not so much. Most of the research has focused on postmenopausal women. Melissa: Okay. You briefly mentioned
15:17 – imaging. Is that something that you recommend for all your patients or is it just certain symptoms
15:22 – that would cause you to do a cystoscopy or CT scan? Or something that you just mentioned earlier?
15:28 – Dr. Hsieh: Studies by others have suggested that most patients with uncomplicated UTIs and, again I’m
15:36 – going to emphasize the word “uncomplicated”, do not routinely need this type of evaluation.
15:43 – I do not see many patients with uncomplicated UTIs. Almost all of my practice are patients who have
15:50 – recurrent or persistent UTIs and, in that patient population, I do think an ultrasound of the urinary
15:58 – tract is not unreasonable. And even cystoscopy. To look in the bladder. Many patients will
16:08 – have inflammatory lesions in their bladder that, if you biopsied, which should not be done routinely,
16:16 – will show the presence of bacteria as well as immune cells. And evidence by Philippe Zimmern,
16:25 – has indicated that, for some of these patients, if you cauterize these lesions in their bladder,
16:33 – even if they’ve had anabolic-resistant UTIs, they can improve. And that’s actually been my experience
16:40 – as well. A subset of my patients with these inflammatory lesions that I’ve caught arise, have
16:46 – had significant improvement. Melissa: Is that only done in the case where there are a few lesions? I imagine
16:52 – if there are a lot of areas in the bladder you can’t cauterize everything. Dr. Hsieh: It depends.
16:59 – It’s a judgment call, obviously. If there’s a very large swath of the bladder then
17:05 – the risk benefit ratio is probably not favorable. Because if you cauterize too much of the surface
17:10 – area of the bladder, the patient’s going to be very symptomatic, just from that, for a long time.
17:16 – Melissa: Okay. At the other end of the spectrum, there’s also an issue of UTI and the elderly.
17:23 – And we get a lot of messages from people who have parents who are experiencing recurrent UTI.
17:28 – Is there a different approach that you would use in this case, to help reduce the symptoms,
17:32 – or even eliminate them entirely? Dr. Hsieh: Well, for for women, I definitely advocate for a trial
17:41 – of vaginal estrogen because there’s just so much medical evidence that that can reduce UTI risk.
17:49 – In men, it’s trickier. Many of these men, that being said, have benign prostatic enlargement
17:56 – and consideration should be made for medical or surgical reduction in size of the prostate.
18:04 – UTIs in the elderly are challenging and can be life-threatening, many of these patients do not
18:12 – present with typical UTI symptoms and can very rapidly progress to life-threatening
18:18 – infections. Melissa: What are some of the symptoms to look for in older people? Because we do hear stories
18:23 – about behavioral change that was later linked to a UTI and, in that case that,
18:28 – could definitely have become life-threatening. Are there things to look for in older people?
18:35 – Dr. Hsieh: Yeah. Many elderly people have atypical symptoms, changes in behavior, fevers of course, or even
18:46 – low temperatures, low blood pressure, should all be evaluated. Melissa: Okay, and urinary incontinence is also
18:56 – raised quite often as an issue in older people. Is there a link between incontinence and UTI
19:01 – and what steps should people take to help with the incontinence symptoms?
19:08 – Dr. Hsieh: Yes, I think there’s potentially some chicken or the egg issue here. Are elderly people prone to
19:17 – UTIs, also incontinent because the UTIs are causing them to be incontinent? Or is the incontinence,
19:24 – or the underlying cause of the incontinence, somehow contributing to their UTI risk. I
19:30 – think it could be both. The first scenario is very easy to understand, the second scenario…
19:35 – There are various bladder forms of dysfunction that could not only promote incontinence but
19:43 – increase UTI risk. Melissa: In those situations, do you think pelvic floor therapy is a helpful option?
19:52 – Dr. Hsieh: I think patients who have clear pelvic floor issues, yes, should try pelvic floor therapy but
19:59 – there are some diagnoses that are, of course, not related to the pelvic floor. For example,
20:05 – an enlarged prostate in a man can increase UTI risk but, of course, pelvic floor therapy is not
20:12 – going to help with that. Melissa: Right. Do you regularly refer patients to a pelvic floor therapist,
20:17 – or is that not something you do? Dr. Hsieh: I do, actually, fairly often for my patients who have IC
20:25 – or related conditions, I think a trial of pelvic floor therapy is indicated. It’s,
20:32 – essentially, a zero risk therapeutic maneuver. The American Urological Association guidelines,
20:39 – actually, strongly recommends consideration of pelvic floor therapy,
20:46 – and even in my patients who have chronic or persistent UTIs, I do think that pelvic
20:52 – floor physical therapy sometimes helps them recover their bladders as well.