Understanding your UTIs with Anastasia Visotsky

By Anastasia Visotsky from Stop UTI Forever

When my doctor suggested that I start taking preventive antibiotics for my urinary tract infections, I began to worry. It meant that I would be taking an antibiotic pill after every sexual encounter and it didn’t sound right to me. Just half a year before that, I was a pretty healthy female so the idea of taking any prescription meds regularly and indefinitely was shocking.

By the time he recommended this course of action, I had already gone through four courses of antibiotics for acute UTIs in less than three months, so the doctor’s suggestion was in line with current clinical guidelines. However, while antibiotics were successful in eliminating my acute infections, I still didn’t know why my UTI kept coming back. Therefore, I wanted to figure out what causes a UTI before agreeing to antibiotics as a preventive measure.

Mechanics of a UTI

When you have a UTI you are rightfully concerned about bladder health. During a UTI, the bladder and lower urinary tract is sensitive and can even cause pain, bloody urine, and can trick you into thinking you constantly need to urinate, so no wonder that UTI treatments and prevention efforts are focused on ridding the urinary tract of the infection.

At the same time, when all your attention is on acute symptoms it is easy to forget how the problem started in the first place. Most think that their UTI starts with sharp pain when urinating and urgency. The truth is, your UTI has been long in the making before you experienced its first nasty symptoms.

You probably know that most of the pathogens that caused your UTI originated in your lower intestines. This means that bacteria that cause an infection in the bladder traveled all the way from the area of your anus. This also means that on the way toward your urethra, the pathogenic bacteria passed near your vagina.

Interestingly enough, the vagina is naturally equipped with a set of protective mechanisms to kill off the unwanted bacteria, and these mechanisms also protect your urinary tract, at least in your urethra.

Consider the following facts about vaginal flora:

Lactobacilli are the main bacterial species in healthy vaginas. They produce lactic acid and hydrogen peroxide that lowers vaginal pH which, in turn, creates an inhospitable environment for opportunistic pathogenic bacteria and yeast.

Lactobacilli prevent pathogens from attaching to the surface of a vagina by producing surlactin and by competing with other microorganisms for adherence to epithelial cells and nutrients.

Some think lactobacilli might be also producing additional antimicrobial compounds preventing pathogens from growing in the vagina.

Therefore, lactobacilli provide a natural defense shield against infection and attacks of opportunistic bacteria and yeast.

Lots of factors can negatively impact the number of lactobacilli in your vagina: stress, poor diet, prescription meds, hormonal changes (periods, pregnancy, or menopause), douching etc. And, if your lactobacilli army is not as strong as it should be, pathogenic bacteria, such as E. coli, can easily colonize the vagina.

The more E.coli bacteria you have in your vagina, the easier it is for them to ascend further up to the bladder through the urethra. Moreover, any extra activity around your genitals (sex, for example) could further help move bacteria from your vagina toward your urethra.

Therefore compromised vaginal flora is a risk factor for UTI.

In my case, for years prior to my first UTI, I had sporadic yeast infections right before my periods. However, since the yeast infection would often go away on its own, I didn’t pay much attention to it.

Little did I know that as soon as your vaginal health is compromised, you have a greater predisposition to developing UTIs. In fact, there is plenty of research showing a connection between bacterial vaginosis (BV) (or any abnormal vaginal flora) and the incidence of UTI.

Antibiotics and UTI

Let’s say you missed the red flags (BV or yeast infection) and now you caught a UTI. In most cases, the pain is severe and you are looking for some immediate relief.

Since a UTI can also lead to kidney infection and even sepsis, doctors rarely take chances and prescribe antibiotics right away. Moreover, there are at least a dozen FDA-approved antibiotics that will quickly annihilate infection-causing bacteria and keep your doctor out of a malpractice suit.

In most cases, patients do not ask questions about the type of antibiotics prescribed. They just pop a pill and go about their business. However, not all antibiotics are created equally. There are so-called ‘narrow spectrum’ and ‘wide spectrum’ antibiotics. The narrow spectrum antibiotics work only on certain types of bacteria (for example, only gram-negative bacteria such as E.coli) while the broad-spectrum antibiotics inflict damage on all types of bacteria (both gram-positive and gram-negative).

