BRITISH BROADCASTING CORPORATION
RADIO SCIENCE UNIT
CHECK UP 6. - Urinary Tract Infections
RADIO 4
THURSDAY 31/03/05 1500-1530
PRESENTER:
BARBARA MYERS
CONTRIBUTORS:
GERALD RIX
PRODUCER:
DEBORAH COHEN
NOT CHECKED AS BROADCAST
MYERS
Hello. Cystitis is often thought of as a woman's condition and it is, of course, more common in girls and women, a feature of the female anatomy. But cystitis, which is just an infection of the bladder, can affect men too. In older men it can be a sign of prostate problems, the enlarged gland can stop the free flow of urine and allow infection to take hold. Babies and children are not immune either - transfer of bacteria from the gut to the urinary tract is easily done. And some children have a physical abnormality which makes them rather prone to this, in which case surgery may be an option.
Well if you have any of the symptoms of urinary tract infection, namely pain on passing urine or blood in the urine, call us now 08700 100 444 and you can put your questions to consultant urological surgeon Mr Gerald Rix, who joins us today from Colchester General Hospital. You can of course always e-mail us if you prefer, the address: checkup@bbc.co.uk. But it's a caller first, we have Jane Pearce on the line from Buckinghamshire. Jane, with a question about an infection which recurs in your case.
PEARCE
Yes I had it last year and it was a long time before it was diagnosed because I didn't have any other symptoms. And eventually the only thing I could think of saying to my doctor was that occasionally I felt as if I was going to get cystitis but I didn't. So it was diagnosed and treated and it cleared up. But I got it again at this time of year, so I'm wondering whether there's anything in food or drink that could be making it worse or whether there's anything I can avoid which could be having a problem.
MYERS
Because it's not very pleasant when you get it?
PEARCE
Well no I just feel awfully ill, tireder and tireder, with still no real symptoms, so that's what makes it so difficult.
MYERS
Well let's find out from Gerald Rix a. whether this is a urinary tract infection and whether it might be in that case connected with external factors - you mentioned the weather or changes in the diet, for example.
RIX
Jane, I'd like to ask, if you don't mind, how was the diagnosis made? Did the doctor actually send off a urine specimen to the lab and did the lab say that they actually managed to grow any organisms in it?
PEARCE
The doctor did a test at the surgery and said that there was blood and white cells in the urine.
RIX
Yes, what your doctor will have done is he will have taken a urine specimen and will have performed what we call a dipstick test and what that does is it detects various things in the urine - blood, protein are often found and they may well be associated with an infection. That's not always completely diagnostic of an infection and the best way to know whether you truly have an infection is to send a sample off to the lab. What they do is they then grow the bugs and if they grow them then we have a definite, what we call a proven UTI. There are other conditions which mimic cystitis where you can have blood and white cells in the urine but they're not necessarily an infection. It's interesting that you say that you don't have the typical symptoms, I mean the typical symptoms are of course, as most women will be able to tell most men quite easily, are a sort of burning feeling, a need to go and pass urine more frequently, an offensive odour to the urine. You said you didn't have any of those?
PEARCE
Well only very occasionally and it would be on Monday mornings and that would be because I drink a lot, as a matter of course, but at weekends if I'm busy I don't drink as much as I do in the week.
MYERS
Are you talking about drinking water?
PEARCE
Yes, yes oh yes.
MYERS
Oh yes indeed, just to clarify that. Because normally that's thought to be quite a good idea generally speaking anyway, whether or not you've got the possibility of an infection. I mean would you comment on that, for example?
RIX
I mean we certainly recommend that people maintain a reasonably good fluid intake and most of us if asked actually don't. In the context of trying to stop infections there's no scientific proof that it does but we say well it sounds sensible to keep the system flushed out and we say we should do it.
MYERS
But the other - the sort of possible causes, I mean can we sort of knock those on the head, I mean is there any reason to suggest that it's anything - if it's there at all - other than an infection in the urinary tract that's causing symptoms, whether or not you can culture this in the laboratory, you may have it as a kind of low grade infection I presume.
RIX
Usually, I mean if you have a proper bacterial infection we should be able to grow the bugs. Now the interesting thing about diagnosing a bladder infection, a cystitis, is that when you send urine to the lab most labs will look for high levels of bacteria. Most labs will not look for low levels of bacteria. There have been some studies to suggest that if you look for lower levels you will in fact make a positive diagnosis of an infection where many laboratories will say no infection. This is the term - no significant growth.
