“It hurts when I pee: Bladder and Urinary Tract Infections” – with Dr. Sara Kostant

Dr. Fox: Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics in women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OB-GYN and maternal-fetal medicine specialist practicing in New York City. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness.

All right, Dr. Sara Kostant, welcome back to the podcast.

Dr. Kostant: Thank you. Good to be here.

Dr. Fox: So we got to schedule this quickly because you got out of jury duty. Congratulations.

Dr. Kostant: Always a great achievement.

Dr. Fox: Sara is a big fan of the jury system, but she wanted to defer her time on the jury.

Dr. Kostant: Yes. No, that’s true.

Dr. Fox: All right.

Dr. Kostant: I’m a supporter of democracy.

Dr. Fox: Yeah. All right. For the record, pro-democracy, Dr. Kostant. And you would be an excellent juror, I believe. I think you’d make a really, really good juror.

Dr. Kostant: Yeah. I think I would be, and there’s a part of me that’s, when I’m retired, I’d love to be a juror, do a nice two-month trial, whatnot.

Dr. Fox: I don’t know. I find they don’t tend to like doctors on juries for some reason. I don’t know. Maybe that’s changing. Every time I’ve gone and said I’m a doctor, they’re like, “Go home.” Nice knowing you. Maybe that’s just in Jersey, don’t know. All right, well, you know, God bless the legal system.

Dr. Kostant: Now I’m here, we can talk about bladder infection.

Dr. Fox: Yes. So we’re gonna talk about bladder infections, urinary tract infections. I’m surprised we haven’t covered this topic yet in four years on this podcast as it’s a really sort of common gynecologic situation.

Dr. Kostant: Yeah, I think it’s probably one of the most common concerns patients come in with when they come in, especially a same-day and more urgent add-on visit.

Dr. Fox: Right, because they can be quite uncomfortable.

Dr. Kostant: Disruptive, by the way.

Dr. Fox: So we’re gonna talk about that, try to sort through, you know, sort of the basic questions, like, what are we talking about, what is it, you know, how does someone get them, how does someone prevent them, how does someone treat them, how do you know if you have it, when to go to the doctor, when to not, all those. And then we’re also going to try to make sure to differentiate sort of a typical gynecologic situation from when someone is pregnant, when it’s a little bit different in terms of how we manage them. So unless we say otherwise, we’re talking about nonpregnant state sort of standard lifetime women. And then when we get to pregnancy part, we will say like, “This is specific to pregnancy,” just, you know, to give everyone an outline of what’s to come. So, how would you describe or define what a urinary tract infection is or what a bladder infection is to patients?

Dr. Kostant: Urinary tract infection, it actually is, you know…I think we throw that term around, but it includes bladder infections and kidney infections. And just to talk about them separately, a bladder infection is basically when a bacteria that’s usually from the vaginal and anal area gets into the bladder where it’s not supposed to be and grows, and the symptoms of that tend to be pain, pain with urinating, sometimes seeing actual blood in the urine, needing to go to the bathroom much more frequently, sometimes feeling like you need to go to the bathroom every 10 minutes. It’s usually pretty, you know, pretty obvious, and it can hit pretty quickly.

A kidney infection is when that infection then moves up through the ureters, which connect the bladder to the kidney and infect the kidney, which is obviously much more serious. And when that happens, in addition to everything I just mentioned, usually, there’ll be a fever as well, generally feeling really sick, nausea, vomiting, and what we call the flank, which is basically the part of the back that’s kind of a little bit more mid-upper back, a little bit on the side where the kidneys side, will really hurt. That’s thankfully not as common. Most of the time, when patients call and come in, it’s because they’re having the symptoms that I mentioned, just the pain with urinating or they’ve seen blood in their urine.

Dr. Fox: Right. So in medicine, we always try to give things more complicated terms than are needed. So we say like frequency, which means going a lot. We say urgency, which means you really feel like you have to go. We say dysuria, which means it hurts when I pee, like burning and itching. And then there’s the sense of not feeling like you emptied your bladder completely. Like, you went, and you’re like, “I still have to go,” that sense. And it’s just because the bladder, right…the reason people normally have a sensation that they have to pee is the bladder sort of gets distended. It gets filled with urine. And that sort of stretch on the bladder wall, there’s a signal that goes to your brain that says, “I have to pee,” right?

And so that’s sort of what happens typically. And then if your bladder wall gets inflamed because of the infection, it’s sort of always sending that signal to your brain. So you always feel like you have to pee. It’s, like, inflamed. It’s irritated. And then even though you go, you still feel like you have to go, and then sort of the burning while you go is because the pee that’s sort of going through the urethra sort of irritates it. It’s just a lot of irritation and pain from the infection.

Now, if someone has a bladder infection, are we treating it because only just to make them feel better, or is there a risk of everyone with a bladder infection who’s not treated it going up and ascending to the kidney and causing a kidney infection, which you said is much more serious medically?

