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URINARY TRACT INFECTION CONSULTATION INFORMATION

Round Rock: 512-828-5522

North Austin: 512-231-1444 www.urologyteam.com

Westlake: 512-328-1313

rev/asj/03/11

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TABLE OF CONTENTS

Overview………………………………………………………………………………………………………....……………2 The Urinary System……………………………………………………………………………………….…………3 - 4 Factors that Increase Risk of UTIs Incidence and Definitions…….…………………..……………………………………………………….…...5 - 6 Initial Screening……………………………………………………………………………………………………………7 History and Physical Examination Urinalysis or Urine Culture Post Void Residual Review of Previous Medical Records Further Evaluation……………………………………………………………………………………………………8 - 9 Voiding Diary Cystoscopy Imagery of Kidneys and Ureters Treatments Options for Recurrent Uncomplicated UTIs ……..…………………………. 10 - 14 Antibiotics Behavior Therapy Vaginal Hormone Replacement Alternative Daily Treatments Appendices……………………………………………………………………………………………………..............14 A. Application of Estrogen Vaginal Cream B. Theracran

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OVERVIEW Your Urinary System

*What are your concerns? *Factors increasing risks for UTIs

Initial Screening *History & Physical Examination *Urinalysis or Urine Culture *Post Void Residual *Review of Medical Records

Potential Further Evaluation *Voiding Diary *Cystoscopy *Upper Tract Imaging

Treatment Options

Continue If Results Are Satisfactory

*Antibiotics *Behavior Therapy *Vaginal Hormone Replacement *Dietary Supplements

If 3 or less UTIs per year

If greater than 3 UTIs per year

*Treat by culture *Self start antibiotics

*Post-coital Antibiotics *Continuous Prophylaxis

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THE URINARY SYSTEM The urinary system is comprised of several muscles, organs, and nerves which collect, store, and release urine. The kidneys form urine by filtering waste and extra water from the bloodstream. The urine is carried through the ureters to the bladder, a hollow muscular organ shaped like a balloon. Located in the pelvis, it is held in place by ligaments attached to other organs and to the pelvic bones. The bladder stores urine until you are ready to empty it. It swells into a round shape when it is full and decreases in size as it empties. A healthy bladder can hold up to 16 ounces (2 cups) of urine comfortably for two to five hours. The bladder opens into the urethra, the tube which allows urine to pass outside the body. Sphincter muscles, circular muscles at the end of the urethra, close tightly to keep urine from leaking. Nerves in the bladder signal you when it is time to empty your bladder. The sensation intensifies as the bladder continues to fill and reaches its maximum capacity. When you are ready to urinate, the brain signals the sphincter muscles to relax. At the same time, the brain signals the bladder muscles to tighten, squeezing urine out. Urine can then leave the bladder through the urethra. When these signals occur in the correct order, normal urination occurs. The normal vagina and is a reservoir organisms. of many types of lactobacillus, streptococcus, and and Klebsiella. coliform bacteria, infections (UTIs). approximately

opens just behind the urethra for different types of Normal vaginal flora consists bacteria including staphylococcus species, fecal organisms such as E.coli, These fecal organisms, or most often cause urinary tract E.coli is responsible for 85% of uncomplicated UTIs.

These organisms that live in the vagina often crawl or get pushed through the short urethra of women and get into the bladder. Most often these bacteria are flushed out with the next void, but sometimes they begin to multiply and an infection develops.

Factors that may make increase the risk for UTI: Infrequent voiding – The bacteria spends a greater amount of time in the bladder allowing it time to replicate and take hold.

