Almost every Canadian women will get a urinary tract infection in their lifetime and for many it develops into a serious ongoing problem.
In this video, Calgary urologist Dr. Richard Baverstock speaks with Calgary Journal reporter Michelle Huynh about the scourge of UTIs, diagnosis, treatment and a possible new vaccine.
Michelle Huynh: How often do you see recurring UTIs in your daily practice?
Dr. Richard Baverstock: As a urologist it would be probably one of the most common referrals that people would get, because it is common, it’s said to be anywhere, one-in-four one-in-five women will get infections. The definition of recurrent UTI is one in six months, or three in a year. So, if somebody has one UTI, they are not going to get sent to a urologist but if they have one in six months or three in a year, then they’re starting to hit the definition of recurrent urinary tract infections and they’re typically going to get a referral.
Because they’re going to say, “What’s the underlying cause?” Now, the frustrating thing is, there is almost never an underlying cause found so it’s not like there’s a fix. It’s not like, “Just do this and you’ll be all better.” This is an incredibly frustrating and common condition. And I often say to people, “If you want to take away the most frustrating part of my practice, take away recurrent urinary tract infections because we haven’t made a tremendous improvement in this in my career or even over the decades.”
Would you say that they (recurrent urinary tract infections) have become more common over the years?
It’s more common because, 20 or 30 years ago, we weren’t seeing as many people well into their 80s and 90s. And so, for females recurrent infections continue on and they worsen particularly when you get into low estrogen state and postmenopausal states later and later in life with vaginal atrophy, diabetes, impaired bladder emptying, prolapse, you’re going to see recurrent UTIs rise and rise. Then you throw in complexity, such as nursing homes, catheters, impaired bladder emptying and that’s why it’s just so common.
You mentioned that not everyone needs a full workup
Not everybody needs an ultrasound, not everybody needs cystoscopy. Often patients want it because they want an explanation, and the explanation is, “You have the world’s most common bacterial infection that one in five women will suffer from. It’s not a good enough explanation… so there must be something wrong with me. Maybe it’s cancer?”
You’re looking for other clues in their diagnosis such as poorly controlled diabetes, evidence of fistula, or connections with the bowel. These are rare things. You often won’t find something. And then there may be a trigger. So in a young female intimacy or sex could be the trigger. The most common trigger in a postmenopausal woman: it’s low estrogen state, the tissues become atrophic.
And so the majority of women with recurrent infections, though, don’t need fancy tests or investigations, because you won’t find anything. It’s frustrating as mentioned earlier that typically there is no underlying cause to this.
Is there a reason why there isn’t? Do you think there’s been enough research in the area, what are your thoughts?
If you go back in time, obviously women have gotten infections as long as we’ve been humans because it’s not a brand-new thing. If you look historically, often people will say, “Yes, I used to get infections. My grandmother had a recipe for a tea or something.” The majority of bladder infections will clear on their own, no matter what happens, time will clear them. Very rarely do they progress to the upper tract or kidney infections. That’s the big worry, “Oh I’m gonna get a kidney infection.” But in general they are self-limited. They are extremely painful and annoying but they’re going to go away.
Then, antibiotics came. The first antibiotics that would have come along would have been Penicillin, Septra, Macrobid. And all of a sudden a woman gets an infection, a doctor can give an antibiotic, and she got better very quickly. So that was all great until we started to see resistance and so resistance to an anti-biotic became a big deal.
Now we’ve created a bigger problem for ourselves which, we’re seeing a lot, is resistance. You’ll see from the guidelines that we try to be really specific on making a diagnosis, and then what antibiotics, do you use first line… and trying to avoid Ciprofloxacin which was, the world’s most amazing general urinary antibacterial or antibiotic but now we see a lot of resistance with it which is unfortunate. It was very effective but it was used a lot.
And so, I think we go back to the basics. Is there something that we haven’t figured out yet? Why do one in five women get this? Is their urethra too short? Do they not have the right protective things in their urine like peptides; do they not have the right receptors to fight off bacteria, or do they have something that the bacteria glom on to? And I think those are probably the questions that still need to be answered. People have done a lot of research on it but there’s no amazing breakthrough yet.
I always draw the analogy to H pylori. H pylori is the bacteria that was found in the stomach, and it was causing ulcers. So for the longest time people thought ulcers were like, “Oh you’re eating too many hot wings or something.” And lo and behold, there was a bacteria in there called H pylori. So now there is a very effective treatment called triple therapy with three medications two are antibiotics, and you can annihilate ulcer disease.
