Why Do UTIs Keep Coming Back?

Dr. Rodriguez: Women tend to get urinary tract infections more than men. Men get them too, but of all urinary tract infections in the US, about ten percent happen in men, so ninety percent happen in women. About one in three women by the age of twenty-four will have a urinary tract infection. You have about a sixty percent chance of having a UTI throughout your lifetime.

Courtney: Welcome to Health Matters, your dose of the latest in health and wellness from NewYork-Presbyterian. I'm Courtney Allison.

This season on Health Matters, we're covering your health from A to Z, asking our experts to break down the health topics and wellness trends we're all curious about. Today, we're at the letter U for urinary tract infections. The symptoms of a UTI are hard to miss: burning pain, frequent trips to the bathroom, and persistent discomfort. UTIs are common, particularly among women, and for some people, they keep coming back. To learn more, we spoke with Dr. Larissa Rodriguez, Urologist-in-Chief at NewYork-Presbyterian and Weill Cornell Medicine.

She explains what causes UTIs, how to prevent them, and how to manage them. We also separate fact from fiction on remedies like cranberry pills, discuss concerns about antibiotic resistance, and explore promising new treatments.

Dr. Larissa Rodriguez, thank you so much for joining us today on Health Matters.

Dr. Rodriguez: Thank you. Thank you for having me here.

Courtney: I'd love to get started with just a basic definition. What exactly is a urinary tract infection?

Dr. Rodriguez: So a urinary tract infection is when a bacteria makes its way into the bladder, and for it to become an infection, the bacteria has to stick to the bladder wall and it starts replicating, so you get more and more bacteria, and it can be really irritating to the bladder itself.

Courtney: How common are urinary tract infections, and who tends to be most at risk?

Dr. Rodriguez: Women tend to get urinary tract infections more than men. Men get them too, but of all urinary tract infections in the US, about ten percent happen in men, so ninety percent happen in women.

And there are different incidences or prevalence according to age. About one in three women by the age of twenty-four will have a urinary tract infection. But overall, if you look at all women in the US of all ages, you have about a sixty percent chance of having a UTI throughout your lifetime.

Courtney: Why are women more prone to them than men?

Dr. Rodriguez: It's anatomic. The urethra in women is very short. So if you think that a bacteria has to make it to the urethra and climb into the bladder, it's a very, very short...the, the urethra in women on average is about three centimeters in length, while male urethra is much longer. And the urethra opens very close to the vagina, and the vagina is usually colonized with bacteria, usually good bacteria, but it can be also colonized with what we call uropathogenic, or bacteria that are more likely to cause infections. If you have a healthy vaginal flora, it's not usually an issue. The flora still climbs into the urinary tract, but people urinate them out and you don't get an infection.

Courtney: Are there certain life stages when they're more common?

Dr. Rodriguez: There's some children that are prone to having them, and then when women become sexually active, and then after menopause, we see another peak, and then in the very elderly, we see another peak of prevalence of UTIs.

Courtney: Why is there a peak at menopause?

Dr. Rodriguez: Lack of estrogen. We need estrogen to have multiple layers of healthy, plump, well-vascularized cells in the vagina. And you need those cells to produce something called glycogen that gives the vagina a particular pH that allows normal bacteria or friendly bacteria, the same bacteria that's in yogurt and probiotics, to grow. And those bacteria acidify the pH of the vagina, protects it from the nasty organisms or the bacteria that can cause infection, and keep the environment very healthy.

Courtney: I think the symptoms are hard to miss, but what are the classic signs of a urinary tract infection?

Dr. Rodriguez: The classic symptoms is feeling like you have to urinate all the time. We call it urinary frequency, but it's even more than frequency. When it's bad, it's like every five minutes, every ten minutes, people feel they have to go to the bathroom. And when they go, it's like some patients describe it as passing glass, like this burning, awful feeling when you're urinating. If it's really bad, some people might urinate blood, and it's very scary for somebody to all of a sudden urinate and look at the toilet bowl and see blood, and it's from that irritation or inflammation in the bladder wall. In very young children, they can have fevers. When an adult have a high fever, it's usually because that infection has climbed up the urinary tract into the kidneys. And when the kidneys are infected, people can get really sick. The very elderly sometimes don't have those typical symptoms of frequency, burning as the primary symptom. They might be confused, fatigued. So those typical symptoms happen more in adults, but the very elderly and the very young, the symptoms can be very atypical.

Courtney: So how can you tell if it's progressed to the kidneys, if it's gone beyond a urinary tract infection? And that's very interesting. You mentioned they climb up the wall. That's kind of a disturbing image of the bacteria climbing.