Dr. Kostant: Yeah. Bladder infections are something that we want to treat because if it does move up to the kidney, that can actually, besides being much more unpleasant and feeling even more awful, that can actually be risky. Someone may require hospitalization. The infection could spread to the bloodstream. I mean, that’s way down the line. But I actually recommend if someone’s having these symptoms not just to…you know, look, hydrating is always good. There’s a lot of remedies that people will sometimes, you know, supplements that they’ll hear about for bladder infections. But I always recommend seeing a doctor and at least giving a urine sample, and depending on how uncomfortable you are treating it or even at least just waiting for the urine culture to come back, to make sure it’s a true infection. Because if it is, if there’s actually really bacteria that is significant, you would want to treat it. It’s not just for comfort.

Dr. Fox: Right. And what’s a little bit interesting about the bladder is that if someone has no symptoms whatsoever and you have them pee and you send the culture, you often will find bacteria in the urine. I mean, the urine isn’t always sterile, that there’s no bacteria in there. It often is, but sometimes there is bacteria in there. And even if it’s at a reasonably high amount, if someone has no symptoms, we don’t typically treat, because usually the body clears it on its own. So it’s important to differentiate nonpregnant women that when someone calls it a bladder infection, it’s not just that there’s bacteria in the bladder. It’s that there’s bacteria in the bladder and they have symptoms.

All right, that’s the difference between sort of the fancy terms asymptomatic bacteriuria, which means you don’t have symptoms, you have bacteria in your urine, versus an infection, which means it’s clinical, that you actually have symptoms from it, that we know that the bacteria have sort of invaded the bladder wall and caused that irritation. And so those we treat. Whereas the asymptomatic, without symptoms, we typically don’t treat because that will usually just clear on its own, or sometimes it’s not a true infection. Maybe the bacteria is not actually in the bladder, but maybe it’s something that just when you peed in a cup, it’s from the vagina. And so there’s a lot of overlap between those two, but we generally don’t treat unless there are symptoms. In pregnancy, it’s different. We do treat if there’s bacteria in the bladder in pregnancy, because pregnant women are more prone to get a kidney infection without the bladder symptoms. So that’s, like, an exception. But for most women, it’s really only if you have symptoms that we would check urine culture and treat if it’s positive.

Dr. Kostant: Yeah. And it’s interesting because I don’t usually routinely just check urine cultures when I have someone come in for an annual gynecologic checkup if they’re feeling totally fine, they’re having no, you know, abnormal bladder issues. Every once in a while, I’ll have a patient who, you know, saw a primary care doctor and had, you know, a urine culture, and they’ll bring me the results. And it will have shown a small amount of bacteria, and they’re feeling fine. And I’ll say to them, “Yeah, I don’t think you need to jump on and get antibiotics right now. If you wanted to repeat this again, it could be that the sample maybe wasn’t sterile enough.” Sometimes if it is a bacteria that does normally cause a bladder infection, like E. coli is the bacteria, I never knew how to pronounce it, Escherichia coli or something, E. coli, still, if it’s a small amount, it could very well be, like you said, that it probably just may have washed out and they’re feeling fine.

Pregnancy is obviously an exception. So I don’t always just send urine cultures on, you know, otherwise healthy nonpregnant patients who are feeling fine just to check. Exception is even if someone’s not having pain, if someone says, “Oh, I’ve suddenly started going to the bathroom, like, every 10 minutes,” like, you know, that would trigger me to get a urine culture. But I don’t think it’s a good idea to just look when someone’s, like, not feeling anything.

Dr. Fox: Right. Because sometimes, you know, the antibiotics, if you treat things that don’t need to be treated, it could be washed, no harm, no foul. Like, you didn’t need to do it. But it could also then cause problems, right? Like, if you were just healthy and decided to take an antibiotic for 10 days for no reason, whatsoever, it could do nothing to you or it could start messing up other things. You can get a yeast infection. You can start getting sort of drug-resistant bugs in your body. There are downsides to taking antibiotics. And so we give them if they’re needed, right, to treat something, but we try to not give them if they’re not needed so you don’t get any of the downsides. And so that would be a case where commonly people are prescribed antibiotics but they don’t really need them. We’ve found some bacteria in their urine but don’t have any symptoms. Again, nonpregnant.

When you’re pregnant, we do check routinely and we do treat routinely, because again pregnant women are at a much higher risk. So I guess actually the best question, number one, why are women more at risk to get bladder infections and urine infections in general? And then, two, why are pregnant women more likely to get kidney infections than nonpregnant women?

Dr. Kostant: So just to answer the last question first.

Dr. Fox: Last question first, all right, we’ll go backwards.

Dr. Kostant: So during pregnancy, the ureters, which carry urine from the kidney to the bladder, tend to get more dilated, and urine just moves a little bit more slowly through them into the bladder. And because of that, it’s a little easier for bacteria to basically go upstream because, normally, it’s like, you know, if you’re trying to go upstream on a river, it’s kind of hard to if the current is going really fast. But in pregnancy, just to kind of carry that metaphor through, if the ureter is like a river, that urine is, like, kind of moving more sluggishly. And so if someone has an untreated bladder infection or even just bacteria in the bladder and it hasn’t even started to cause symptoms yet, it can just get up into the ureter and get up to the kidney more easily because it’s not getting flushed out. And I’ve seen pregnant patients basically feel fine and then just get a kidney infection. Like, they never even had the bladder symptoms. It happened so fast. So it’s not even like they had an untreated bladder infection. Almost like, it was a bladder infection for, like, maybe a few hours, and then it already had spread to the kidney. So that’s the issue with pregnancy.