Now, in case if you’re wondering, your friendly lactobacilli bacteria are gram-positive. So if you take a wide-spectrum antibiotic, you will damage the population of your friendly bacteria along with killing off the pathogenic bacteria.

So why don’t doctors just use narrow-spectrum antibiotics in that case? Unfortunately, you can’t always be sure what type of bacteria caused your UTI. For example, it could be an E.coli (gram-negative) or Enterococcus faecalis (gram-positive), or both types at the same time. In order to know for sure, you must first correctly collect urine, send it to a lab, and wait for at least 24 hours to see what type of bacteria grows in your urine sample (this is called a urine culture test). Therefore, most doctors rushing to rid you of the painful symptoms prescribe a wide-spectrum antibiotic to cover all bases.

Unfortunately,  your population of friendly lactobacilli is vulnerable to wide-spectrum and narrow spectrum antibiotics targeting gram-positive bacteria. That’s why one of the most common side-effects after antibiotic treatment in women is a yeast infection. 

That’s also why, paradoxically, you might be more prone to UTIs right after an antibiotic treatment for a UTI, causing a cycle of repeated UTIs. So if you are happily engaging in sexual activity right after your antibiotic treatment, you are asking for trouble.

The right answer would be to restore vaginal health after a course of antibiotics prior to restoring your sex life. Priorities, ladies!

Once I figured this out, I researched the type of bacteria that are considered to be the most beneficial lactobacilli strains for vaginal health and was able to find a product that worked for me (I took Rephresh Pro-B for several months).

Not all probiotics for UTI prevention are created equally in terms of both their CFU and effectiveness of delivery.

Several important factors to pay attention to are:

#1. Type of lactobacilli in your women’s probiotic. For vaginal  health, the top species to look for are Lactobacillus crispatus, L. gasseri, and L. jenensii, with other beneficial well-researched species being L. rhamnosus GR-1 and L. reuteri. Look for a product that contains these strains. 

#2. The total number of colony forming units (CFU). You need at least 10 million per day of the two strains referenced above, otherwise, you could be never sure how many CFUs of these strains you are getting.

#3. Guaranteed viability at the moment of expiration, not manufacturing. Look for products that state number of alive CFUs at the expiration date.

#4. And also remember to feed your bacteria with plenty of fiber or prebiotics!

Remove extra bacteria

Since pathogenic bacteria ascend from the anus upward toward the urethra, it’s important to adjust your hygiene habits while restoring vaginal flora with probiotics.

In my case, I used a tea tree oil wash after sex to eliminate any bacteria that could still be on the surface of my genitals. Tea tree oil has great antimicrobial properties and at the same time does not kill lactobacilli.

In some cases, using tea tree oil or lavender oil suppositories could help speed up the process to combat yeast and pathogenic bacteria in your vagina.

Also, make sure to eliminate anything that could negatively impact vaginal flora. For example, I stopped using any contraceptives that contain Nonoxynol-9 and changed the type of lube I use.

Nonoxynol-9 is a known irritant that not only inflames the vaginal lining, making it easier for pathogenic bacteria to establish a colony but also kills lactobacilli, so you definitely do not want to use products with this spermicide.

As to commercially available lubes, many of them include nasty ingredients that could provide food for candida and as a result will lead to yeast infections. Look for water-based lubes instead.

Another thing to add: if you look at the days when you had your UTI symptoms with respect to your cycle, you might notice that the infection started right before or right after your periods. This is because the number of lactobacilli fluctuates depending on where you are in your cycle. Knowing that, and if you are still working on breaking the cycle of UTIs, you might want to skip those days and avoid sex until your vaginal flora is fully restored.

While the role of a healthy vagina in UTI prevention has been studied for years, unfortunately most physicians haven’t yet gone beyond official treatment guidelines and experimented with novel prevention strategies. Patients are often left on their own to figure things out. Thankfully this is changing, at least for US-based urologists: new proposed guidelines by AUA include vaginal health evaluation as a part of UTI prevention strategy.

For more UTI-related pearls of wisdom, check out Anastasia’s excellent UTI resource Stop UTI Forever.