Dr. Rodriguez: Normally, urine is made in the kidneys, and these little tubes called ureters drain into the bladder. And if you have an infection in the bladder, they start kind of climbing up that ureter until they get themselves into the kidney, and it's called a pyelonephritis. And people who have pyelonephritis will have very high fevers, malaise. They can have nausea. They will have flank pain in the kidney that has the infection, and they will have really bad back pain, weakness. They can get really sick.

Courtney: So some people get one UTI and never have another, while others seem to get stuck in a cycle of infections. What does it mean to have a recurrent UTI, and why do they keep coming back?

Dr. Rodriguez: The American Urologic Association defines recurring UTIs as more than three UTIs in a year. If your vaginal epithelium changes, then for some people, if they're more colonized with this kind of nasty bacteria that are more likely to cause infections, and the bacteria is still there, they're more likely to get one after the other. And some of it is because of menopause, but a lot of it is antibiotics. You know, antibiotics don't know which bacteria to attack. It attacks all bacteria. It kills the bad ones, but it kills the good ones too. And then you need to re-replenish those good bacteria, and if you don't have a chance to do that, then you get colonized with more nasty bacteria, you get another urinary tract infection, you get another course of antibiotics, you wipe out all your good bacteria again, and then you get in this cycle.

Courtney: Can we talk more about how UTIs are typically treated?

Dr. Rodriguez: It's usually treated with antibiotic. Once the infection is in the bladder wall, once you have symptoms, most people need an antibiotic to treat it. Otherwise, that infection will keep in that bladder wall, and that bacteria will keep growing and growing and growing. Those antibiotics have to penetrate tissue and be able to kill the bacteria, and we recommend, because of that resistance and because you don't wanna wipe out all your flora, very short courses of antibiotics. The recommendation is that people are treated for uncomplicated urinary tract infections for three or four days. So when people are given two weeks of antibiotics, that is not helpful, when the short course of antibiotics should kill the majority of this bacteria without then continuing wiping out your normal flora.

Courtney: Is there a concern about developing antibiotic resistance?

Dr. Rodriguez: Absolutely. So, specialists would recommend that nobody's treated without a culture. We don't want to wait three days for the culture to come back and you're not treated. We can start treatment, and we can then adjust the antibiotics depending what that culture shows and the sensitivities of the organism, because we want to treat you with the most narrow antibiotic specific for that bacteria instead of a broad antibiotic that kills all bacteria. So the narrower, the better, and the shorter the course, the better.

Courtney: And I think that speaks to the importance of finding a good urologist you can trust to work with to develop a plan, especially if these are recurrent.

Dr. Rodriguez: Yes. And for recurrent infections, for some patients, we try to prevent them. There are ways that we can help prevent these infections so that you are not submitting yourself to antibiotic course after antibiotic course.

Courtney: So a treatment that seems like it's getting more attention lately that's not an antibiotic, I'm probably going to pronounce this wrong, is methenamine hippurate. Please correct me.

Dr. Rodriguez: Methenamine.

Courtney: Methenamine. Can you describe it?

Dr. Rodriguez: Yeah.

Courtney: What's the research around it? How does it help when it's not an antibiotic?

Dr. Rodriguez: It is not antibiotic because it doesn't penetrate tissue to kill bacteria. It really just sits in the urine, in the bladder. A byproduct of the medication is formaldehyde. It is a very strong antiseptic. I tell my patients, "Think about antiseptics. They kill ninety-nine percent of bacteria." You know, the gels we used with COVID and now we all use all the time, they're not antibiotics, but they are still something you can use to kill the majority of bacteria. So it works the same way. So if there's a bacteria in the urine, it will kill it so you can urinate it out and get rid of it.

Courtney: That's amazing, and it sounds like it's a promising advance. And am I correct that this is preventative?

Dr. Rodriguez: Yes. Once it's in the bladder wall, you need an antibiotic to treat it. This won't treat it.

Courtney: What are some other promising advances in treating UTIs?

