Urinary Tract Infections

Lower urinary tract infections (referred to as UTIs in this article) account for millions of doctor visits per year with the urinary tract being the second-most common site for infection ^[1]. The term urinary tract infection refers to the presence of a certain number of bacteria in the urine, usually more than 100 000/mL. UTIs can occur in both men and women, however, they are about fifty times more common in women than men. This is likely due to the fact that women have shorter urethras allowing bacteria to ascend more easily into the bladder ^[2]. UTIs affect as many as one in five women at some time during their lifetime with about 20% of these women having reoccurrence or chronic infections. The more infections one has had the higher the incidence of reoccurrence. UTIs usually present with the following symptoms: pain or burning sensation on urination, frequent urge to urinate, pressure or pain above the pubic bone even when not urinating, fatigue, and difficulty passing urine. Pyuria, white blood cells in the urine, causes the urine to be cloudy or milky and hematuria, blood in the urine, can cause the urine to be pink or reddish tinged. UTIs can be asymptomatic, especially in children and the elderly. Children often do not present with the above symptoms but the following less specific symptoms can suggest a UTI: irritability, incontinence, diarrhea, poor appetite, and fever. If a fever, flank pain, nausea, and vomiting occur the infection may have reached the kidneys causing acute pyleonephritis, which is a serious condition and requires medical attention ^[1].

Risk factors include being female, sexual activity, mode of birth control, menopause, diabetes, catheter use, and urinary tract obstruction, such as a stone, tumor, or enlarged prostate. The urinary tract is normally a sterile environment, however bacteria can migrate to the urethra from the rectum or vagina. Most infections are due to bacteria with the most common agent being E. coli accounting for 80% of UTIs. Other bacteria include: Klebsiella pneumonia, Proteus mirabilis, Enterobacter aerogenes, Staphylococcus saprophyticus, Enterococci, and Staphylococcus aureus. E. coli and Proteus bacteria are able to adhere to epithelial cells of the urinary tract. The female urethra is prone to bacterial infection due to its proximity to the anus and vagina. The ability of pathogenic bacteria to colonize is associated with altered vaginal and colonic flora, which can due to other genital infections and/or the use of antibiotics and spermicides. The loss of Lactobacilli, a nonpathogenic flora of the vagina and urethra, results in easier colonization of E. coli. Urine normally prevents infection via its antibacterial and flushing mechanisms ^[1].

Diagnosing a lower urinary tract infection involves analyzing a urine sample to look for red blood cells, white blood cells, and bacteria. Sometimes a urine culture will be done to determine which bacterium is causing the infection so the most effective antibiotic can be utilized. Imaging, such as an ultrasound or CT scan, may be done if an abnormality in the urinary tract is suspected. In the event of recurrent UTIs, a cytoscopy may be done in order to visualize the inside of the urethra and bladder ^[3]. There are a number of ways to reduce your risk of developing a UTI. It is important to drink plenty of fluids, especially water, in order to ensure you are voiding your bladder regularly to flush out bacteria and prevent their adherence. Wiping from front to back after urinating and after a bowel movement helps prevent bacteria from migrating from the anus to the vagina and urethra. Voiding your bladder soon after intercourse can help reduce UTIs especially in females who notice they develop them after sexual activity. Feminine products can be irritating to the genital and urethral areas and should be avoided. Wearing cotton underwear can reduce the chance of UTIs as well because it is more breathable ^[3].

Conventional approaches

Since the majority of UTIs are bacterial in origin they are most commonly treated with antibiotics during an acute episode. It is not uncommon to use an antibiotic for long-term prophylaxis in individuals experiencing recurrent infections. Antibiotics effectively treat and prevent recurrent UTIs, however frequent antibiotic use results in altered vaginal and intestinal flora as well as antibiotic resistance. Therefore, alternative methods of prevention and treatment for simple UTIs are desirable ^[1]. The most common antibiotics used to treat simple UTIs include: sulfamethoxazole-trimethoprim, amoxicillin, nitrofurantoin, ampicillin, ciprofloxacin, and levofloxacin. Symptoms typically clear up within a few days of treatment. In people who experience frequent UTIs, longer courses of antibiotics or prophylactic antibiotic use (i.e. after sexual activity) may be used ^[3].

Naturopathic Approaches

Vaccinium macrocarpon (Cranberry)

Cranberry is an anti-adhesion agent that is effective in the form of pure juice, sugared cocktail, and capsulated and tableted extracts. One study demonstrated a 20% and 18% decrease in antibiotic use when cranberry juice and tablets, respectively, were consumed compared to placebo. A study done in elderly women showed that women who consumed 300 ml of cranberry cocktail had significantly less bacteriuria with pyuria compared to the placebo-drink group after 6 months ^[1,4]. A meta-analysis of the cranberry trials concluded that cranberry significantly reduces the incidence of UTIs over a 12-month period in women with recurrent UTIs ^[1,5].