PEARCE
Well my doctor has actually sent off now a specimen to the laboratory to find out and she's also organised a scan of my kidneys and my bladder.
RIX
Quite right, I mean that is very much the standard investigation that we would perform - an ultrasound scan to make sure there's no obstruction to the drainage of urine, that your bladder empties properly, there's nothing like a stone in the kidney - all of which can be associated with infection.
MYERS
Jane we'll have to I think leave it at that for the moment because we're very well aware of all the calls that are stacking up and I hope you'll stay listening and get some further information as we go along. But it sounds as though Gerald that what's happening for Jane, these tests and so on, at least she's being well looked after.
RIX
She's certainly going down the right route, absolutely.
MYERS
Okay, and are you discounting changes in the weather then?
RIX
Yes, I mean in answer to the original question whether food - no association.
MYERS
No bearing on the matter, okay. Let's go to Kieran Duggan who's in London and has a seven-year-old son with UTI infections - recurrent infections. As I said earlier babies and children not immune as it happens. Kieran, what's the question for Gerald Rix?
DUGGAN
Hi, the question I've got is my Charlie, he's seven years old, and this is the second time he's had the infection, the first time was when he was four years old, and he was scanned, given antibiotics and obviously got over it. But I'd just like to know why he's getting it and what we can do to stop him getting it.
RIX
The scan that he had, do you know what sort of scan it was, was it an ultrasound scan where he had a bit of jelly put on his tummy and they looked at his kidneys or was it something called a DMSA scan, a renogram or a nuclear medicine scan?
DUGGAN
I think it was the latter one that you said - renogram - because we did have to wait for it, we did have to wait to get the appointment. And they said because he was so young they wanted to check that his kidneys weren't scarred.
RIX
Scarred, correct. The thing about infections in children is that you very much want to know whether there has been any damage to the kidneys, so you do a renogram to see if there's any scarring. They would also do a scan called an ultrasound to see if there's any abnormality to the drainage of the urine from the kidneys or if urine is perhaps going the wrong way. Now usually if there are no scars and the first scan is normal and it's a single infection you treat it and then you wait to see what happens. If he is getting further infection that probably warrants slightly more detailed examinations to see whether there are other conditions that are causing it. Specifically there's something called a micturating cystogram or a micky cyst [phon.], where you look to see where the urine travels the wrong way - where it travels from the bladder up back towards the kidneys, as this can be a common cause of infection. So what I'd suggest to you is that you perhaps approach your doctor again and that he be referred for further investigation.
DUGGAN
But is there any particular reason why he gets it, because he has two elder brothers and one younger sister and they're all fine, none of them have ever had anything like this, so we're just trying to find out exactly why he's got it and if there's anything we can do, I mean i.e. his diet. At the moment the only thing we can do, obviously we're trying to give him some more water but trying to get a seven year old to drink just plain water is not easy.
RIX
And to be honest, as I said, diet really has very little impact on infections or preventing them, except for cranberry juice but we can talk about that later. The drinking again - I wouldn't force him to do that. What we really need to do is find out whether there's any abnormality in his urinary tract, which might be the case of the infection. You can't really prevent anything there but it's important to find out - well you can't, we can - it's important to find if he has one of those.
MYERS
Thank you for your call, we'll leave it there. But can I bring in an e-mail we've had from Steve in Newcastle, who's got two children and both of them have renal reflux and he's asking whether this could be passed on genetically, and I wonder if that touched a little bit what Kieran was getting at - whether - how these things happen in families, some children seem more vulnerable to things, other children not so. Renal reflux - for a start, can you explain that Gerald?
RIX
Yes, I mean what this is urinary normally passes from the kidneys, down a couple of tubes called the urethras - one on each side - into the bladder. Now normally it stays in the bladder until you empty your bladder when it goes down the water pipe. There's a valve at the junction between the urethra and the bladder which prevents urine going the wrong way. Now if you have a condition called reflux or the proper term is vescicoureteric reflux, what happens is this valve mechanism doesn't work, so when the bladder contracts and generates a fairly high pressure urine gets squirted back up from where it came from. Now the way that that causes infections is that you're not fully emptying your bladder, there's always a little reservoir that stays there and gets recycled and recycled and recycled and causes infection. And this is one of the important causes in children of infections and one of the important things we look to exclude. So Kieran's son, this is exactly what I was alluding to. Interestingly enough it is familial - there is an association - so if you have a sibling who has the condition and you get infections yourself there's a good chance that you may have the same condition, in fact some of my colleagues would advocate that if you have a child with reflux in the family you screen the others to make sure they don't have it either, perhaps asymptomatically.