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Incomplete voiding – An excess amount of urine is left in the bladder and the bacteria is not completely flushed out with each void. Personal Hygiene – Perineal contamination with feces increases the risk of coliform bacteria in the vagina and near the urethra will increase the risk of urinary tract infections. Sexual Activity – Trauma to the urethra and surrounding tissue may increase susceptibility to infection and also the bacteria can be mechanically pushed into the urethra. Use of spermicidal contraception – The actual spermicide changes the normal flora in the vagina and more coliform bacteria colonize the area. The presence of these strains of bacteria leads to a greater risk of a UTI. Genetics – Certain cells on the vaginal mucosa and the urethra can express receptors that actually allow certain bacteria to attach and pull themselves into the bladder causing an increase risk of a UTI. This receptor expression tends to run in families. Hormonal Status - A lack of estrogen allows for thinning and deficiency of the tissue in the vagina and urethral that may allow for greater susceptibility to UTIs. This lack of estrogen also changes the pH of the vagina which allows for colonization with more coliform bacteria and increases the risk of UTIs. Diabetes – Persistently high blood sugar levels cause immunosuppression which allows for greater susceptibility to UTIs. Additionally, transient high blood sugars cause a spilling of sugar into the urine which acts as food for bacteria and makes it much easier for bacteria to grow and replicate. Immunosuppression – There are a variety of causes of immunosupression which decreases a person’s ability to fight off infections.

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INCIDENCE & DEFINITIONS Up to 30% of women will experience at least one UTI by the age of 24, and 50% of women will experience at least one in their lifetime. Once a patient has experienced a UTI, she is much more likely to develop subsequent infections. Symptoms of a UTI often consist of burning with urination, urgency and frequency, suprapubic discomfort, increased incontinence, difficulty emptying, and occasionally gross blood in the urine. If a urine sample is obtained, there is often a foul odor and cloudiness. At initial diagnosis, a urinalysis is often performed which may give a good indication of the presence of a bacterial infection; however, ideally, a urine culture is obtained to identify the bacteria and determine any resistance patterns that may be present. This begins to become more important as patients have increased numbers of recurrent UTIs. Simple, uncomplicated UTIs often respond to short courses of antibiotics. Often these infections are treated by primary care offices over the phone. If UTIs become recurrent and frequent, however, providing a urine sample for culture with subsequent symptoms becomes increasingly important.

Definitions UTI (Urinary Tract Infection) - An inflammatory process in the bladder or urinary tract, usually due to the presence of bacteria. Urinalysis – A simple laboratory test where a dipstick is introduced into the urine sample. Based on color changes of the stick, the presence of various substances or cellular material can be detected. The reliability of the test is based on the purity of the sample. Urine Culture - The urine is actually spread on a dish with bacterial nutrients to allow for growth and identification of the infecting bacteria. Bacteriuria – The presence of bacteria in the urine which is not associated with any specific symptoms and does not require treatment. Pyuria - The presence of white blood cells in the urine, which may represent an inflammatory process or infection. Cystitis – An inflammatory process in the bladder usually associated with symptoms of burning with urination, frequency, urgency, occasionally suprapubic pain, increased incontinence or bleeding. This condition may or may not be the result of the presence of bacteria in the bladder. Coliform Bacteria – Bacteria most abundantly found in the stool. It is named after the shape of the bacteria and is the most frequent cause of uncomplicated bladder infections.

7 Atrophic vaginitis – A lack of the hormone estrogen which allows for thinning and deficiency of the tissue in the vagina and urethra which may allow for greater susceptibility to UTIs. This lack of estrogen also changes the pH of the vagina which allows for colonization with more virulent types of bacteria. Uncomplicated UTI – A bladder infection found in a healthy patient with a structurally and functionally normal urinary tract. Complicated UTI – An infection associated with factors that cause an increased risk of acquiring an infection or a decreased ability to clear that infection. These factors could include immune suppression, an inability to empty the bladder, a stone or foreign body within the urinary tract, or other structural abnormality. Recurrent UTI – A re-infection describes an event associated with reintroduction of bacteria into the urinary tract from outside after successful treatment of a previous infection. Often different organisms are cultured. Bacterial persistence - A recurrent UTI caused by the same bacteria reemerging from a focus within the urinary tract, such as an infectious stone or foreign body within the urinary tract. The same organism repeatedly is cultured. Prophylactic antimicrobial therapy – This is a regularly scheduled dose of antibiotics over an extended course of time taken in an attempt to prevent re-infection. Breakthrough infection – An infection that is contracted despite appropriate use of antibiotic prophylaxis. PVR – The measurement of how much urine is left in the bladder after voiding. Clean catch specimen – A urine sample obtained by voiding into a cup. contaminated by vaginal bacteria even after wiping prior to collection.