The current evidence suggests that cranberry juice is effective in preventing UTIs in women with recurrent UTI and in the elderly but not in children or adults with abnormal bladder function requiring catheterization ^[1,2]. Cranberry juice inhibits adherence of 75% of 77 E. coli isolates in vitro. In a clinical setting, 15 of 22 subjects given 15 ounces of cranberry juice demonstrated significant anti-adherence activity in urine 1-3 hours after the juice was consumed. It was found that cranberry juice is safe and effective for the prevention of UTIs during pregnancy, which is important because UTIs are common in pregnancy and can progress more easily to acute pyelonephritis ^[1]. Cranberry may interact with warfarin due to its potential to increase INR (i.e, increased bleeding risk) ^[6]. This interaction, however, is limited to anecdotal reports. Clinical trials have found that moderate consumption of cranberry juice does not affect warfarin anticoagulation. Consuming more than 600 mL of cranberry juice daily could potentially affect warfarin but this amount is well over the amount recommended (i.e. 250-300 ml/day) in the treatment and prevention of UTIs ^[7]. Therefore, due to conflicting data, patients should be closely monitored when initiating a cranberry juice regiment when currently taking warfarin ^[1].

Berberine

Berberine is a plant alkaloid found in various plants, including Hydrastic canadensis (goldenseal) and Berberis vulgaris (barberry). Berberine extracts and decoctions have demonstrated significant antimicrobial activity against various organisms, including bacteria. Berberine inhibits the growth of several bacteria including both sensitive and resistant E. coli ^[1]. Bacteria inhibited include: S. aureus, P. aeruginosa, E. coli, and B. subtilis ^[1,8]. Berberine’s anti-infective activity is believed to be at least in part due to its ability to prevent adhesion to uroepithelial cells. Berbeine can indirectly affect UTI occurrence due to the fact that E. coli often migrates from the gastrointestinal tract and therefore treating GI-associated E. coli can impact UTI occurrence. Using berberine to successfully treat intestinal dysbiosis may be preventative for UTIs. Berberine should be avoided in pregnancy due to its potential to cause uterine contractions and miscarriage ^[1].

Vitamin C and D-Mannose

Vitamin C prevents UTIs and may effectively treat UTIs due to its ability to increase the production of nitric oxide in acidified urine ultimately decreasing the growth of E. coli ^[9]. One study found that UTI occurrence was significantly lower in the group receiving vitamin C compared to placebo ^[1]. D-mannose is a simple sugar that prevents adherence of certain bacteria, such as E. coli ^[1]. It has been shown to not disrupt the gastrointestinal flora and is considered safe in children and pregnant women ^[9].

Probiotics

A number of probiotics have been studied for effectiveness in the prevention of recurrent UTIs. Improving the gut and/or vaginal flora can impact the urinary tract due to the migration of E. coli from these areas to the urinary tract ^[1]. Lactobacilli are the dominant bacteria found in the vagina and have antimicrobial properties that help control the other urogenital flora ^[10]. Lactobacilli produce lactic acid and hydrogen peroxide, which kill bacteria, and also produce biosurfactant that inhibits the adhesion of pathogenic bacteria. Therefore, vaginal lactobacilli protect the female urogenital tract from pathogen colonization and can aid in the prevention of UTIs ^[11]. Vaginal suppositories with L. crispatus have been shown to reduce the occurrence of UTIs significantly ^[11]. Weekly use of probiotic suppositories has been shown to reduce the incidence of UTIs after 12 months of use ^[1].

Estriol cream

Recurrent UTIs are a common problem in postmenopausal women due to the decrease in estrogen and its role in maintaining health vaginal mucosa and flora. Women given estriol intravaginally had significantly less incidences of UTIs as compared to those who received placebo. Lactobacilli were absent in all vaginal cultures prior to treatment and reappeared after one month in 22 of 36 estriol-treated women but in none of the 24 placebo-treated women. The rate of vaginal colonization with Enterobacteriaceae fell from 67% to 31% in women treated with estriol and remained unchanged in those receiving placebo. The use of topical estriol may be safer than oral estrogens because it does not produce the systemic effects associated with oral estrogens ^[12].

Conclusion

As outlined in this article, there are various natural therapies that can be used in the prevention and treatment of UTIs. Given the ever-increasing risk of antibiotic resistance and side effects associated with antibiotic use, alternative treatments should be considered for simple lower urinary tract infections. Cranberry has been shown to be effective in preventing UTIs in women with recurrent UTI and in the elderly due to its anti-adherence activity. D-mannose and vitamin C decrease the incidence of UTIs by preventing adherence and increasing the production of nitric oxide, respectively. Utilizing antimicrobial agents, such as berberine, can help treat and prevent UTIs. Establishing healthy gut and vaginal flora is crucial in the prevention of UTIs and can be accomplished using antimicrobial agents, such as berberine, and probiotics. The use of topical estriol is associated with a decrease in the rate of vaginal colonization with Enterobacteriaceae and an increase in the rate of vaginal colonization with lactobactilli, thereby decreasing the incidence of UTI in postmenopausal women ^[13].