MYERS
We're getting a lot of questions about children, possibly something to do with the fact children are at home from school for the Easter holidays, but in this case Abbey has e-mailed saying that her 16 week old son was admitted to hospital with E. coli septicaemia and tests showed that this had been caused by a urine infection. Ultrasound has shown he has a kink in the urethra of this left kidney, so I guess that ties in with what you're saying about the plumbing and it not perhaps being straightforward. But the question from Abbey is he's due to have a scan and she would like to know what the implications might be if any scarring of the kidney is found?
RIX
Yes, I mean E. coli is the commonest organism causing urinary tract infection, and most times it causes cystitis, which is fairly unpleasant but not necessarily life threatening. One of the complications of an E. coli infection can be septicaemia which is a very serious infection and obviously this child's being very carefully investigated as a consequence. Finding a kink means that there is something which is preventing urine draining freely in the urinary tract. It will probably require some form of correction. Depending on the severity and the degree we might start off by treating with antibiotics to see whether this controls the condition or in fact whether we might need to resort to surgery to correct it. So an operation is on the cards but depending on the details of what they actually find.
MYERS
Thank you very much. We'll go to the phones again, Shropshire and Anne Whitehead wants to talk to us about infections which she's had for six months now. Are you struggling with that Anne, it sounds quite a long time to have a urinary tract infection?
WHITEHEAD
Yes, well I'm getting a bit tired of it ...
MYERS
I'm sure you are.
WHITEHEAD
I have a week's course of antibiotics, I send in the sample when I finish that and back it comes positive every time.
RIX
Is this again the same that the urine sample gets sent to the lab and the lab say yes we have grown an organism in your urine?
WHITEHEAD
Yes.
RIX
How long has this been going for - six months?
WHITEHEAD
Yes.
RIX
Has anything changed in your life - have ...?
WHITEHEAD
No nothing at all.
RIX
You've not undergone the change?
WHITEHEAD
No.
MYERS
Are you otherwise well?
WHITEHEAD
Well only so, so. I said when I answered - when I first phoned up that I'm a diabetic and I believe that has some bearing on it.
RIX
I was about to ask you - has someone looked at diabetes. Diabetes is very ...
WHITEHEAD
Yes it's a type II diabetes, I've had it for about four years.
RIX
Yes, I mean diabetes is very relevant for two reasons. The first is if the diabetes isn't as well controlled as it might be then sugar levels in the urine are raised and of course bacteria like to feed on sugar, it's how they get their energy. The second factor - I mean against you if you like - is the fact that with diabetes there is a reduced resistance to infection, your white cells don't quite work as well as they might. So a combination of the two could certainly give you recurrent infections. Having said that we would also look to make sure that your bladder empties properly, that there isn't enough factor which could produce infection.
WHITEHEAD
Yes. My GP's just started me on a different tack - a three week course of norfluoxetine and to take two tablets a day for the first week and then the balance - one tablet for the remaining number of tablets.
RIX
That's right and the infections that you've had up until now - they have been treated with a course of antibiotics?
WHITEHEAD
Yes, a different one every time, I haven't made a note of what they were.
MYERS
Don't start to tell us.
RIX
The important thing is if you really are getting many, many infections and we've gone through things like controlling your diabetes then one of the very good treatments is to give you a low dose antibiotic tablet to take every day in order to prevent recurrent infections. One of the things that you might like to consider doing yourself is to take cranberry capsules. Now I wouldn't advocate cranberry juice because of the diabetes, the high sugar content would give you difficulties ...
WHITEHEAD
Oh would it, yes I have started drinking cranberry juice because it's supposed to be helpful.
RIX
Well it is, only the thing about cranberry juice it is a natural product. It has been demonstrated to stop the bacteria that cause infections sticking to your bladder walls and to prevent infections. It doesn't really work to treat an acute infection but in people who take it who get infections like yourself will get less infections over the course of time. But because of your diabetes you should take the capsules which don't contain the sugar but contain all the active ingredients of the cranberry.
WHITEHEAD
Oh I see.
