0:07 I'm going to speak to you on prevention
0:08 of recurrent urinary tract infections
0:11 using natural therapy. Um this is
0:13 something I'm really have a lot of
0:15 experience in and working in the
0:18 functional urology space. We see just so
0:20 many UTI and men and women. I think as
0:23 urologists we have a responsibility here
0:25 to really you know lead in this space
0:27 whether it's you directly or with some
0:29 of your advanced practice providers. So
0:32 I'm going to go over the AUA guidelines
0:34 which are excellent on this topic, talk
0:36 about antibiotic stewardship, and then
0:39 help design individual patient center
0:41 treatment plans that you can use in your
0:43 practice. That's going to center a lot
0:46 around natural therapy. Um urinary tract
0:49 infection is a huge problem. Okay. Uh a
0:52 million admissions per year, two billion
0:56 dollars spent. 60% of women will
0:58 experience a UTI in their lifetime. So
1:00 this is a a common problem. It's not
1:03 going away and it's something that u is
1:06 something very concerning uh in many
1:09 practices. Uh in women, younger women,
1:12 it's a 30 to1 ratio. So this is mostly a
1:14 female problem with the exception of
1:18 neonates and and the elderly.
1:21 So what is a UTI? We're urologists. We
1:23 know this definition. I only bring this
1:25 up so you remember the difference
1:28 between a UTI and pylonritis. So this
1:30 talk is not about pyon nephritis. It's
1:34 about lower urinary tract infection.
1:35 The pathogen typically is going to be
1:38 ecoli. This was mentioned the other day.
1:39 You guys remember this from medical
1:42 school. The p fimria bind up the
1:44 receptors on the epithelium. They lock
1:46 in and then the patient gets an infection.
1:48 infection.
1:50 Glucose is a huge problem that I see in
1:53 my practice. When we do the dips, we see
1:56 glucose very commonly. We see hemoglobin
1:58 A1C's over 10. So this is a spot where
2:00 you really could, you know, be a little
2:02 bit of a primary care provider and talk
2:05 about weight loss and better glucose
2:08 control and eurogenital hygiene.
2:11 Um the pathogens are almost always uh
2:14 E.coli, proteus or klepsella and our
2:16 caucus are the ones we see in our
2:18 community, but there are some regional
2:22 variations based on your hospital um
2:24 that you're working at. The risk
2:27 factors, it's pretty simple. For young
2:29 women, it's almost always related to
2:31 sexual intercourse. For older women,
2:34 it's almost always related to estrogen
2:37 deficiency. So, think about those two
2:39 things. The patient will often say, "Why
2:41 am I getting this? What's changed in my
2:44 life? What behavioral intervention can
2:46 you make or what hormonal intervention
2:48 can you make?" Diabetes, I mentioned, is
2:51 a big problem. So, pay attention to that one.
2:53 one.
2:55 The diagnosis is pretty simple. We know
2:57 we know what this looks like. We know
3:01 what pylonritis looks like.
3:04 History, physical, urine analysis. It's
3:07 not hard. Um I often give patients
3:09 dipsticks so they can um test
3:11 themselves. They can buy them now over
3:13 the counter. This is very useful.
3:15 Patient calls up and says, "I think I
3:17 have a UTI. It's Friday afternoon. You
3:19 know, they want to have treatment. at
3:21 least have them dipstick the urine so
3:24 you can get a general idea. We want to
3:26 get as much culture information as we
3:28 can. It's not uncommon we get a referral
3:30 for recurrent UTI and there's not a
3:33 single positive urine culture in the
3:34 chart. Has anybody ever seen that
3:37 problem? Yeah. All the time. And
3:39 sometimes it's hard when you're working
3:41 in different systems and maybe there is
3:44 culture data. But um good friend of mine
3:46 Ryan Tlei, his wife Terry is an ER
3:48 doctor. I asked her one day, "Why don't
3:51 ER doctors ever get urine cultures? They
3:54 only do dips." She said, "Well, um, we'd
3:56 have to follow up on it." So, you know,
3:59 in the ER, you want to really kind of
4:02 treat and and move on. You don't order
4:04 tests. And so, and people are getting
4:05 all their care in the ER, urgent care,
4:08 there's going to be no cultures. Um, Jen
4:10 Anger, Una Lee, people, you know, who've
4:12 been at this meeting, wrote the
4:14 guidelines. Um, this is very useful. So,
4:17 let's go through this. um most of the
4:21 evidence is going to be level C um
4:24 through this problem. So urine analysis,
4:28 urine culture, treat based on that.
