NOTE:  THIS IS A MEDICAL BLOG, SO USE OF MEDICAL IMAGES THERIN IS NOT TO BE CONSTRUED OR USED AS ANYTHING OTHER THAN ASSISTING IN THE UNDERSTANDING OF HUMAN ANATOMY, PHYSIOLOGY, AND HEALTH.  IMAGES POSTED HERE ARE USED AND LINKED TO OTHER HEALTH SITES.  THIS PAGE DOES HAVE IMAGES OF THE FEMALE PERINEUM FOR EDUCATIONAL PURPOSES.  Disclaimer: these are my own thoughts and philosophy and not to be construed as “medical advice” for legal purposes. Always check with your own doctor before undertaking any new health measures, as all of us have unique health conditions that may exclude or risk-stratify a particular change.

First of all, if you are in pain, running a fever, have blood in your urine, are feeling confused, or have other concerns, don’t mess around with this website–go see your doctor.  When you are being treated, come back and read at your leisure.   A simple urinary tract infection can lead to a life-threatening illness, or what you think may be a UTI can be something completely different.

Urinary tract infections in women are probably one of the most annoying problems that women have to deal with.  Not only do they cause discomfort, ranging from burning, itching, aching, urgency and frequency, but untreated they can lead to kidney infections and particularly in older persons, delirium, even urosepsis (where bacteria get into the bloodstream).  The urinary tract starts with the urethral opening, and goes all the way through the urethra to the bladder up the ureters to the kidneys, so a UTI is a non-specific infection that occurs somewhere along this tract, and usually starts from the urethral opening.

There are the one-time urinary tract infections that happen, are treated, and disappear, and then there are women who seem plagued by these things over and over again, and can’t seem to get any relief.

Women try all sorts of home remedies, from abstinence, to cranberry juice, but sooner or later they end up in the doctor’s office, where a well-meaning doctor may give out a long course of antibiotics to “cure” the problem.

What we as physicians don’t always realize is that we may be contributing to the cyclical problem of recurrent UTI’s and promoting IBS (Irritable Bowel Syndrome) by overtreating urinary tract infections, not culturing urine, and not looking to find out WHY women keep having them.

I am a great believer in understanding biology and how things work.  So the first thing is to examine the female perineal area so that we can understand how urinary tract infections happen in the first place.

http://www.dana-farber.org/Health-Library/Vulvar-Cancer-Treatment-(PDQ®).aspx

So what do we see that may be significant here?

Look at the proximity of the clitoris to the urethral opening.  Note that this varies in women quite a bit and may have even closer proximity, or with age and childbirth more stretchy skin that brings the two even closer.

The vagina is also very close to the urethra, and it is easy to see how bacteria in the vaginal area can reach the urethra.

Moreover, look at the proximity of the anal opening.  When we poop and use toilet paper to wipe, the possibility of introducing some bacteria from stool is always there.  A dangling tampon string can also be a culprit. That’s why we suggest that women wipe from front to back, not back to front.

• 80% or more of urinary tract infections in women are due to E. coli.

Urinating provides a natural cleansing of the peri area in women, helping to wash things towards the back.

Other things to note include how many folds of skin are there and how moisture, irritation, and resulting bacteria and yeast can find a place to grow.  These folds of skin can be more pronounced as we age, and (as mentioned) after childbirth.

This is a very sensitive area, as most women would agree!

Whether you are cleansing after pooping or peeing, washing your peri area, shaving your peri area, having your clitoris stimulated, or having various forms of sexual intercourse, from oral to penetrating, all of these things have the potential to cause some inflammation–some of it linked to pleasure, other to simple irritation.

What do all of these things have in common?  Inflammation.  Whether it is inflammation of the hair follicles, peri area, the urethra, or the bladder itself, this is the state that causes the trouble, because the inflammation thins out the epithelial lining and provides a rich bed for bacteria to adhere and populate.

Why do so many women starting a UTI feel symptomatic but don’t grow any bacteria?  Perhaps it is simply because they have created a state of irritation/inflammation in the peri area that they can feel, and bacteria may be adherent and not loose into the urine until more days have passed.  Perhaps because they were drinking a lot of water to feel better and the urine was diluted too much to have enough bacteria to grow.