I don’t know if there’s not been enough research (on UTIs), or if we got sidetracked by the effectiveness of antibiotics. I would say we’re returning to it now because if you look at the importance of using antibiotics, only when you really need them and not overusing them, then there will be a return to say, “Well, what else could we do?” And in some countries like Holland, for example, it’s extremely difficult to get an antibiotic for things. Whereas some countries, Spain, Mexico, you’ve got the best antibiotics over-the-counter.
So there’s a huge difference between those two countries and Holland would have very little resistance. Spain and Mexico where you can get Cipro and Septra over the counter will have a tremendous problem with resistance. So I digress there, but I just give you an idea that that it’s a very complicated answer to say, “We don’t know yet.”
Maybe there’ll be a massive breakthrough and we’ll discover something that was missing, but as of right now, we haven’t found it.
I spoke with a clinician who believed that there was a really big distinction between irritation and infection. Do you believe in that kind of distinction?
There’s a condition called asymptomatic bacteria. So we used to think for the longest time that the bladder is sterile. And lo and behold the bladder has its own biome and its own group of bacteria. Some women can have a positive urine culture and have no symptoms. So they have what’s called ‘asymptomatic bacteria’. You do not need to try and annihilate that. In fact, trying to annihilate that is only going to create resistance.
Then, another group of women would have all the features of a cystitis and are convinced they have a bacterial infection but they don’t grow anything. So without a bug, maybe we just haven’t identified it yet, like an H Pylori, a virus or bacteria or fungus, or is there something else causing the inflammation, the symptoms?
My thought would be yes and that’s what we go after. It’s usually things like the irritation of the pelvic floor which will mimic all the features of a bladder infection so we try to really focus on what are the things causing irritation to the pelvic floor and what things can we do to alleviate the symptoms of irritation of pelvic floor and improve the symptoms that people might attribute to a bladder infection that’s culture negative, and try to avoid antibiotics.
But, that’s us doing it, whereas, that person shows up on a Friday night to a walkin clinic, they’re almost certainly going to get an antibiotic because that’s what they want. That’s what they demand. And to be honest that might be the fastest way to get somebody out because it isn’t wrong. But if you say, ‘well, what else can we give you until we get this culture result back and if it’s negative, then we avoided giving you an antibiotic that you didn’t need.’
Those are people that we end up seeing. The doctor family doctors have been given them lots of antibiotics and they’re not getting better, what else could it be? Which is a bit different than the topic of recurrent urinary tract infections which is culture proven so you’ve got your E coli or Klebsiella. You’ve got your most common bacterial infections proven on culture, which is what recurrent urinary tract infections are.
But I spend my entire life seeing people who are convinced they have their infection and there’s no cultures proving it yet. And now we’re going after other diagnoses.
Family physicians are typically on the front line of those who are first approached or sought after when someone is experiencing symptoms of a recurrent urinary tract infection. So could you talk to us about how physician practices have changed over the years and maybe what kind of guidelines have influenced this?
The best relationship is obviously a patient that has a well-established family doctor that knows them, that is accessible, so that what I would do in my practice if somebody has recurrent infection, I would say, “Here is a urine culture requisition. Here is an orange top container that is sterile.” When you believe you’re getting an infection,
Take a midstream urine, take it to the lab. If it’s at night, put it in the fridge and drop it off the next day, because then you have the most important thing: a culture that’s cooking, so we can get a diagnosis. Because when I see people and I look up, “Hey you haven’t had a positive culture. What is this?” That’s probably the most important thing for a family physician to be able to make the call, get them going at the lab, and then you’re going to make a diagnosis. Basically without that culture to say are we going to treat this as an infection or not? Can we wait this out, or are your symptoms too bad?
And that’s going to be very individual. I don’t want to say that physicians do it right or wrong. What I would like to see not happen is you go to the strongest antibiotics that we have, ciprofloxacin. The guidelines are very clear on what you should give first. You’re going to get Septra, which is a sulfa antibiotic, not if they have an allergy. You’re going to give Macrobid, which is nitrofurantoin, the resistance has not changed very much in decades. Or you’re going to get fosfomycin, a three-gram package in water times one dose. So if you follow the guidelines, that’s what you’re going to get.
And you’re not going to go to a bigger gun right off the bat. If the person can wait it out, and you can say well let’s get some further information. We usually will always get a urinalysis. The urinalysis analysis could show white cells, red cells and nitrites and you might also see bacteria so it’s going to lead you in the direction to say this is most likely a UTI.
