Vaccines a welcome breakthrough for persistent UTIs
For some women, UTIs are a stubborn and distressing problem. But there are treatments available, including new vaccines, and they need not suffer in silence.
Urinary tract infections are an unpleasant affliction for a significant minority of reproductive-age women. While ascending infection and sepsis from pyelonephritis (kidney infection) are uncommon, cystitis (bladder infection) is a significant cause of distress, pain and absenteeism from work. The nuisance, cost and side effects of antibiotic use, including thrush, are their own problem. Poor antimicrobial stewardship, leading to antibiotic resistance, presents a wider problem for the community.
Discomfort with urination (dysuria) and/or an increased frequency of trips to the toilet each day are common symptoms and not always reflective of a UTI. A simple mid-stream urine test can confirm whether or not it actually is a UTI and, depending on the bacteria found, it might guide antibiotic or non-antibiotic treatment.
A minority of women will suffer recurrent UTIs, defined as two proven infections within six months or three within 12 months.
An important start in prevention is to address hydration, recommending that patients drink at least two litres of fluid per day. Because caffeine and alcohol are weak diuretics, the consumption of tea, coffee and alcoholic drinks should be minimised. Acidic foodstuffs including citrus, tomatoes and vinegar can worsen symptoms.
Other simple measures might be to change to wearing cotton underwear and avoid tight clothing that contributes to localised heat and sweating.
Many women will notice an increased frequency of UTIs with sexual intercourse. Basic strategies like emptying the bladder before and after intercourse are effective in some. Some women will notice fewer infections if lubrication is adequate, they are well hydrated and they shower prior to intercourse. In extreme cases it is worth discussing the pros and cons of prophylactic antibiotic use.
While the yield of a diagnostic ultrasound is typically low, it is a perfectly safe, accessible and inexpensive test that will rule out causes such as a congenital abnormality of the urinary tract. Many patients have medical conditions that make them vulnerable to recurrent UTIs. Diabetes should be considered and is readily screened for.
In some women a healthier vaginal environment will mean there are fewer pathogens in close proximation to the urinary tract. The best way of populating the vagina with Lactobacilli is to make natural yoghurt part of the diet. Different strategies might be required, for example for those women with lactose intolerance. Commercially available preparations of Lactobacilli are more expensive but available without prescription.
Some patients will require referral to a urologist, a surgical specialist with expertise in problems affecting the kidneys and bladder (and prostate). They might suggest putting a small camera in the bladder (a test called a flexible cystoscopy) to exclude serious pathology, such as tumours or kidney stones.
There are other risk factors for chronic infection including incomplete bladder emptying. This might be a neurological problem or it might be an anatomical problem – associated with pelvic organ prolapse, for example. Some patients will need to see a gynaecologist.
Of course, the family GP is best placed to determine where investigation and/or referral is required. The likely causes in a 21-year-old are completely different to those in a 55-year-old.
In some patients the degree of disability will be sufficient to require prescription of urinary antiseptics such as Hiprex (Methenamine), a medication that has been used with success by many patients for many years. Others will be advised to take high-dose vitamin C or to drink cranberry juice.
D-mannose is an over-the-counter preparation thought to exert antibacterial activity by inhibiting the adherence of bacteria to the bladder lining.
An exciting development in recent years has been the development of preventive vaccines. They are available only under the Special Access Scheme and thus require an application to the Therapeutic Goods Administration. The MV140 vaccine delivers an inactivated combination of four bacteria known to cause recurrent UTIs – namely E. coli, Klebsiella pneumoniae, Enterococcus faecalis and Proteus vulgaris. The Uromune vaccine has proven readily acceptable to patients, being administered as a once-daily sublingual spray for three months with side effects uncommon. Studies have shown a significant reduction in UTI rates.
OM-89 (Uro-Vaxom) is another vaccine that delivers protection against multiple strains of inactivated E. coli.
The expansion of the National Immunisation Program to include a whole series of viruses to prevent serious childhood and adult illnesses has been an enormous success for the Australian population. Vaccines against other pathogens such as Group A Streptococci, Group B Streptococci and malaria remain elusive. While not preventing life-threatening infections, these two new vaccines are preventing disability in another group of Australians.
Women need not suffer in silence. Some of these measures are elegant in their simplicity. Others are right at the cutting edge of science.
Dr Michael Gannon is a consultant obstetrician and gynaecologist with 18 years experience as a specialist. He has delivered more than 5000 babies. He served as president of the AMA from 2016 to 2018, and is president of leading professional indemnity provider MDA National.
This column is published for information purposes only. It is not intended to be used as medical advice and should not be relied on as a substitute for independent professional advice about your personal health or a medical condition from your doctor or other qualified health professional.