As I mentioned, the most common bug that causes urinary tract infections is E. coli.  More than 80% of UTI’s are due to this bug from our colon.  There are forms of E. coli implicated in recurrent bladder infections that have molecules which help them stick (adhere) onto urinary tract tissue (especially inflamed tissue).

Women are more prone to urinary tract infections because of the proximity of the urethra to the anus as well as having a short urethra.  Women who do not empty their bladder completely (for example as with a cystocele) create an environment for bacterial growth.

When women have had a hysterectomy, the ligaments that help to hold up the bladder are damaged by the removal of the uterus, and sagging as well as other complications, like fistulas (a hole between the bladder and the rectum) can result.  The uterus and the bladder share tissue connections, as the uterus sits partly on top of the bladder (which is why pregnant women seem to want to go to the bathroom so often!).

These pictures are all from general internet searches, linked to some great articles and studies.  Links should all be available to the original sources.  Picture #1 = normal female anatomy;  Picture #2 = cystocele;  Picture #3 = prolapse; Picture #4 = fistula; Picture #5 = atrophic vaginitis with treatment since menopause and without; Picture #6 = atrophic vulvovaginitis untreated since menopause, then treated with topical estrogen therapy.

http://urology.med.miami.edu/specialties/female-pelvic-health

http://urologynorthwest.com/our-clinic/services-and-procedures/cystocele/

http://www.webmd.com/women/vaginal-vault-prolapse

 

http://www.indiahospitaltour.com/images/innerpage/urology/Vesicovaginal-Fistula.jpg

 

Figures 4 & 5:  http://www.medscape.org/viewarticle/589836

URINARY TRACT INFECTIONS AND SEX

“Honeymoon cystitis” is a term used for the urinary tract infection that is linked to sexual intercourse.  However, making a woman afraid of having intercourse due to recurrent urinary tract infections is like the proverbial cutting the nose off to spite the face.  It’s just wrong.  Understanding, however, how a urinary tract infection can be linked to intercourse is fairly simple.  It’s all about friction and the opportunity to introduce bacteria into the urethra, whether during clitoral stimulation or by vaginal penetration, or by a combination of anal and vaginal penetration.  Oral stimulation can also be a source of bacteria into this sensitive area.

You are directed to urinate after sexual intercourse because of the cleansing effect of the urine in pushing away bacteria from the urethra itself.

URINARY TRACT INFECTIONS THAT ARE RECURRENT

The caution in urinary tract infections that are recurrent is that we docs have a habit of prescribing antibiotics without looking at why the infections are happening in the first place.  It is miserable to feel uncomfortable, then drop everything, go to the doctor, get an antibiotic, and start the whole process all over again a few weeks later.

One of the things that I know as a physician and scientist, is that antibiotics have a habit of  killing off good bacteria as well as “bad” ones.  Why is this important?

The flora of the perineum in a healthy premenopausal woman is different than that of a post-menopausal woman.  Why?  Because the estrogen that women produce helps to grow a different variety of bacteria in this area–ones that help to deter the E. coli and other bacteria that don’t belong in the urethra.

The other issue that we as docs have is a habit of overprescribing antibiotics–higher dose for longer than necessary.  This does a couple of things.  First of all it is wiping out beneficial bacteria for a longer period, secondly it may be leading to building resistance to the antibiotics of choice by the bacteria in your body. Certain antibiotics, like Cipro, have been prescribed so much that they may not work as well any more.

Knowing if you might have a structural problem, for example, after a hysterectomy where the shape and suspension of the bladder may have changed, or where a fistula might have developed (see picture above) or a cystocele (see picture above–basically a bulge in the bladder that keeps the bladder from emptying all the way), is also important.

Pelvic floor muscles that are weak, may also contribute to incomplete emptying of the bladder.  Neurological issues sometimes occur and may even originate in the lower back from labor and delivery, pelvic surgeries, arthritis or other sources of nerve compression.

The insertion of a catheter.  Having an indwelling catheter, or even a temporary catheter can cause UTI’s from injury, irritation, or bacterial exposure.

And simply stated–when you are going through a UTI, you have a lot of irritation and inflammation that needs to heal in order to maximize the resistance to your own E. coli.  An irritated urethra, with a swollen, thin layer of tissue is ripe for bacteria to grow on.