And then what did the culture show? Because if the culture shows no growth, and you’ve sent the person away on seven days of ciprofloxacin because they said to you ‘three days doesn’t work for me, I always need 10 days’ and the culture is no growth.Then, what the heck, then you’re gonna get C Diff, Achilles tendon rupture, and then resistance to Cipro. So I think you go with urinalysis, wait on the culture and make a decision about the most appropriate antibiotic. Then follow up on it.
And that would be my recommendation. Then there are situations where you can potentially avoid an antibiotic. So some women will say, “I don’t want to take an antibiotic.” Well, what else can they do? If you look at the guidelines then (drinking) 1.5 to two litres of water per day seems to be beneficial.
If they are postmenopausal women ensure that they’re using vaginal estrogen. So that is topical estrogen applied to the vagina, that’s been shown to reduce recurrent infections by four times. So that’s a game changer. And then you can look at symptomatic relief until the culture comes back. You can look at anti-inflammatories, such as standard Advil. You can look at Pyridium (phenopyridine) which turns the urine orange. It’s basically a urinary analgesic, and then there’s a few natural products.
One called Cystoplus or even baking soda and water that may give people some relief to that burning until the culture comes back. The guidelines are pretty clear on things that you can do and, and then some. People may try to rescue with cranberry although usually at the point that it’s a bacterial infection most people will want an antibiotic because they’re going to get better quicker. But we know that they’re probably going to get better, even if they don’t get it.
Because most people will clear a bacterial infection. So I think there’s lots of things you can do without giving an antibiotic. If you’re going to give antibiotics, try get the most specific one to the urinary system and avoid the big guns, so that we can get away from all of this resistance. Send a culture, so that we know what this is because when you (family physicians) send them to me the first thing I do is look on Netcare.
And then it’s my job to sort out those situations which are recurrent infections, which I will take to mean that a culture was shown to be positive.
That’s very interesting you mentioned cranberry juice. I just spoke to another clinician who said that there’s not actually much scientific backing behind that, or the D-mannose.
Cranberries–and the PAC (proanthocyanidins) molecule–have obviously played a role in First Nations (medicine) and even grandma’s tea recipe. So we know that in the lab that cranberry can bind up the P fimbriae, the little arms of the E coli and stop it from adhering.
I think the studies are really poor on cranberry, because it is a natural product. They are not funded by pharma and a lot of it is anecdotal. Ocean Spray is sugar that touched a bit of a cranberry to make it very pleasant. If you chewed on a bag of cranberries, you’re not going to get very far on them because they’re intense, not tasty at all. So, you need a lot of cranberry concentration in order to potentially play an important role. So, the company Utiva is a made in Canada story, and they have just come up with a cranberry capsule that has 36 (mgs of) PACs. And one tablet is equivalent to 9 Costco tablets.
Now, do I think a cranberry capsule is going to beat out a package of fosfomycin three grams, absolutely not. But if you’re looking for ways to reduce recurrent infections. I don’t think there’s harm in taking cranberry. There may be benefit. You have got to make sure you take the right product… (Dr. Baverstock discusses a range of studies)
So when patients say, “I don’t want to take any more antibiotics doctor,” I’m going to say, “Well make sure if you’re going to take a cranberry supplement, you’ve got to take something that has enough of the active ingredient and from the studies it looks like you need 36 PAC’s. The best one we know of is from Utiva health.”
I think it’s totally fine to take it. What is it going to be though? One dollar a day? It’s not going to be covered by an insurance plan, so that’s going to be another decision. That’s $365 a year for cranberry tablets so it better work pretty well. That’s the judgement each person is going to make.
I think I spoke to several women actually who spent upwards of 20K, trying to cure their urinary tract infections.
I totally understand women’s frustrations, particularly with recurrent UTI and searching for an answer. And so I think in searching for the answer a bunch of natural products have been tried. There’s post-coital antibiotics we haven’t talked about: taking a single tablet after intimacy is an important thing for some women that works well. You can self start so if you’re traveling and you get into UTI you can start your own antibiotics and all of these are just strategies that we use, because this is such a common problem that we’ve been unable to break the cycle. (There’s also) suppressive antibiotics we take at a low dose continuously. We do that a lot in children, and then we’ll do that a lot in say postmenopausal women, where, and it kind of breaks your heart to give somebody an antibiotic every single day, but they’re just so burdened by them (UTIs) that they’ll do anything to get a break from it, so they take a low dose continuously.
I actually recently spoke to this online women advocacy group for UTIs and they’ve mentioned that they believe there is a gender bias and treatment and diagnosis for women with recurrent UTIs, and I just wanted to know what are your thoughts on this?
