I'm going to speak to you on prevention
of recurrent urinary tract infections
using natural therapy. Um this is
something I'm really have a lot of
experience in and working in the
functional urology space. We see just so
many UTI and men and women. I think as
urologists we have a responsibility here
to really you know lead in this space
whether it's you directly or with some
of your advanced practice providers. So
I'm going to go over the AUA guidelines
which are excellent on this topic, talk
about antibiotic stewardship, and then
help design individual patient center
treatment plans that you can use in your
practice. That's going to center a lot
around natural therapy. Um urinary tract
infection is a huge problem. Okay. Uh a
million admissions per year, two billion
dollars spent. 60% of women will
experience a UTI in their lifetime. So
this is a a common problem. It's not
going away and it's something that u is
something very concerning uh in many
practices. Uh in women, younger women,
it's a 30 to1 ratio. So this is mostly a
female problem with the exception of
neonates and and the elderly.
So what is a UTI? We're urologists. We
know this definition. I only bring this
up so you remember the difference
between a UTI and pylonritis. So this
talk is not about pyon nephritis. It's
about lower urinary tract infection.
The pathogen typically is going to be
ecoli. This was mentioned the other day.
You guys remember this from medical
school. The p fimria bind up the
receptors on the epithelium. They lock
in and then the patient gets an infection.
infection.
Glucose is a huge problem that I see in
my practice. When we do the dips, we see
glucose very commonly. We see hemoglobin
A1C's over 10. So this is a spot where
you really could, you know, be a little
bit of a primary care provider and talk
about weight loss and better glucose
control and eurogenital hygiene.
Um the pathogens are almost always uh
E.coli, proteus or klepsella and our
caucus are the ones we see in our
community, but there are some regional
variations based on your hospital um
that you're working at. The risk
factors, it's pretty simple. For young
women, it's almost always related to
sexual intercourse. For older women,
it's almost always related to estrogen
deficiency. So, think about those two
things. The patient will often say, "Why
am I getting this? What's changed in my
life? What behavioral intervention can
you make or what hormonal intervention
can you make?" Diabetes, I mentioned, is
a big problem. So, pay attention to that one.
one.
The diagnosis is pretty simple. We know
we know what this looks like. We know
what pylonritis looks like.
History, physical, urine analysis. It's
not hard. Um I often give patients
dipsticks so they can um test
themselves. They can buy them now over
the counter. This is very useful.
Patient calls up and says, "I think I
have a UTI. It's Friday afternoon. You
know, they want to have treatment. at
least have them dipstick the urine so
you can get a general idea. We want to
get as much culture information as we
can. It's not uncommon we get a referral
for recurrent UTI and there's not a
single positive urine culture in the
chart. Has anybody ever seen that
problem? Yeah. All the time. And
sometimes it's hard when you're working
in different systems and maybe there is
culture data. But um good friend of mine
Ryan Tlei, his wife Terry is an ER
doctor. I asked her one day, "Why don't
ER doctors ever get urine cultures? They
only do dips." She said, "Well, um, we'd
have to follow up on it." So, you know,
in the ER, you want to really kind of
treat and and move on. You don't order
tests. And so, and people are getting
all their care in the ER, urgent care,
there's going to be no cultures. Um, Jen
Anger, Una Lee, people, you know, who've
been at this meeting, wrote the
guidelines. Um, this is very useful. So,
let's go through this. um most of the
evidence is going to be level C um
through this problem. So urine analysis,
urine culture, treat based on that.
Statement number four, cystoscopy and
upper tract imaging should not be
routinely obtained. How many people do a
systo on every patient that gets
referred to them for a UTI?
How how many people are selective?
Yeah. And I think that's the right
thing. at C. So you a lot of people want
that. They're demanding that they're
looking for an answer. Maybe there
there's some something that you're
concerned. How many people do a workup
with the CT and IVP and find nothing
most of the time?
Yeah. And so the more workup you do, the
more expectation there's going to be
that you are going to find something. Um
the Eurogen testing, um I know some
people uh use this in their office. this
is becoming more uh available and in
select cases we do use this. Um so let's
get into sort of the granular stuff. You
know how long do you treat, who do you
treat, which antibiotic.
