The urology specialist's best advice on how to prevent & manage urinary tract infections

Recurring urinary tract infections have marked a large part of my youth. During the 90s, I had more infections than I can count and took more antibiotics than I dare to think about. For many years, I underwent numerous different tests, but I never got a proper explanation. Very quickly, I learned what was a risk and how I could prevent it. For example, not urinating after intercourse was a 100% guarantee of a urinary tract infection, which I quickly learned. It is now almost three decades since I had repeated urinary tract infections, but it is still a rule without exception to urinate after sex – because who dares to take a chance? Today, we know a little more about the causes behind recurring urinary tract infections than when I was in my 20s, and in hindsight and with more knowledge, I can see several potential reasons why I suffered from infections for so many years. For that reason, I am especially happy to present this interview with Tareq Alsaody, senior physician and urology specialist, with whom I have had a long conversation about precisely – urinary tract infections!

Question: What are the primary causes of some women experiencing chronic urinary tract infections?

Tareq: The primary reason women are more prone to urinary tract infections is anatomical factors. Women have a shorter urethra that lies close to the anus and vagina, which makes it easier for bacteria from the bowel to migrate to the urethra. Most urinary tract infections are caused by bacteria from feces. Urine cultures show that the most common bacteria in urinary tract infections are gram-negative bacilli, which are part of the intestinal flora. This means that the bacteria usually come from the bowel.

It was previously believed that urine was a sterile environment, but now there is evidence that bacteria normally exist in the urine and that there is a bacterial flora in the bladder and lower urinary tract that live in harmony with the body. This is called the microbiome. I believe more established facts are needed, but it sounds logical that there may be bacteria with which we live in symbiosis and harmony. When this harmony is disturbed, especially in the lower urinary tract, for example due to disturbed bowel function, sexual intercourse, from the vagina for some reason, or with weakened immune defense, both locally and generally, these bacteria can cause infections. It is somewhat reminiscent of the microbial balance in the vagina. A simple urinary tract infection may only need to be treated with a course of antibiotics, but if it becomes a more complicated case, it is never wrong to consult a general practitioner or a bowel function specialist because several different diagnoses can affect one's urinary tract immunity.

Question: What is the difference between urinary tract infection, urethritis, and chronic urinary tract infection?

Tareq: A urinary tract infection means that part of the urinary tract has an infection. It can be in the upper urinary tract, such as the kidneys and renal pelvis, or in the bladder itself. The word inflammation differs from infection. Inflammation is the body's reaction to irritation or an irritating factor. If this inflammation, that is the tissue's reaction, is focused and concentrated in the urethra, it is called urethritis. However, urethritis is often part of an inflammation in the bladder, the urethra, or even in both the vagina and the urethra.

A pure urethritis is rare and there is not much statistics on it. Maybe it is part of an inflammation that has calmed down in the bladder but remains in part of the urethra. The urethra contains small glands where bacteria can sometimes develop, form colonies, and cause a reaction. In many cases of what is called urethritis, no bacteria are found, which may mean that there has previously been an inflammation that has left behind a hypersensitive tissue. 

Question: So is it a hypersensitive tissue that can be the cause of getting several urinary tract infections one after another?

Tareq: Maybe, if you never find bacteria. But if you can find bacteria, and it turns out to be different types of bacteria in different cultures, it means that each infection is a new infection. This may indicate that the problem is a reduced local defense in the urinary tract tissue of the person in question, which makes it easier for the bacteria to establish and cause an infection. It is still common to do several cultures, examine the bladder with ultrasound or CT scan, and also with cystoscopy (looking into the bladder under local anesthesia), without finding any visible abnormality. There is likely one or more factors that we have not yet identified. The concept of the microbiome and a bacteria-rich environment living in harmony may be an explanation.

Question: What counts as a chronic urinary tract infection?

Tareq: There are different opinions about this, but it is said that if you get three or more urinary tract infections within six months, it is considered recurrent urinary tract infection. I think the choice of words is also important. Do you want to call it repeated urinary tract infections or new ones if you get several urinary tract infections but with the same bacteria? Saying chronic sounds like it will never go away, that you believe you are sick forever. Are the same bacteria found in each culture or are they different bacteria? If they are different bacteria, you need to broaden your view on the matter and perhaps consult other specialties and take a closer look at the woman's immune function, general condition, other medications, previous surgeries, trauma, lifestyle, what she eats and drinks, routines during sexual intercourse, and routines during toilet visits. A chronic infection sounds like you are sick forever and that is not the case with urinary tract infections.

Question: Is there any genetic cause for recurrent urinary tract infections?

Tareq: It cannot be ruled out. There is research that has looked more closely at genetic markers and there seems to be a basis for a genetic tendency to urinary tract infection, where some individuals have reduced local immunity. It is important to distinguish between anatomical malformations and genetic factors. If a person has a malformation affecting urinary tract function, there is often an increased risk. Regarding non-visible genetic factors, the immune system can play a decisive role.

