UTIs in older women are often misunderstood
Many women, particularly those in their post-menopausal years, know all too well the pain and inconvenience of having a urinary tract infection (UTI).
“This is such a common issue, but it’s also misunderstood, not just by patients but also, I’ve noticed, by a lot of physicians as well,” said Hyannis urologist Bijan Salari, MD, of Urology Associates of Cape Cod.
The story topic was recently suggested to Cape Cod Health News by a reader who said that several of her friends, who had recently been diagnosed with dementia, also had recurring UTIs, and wondered if there was a connection between the two.
While there is no known correlation between dementia and urinary tract infections (UTIs), women with dementia are at a high risk of being over-treated for the condition, Dr. Salari said. The association is more age-related that dementia-related, but older women (and men) are more apt to suffer from dementia, he noted.
One of the biggest misconceptions around the issue is the definition of a UTI, he said. A UTI should not be the clinical diagnosis unless a woman has actual symptoms, like burning with urination, significant worsening of frequency, or urgency in urination, or occasionally, bladder pain. Simply finding bacteria in the urine isn’t enough cause for a true diagnosis, he said.
Normal Bacteria in Urine
Part of the problem is that until about 15 years ago, doctors believed that urine was sterile. That meant that any bacteria that was discovered in a urine sample automatically triggered a UTI diagnosis and led a lot of women to be over-diagnosed and over-treated. Doctors did now know that urine contains many kinds of normal bacteria.
Normal bacteria found in urine include:
- Mixed flora
- Lactobacillus
- Group B strep
- Staph epidermidis
“These are not typically causes of UTIs and generally we would recommend not treating them,” Dr. Salari said. “If you look at the American Urological Association, there’s a lot of concern right now about recurring UTIs and treating them, because we’re really starting to see more resistant bacteria that are requiring patients to go into the hospital to get IV antibiotics, which is then more likely to lead to c. diff (c. difficile).”
Strategies for Treatment
Instead of treating all bacteria with an antibiotic, Dr. Salari recommends that all patients with a suspected UTI have a urine sample cultured before prescribing an antibiotic. He also recommends that all women have a pelvic exam to rule out other causes that might lead to bacteria lingering long enough to cause a UTI.
“It’s really important that, if somebody is at Urgent Care or their primary care, to make sure the urine is sent for a culture to ensure that there is actually a UTI, because there are other problems, such as overactive bladder or even vaginal changes in menopause like atrophic vaginitis, that can also cause symptoms that seem like a UTI,” he said. “They’re being treated for UTIs but there are actually other solutions to those problems that are much better.”
The only two populations who should be treated with antibiotics, even if they don’t have symptoms, are pregnant women and people having urologic surgery, to make sure they don’t develop a bad infection.
Dr. Salari emphasized that patients need to understand that taking an antibiotic isn’t risk-free, even if they do need one.
“It’s important to realize that even if antibiotics are given for a UTI, they affect the entire body,” he said. “They don’t just selectively target bacteria in the urinary tract, but they really remove all bacteria throughout the body including healthy bacteria in the gut and healthy vaginal bacteria in women as well.”
That can lead to c. difficile, yeast infections, more recurrent UTIs and antibiotic resistance.
Prevention
Even though UTIs are common, it is not a given that all older women are doomed to suffer from them. Dr. Salari recommends the following prevention strategies:
- Take a daily cranberry pill that contains 36 milligrams of proanthocyanidins. Drinking cranberry juice is not as effective as taking the pill.
- Post-menopausal women should use a prescription vaginal estrogen cream or pill two to three times a week. Vaginal estrogen restores healthy bacteria in the vagina which prevents harmful bacteria from growing. Since vaginal estrogen is topical, it does not increase the risk of breast cancer.
- Drink 1.5 liters of fluid a day (50 fluid ounces) in addition to your usual hydration intake. A 2018 study published in JAMA showed that women who drank the extra fluid reduced UTI episodes by 50 percent.
- Taking a D-mannose supplement can help prevent UTIs by blocking the activity of a specific type of bacteria.
- Taking a methenamine supplement can make the urine more acidic to stop bacteria growth.
The first three recommendation are the most effective, Dr. Salari said. D-mannose and methenamine are popular but they are not as robust as cranberry pills, vaginal estrogen and extra hydration.
