Can more be done to prevent chronic/recurrent uti’s? A plea to Doctors everywhere

Recurrent urinary tract infections (rUTIs) are a significant problem in women.  Approximately 25-40% of women in the United States, aged 20-40 years, each year have an uncomplicated UTI (1). After a first UTI, roughly 25% of women have a confirmed recurrence within the next 6 months, and about 3% of those have a second recurrence within the same period of time.  Unfortunately, we don’t have reliable data determining the frequency rate of sexual intercourse specifically related occurrences but as any woman who has been plagued with these knows a UTI or urinary related symptoms can occur much more frequently.

 One of the causes of recurrent UTI in women is hormonally mediated vestibular atrophy.  Roughly 25% of women are using hormonal birth control at any given time each year in the U.S., and a significant proportion of these women end up experiencing hormonally mediated vestibular atrophy and other related conditions like recurrent UTI or UTI like symptoms. In some of these women UTIs are sexually induced and present 4-24 hours after sexual activity.  Most of the time women are provided with a prescription plan of prophylactic antibiotic without determining if there is a root cause for the rUTI.

 I believe more can be done to improve future outcomes of this condition with little investment from both the HCP and patient.

When I sought treatment for rUTI, only the standard protocol for a UTI was followed (answer questions about urinary symptoms only, pee in cup) and each UTI was treated with antibiotics. However, an endless cycle of UTIs and antibiotics is not a satisfactory outcome, not feasible for patients, nor an acceptable quality of life. Regardless of the flip flopping of unreliable clinical studies at present, we do know that antibiotics for UTI’s destroy much needed gut bacteria as well as other hypothesized effects. In the cases of rUTI, care needs to go beyond the current standard of prophylactic antibiotics as this plan is inadequate and lacking in motivation to determine the cause of the rUTIs which will improve the patient’s quality of life, reduce office and ED visits (and thus time charting), reduce medical costs, and most likely improve the patient’s sexual satisfaction.  

When a broader approach is taken, and a simple set of only a few questions are asked, the cause of recurrent UTIs are discovered-the symptoms and subsequent non-complicated rUTI’s are usually due to hormonally mediated atrophy (Genito-urinary Syndrome), which is not only a problem experienced by those in perimenopause or past menopause. This is a real issue affecting women well below the age when sexual hormones start to decline, many while they are still teens!  If you are unsure as to how hormonal birth control affects the vulvovaginal tissues and urethral opening, please take a few minutes to read up on what Stephanie Prendergast, MPT, Cofounder of Pelvic Health and Rehabilitation Center has published. The following article has summed up the latest clinical evidence:

https://pelvicpainrehab.com/female-pelvic-pain/2219/oral-contraceptive-pills-cause-vulvodynia-time-finally-end-controversy/

Many health care professionals are learning to rely on patient advocates more and more to help provide them much needed info which can help shape patient care and satisfaction but if you would like additional information and sources for the points I have raised, take a look at some of what Dr. Rachel Rubin, Dr. Andrew Goldstein, and Dr. Irwin Goldstein have to say on the topic.  My job as a Patient Advocate is to provide you with insight on how to improve patient care when dealing with this issue.

I propose that a brief, purposeful questionnaire about other vulvovaginal symptoms could be employed to determine if urinary symptoms and conditions, specifically recurrent type, stem from hormonally mediated atrophy or another vestibular or pelvic floor related condition, or if the symptoms are truly only a urological condition.  

We (patients) know that HCPs have terribly busy schedules and have a very limited amount of time available to spend with each patient; you’re understaffed, overworked, and burned out.  You’re under restrictions from insurance companies and charting requirements from the ‘money men’ running your facility, you do your best to take in the information provided by the patient in an unrealistically small amount of time to determine the best diagnosis and treatment available. However, I believe a large proportion of recurrent UTIs and sexually induced UTIs could be resolved without much additional time, effort, or resources from the HCP in any department or specialty. If it is determined via patient reporting that their urologic symptoms are recurring (or happening all the time, chronic, [insert patient vocabulary here]) a short, purposeful questionnaire provided to those specific patients prior to visit, or during the initial in-room interview, could provide the HCP with important details on the potential source of recurrent UTIs and give direction to the visit, diagnosis, and treatment. By screening for signs and risk factors for vestibular atrophy/Genito-urinary Syndrome, this simple questionnaire has the ability to greatly reduce or eliminate clinic/ED visits, unnecessary exposure to a full course of antibiotics or prophylactic antibiotics, and greatly improve the patient’s sexual health and satisfaction, and just LIFE in general!  Dealing with frequent urological symptoms that don’t get resolved or that come back quickly have a significant impact on all aspects of life: work, relaxation, family care, sexual health, running errands-all of it is impacted because the symptoms are so uncomfortable and when they become a large part of your life due to not finding resolution it takes a huge toll on one’s mental health, relationships, and ability to experience intimacy with one’s partner.