Despite a genetic predisposition, it is not a predetermined situation. About 20–30% of the risk can be linked to genetic factors, while 70–80% can potentially be influenced by lifestyle changes. It is common to ask about urinary tract infections in the family, and it can sometimes turn out that other factors such as bowel dysfunction or habits like rarely visiting the toilet can increase the risk through urine retention and thus bacterial growth.

Sometimes hygiene measures can also play a role; excessive use of hygiene products in the genital area can cause chemical irritation that affects the immune system or disrupts the gut flora, which can increase the risk of urinary tract infection. Investigating recurrent urinary tract infections in women often requires more time and thoroughness.

Question: What role do diet and lifestyle play in the prevention and management of chronic urinary tract infections?

Tareq: When it comes to diet, strong spices can sometimes be excreted in the urine and have an irritating effect on the bladder lining, which can disrupt the bacterial flora and immune system. It is important to be aware of this especially if you experience symptoms similar to a urinary tract infection despite a negative culture. Diet also includes other factors such as nicotine and alcohol, which can negatively affect health, including urinary tract function. Avoiding these substances as much as possible can be beneficial for maintaining general health and minimizing the risk of urinary tract infections.

Question: Is there anything more you can tell about the study with a vaccine that could prevent urinary tract infections?

Tareq: The vaccine is called MV140, for the prevention of recurrent urinary tract infections. The purpose of the study was to evaluate whether a sublingual vaccine, MV140, can reduce recurrent urinary tract infections (rUTI) in women treated for three or six months. There were 240 women in the UK and Spain aged 18-75 who participated, with the criterion that they must have had at least 5 uncomplicated cystitis (urinary tract infections). The study was a randomized, double-blind, placebo-controlled multicenter study where participants were randomly divided into three groups receiving the vaccine for 3 months, 6 months, and a placebo group. The evaluation measured the number of urinary tract infections and the proportion of infection-free patients over nine months. Perceived quality of life and safety were also assessed.

The result showed:

🌸 Urinary tract infections: The median number of urinary tract infections was 3.0 (placebo) compared to 0.0 (MV140 groups).

🌸 Urinary tract infection-free patients: 25% for placebo, 56% for 3-month MV140 and 58% for 6-month MV140.

🌸 Side effects: A total of 205 side effects were reported: 81 (placebo), 76 (3-month MV140) and 48 (6-month MV140).

The conclusion is that MV140 reduces the number of urinary tract infections and increases the proportion of UTI-free patients but it is still only available as a licensed medicine. Treatment with MV140 also proved to be safe for women with recurrent urinary tract infections, but long-term studies are desired to know if the effect remains in the body.

Reference: Lorenzo-Gomez, MF., Foley, S., Nickel, C. et al. 2022 Sublingual MV140 for Prevention of Recurrent Urinary Tract Infections. NEJM Evidence 1, 1 (2022). Digital journal, available to subscribers.

Question: How do hormonal changes, such as menopause, affect the risk of developing urinary tract infections?

Tareq: Hormones definitely play a crucial role in the environment that can predispose to urinary tract infections. Estrogen has been shown to have a preventive effect against infections, which is known for the vagina and probably also for the urinary tract. Therefore, local estrogen is a treatment method often considered for women who experience recurrent urinary tract infections and no longer menstruate, with presumed good effect.

Question: What other causes can underlie urinary tract infections?

Tareq: When it comes to young girls who have not yet reached puberty and suffer from urinary tract infections, it is likely not due to hormonal factors. It may instead be related to not fully emptying the bladder during urination, limited knowledge about local hygiene and the use of toilet paper, and in some cases constipation. The effects of gut health on bladder behavior are also crucial. Just as vaginal health affects urinary tract health, the condition of the skin is important; for example, people with poor skin health, such as untreated diabetes, have an increased risk of urinary tract infections. Sugar in the urine can be both irritating to the bladder's mucous membrane and a nutrient for microorganisms, which can facilitate infections. It is therefore important to consider these factors when investigating and treating urinary tract infections.

Question: Can the use of contraceptives affect the risk of developing urinary tract infections?

Tareq: A disruption of hormonal balance can affect the urinary tract – this includes the use of contraceptives such as birth control pills. Hormones play a significant role in the body's entirety.

Question: A young woman who takes birth control pills and has recurrent urinary tract infections – is it established that another form of contraception is recommended?

Tareq: When managing a young woman with recurrent urinary tract infections and use of birth control pills, it is important to consider the whole picture to address any contributing factors:

1. How is the bladder emptying, specifically urination? Are there obstacles at work that prevent her from going to the toilet?
2. Access to the toilet – is it clean and does she feel comfortable there?
3. Bowel function – is it regular?
4. Diet and drinks – is there anything that can affect the immune system and thereby the health of the urinary tract?
5. Sexual activities – have the symptoms started after she got a new partner? How was it before? Discussion about local contraceptives, such as spermicides, may be relevant.

Question: Does intercourse increase the risk of urinary tract infection in women?