Dr. Rodriguez: So there is a number of companies that are working on new antibiotics, mostly because of the amount of resistance that we have in the United States and other parts of the country where there are bacteria that are more and more resistant to antibiotics. So it's a very active area of research, development of new antibiotics that work in different pathways and different ways to kill bacteria. Another very active area of research is diagnostics. A urine culture takes usually about three days for us to grow the bacteria, to identify the bacteria, and to determine the specificity of which antibiotic will be best for your bacteria. Three days is a long time, so we inevitably have to treat empirically or guess the best guess based on where you live and the resistance patterns for patients, and then alter that once those results come back. So if you can do something that in six hours you have that information, so you can really narrow that antibiotic for a patient, that would be great. Other areas of research has to do with that microbiome. Can you change that microbiome in a way that will be protective? People who have recurrent infections have a very different gut bacteria than people who don't have recurrent infections. How can we change the gut microbiome of somebody that is susceptible to infections to try to give them the protective one so that they can grow the nice bacteria more likely instead of the more nasty bacteria? And it's called a fecal transfer. It's exactly what it sounds like, is you take the bacteria of the stool of somebody who never has UTIs and try to colonize the person who has recurring urinary tract infections. Another area of research is vaccine development. There are two vaccines that are oral vaccines that are E. colis that have been attenuated, so they're no longer infectious. They take some of the infectious capacity and create these oral vaccines. One is sublingual, and another one is actually like a little tablet that you take, and they're used in Europe. There's no vaccine that have been FDA approved in the United States, so we don't have them.

Courtney: So we hear a lot about supplements to help with UTIs, whether it's cranberry pills, D-mannose, probiotics. Do any of these work, or is there any research to back it up?

Dr. Rodriguez: Cranberry actually has a byproduct that has been researched. It's A-type proanthocyanidins. People call them PCAs, and the way they work is that they prevent the bacteria or they slow them down so that they are slow at sticking to the bladder wall. The issue with them is that they're very finicky to processing.

So a lot of supplements that have cranberry do not have active PCAs in them. There are a few that have been studied that do have them, but there are many in the market that don't. D-mannose is a type of sugar that is present in some fruits. It's a monosaccharide or a simple sugar, and it's been recommended to prevent infections. There have been a number of randomized trials that have shown no effectiveness of D-mannose, so it currently not part of our guidelines and not recommended to patients.

Courtney: I did see something in the research about kind of taking a probiotic when you're on an antibiotic can kind of be like spitting in the wind. What about taking a probiotic when you're healthy to try to kind of help the good bacteria grow?

Dr. Rodriguez: You can. The other thing I can say, probiotics, usually patients take it by mouth, you know, and the way that probiotics by mouth works is that it has to first colonize the gut, and from the gut, it slowly colonizes the vagina. You can put them directly in the vagina. So if patients are having such frequent UTIs that that process of colonizing the gut and then colonizes the vagina is way too much, it comes in a form that you can put it as a vaginal suppository, and you put in the lactobacillus or the probiotic directly into the vaginal canal.

Courtney: What are the biggest myths or misconceptions about UTIs that you wish more people understood?

Dr. Rodriguez: Is this idea that it's hygiene, that somehow if you clean better, you will have less urinary tract infection, and that's actually worse. Douching, boric acid, all those things are bad for your microbiome, are bad for your natural bacteria, are bad for the tissues. You don't want to do those things.

Courtney: People also say to urinate after sex. Is that something you should do?

Dr. Rodriguez: It makes sense if the act of intercourse is more likely to push a bacteria up the urethra, which likely is, and you just want to urinate it out so it doesn't cause an infection, then urinating after intercourse will be helpful. But again, that's presuming that the bacteria that is going up the urethra is a nasty bacteria. If you had normal bacteria or lactobacillus, you don't need to, you know. So that's why for the majority of women who don't have urinary tract infections, they don't have to urinate after sex.

Courtney: So we've covered a lot about managing UTIs. Anything else you want to share with patients? Any final thoughts maybe for someone struggling with them?

Dr. Rodriguez: If you are one of those people who have recurrent infections, don't get satisfied with just getting antibiotic after antibiotic. Make sure that cultures are taken and that they're true infections. One of the things people miss often is that there are many other things in the urinary tract that can present with very similar symptoms are not based on bacteria, so that taking antibiotics actually is not helping you. And if you're having them all the time, to try to see a specialist and make sure there's nothing wrong with your urinary tract that's making you more prone. And if that's not the case, that they can put you on a regimen to stop them or to prevent them.

Courtney: Dr. Rodriguez, thank you so much for such a wonderful conversation on this. It was such a pleasure having you on the show.

Dr. Rodriguez: Thank you so much, Courtney. It was really great to be able to inform patients about their choices and alternatives they have to prevent this.

Courtney: Our many thanks to Dr. Larissa Rodriguez. I'm Courtney Allison. Health Matters is a production of NewYork-Presbyterian. The views shared on this podcast solely reflect the expertise and experience of our guests. To learn more about Dr. Rodriguez's work with patients, check out the show notes. NewYork-Presbyterian is here to help you stay amazing at every stage of your life. Join us next time when we talk about breast cancer screening and the importance of remaining vigilant about your breast health. That's in two weeks right here on Health Matters. So you don't miss it, be sure to follow and subscribe on Apple Podcasts, Spotify, or wherever you get podcasts.