MYERS
So something to try there. So the cranberry juice then, as you explained, is quite a reasonable home remedy, I know a lot of people do use it, and capsules are available and presumably equally effective if that's more appropriate, as it might be in the case of Anne. Can I just mention another couple of tips that have come in, well you might call them home remedies? And one is from Audrey Darley, who says: Half a teaspoon of bicarb of soda in warm water for cystitis. Is she drinking that or bathing in it or what?
RIX
She's probably drinking it. I mean the way that works is it makes your urine less acid. Most of us eat quite a lot of meat, therefore our urine tends to be acid, vegetarians tend to have an alkaline urine, but if the urine is very acid and you have an infection then that acidity irritates and produces a lot of the symptoms. So bicarbonate of soda will dampen down the acidity and help with the symptoms, it won't cure the condition but it'll make your life more tolerable.
MYERS
Another one from Lesley Whittle, a natural remedy, which it says here, Waterfall D. Mannose cleared up her UTI. I haven't heard of it, have you?
RIX
That's an unusual one I have to say.
MYERS
But you've not heard of it?
RIX
No.
MYERS
Okay, well thanks for the tip, we can't comment because Gerald hasn't heard of it. But the business about antibiotics obviously tried and tested and generally perfectly effective for a lot of people - is that a first line of treatment?
RIX
Antibiotics is what we would prescribe. Some people will say my infection cleared up after a few days of drinking plenty of water, what often happens is that it goes to a sub-clinical level, the bugs are still there but you no longer have the symptoms. There certainly have been trials done, not so much comparing treatment versus no treatment but there was a vogue at one point of giving a single dose of antibiotic to see whether to swallow a pill would cure the problem. Comparing that with a three day course of antibiotics quite clearly showed that a single dose will not cure the problem, so by inference not taking any antibiotics at all won't either. So usually we advocate a short course of antibiotics after you've sent a urine specimen off so that we can see whether an infection or not.
MYERS
There are a lot of people, and I think our next caller Laurel is one of them, who is a little bit of suspicious, certainly has reservations about taking antibiotics. Is that the case - you've got recurrent infections, have you been treated with lots of antibiotics?
LAUREL
Yes, yes it is, good afternoon to you both. Yes I've had urinary problems all my life and I'm now a pensioner, so that obviously I've lived with a lot of different problems, including continence problems and urinary frequency and urgency for a long, long time. But over the past two to three years I've been having repeated infections, which I had managed to keep at bay more or less for 40 years and all of a sudden they started to break out again. I waited for about six months to see if the pattern settled and if my own home remedies didn't work but I was getting a lot more pain, a mid-line pain from the naval downwards and various changes in my normal pattern of things. So that I went to seek help about the new symptoms in the summer of 2003 and asking if I could have a repeat of cystoscopy and biopsies which had been done before because a consultant had said I had bladder cancer and fortunately it was found after the tests that I didn't. But I'm sort of on the at risk list. Now I still haven't had those tests and this is a long time waiting and in the mean time I've been put on a regime of prophylactic antibiotics and I'm not happy living with that permanently ...
MYERS
Okay Laurel, I'm going to stop you because it's obviously quite a complicated medical history there and thanks for explaining that. So the bottom line really what would you say Gerald - I mean you just don't want to keep on taking antibiotics?
RIX
No absolutely not, I mean in her case it sounds as though she has been fairly extensively investigated before. It probably looks as though you need to be reinvestigated if this has been a little while down the line, I mean quite rightly you're being treated as though you had an infection but you're quite right to assume that maybe something else is going on. Now I'm not suggesting that something is but it is important, in your case, particularly from your past medical history, probably to have a look - to revisit the whole issue again.
LAUREL
And that's what I've been waiting for - it's been promised for six months and still hasn't happened, so I don't - apart from trying to follow up, from which I get no response, I don't know what else to do for myself.
RIX
Have you had any blood in your urine?
LAUREL
Yes, a lot of fresh blood and I've reported all that, oh yes.
RIX
I mean generally speaking a urologist would take that very seriously, we tend to have a fairly low threshold for investigating that and in fact we have targets which mean that we should investigate anyone with that sort of condition fairly quickly. If you perhaps stress that you might find that things get done more quickly.
MYERS
Thanks for talking to us about that. Just wondering about that, of course citing blood in the urine is always a bit of a shocker but it does seem to be a symptom for many women, alongside the other pain and so on that we've been talking about. Should you immediately on seeing blood go to the doctor or should you accept that that's the pattern for you - this infection is leading to blood in the urine?