These are the AUA guidelines and I'm
just going to walk you through what they
tell us to do here.
So strong evidence to not treat
asymptomatic bacteria. I think we all
spent time educating our referring
doctors on this and patients. um you
really have to stand strong on that
because people want treatment and you
can treat them, but you don't need to
treat them with antibiotics.
You go through your evaluation, you're
going to get a urine, you're going to
get a culture, and then you're going to
go ahead and treat. So, how long do we
treat and what do we treat with? These
are the three drugs we treat with these
days. The trend is to treat for a
shorter duration. Nitrofarentin 5 days,
Bactrum 3 days, phosphomiasin one day.
How many people use phosphomiasin?
Yeah, this is extremely useful. Um, you
can call up your lab, ask them to run
sensitivities for this. They will do
this for E.coli. They won't do it for
every organism, but if it looks like
you're going to have to go to IV
therapy, this is a spot you can have
them test and maybe use single dose phosphomyin.
phosphomyin.
Um, so let's talk about guideline number
10. What to do with the recurrent
patient. And I think those are the
referrals that we see. You want
something that has low allergy
potential, rare adverse events,
infrequent dosing, and something that's
going to be affordable.
Um, I like to use TMP sulfur. Sometimes
I just use straight up TMP. 100
milligrams, no interactions, very well tolerated.
tolerated.
Nitrofen towin I'll use in women
especially 50 to 100 milligrams doesn't
prevent sudamonus or proteius so look at
what maybe UTI they've had recently
phosphomiasin I see my infectious
disease colleagues doing this once a
week so maybe patient who has a chronic
catheter who's getting recurrent pylo
ending up in the hospital this is often
where they go one dose a week phosphomyosin
phosphomyosin
what about floricquinolone Um, I'm using
way less fluoricquinolones than I've
had, you know, in years because of the
blackbox warning. You only need to have
one patient in your practice that has
really severe plantar fasciitis or acute
Achilles tendon rupture and you'll use
less fuicquinolones. How many people
have had a patient that has had a side
effect from floricquinolone?
Yeah. And Dr. Brand there gave his legal
talk and I would argue that if you had
other antibiotics you could have chosen
you may be at some medical legal risk.
So what about the suppression?
Um what is the definition of recurrent
UTI? People get referred for that. It's
two in six months three in a year non-complicated
non-complicated
options for if it's definitely related
to intercourse postcoidal is the
simplest thing that you can do. Um or
you can put them on suppressive therapy.
I prefer methanamine which is a hip
wrex. So let's look at this. If anybody
wants to take a picture of this slide,
this is really simple stuff to do. Um
intermittent prophylaxis or continuous
prophylactis. This works. Okay? And try
to find inexpensive antibiotics that
have low allergy potential and that have
very few GI side effects.
Um, what about long-term prophylactis?
Trimethoprine generally is going to
work. Sometimes I'll get on a rotation.
Trimethoprine for three months,
nitrofurentonin for three months, and
then I will do uh try uh methanamine for
three months, and then start back over.
This is what I'm excited about is more
the natural therapies. In Colorado, we
have a lot of people that really want to
embrace natural therapy, organic
therapies. They really don't want
antibiotics. They don't want
multi-drugresistant organisms, the GI
side effect, the yeast infections, and
everything that goes along with chronic
antibiotic usage.
So, water, right? This is really basic.
Drink more water. Drinking as much as
two liters of water a day will decrease
your UTI risk by 50%. That's a big
difference, right? That's about what a
daily antibiotic would do. Um, people
that have feal incontinence, I recommend
a bedet and patients will put this in
their home bathroom and this really
helps quite a bit. And then a detachable
shower head and uh they can shower
before and after sexual intercourse.
This works really well. So I mean this
is really easy stuff that we can do. We
can recommend um I don't work for this
company. I don't speak for them. This is
over-the-counter really cheap stuff. The
CME people asked that I block that out.