We can do better.

What are these simple, few questions?

Glad you asked!

The questions are yours to use freely, no intellectual property infringement.  Copy/paste them, download/print them, make your own adjustments, use them on official paperwork in your clinic, use them unofficially when you are interviewing and/or examining your patient.  PLEASE, JUST USE THEM!

  1. (Most important, IMO) Do you have pain at the vaginal opening such as with PENETRATION of any kind-sexual or with the use of menstruation products like tampons/menstrual cups?
  2. Are you using hormonal birth control (or hormone [both estrogen and/or testosterone] blockers)?
  3. Do you have UTI symptoms that return negative test results? Or have UTI symptoms often that may come and go throughout the week/month?
  4. Do you find your UTI’s or UTI symptoms start within a short time after sexual penetration-partnered or masturbation?
  5. Have you noticed vaginal dryness or a discharge that seems not normal for you but isn’t typical YI or BV discharge?

That’s it!

You ask these 5 questions, and you can stop the cycle of most UTI’s, related symptoms, and UTI visits.   You might not be equipped to perform a visual exam to then diagnose Genito-urinary Syndrome, or be comfortable conducting one, but if the answers to the 5 questions above are affirmative and you cannot conduct an exam/education/treatment plan then you have the knowledge needed to refer this patient to the appropriate specialist who IS familiar with these symptoms, syndromes, and conditions that can help get the patient on the path back to long term health.

Too many HCP’s are not listening to young women and discarding their symptoms due to outdated, or lack of, medical training.  Birth control, which is a large factor in mainly young women experiencing hormonally mediated vestibular atrophy, isn’t the ONLY factor for vestibular atrophy or urinary symptoms/infections, and birth control doesn’t cause this problem in all who use it-Dr. Andrew Goldstein and co-authors Zoe R Belkin, Jill M Krapf, Weitao Song, Mohit Khera, Sarah L Jutrzonka, Noel N Kim, Lara J Burrows, Irwin Goldstein published a wonderful article showing how the androgen receptor length is playing a role in this problem you should also check out:

https://pubmed.ncbi.nlm.nih.gov/25187224/

But besides birth control there are other factors that affect young people born with vaginas such as PCOS, minor pituitary problems, past birth control use that may be perpetuating high levels of SHBG, estrogen AND/OR testosterone blockers, conditions that could be causing premature ovarian failure or full-blown infertility the patient isn’t aware of yet.  There are causes of infertility that still allow a person to have regular menstrual cycles, there may be poor receptor activity at the vestibule and no matter how normal the serum hormone levels are the vestibule will have atrophy causing Genito-urinary Syndrome.  These are all common conditions that also affect young individuals and with upwards of about 40% of those assigned female at birth now reporting some type of sexual dysfunction or pain we need you to reconsider seeing age as a disqualifier.

Patient Advocates know not all Urologists/Primary Care providers/Internal Medicine providers/Urgent Care or ED Drs. are trained in or feel capable to handle vestibular atrophy/Genito-urinary Syndrome but not investigating what is causing a woman to go into a clinic with multiple UTI’s/symptoms each year, not suggesting they seek addition help with an HCP who is familiar with vestibular atrophy or Genito-urinary Syndrome, or defaulting to prescribing prophylactic antibiotics as the first line of treatment for rUTI’s needs to not be the standard procedures for care going forward.

Let us, your patients, help you come up with easy to implement, long term solutions such as the 5 questions I am suggesting.  We can work together to improve the lives of those you are trying to help.

References

1            https://emedicine.medscape.com/article/233101-overview#a5

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