This is often

Catheterized specimen – A urine sample obtained by placing a small catheter into the bladder. This is often a more reliable way of obtaining a non-contaminated sample. Bacterial Resistance – When a bacteria has obtained the ability to multiply and thrive despite exposure to the appropriate concentration of an antibiotic.

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INITIAL SCREENING I. History and Physical Examination Your physician will inquire into your symptoms, past urological and gynecological history, prior surgeries, and medical conditions such as diabetes or stroke that may predispose the patient to recurrent bladder infections. A physical examination is then performed, frequently with special attention to the pelvic examination. A pelvic examination will determine if the bladder and urethra are normal and whether the vaginal tissue is healthy.

II. Urinalysis or Urine Culture A clean catch or catheterized urine sample will be collected and analyzed to determine if you have a urinary tract infection, blood, or other abnormality in your urine. If infection is suspected, the urine sample will be sent for culture.

III. Post Void Residual This test is performed to see whether any urine remains in you bladder after you have attempted to empty it completely. Measurements may be made by catheterization or ultrasound. A normal post-void residual is less than 100 cc of urine remaining in the bladder.

IV. Review of Previous Medical Records It is very important to review previous culture results. This helps determine whether true bladder infections have been present or whether these are re-infections or persistent UTIs. The need for additional work-up may be dependent on information obtained. Additionally, other urologic conditions may “mimic” UTI symptoms and treatment might significantly differ.

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FURTHER EVALUATION I.

Voiding Diary A voiding diary is an essential part of your evaluation. It will allow you to communicate clearly with your physician about the status of your bladder, including how frequently you urinate during the day and at night, how much fluid you drink during the day.

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Cystoscopy Cystoscopy (also called Cysto) is a test that allows your doctor to look at the interior lining of the bladder and urethra, areas which usually do not show up well on x-rays. A cystoscope is a thin lighted viewing instrument that is inserted into the urethra and advanced into the bladder. Your doctor then examines the inside of your bladder for stones, tumors, pockets that don’t empty, and foreign bodies. Just before the procedure, you will be allowed to empty your bladder. Cystoscopy is usually performed with local anesthesia; a small amount of numbing jelly is placed into your urethra to reduce discomfort. After the anesthetic takes effect, a well-lubricated Cystoscope is inserted into your urethra and slowly advanced into your bladder. If your urethra has a spot that is too narrow to allow the scope to pass, other smaller instruments are inserted first to gradually enlarge the opening. Once the Cystoscope is inside your bladder, sterile water is instilled through the scope to expand your bladder creating a clear view. The Cystoscope is usually in your bladder for only two or three minutes. You may feel a cool sensation, an uncomfortable fullness, or an urgent need to urinate. Try to relax during the procedure by taking slow, deep breaths. Most people report that this procedure is not nearly as uncomfortable as they had expected.

10 After the procedure, you may need to urinate frequently, with some burning during and after urination for a day or two. A pinkish tinge to the urine can be common for several days after Cystoscopy. Afterwards, you should drink ample fluids to help minimize the burning and to prevent a urinary tract infection. Call 512-231-1444 to talk to the Triage nurse or your doctor immediately if:

III.

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Your urine remains red or you see blood clots after you have urinated several times.

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You are unable to pass urine 8 hours after the procedure.

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You develop a fever, chills, or severe pain in your flank or abdomen after the procedure.

Imaging of the Kidneys and Ureters A CT scan or ultrasound of the upper part of the urinary tract may be appropriate, especially if the infections have been difficult to treat or have been associated with fevers, elevated blood counts, or nausea and vomiting. This indicates potential involvement of the upper tracts. Additionally, breakthrough infections or persistent UTIs may indicate the need for further upper tract evaluation. Kidney stones or urethral obstruction are infrequently found.