4:30 Statement number four, cystoscopy and
4:32 upper tract imaging should not be
4:35 routinely obtained. How many people do a
4:37 systo on every patient that gets
4:40 referred to them for a UTI?
4:44 How how many people are selective?
4:45 Yeah. And I think that's the right
4:47 thing. at C. So you a lot of people want
4:49 that. They're demanding that they're
4:51 looking for an answer. Maybe there
4:53 there's some something that you're
4:55 concerned. How many people do a workup
4:58 with the CT and IVP and find nothing
5:00 most of the time?
5:03 Yeah. And so the more workup you do, the
5:05 more expectation there's going to be
5:07 that you are going to find something. Um
5:10 the Eurogen testing, um I know some
5:12 people uh use this in their office. this
5:15 is becoming more uh available and in
5:19 select cases we do use this. Um so let's
5:21 get into sort of the granular stuff. You
5:23 know how long do you treat, who do you
5:26 treat, which antibiotic.
5:27 These are the AUA guidelines and I'm
5:30 just going to walk you through what they
5:32 tell us to do here.
5:34 So strong evidence to not treat
5:37 asymptomatic bacteria. I think we all
5:39 spent time educating our referring
5:42 doctors on this and patients. um you
5:44 really have to stand strong on that
5:46 because people want treatment and you
5:48 can treat them, but you don't need to
5:51 treat them with antibiotics.
5:54 You go through your evaluation, you're
5:55 going to get a urine, you're going to
5:57 get a culture, and then you're going to
5:58 go ahead and treat. So, how long do we
6:02 treat and what do we treat with? These
6:03 are the three drugs we treat with these
6:06 days. The trend is to treat for a
6:09 shorter duration. Nitrofarentin 5 days,
6:13 Bactrum 3 days, phosphomiasin one day.
6:16 How many people use phosphomiasin?
6:19 Yeah, this is extremely useful. Um, you
6:21 can call up your lab, ask them to run
6:24 sensitivities for this. They will do
6:26 this for E.coli. They won't do it for
6:28 every organism, but if it looks like
6:29 you're going to have to go to IV
6:31 therapy, this is a spot you can have
6:34 them test and maybe use single dose phosphomyin.
6:36 phosphomyin.
6:39 Um, so let's talk about guideline number
6:41 10. What to do with the recurrent
6:43 patient. And I think those are the
6:44 referrals that we see. You want
6:46 something that has low allergy
6:48 potential, rare adverse events,
6:51 infrequent dosing, and something that's
6:53 going to be affordable.
6:55 Um, I like to use TMP sulfur. Sometimes
6:58 I just use straight up TMP. 100
7:00 milligrams, no interactions, very well tolerated.
7:02 tolerated.
7:04 Nitrofen towin I'll use in women
7:08 especially 50 to 100 milligrams doesn't
7:10 prevent sudamonus or proteius so look at
7:14 what maybe UTI they've had recently
7:16 phosphomiasin I see my infectious
7:18 disease colleagues doing this once a
7:20 week so maybe patient who has a chronic
7:23 catheter who's getting recurrent pylo
7:26 ending up in the hospital this is often
7:28 where they go one dose a week phosphomyosin
7:30 phosphomyosin
7:33 what about floricquinolone Um, I'm using
7:35 way less fluoricquinolones than I've
7:37 had, you know, in years because of the
7:40 blackbox warning. You only need to have
7:42 one patient in your practice that has
7:45 really severe plantar fasciitis or acute
7:47 Achilles tendon rupture and you'll use
7:49 less fuicquinolones. How many people
7:50 have had a patient that has had a side
7:53 effect from floricquinolone?