Tareq: Intercourse can probably increase the risk of urinary tract infection in women who are more prone to UTIs. If the bladder is not emptied properly after intercourse, bacteria introduced into the urethra during the act can remain and cause infection. Therefore, urinating after intercourse is especially important to flush away any bacteria that may have moved closer to the urinary tract during intercourse. It is actually also good to urinate before intercourse. If the bladder is full, it can be uncomfortable and painful to hold it.

Question: Are there any new or ongoing studies that provide insight into the treatment or prevention of chronic urinary tract infections?

Tareq: Absolutely! New studies and systematic reviews are constantly ongoing, providing valuable insights. It is always exciting to follow the research because new ideas and treatment approaches can be discovered, which can lead to better understanding and treatment of chronic urinary tract infections.

Question: How effective are natural remedies like D-mannose and cranberries, as well as home treatments, compared to traditional medical treatments for urinary tract infections?

Tareq: All agents that alkalize the urine are interesting. When the bacteria reach the bladder, they begin to form colonies, which leads to the formation of a biofilm on the mucous membrane. Biofilm can also form on catheters and is a common cause of recurrent urinary tract infections in catheter users. Natural remedies believed to have an effect are those that prevent the formation of this biofilm. To achieve this, one needs to change the chemical behavior of the urine from acidic to alkaline, which, for example, D-mannose and cranberries can contribute to. There is also a belief that vitamin C can be effective, but there are concerns that high doses may contribute to the formation of urinary stones, which requires caution. Solving one problem while risking creating another is a constant balancing act.

Question: We have many customers who say they no longer get urinary tract infections since they started using VagiVital AktivGel. We have no studies of our own on this, but what do you think about it?

Tareq: It is probably because the mucous membranes become rehydrated and the bacteria no longer have the same opportunity to enter. In addition, the gel almost forms a protective film. There are several speculative explanations. Perhaps the gel protects the mucous membrane. Furthermore, it may reduce the risk of trauma when wiping with toilet paper or during intercourse, as the mucous membrane is not affected as much. It may also be that the gel has a stabilizing effect on the bacterial flora. It is an interesting question that needs to be explored further.

Read more reviews about VagiVital AktivGel here!

Question: What impact does psychological stress have on the frequency or severity of chronic urinary tract infections?

Tareq: Stress definitely has an impact. If we talk about infections caused by bacterial growth, stress is in some way a type of inflammation in the body, a challenge. Especially if the stress is long-term and negative, it can lower immunity. It is a fact that the body is a unit. If you study anatomy, tissue knowledge, and physiology, you see great similarities between different systems, even though they are in different parts of the body.

Question: What are your recommendations for women with suspected recurrent urinary tract infections?

Tareq: If a woman gets a urinary tract infection for the third time within six months, it may be time to seek further help and 1177 is always a good starting point. Digital healthcare is also becoming increasingly common, allowing consultations with a healthcare provider wherever you are, to start an investigation process. If the antibiotic treatment is well-founded, after a thorough investigation, antibiotic courses are completely acceptable. There is a category of urinary tract infections that respond well to preventive antibiotic doses, which is a small dose. Usually, one starts with a urine culture to determine which antibiotics are effective against the bacteria and then chooses one that the patient tolerates for treatment over 5–7, sometimes 10 days with a full dose. After that, 25–30% of the dose can be used over the next 3–6 months to see how it develops. A medicine that is relatively underrated is Hiprex, which is a urinary antiseptic with bactericidal effect. It is used as an antiseptic in the bladder to hopefully prevent infections. But so far, there is no medicine that I know of that provides 100% effectiveness in users.

Question: What are your 3 best tips for women with recurrent urinary tract infections?

Tareq:

1. When facing recurrent urinary tract infections, it is important first and foremost to reflect on one's daily life and lifestyle. It is about identifying patterns, such as when the infection usually occurs and under what circumstances.
2. It is crucial to do a urine culture to identify which bacteria are involved. A urine dipstick can provide a preliminary indication by showing the presence of red blood cells, glucose, nitrite (a byproduct of bacteria), white blood cells, and more. If the test is positive for nitrite, it suggests that bacteria are growing in the urine in significant amounts, making a culture even more valuable to precisely determine the type of bacteria.
3. After completing an antibiotic course, it is also always wise to wait a few days and then do a follow-up culture. If the bacteria continue to grow despite the treatment, it may indicate that there are factors facilitating recurrent infections and requiring further investigation.

Buy VagiVital Urinary Tract Infection Self-Test that measures leukocytes, blood, protein, and nitrites with 99% accuracy here!

FINAL WORDS

From experience, I know that recurrent urinary tract infections can be both complex and frustrating to manage, but with the right knowledge and preventive measures, they can decrease in frequency and severity. There is ongoing new research on the subject and there is hope. Urology specialist Tareq Alsaody also emphasizes the importance of understanding the underlying causes, conducting thorough urine cultures, and reflecting on lifestyle factors. By following this advice, women can hopefully better prevent and manage urinary tract infections, which in turn contributes to an improved quality of life ❤️

Take care of yourself & Stay Pussytive ❤️

/Fanny Falkman Grinndal

Business Manager Nordics
Peptonic Medical AB
fanny.falkman-grinndal@peptonicmedical.se