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TREATMENT OPTIONS FOR RECURRENT UNCOMPLICATED UTIs I. Antibiotics

A. Treat by Culture This course of therapy is appropriate if patients are getting 3-4 UTIs or less per year and the patient has had a negative work-up in the past. When symptomatic, the patient leaves a urine sample for culture and then proceeds to take antibiotics based on the identification and resistance patterns of the particular strain of bacteria that is infecting the bladder. A reliable patient can even take culture vials home with instructions on how to obtain the culture at home and return it to the clinic within a couple of days. Antibiotics can be kept at home to help minimize the impact on the patient’s lifestyle. Again, it is very important to obtain the urine culture when treating these recurrent infections. B. Post-coital Prophylaxis This type of therapy is appropriate for patients with UTIs that are always associated with intercourse. A small dose of antibiotics is taken around the time of intercourse to prevent the onset of symptoms. It is best to take this just prior to activity, but if that is not possible, as soon as possible after intercourse is acceptable. C. Continuous Prophylaxis With this type of therapy, a small dose of antibiotics is taken on a daily basis to prevent recurrence of UTIs. The dosage is usually very small and should be taken at bedtime. Generally speaking, the urine is most concentrated overnight and spends the most time in the bladder, therefore a bedtime dosage is often most effective. With this treatment, it is very important to take the medication on a routine basis. If doses are missed or sporadically taken, antibiotic resistance may develop. If this happens, it not only may affect the ability to treat future UTIs but also other bacterial infections. This is very important.

12 Most commonly used antibiotics for UTIs and possible side effects: Macrodantin (Macrobid or nitrofurantoin) – This antibiotic is great for urinary tract infections. The kidneys concentrate the antibiotic so the only place it gets to high enough concentrations to kill bacteria is in the urinary tract. It does not change the colonic flora, therefore minimizing complications like diarrhea. Side effects of long-term use may include fibrosis or scarring of the lungs and peripheral neuropathy. Generally, the medication is considered safe during pregnancy, except with rare genetic metabolic deficiencies. Bactrim (Septra or sulfa/TMP) – This drug is made up of two types of antibiotics, trimethoprim and sulfamethoxazole, which may work better in combination. It is relatively broad-spectrum, meaning it may interfere with colonic and vaginal flora which may increase the risks of diarrhea and vaginal yeast infections. Unfortunately, many people have allergic reactions to the sulfa portion of this medication. This drug should not be taken early during pregnancy and may affect the effectiveness of oral contraceptives. Trimethoprim – This antibiotic may be used alone especially for those taking antibiotics for UTI prophylaxis. It works well on a daily basis. It should not be taken during pregnancy. Quinolones (Levaquin, Levofloxacin, or Cipro) - This is a class of antibiotics often used to treat infections of the genitourinary tract. It is also broad spectrum, therefore diarrhea and vaginal yeast infections may be problematic. Overall, resistance patterns to this class of antibiotics are increasing in individuals and in the community. A bacteria that is resistant to one drug of the class, may easily become resistant to the entire class of antibiotics. Besides common side effects like diarrhea and dizziness, peripheral neuropathy, colitis, and tendon ruptures are severe potential complications. This drug should not be taken during pregnancy. Cephalosporin (Keflex) – This class of antibiotics is related to penicillin and also has broad spectrum coverage. With this antibiotic, changes in bowel patterns and vaginal yeast infections may be problematic. Resistance patterns may also develop. It is considered safe during pregnancy and breastfeeding but may affect the effectiveness of oral contraceptives. Doxycycline – This antibiotic is from the teteracycline class of antibiotics. It works well for some types of urinary tract infections. The greatest side effect is nausea and sun sensitivity. It is not safe during pregnancy or breastfeeding, but may have less of an effect on the effectiveness of oral contraceptives. Fosfomycin (Monural) – This is a relatively uncommon antibiotic that is taken as a one-time dose for uncomplicated urinary tract infections. It comes as a packet of crystals to be mixed with water and may cause diarrhea. It is relatively safe during pregnancy. Methenamine (Hiprex, Mandelamine, or Urex) – Used primarily for prophylaxis, this drug is more a urinary antiseptic - not really an antibiotic. It metabolizes into formaldehyde in the urine if the urine is acidic. It is usually taken in conjunction with Vitamin C for urine acidification and normally is prescribed twice daily. It is generally very well tolerated.