RIX
Not really, I mean blood in the urine is something which can harbour a benign condition such as an infection but it can also mean something more serious. It's always unsafe to assume that it is a benign condition and we certainly would investigate it.
MYERS
Okay, thank you. We'll go to another e-mail, Clare Wasserman is asking: What effect does an infection of E.coli in the urine have on pregnancy? And if the symptoms are minimal does one - presumably she - really need to take antibiotics? It's this resistance to antibiotics, as well as antibiotic resistance.
RIX
I can understand people being resistant to taking tablets, I mean particularly when you're pregnant you don't want to subject your baby to anything that they don't really have to have. But in the case of somebody who's pregnant who has an infection it is actually very important to take antibiotics and in fact if you have an infection or are found to have bacteria in your urine while you're pregnant we usually recommend that you have a low dose of antibiotics throughout the course of the pregnancy in order to prevent this infection becoming more serious. If I can give you an idea of the importance of this - if you do not treat bacteria in urine in pregnant women one in three will get a fairly serious infection. That itself puts the pregnancy at risk. So it's the lesser of two evils - take the tablets, you'll probably be fine, there are antibiotics which are well recognised to be safe in pregnancy and as long as you make sure you're on one of those you should have no problem.
MYERS
So if there's someone who has regular cystitis in the normal course of events, if I can put it like that, and you perhaps just treat it symptomatically at home with home remedies, if you're pregnant you should actually take a more proactive approach?
RIX
You should certainly get your urine looked at, certainly get it cultured to make sure you don't have any bacteria. If you don't, that's fine, but if you do you should have something done about it.
MYERS
Let's go to another caller now in - we've got Flora waiting for us in Southend. Hello Flora.
FLORA
Hello.
MYERS
Yes, I gather you've got a question about catheterisation and the effect that that might be having. Just explain very briefly what the story is please.
FLORA
I've had MS for about 40 years. One of the symptoms is bladder - loss of control - which has only come on with the last 10 years. But I can deal with that but I've been getting infections. My doctor's given me one to take at night called trimethoprim to keep the infection down, then when I do - that doesn't work - when I do get an infection I get a tablet called ciprofloxacin to cure it, which it does within five days. In between I am catheterised in the morning with the help of my husband and then in the evening I'm catheterised. I have a bidet in the bathroom which enables me to give myself a thorough wash - front and back - and I drink water and I drink cranberry juice. So why do I keep getting these infections?
RIX
I mean MS is - well as I don't need to tell you - is a very disabling condition. It affects the bladder in two main ways. One is it can make the bladder excessively active and can produce urine incontinence. The other is it doesn't allow the bladder to empty properly. What that means is that you have this reservoir of urine. It sounds as though that's what you're getting because you're being helped to empty your bladder twice daily. Maybe you need to increase the frequency of bladder emptying, if during the day you're not passing much urine and you've got a pool of urine in there you need to increase your self catheterisation regime. You probably need to get this looked at very carefully by essentially a specialist. But you're doing the right things with the cranberry juice, the hygiene - these are all important things that you can do to help yourself.
MYERS
I mean can you say for all of us really, Flora you mentioned the importance of hygiene, and we are talking about a bacteria and E.coli I think is the common one that gets passed into the urinary tract, so I mean it behoves us all to take as much care of ourselves and to be hygienic in washing and so on and so forth - Flora mentioned a bidet, I don't know whether everyone's got a bidet but is that relevant do you think?
RIX
Well as you said E.coli is a bacterium which is found in the bowel and when it goes round the corner into the urinary tract, which is very easy in women because it's a very short journey, it produces infection. It's much more difficult in men to get there directly. So particularly for women hygiene is very important, make sure you empty your bladder, make sure you keep yourself clean. Intercourse is relevant - that can exacerbate infections, it's important to flush yourself out by passing water before and afterwards.
MYERS
Well with those tips we will have to draw a line under our programme, always too soon. But thank you very much indeed Gerald Rix for being our expert today. And thanks, as always, to everyone who has phoned and e-mailed us, we appreciate that. If you would like to hear this programme again you can find it, go to our website bbc.co.uk, simply follow the trail to Check Up or if you'd like to speak to a real person then call our helpline, that's 0800 044 044. Next week: hearts that go too fast, too slow, cardiac arrhythmias, our topic in Check Up, do join us at the same time next week.
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