There are other factors that may need to be controlled–temporarily or permanently, depending on your individual sensitivity to the items in question:

THINGS TO AVOID WHILE HEALING AND BEYOND

1. Scented soap used to wash the perineum.  Use a simple unscented, hypoallergenic soap, like the simple Ivory soap for a couple of weeks, covering treatment time and recovery.
2. Bath additives and vaginal deodorizers.  Avoid them–scented bubble baths, oils, perfumes, anything with the potential to irritate.  The exeption is a hypoallergenic oatmeal bath, which can provide comfort and anti-inflammatory treatment.
3. Spermicide foam.  This can be irritating, is not usually very effective, and can damage condoms.  In addition, if you have a latex allergy, latex condoms may cause inflammation as well, so look at the product and packaging.  Always have safer sex.  Condoms are a barrier for illnesses that can be transmitted when only using pills, foams, or other methods of birth control without a barrier, so always have careful sex with a healthy partner.  No form of birth control or barrier is absolute.
4. Hot tubs.  Hot tubs can be a great source of both irritants from chemicals and bacteria when the chemicals are not in balance.  If you like a nice soak after a workout, opt for a nice hot shower.
5. Scrubbing the peri area.  Sometimes trying to be too clean can inadvertantly make things worse.  Be gentle to your peri area–you can wash it gently with your hands.  A rough bath pouf may be causing irritation and exposing your skin to unwanted bacteria.
6. Shaving the peri area.  What we often don’t think about is what the use of hair in the perineal area is for.  For one, it creates a cushion for better air flow to the peri area, which protects from too much moisture buildup.  Shaving creates micro nicks that are a nidus for bacteria and can promote bacterial folliculitis.
7. Inadequate drying of the peri area.  After bathing, patting dry the peri area with a clean towel, even using a cool blow dryer can help to prevent irritation from moisture and subsequent yeast growth that makes the peri area red and irritated.
8. Personal hygenic wipes.  Other than those like Tucks pads with witch-hazel, refrain from the use of hygenic wipes because many of them have irritating ingredients that can increase inflammation.
9. Feminine hygiene pads.  Watch for ones that are scented or contain ingredients that may be irritating.  Avoid if possible.  If not possible, try to change them as frequently as possible, because bacteria will grow in the moisture that is being trapped and can be transferred into the urethra very easily.  This can be a source of yeast infections as well, as yeast likes a moist surface to grow on.
10. Tampons.  Change frequently, watch where the string goes.  The tampon string, when dangling can transfer fecal material right into the vaginal and urethral area.  A tampon that is left in too long can grow bacteria.
11. Laundry detergent, fabric softener, fabric dyes, elastic in fabrics, new clothes.  The laundry is a place that we often forget as a source of irritation.  Many of the detergents on the market contain substances that, although they will brighten and deodorize your clothes, will be major skin irritants.  In addition the starches, dyes and other treatments on new clothing can also cause inflammation. This may be particularly true if you suffer from eczema (atopic dermatitis).
12. Refrain from sex… until your symptoms have resolved!  You should have a happy, fulfilled, joyous sex life, but if you are feeling discomfort from irritation, allow your body a chance to heal first.