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II. Behavior Therapy to Reduce Urinary Tract Infections A. Drink Additional Fluids Drinking additional fluids increases the amount of urine produced on a daily basis. With increased urine production, the bladder is emptied and flushed out more often. The bacterium that does make it to the bladder spends less time in the bladder and therefore has less of a chance to multiply and cause bladder infections. B. Void after intercourse Any bacterium that has been manually pushed into the bladder is flushed from the system before it has a chance to cause urinary tract infections. C.

Double void

Double voiding means to return to the bathroom soon after a previous void and try to empty again. With this second void, the idea is to attempt to empty the bladder closer to empty. The further the bladder empties, the less chance the bacteria has to remain in the bladder, multiply, and cause bladder infections. D. Change contraception Spermicide used on either condoms or diaphragms can alter the pH of the vaginal cavity. This change in pH alters the normal flora in the vagina so more coliform bacteria can colonize the area. The presence of these strains of bacteria may lead to a greater risk of a UTI. E. Personal Hygiene Most urinary tract infections are caused by bacteria that live in the stool. If stool is sitting around the vagina or on the perineum, this will increase the chances of the bacteria making it to the bladder. Therefore it is important to maintain good personal hygiene and cleanliness after bowel movements and make sure that wiping always occurs from front to back.

14 G. Maintain Bowel Regularity Constipation and impaction can increase the risk of stool contamination on the perineum. Eat more fiber! The best way of adding fiber to the diet is increasing the quantity of fruits and vegetables that are eaten. This means a minimum of five servings of fruits or vegetables every day. For many people, however, the amount of fruits and vegetables that are necessary may be inconveniently large or may not provide adequate relief from constipation. In this case, fiber supplements can be useful. Benefiber, Metamucil, and Citrucel are common over-the-counter supplements which work well.

Good Diabetic Control

H.

Maintain

If diabetic, it is very important to get the blood sugars under good control. When blood sugars are high, glucose spills into the urine through the kidneys. This provides excellent food sources for any bacteria present in the bladder and allows for bacteria to rapidly multiply. This significantly increases the risks of urinary tract infection. Additionally, elevated blood sugars long-term can cause immunosuppression which also increases the risk of UTI.

III.

Vaginal Hormone Replacement After menopause or a hysterectomy, a woman’s body produces less of the hormone estrogen. This drop in estrogen allows for thinning and deficiency of the tissue in the vagina and urethral that may allow for greater susceptibility to UTIs. This lack of estrogen also changes the pH of the vagina which allows for colonization with more virulent types of bacteria. Applying estrogen in the form of a vaginal cream, vaginal tablet, or ring may help relieve some of these symptoms. (See appendix for application directions.)

Estrogen supplementation is a controversial issue. The amount of estrogen that is absorbed into the blood stream from this vaginal application is small, just a fraction of the dose that would be absorbed by oral administration. Generally it is considered safe, however may be contraindicated in those with a history of some cancers and clotting disorders.

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IV.

Alternative Daily Treatments A. Cranberry Supplementation

Drinking cranberry juice has long been thought to prevent and treat urinary tract infections. There have been several recent scientific studies that have verified this information. It appears that cranberry supplementation helps prevent specifically E. coli infections which account for 80 – 85% of common UTIs. It works by preventing the bacteria from adhering to the bladder walls. It does not prevent the bacteria from entering the bladder. Many cranberry juices bought in the grocery store are full of sugar (a source of empty calories) and have a very low concentration of actual cranberry juice. Therefore it is very important to read labels if consuming the actual juice. The recommended dosage of juice is 16 ounces of unsweetened cranberry juice daily. Another option is to purchase cranberry supplementation in a pill form. Supplementation is this form should be taken twice daily. These supplements are not regulated by the FDA, so it is important to choose a reputable company from which to purchase them.

B. Vitamin C supplementation Vitamin C supplementation is used to acidify the urine creating an unfriendly environment for the bacteria to multiply and grow. There is no scientific evidence that this works in preventing urinary tract infections although in some individuals it may be helpful. If taking a supplement to acidify the urine, one may be more likely to develop kidney stones.