7:56 Yeah. And Dr. Brand there gave his legal
7:58 talk and I would argue that if you had
8:00 other antibiotics you could have chosen
8:03 you may be at some medical legal risk.
8:06 So what about the suppression?
8:08 Um what is the definition of recurrent
8:11 UTI? People get referred for that. It's
8:13 two in six months three in a year non-complicated
8:16 non-complicated
8:18 options for if it's definitely related
8:21 to intercourse postcoidal is the
8:24 simplest thing that you can do. Um or
8:26 you can put them on suppressive therapy.
8:28 I prefer methanamine which is a hip
8:31 wrex. So let's look at this. If anybody
8:33 wants to take a picture of this slide,
8:36 this is really simple stuff to do. Um
8:39 intermittent prophylaxis or continuous
8:42 prophylactis. This works. Okay? And try
8:45 to find inexpensive antibiotics that
8:48 have low allergy potential and that have
8:52 very few GI side effects.
8:55 Um, what about long-term prophylactis?
8:57 Trimethoprine generally is going to
8:59 work. Sometimes I'll get on a rotation.
9:01 Trimethoprine for three months,
9:04 nitrofurentonin for three months, and
9:07 then I will do uh try uh methanamine for
9:11 three months, and then start back over.
9:12 This is what I'm excited about is more
9:14 the natural therapies. In Colorado, we
9:16 have a lot of people that really want to
9:18 embrace natural therapy, organic
9:20 therapies. They really don't want
9:22 antibiotics. They don't want
9:25 multi-drugresistant organisms, the GI
9:28 side effect, the yeast infections, and
9:29 everything that goes along with chronic
9:32 antibiotic usage.
9:34 So, water, right? This is really basic.
9:37 Drink more water. Drinking as much as
9:40 two liters of water a day will decrease
9:43 your UTI risk by 50%. That's a big
9:45 difference, right? That's about what a
9:48 daily antibiotic would do. Um, people
9:50 that have feal incontinence, I recommend
9:53 a bedet and patients will put this in
9:54 their home bathroom and this really
9:57 helps quite a bit. And then a detachable
10:00 shower head and uh they can shower
10:02 before and after sexual intercourse.
10:04 This works really well. So I mean this
10:07 is really easy stuff that we can do. We
10:11 can recommend um I don't work for this
10:13 company. I don't speak for them. This is
10:16 over-the-counter really cheap stuff. The
10:18 CME people asked that I block that out.
10:21 But find a product in your pharmacy that
10:24 people can use to cleanse themselves.
10:26 This product comes in a pack. There's
10:28 wipes and there's foam. It works
10:31 extremely well. Um, anybody want to
10:34 guess how many baths a patient in a
10:38 nursing home gets per week?
10:42 One. One. Okay. So at least on the other
10:44 days they can wipe down with these
10:46 eurogenital wipes. This is what happens
10:48 in the hospital. Wipe the catheterss
10:51 down. Wipe your super pubic down. And
10:53 then for younger patients they can use
10:55 this almost like a a foam like a
10:58 spermicide foam. Put it on themselves,
11:01 put it on their partner uh and then take
11:02 a shower after having sexual
11:04 intercourse. This will virtually
11:07 eliminate recurrent UTI in someone
11:10 that's related to kitis.
11:12 Cranberry. This came up the other day.
11:14 Cranberry. Pick the right cranberry.
11:17 People say cranberry doesn't work. Yes,
11:19 it does. Um, de manos doesn't work. De
11:23 Manos is not cranberry.
11:25 Find the right cranberry. 36 milligrams
11:29 a pack. The pack binds up the pimria.
11:31 The body washes it out. Um, there's no infection.
11:34 infection.