THINGS YOU CAN DO ALONG WITH ANTIBIOTICS

1. Drink water in boluses.  If you are drinking 8 glasses of water a day, opt for at least 8 oz of water as a bolus at a time, or drink a 16 oz bottle of water at once.  Not only does this hydrate you, but it will help to flush out your kidneys and your bladder.  Refrain from sweetened beverages, from soda, all which can promote irritation or increase bacterial growth, especially in diabetics who may spill sugar in their urine.
2. Cranberry Concentrate Capsules.  There have been some good studies showing that cranberry concentrate helps to foil E. coli from adhering to your tissue in the urinary tract.   Cranberry juice has lots of sugar in it and not as much of the good stuff as the capsules do.  If you suffer from chronic UTI’s you can try using these capsules as a preventative.
3. Kefir.  (I like Lifeway because it is available, a quart for under $3 at the local grocery) Prescriptive probiotics are being used in Europe, but not currently in the United States, as a formula to help prevent UTI’s.  The key, however, with probiotics is that they are not one or two bacteria but many different beneficial bacteria that are essential to the body’s balance.  Although there are expensive over-the-counter probiotics out there, I suggest Kefir.  It is like yogurt or buttermilk, but has many other beneficial digestive bacteria.  It may also be helpful for folks with irritable bowel syndrome, and appears to be 99% lactose free, because the bacteria digest the lactose.  There are flavored and unflavored versions, and it can be drunk by itself or in a health smoothie (peanut butter, bananas, apples, berries–very tasty).  Digestive bacteria seed the intestinal tract all the way out.  Just like the noxious bacteria (E. coli), they will populate the peri area, but do good things including the control of yeast overgrowth.
4. Witch Hazel.  Soothing, used for pregnant women, used in Tucks pads.  If you are going to clean or soothe your peri area, this is a good substance to have.  Inexpensive, you can put it on a cotton swab, or if you prefer you can buy hemorroidal pads like Tucks.  We recommend these pads for pregnant women who suffer from a lot of inflammation after giving birth.
5. Hypoallergenic oatmeal bath.  Very soothing.
6. Water squeeze bottle.  Another thing used by pregnant women to soothe discomfort from inflamed perineal tissue or stitches after childbirth, this soothing stream of cool water can help to gently cleanse the peri area.  Blot dry afterwards.
7. Wash your undergarments in hypoallergenic detergent.   This helps minimize the irritation from scents of prior detergents or fabric softeners.  There are many different fabric additives–dyes, starches, coatings, scents, polymers that are part of clothing and can cause irritation to moist sensitive areas of skin.  In addition previous use of fabric softeners, detergents, or other chemicals can leave residues on clothing that can continue to promote irritation.
8. Kegel exercises.  Described as contracting the muscles of the pelvic floor (with a sensation of trying to elevate and squeeze closed the urethra and anus) can help.  There are also stimulator machines that use electrical impulses, from implantable to physical-therapy portable or a discrete home-use device that is similar, which can strengthen pelvic floor muscles.  This can also help, sometimes, with other urinary control issues like stress incontinence (when you sneeze or cough and lose urine).
9. Prescription:  phenazopyridine (Pyridium). If you are irritated, relief can be found with this product–it is not a cure, but a symptomatic treatment that can be used short term.  The usual dose is 100-200mg three times a day for 2 days, taken after meals.  It does have some potential toxicity. For folks with kidney or liver problems, see your doctor for dosage changes.  Similar products are available over the counter under various brand names.
10. Prescription:  fluconazole (Diflucan).  Because yeast is known to increase in population during antibiotic treatments, getting a prescription for one 150mg of fluconazole to take after you have treated your UTI can help to prevent the overgrowth of yeast that might be causing other sorts of inflammation in the perineal area.  We all have yeast in our vaginal area, but when it increases too much, it will cause redness and irritation.  This is one of the things that probiotics like Kefir (and yogurt) can help.
11. Prescription:  estrogen cream (Premarin or other commercial formulation or bio-identical (my preference).  For post-menopausal women, many urologists find that with the regular use of a small amount of estrogen cream in the peri area, that women may resolve recurrent urinary tract infections.  The atrophy that occurs during menopause manifests as vaginal dryness, pallor, loss of elasticity and firmness, loss of good bacterial balance, and the small amount of estrogen helps to improve those conditions (which also helps to minimize irritation).
12. Prescription:  anti-spasmotics (Uribel or other commercial formulations of hyoscyamine, methenamine, methylene blue, and phenyl salicylate).  This powerful (but potentially toxic) combination is popular with urologists for folks who are truly suffering with painful urinary tract symptoms including ureter, bladder, and urethral spasms with burning.  It may also be used with “interstitial cystitis” a chronic bladder inflammation disorder.  Hyoscyamine is one belladonna alkaloid (others include scopolamine and atropine) a derivative of the belladonna plant (also known as deadly nightshade), used for anti-spasmodic purposes.  It can be toxic, but is rendered medically useful in prescriptive medicine where concentrations are controlled.  The methenamine and methylene blue act as antibiotics and the phenyl saliclylate is for pain.

WILL I NEED LONG TERM ANTIBIOTICS?

This is a question to discuss with your doctor.  I would consider this:  if you have tried all of the above, have been cleared by a urologist who has checked your physical structure thoroughly and does not find anything that can be addressed, then it may be an option for you.  Always ask for the pros and the cons.  And always, always try to find out WHY this is recurring for you.

Best of Health,

Doc Bea