C. D-mannose D-mannose is a naturally occurring sugar. Supplementation with d-mannose may decrease the risk of urinary tract infections caused by E. coli, which cause 80-85% of all bladder infections. It works by preventing bacterial adherence to the bladder wall.

D. Probiotics Adding probiotics to your diet essentially is adding good, live bacteria to your colon. These supplements usually contain Lactobacillus acidophilus and bifid bacterium. This good bacterium colonizes the colon and

vagina and basically crowds out the other organisms like coliform bacteria. If the coliform bacterium is not present near the urethra, urinary tract infections are less likely. They can be taken in a pill form, or can be found in a variety of foods now, mostly commonly yogurt.

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APPENDICES

A. Application of Estrogen Vaginal Cream B. Theralogix Cranberry Supplementation

17 Appendix A

Fingertip Application Method For Estrogen Vaginal Cream 1. Wash your hands with soap and water. Dry thoroughly.

2. Squeeze out enough cream from the tube to cover 1/2 of your index finger. (See figure 1.) 3. Locate the vaginal opening. (See figure 2). Immediately above the vagina is the urethra (a small opening where urine is eliminated from your body). The urethra may not be as easily identified as the vagina because the opening is much smaller; however, use the diagram to determine its approximate location. 4. Carefully spread the cream onto the external vaginal/urethral area (see figure 2, boxed area). As the cream is spread, some may be gently inserted into the vagina; however, it is not necessary to push the cream high into your vagina.

This instruction sheet is provided to help your practitioner explain his/her preferred method for applying vaginal estrogen cream. Your doctor or nurse will likely use this sheet to assist in their patient education activities. Please note that this information is not intended to replace your practitioner's instructions; always follow your doctor's specific directions regarding the use of any prescription medication.

18 Appendix B

Theralogix Cranberry Supplementation TheraCran is a standardized, high-quality, high-potency cranberry supplement formulated to support and maintain normal urinary tract health.* The formulation of TheraCran is overseen by an advisory board of leading academic physicians and scientists. How is TheraCran different? TheraCran is the first and only cranberry supplement that has been independently tested and certified for proanthocyanidin (PAC) and other flavonoid content. PACs are the compounds that researchers have determined to be the active component of cranberries. For a cranberry supplement to be effective in reducing the risk of urinary tract infections, it must provide an adequate dose of these PACs. Research indicates that 30–35 mg PACs per day is needed for urinary tract health. TheraCran is the first cranberry supplement to use a new high-potency cranberry powder containing at least 2.5% PACs. Most supplements on the market contain cranberry powder with only 1% PACs. As a result, it may take up to six capsules per day of these other supplements to get the recommended amount of active ingredients. Because TheraCran provides a more concentrated dose of PACs, only two capsules per day are needed: one in the morning and one in the evening. TheraCran contains no cellulose or other agents that can bind to PACs, dramatically reducing their effectiveness. Most other cranberry products do contain cellulose binders and are not effective. Q. How is TheraCran different from drinking cranberry juice? Two TheraCran capsules per day have almost no calories but provide the same bioactivity as drinking 10-12 ounces of 27% cranberry juice cocktail every day. While TheraCran capsules are virtually calorie and sugar free, 10 ounces of juice contains approximately 175 calories and lots of sugar. Taking in the extra calories and sugar every day can add up over time, and can result in weight gain. In addition, people with diabetes can safely take TheraCran, and it will not affect their blood sugar levels as sugary juice will. Patients watching their weight or their blood sugar levels will benefit from choosing TheraCran over cranberry juice. Q. Are there any side effects from taking TheraCran? No, taken at the recommended dosage of two capsules per day, no side effects should occur. Q. Will TheraCran interact with my medications or other dietary supplements? There are no known dietary supplement interactions with TheraCran. It is safe to take with other dietary supplements. When taken at the recommended dosage, TheraCran is not likely to interact with any prescription medications. It used to be thought that cranberry juice or cranberry supplements would increase the effect of warfarin (Coumadin), a blood thinner. Recent studies have proven that there is no significant interaction, and cranberry is safe to take (the recommended dose -1 capsule, twice a day) while taking Coumadin.