Well, I certainly would say women are more commonly getting recurrent UTIs. Do we not take it as seriously? I suppose with men, we usually find an underlying cause, so it’s usually prostate urethral structure because the male urethra is much longer so there’s a lot more protection from the tip of the penis back to the bladder, than there is with a woman, which is short, adjacent to the vagina, and the anus. So, there’s a gender difference between men and women.
I guess it always comes back to this: If men suffered from recurrent infections–one in five men– would we have made a lot more progress on recurrent infections? People say, “If men had this, it would be solved by now.” I suppose maybe that’s possible. But men don’t suffer from recurrent infections, there’s usually always an underlying cause, and we haven’t been able to make any major breakthroughs yet with women.
I don’t ever get the sense that people are in meetings like, “Well let’s not talk about that because that only happens to women.” Because tons of health care providers are women, and tons of health care providers that are women get recurrent infections. We just haven’t made the progress that we’ve made with recurrent infections that we did with COVID vaccination in 250 days. When there’s something that everybody in science wants to work on a lot of progress is made. I’m disappointed on that front, that we haven’t made the progress where we fix this. I’m pessimistic we’ll get a fix, unless there’s vaccines.
Will we get a vaccine that’s effective for the most common bacteria? That’s probably the single most exciting thing that is coming down the pipeline is potentially vaccines for UTIs.
How far along are we with these vaccines?
There’s one in use in Europe, Spain. We haven’t got Health Canada approval for the vaccines here in Canada, but they’re coming. It’s sublingual, so (taken) under the tongue. Bacterial components, are the most common bacterial infections that cause urinary infections. Looking at the research – a review article published in the Canadian Urology Association Journal – we’re talking game-changer, like zero infections in six months. Not one, but zero. That’s the most exciting thing (vaccines) we are going to see in the coming years. Once we get that approved, could we make then make huge headway? In my career will I see a change?
So for all the women out there, Dr. Baverstock, who may be suffering from these recurrent urinary tract infections. Do you think they could be looking forward to this in their lifetime?
I would hope so, just like we’re gonna look forward to COVID vaccinations, I would hope that we could get to the point where people didn’t suffer from recurrent infections.
Now, who’s going to get it (vaccines)? How do you meet the criteria? Do you want to take it? These are all the questions we don’t have answers to and I refer again the review article by Curtis Nickel in the Canadian Urology Association Journal, they touch on this. I’ve never seen the product in use yet, I’ve just read the studies and most recently heard him speak and it’s impressive. It’ll be the best thing that we’ve ever seen happen with recurrent infections. Do you need it regularly, do you need to top up, is it one and done? Those are things we just don’t know, because the studies are just not that old. But I think that’s probably the most exciting thing that we’ll see in our careers.
Would you be able to give a couple last words on how clinical outcomes and quality of life could be improved for women with recurrent urinary tract infections?
Certainly, this is an incredibly frustrating condition for women. It’s a painful condition obviously to have the symptoms of a cystitis, terrible urgency, frequency, burning. People would describe it as being almost chained to the toilet where they just can’t get rid of that sensation,
So incredibly common. It affects people’s quality of life, tremendously. And then they start to avoid things like intimacy, because those can be triggers for infection so that can affect them and their relationships that they have in their lives, which is obviously really unfortunate.
The diagnosis is based on culture, which is probably a very old fashioned way of diagnosing it. There’s probably better ways, but we haven’t had a game-changer in diagnosing yet. We’ve talked already today about some of the prevention things. Some of the things we know maybe work: water, cranberry, topical estrogen that we should make sure we talk to our patients about. And then making sure that we choose the right antibiotic, the right time to give it, so that we’re not creating more and more resistant patterns. The future is hopefully going to be vaccinations as one of the options that hopefully will come. And then I think my kind of final note is, “Who needs to see a urologist?”
When you’re getting recurrent infections, to be truthful, probably not many people, most people could probably be managed by their family physician for this. If there’s an underlying condition: immunosuppression, poorly controlled diabetes, pelvic floor prolapse, then those would be conditions, also incontinence, where you’d say, “Okay, you need to see a urologist just because we need to rule that out.” So if you’re incontinent, and you have a bad prolapse, uncontrolled diabetes, or you’ve had a kidney transplant or you’ve had previous urologic surgery, then that’s when we should be getting involved. It’s actually a topic I’m extremely passionate about because it is such an important thing for so many women, and I hope we see a breakthrough. Usually we just work through strategies, try to come up with a way so it doesn’t happen and ruin their vacation, their honeymoon, their holiday, or something. For the most part this is a family medicine condition that can be well-managed with your family doctor.
Editor’s Note: This interview was conducted in Winter 2021 and has been edited for length and clarity. It is not a full transcript. For citation, please check against the video.