11:37 36 milligrams a pack is as effective as
11:40 a daily dose antibiotic. This is where I
11:43 have people start with. Um, this can be
11:45 pricey. Some of these products are
11:48 pricey, but it's worth it and it's less
11:52 expensive than going to urgent care.
11:55 Um, lactobacillus and probiotics would
11:58 be the third tier, right? Water,
12:02 wipes, cranberry, probiotics. Those four
12:05 things I talk about every day in the
12:08 clinic. Methanamine. What does
12:10 methanamine do? This basically creates a
12:13 formaldahhide bomb in the bladder. You
12:16 combine it with daily vitamin C. It's
12:18 going to work very well. You do want to
12:20 be cautious in people with renal
12:22 disease. I have them dose this a gram
12:25 every other day. And methanamine really
12:27 works. Methanamine is not an antibiotic.
12:29 It's just a salt. Okay. So, it's very
12:33 simple. So, let's um talk specifically
12:35 about the female patient. And I think
12:38 Katie touched on this quite a bit on the
12:40 post-menopausal patient. I'm not going
12:42 to repeat this, but I really believe
12:45 estrogen is going to be the mainstay and
12:47 this is an important conversation to
12:49 have with your older patients.
12:53 Um, this is another algorithm um from
12:55 Eurogycology that I find really useful.
12:58 If you get down to the bottom here, this
12:59 is where I spend most of my conversation
13:02 right here. lifestyle changes, modify
13:05 the risk, cranberry, vitamin C, vitamin
13:07 D, and then eventually methanamine and probiotics.
13:09 probiotics.
13:12 This creates a lot of distress. How many
13:14 people have had difficult conversation
13:16 with the patient in their office about
13:19 recurrent UTI?
13:22 Yeah. And it's five o'clock on Friday.
13:23 People want treatment because they feel
13:25 no one's taking them serious. Nobody's
13:28 listening. Nobody's doing anything. And
13:31 I I hear that all the time. So I I think
13:32 this is something where you could really
13:35 make a big impact. The New York Times
13:39 actually wrote about this recently.
13:41 What happens in menopause? Well, the
13:43 estrogen levels fall, lactobacillus fail
13:47 to grow, pH drops, here comes the
13:50 infection. Um so parmenopausal patients,
13:52 post-menopausal, it's going to center
13:55 around estrogen. Um I'm going to skip
13:57 through this because it's been spoken to
14:00 postcodal therapy we covered. And then
14:03 the imitators, okay, the imitators are
14:06 really important. So if it's not a UTI,
14:08 and I say to patients when you're having
14:11 these episodes, I try not to say when
14:13 you have a UTI, when you have these
14:15 episodes, if I'm thinking it might be
14:17 something else, tell me what's going on.
14:20 Well, I have an infection. I understand
14:22 that, but tell me what the symptoms are.
14:25 What other diagnosises can we consider?
14:30 It's going to be GSM, OAB, IC, or one of
14:32 these other things. Think about it. Work
14:35 up patients that do need a workup, but
14:37 the more work up you do, the higher the
14:40 expectation gets.
14:42 So, in conclusion, urinary culture is
14:45 necessary for a diagnosis, treatment,
14:48 prevention. Cystoscopy, upper tract
14:51 imaging, rarely indicated. I rarely do
14:54 it. Um UTI therapy should be for the
14:57 shortest duration possible. Methanamine
15:01 is as effective as nitro furin. Um and
15:04 cranberry prophylaxis 36 milligram pack
15:06 is as effective as antibiotic. Your goal
15:10 is to decrease the UTI. Someone will
15:12 call me up six months later and say you
15:14 know none of this is working. Well what
15:16 happened? I got a UTI. Okay. How many
15:19 did you get last year? Well, every month
15:22 this year, one or two. It's working.
15:24 We're going to decrease it. We may not
15:26 eliminate it.
15:28 Um, just a little plug here on
15:30 functional urology. We're having our
15:33 meeting uh in August. Um, I hope people
15:36 can attend. We have a full day on
15:37 functional stuff. It's a good
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