But find a product in your pharmacy that
people can use to cleanse themselves.
This product comes in a pack. There's
wipes and there's foam. It works
extremely well. Um, anybody want to
guess how many baths a patient in a
nursing home gets per week?
One. One. Okay. So at least on the other
days they can wipe down with these
eurogenital wipes. This is what happens
in the hospital. Wipe the catheterss
down. Wipe your super pubic down. And
then for younger patients they can use
this almost like a a foam like a
spermicide foam. Put it on themselves,
put it on their partner uh and then take
a shower after having sexual
intercourse. This will virtually
eliminate recurrent UTI in someone
that's related to kitis.
Cranberry. This came up the other day.
Cranberry. Pick the right cranberry.
People say cranberry doesn't work. Yes,
it does. Um, de manos doesn't work. De
Manos is not cranberry.
Find the right cranberry. 36 milligrams
a pack. The pack binds up the pimria.
The body washes it out. Um, there's no infection.
infection.
36 milligrams a pack is as effective as
a daily dose antibiotic. This is where I
have people start with. Um, this can be
pricey. Some of these products are
pricey, but it's worth it and it's less
expensive than going to urgent care.
Um, lactobacillus and probiotics would
be the third tier, right? Water,
wipes, cranberry, probiotics. Those four
things I talk about every day in the
clinic. Methanamine. What does
methanamine do? This basically creates a
formaldahhide bomb in the bladder. You
combine it with daily vitamin C. It's
going to work very well. You do want to
be cautious in people with renal
disease. I have them dose this a gram
every other day. And methanamine really
works. Methanamine is not an antibiotic.
It's just a salt. Okay. So, it's very
simple. So, let's um talk specifically
about the female patient. And I think
Katie touched on this quite a bit on the
post-menopausal patient. I'm not going
to repeat this, but I really believe
estrogen is going to be the mainstay and
this is an important conversation to
have with your older patients.
Um, this is another algorithm um from
Eurogycology that I find really useful.
If you get down to the bottom here, this
is where I spend most of my conversation
right here. lifestyle changes, modify
the risk, cranberry, vitamin C, vitamin
D, and then eventually methanamine and probiotics.
probiotics.
This creates a lot of distress. How many
people have had difficult conversation
with the patient in their office about
recurrent UTI?
Yeah. And it's five o'clock on Friday.
People want treatment because they feel
no one's taking them serious. Nobody's
listening. Nobody's doing anything. And
I I hear that all the time. So I I think
this is something where you could really
make a big impact. The New York Times
actually wrote about this recently.
What happens in menopause? Well, the
estrogen levels fall, lactobacillus fail
to grow, pH drops, here comes the
infection. Um so parmenopausal patients,
post-menopausal, it's going to center
around estrogen. Um I'm going to skip
through this because it's been spoken to
postcodal therapy we covered. And then
the imitators, okay, the imitators are
really important. So if it's not a UTI,
and I say to patients when you're having
these episodes, I try not to say when
you have a UTI, when you have these
episodes, if I'm thinking it might be
something else, tell me what's going on.
Well, I have an infection. I understand
that, but tell me what the symptoms are.
What other diagnosises can we consider?
It's going to be GSM, OAB, IC, or one of
these other things. Think about it. Work
up patients that do need a workup, but
the more work up you do, the higher the
expectation gets.
So, in conclusion, urinary culture is
necessary for a diagnosis, treatment,
prevention. Cystoscopy, upper tract
imaging, rarely indicated. I rarely do
it. Um UTI therapy should be for the
shortest duration possible. Methanamine
is as effective as nitro furin. Um and
cranberry prophylaxis 36 milligram pack
is as effective as antibiotic. Your goal
is to decrease the UTI. Someone will
call me up six months later and say you
know none of this is working. Well what
happened? I got a UTI. Okay. How many
did you get last year? Well, every month
this year, one or two. It's working.
We're going to decrease it. We may not
eliminate it.
Um, just a little plug here on
functional urology. We're having our
meeting uh in August. Um, I hope people
can attend. We have a full day on
functional stuff. It's a good