Dr. Fox: Right. And then why women more so than men for urine infections.

Dr. Kostant: Yeah. So for women, the urethra is shorter in women than in men. So it’s just also easier for bacteria to get into the urethra, into the bladder, altogether because, you know, everyone gets bacteria all the time into the urethra. You know, it’s pretty common. And you know, as you urinate, some gets flushed out. If you’re well hydrated, you know, you’ll urinate more. It’ll flush out more. But because the urethra is shorter in women, it just is able to get into the bladder more quickly.

Dr. Fox: Right. Are there any, amongst women, risk factors for getting urine infections, like some things that make you more likely or some things that people should watch out for potentially?

Dr. Kostant: Yeah, definitely, again, for nonpregnant women, one risk factor, just going back to what we were talking about, having what we call vaginal atrophy or very basically low estrogen levels, either from breastfeeding or from perimenopause or post-menopause, makes the tissue around the urethra also very thin. So low estrogen doesn’t just affect the vaginal tissue, it really affects the tissue also in the opening of the vagina and the urethra. And that alone can significantly increase the risk of getting a bladder infection because the tissue is just much drier and thinner, and bacteria can latch on more easily. So I’ve had patients breastfeeding and post-menopause that I’ve actually recommended vaginal estrogen cream if they keep getting recurrent bladder infections to treat that. And for post-menopausal patients, especially elderly patients, it can actually potentially, like, keep them out of the hospital.

Dr. Fox: Right.

Dr. Kostant: They can keep them, you know, from eventually even getting a kidney infection. So that’s one risk factor is what we call, again, vaginal atrophy or just thin, dry vaginal tissue that happens with low estrogen levels. Another is just for general hygiene. You know, the vaginal and anal area is full of, you know, normal bacteria. There’s a bacterial balance there. Most of the bacteria that cause bladder infections tend to come from the gut, E. coli being the most, you know, common one. It’s not normally in the vaginal area. But in general, you know, one of the classic things that I remember being told by my pediatrician is always wipe front to back because you’re pushing the E. coli bacteria away. You know, sometimes, especially kids, you know, they wipe the other direction, and it pushes E. coli, like, into the area of the urethra.

So just generally being mindful of that. You know, basic cleanliness, you know, should help most people. It’s not like…I don’t tell people who have recurrent bladder infection, actually, it’s probably not a good idea at all to, like, aggressively wash that area. You know, if you basically just shower regularly, you should be fine. You don’t necessarily need to wash the area with soap if you have recurrent bladder infections because that actually can create other bacterial imbalances.

And then, also, for women, just having vaginal intercourse can increase the risk. Some women will get bladder infections specifically after intercourse because bacteria just gets pushed into the urethra. And again, the urethra is shorter in women than in men. One thing that can help with that is emptying the bladder right after intercourse, but some women even need to actually take an antibiotic right after intercourse to prevent that from happening. And again, that’s something that I’ll do if this is really just a very routine regular thing. Not everyone needs to have an antibiotic every time they have sex. But that’s another risk factor is just, again, having vaginal intercourse.

But there are many people who get these infections who have, like, no particular risk factors. Like, you know, it just happens. It’s a part of everyone’s life at some point.

Dr. Fox: I mean, there’s obviously other times when it’s much more common. Like, people in the hospital are more likely to get them. If you have a catheter put in your bladder, it’s more likely to happen. I mean, again, those are unusual because it’s not something that happens in a typical day for people. But those are other risk factors. So if someone suspects they have a bladder infection, right, they’re like, “Oh, you know, I have pain when I pee, and I have bladder pain,” you know, whatever, what do you recommend they do? Like, what should they do at that point? Should they go to an urgent care? Should they call their doctor? Should they try to do something at home? Like, what would be your advice to them? This is it, listeners. Here we go. This is what Sara thinks you should do.

Dr. Kostant: So I think that you should call, if you have a gynecologist or primary care doctor, call them, or go to an urgent care. I usually will start, if it’s like a Sunday and someone’s calling, and they’re in a lot of pain, and they’re having blood in their urine, and it’s really obvious that it’s a bladder infection, I…

Dr. Fox: Right, just over the phone.

Dr. Kostant: Just over the phone, it’s classic and it’s not like they’ve had this going on for a month, I’ll go ahead and treat them just preemptively. I’ll, you know, basically check their antibiotic allergies. I’ll send in an antibiotic just, you know, for their comfort. Because on Sundays, obviously, when our office is closed, the most ideal situation, yes, it’s great to get a urine culture sent, and I’ll say, “If there’s an urgent care where you can leave a urine culture or a lab open, by all means, do that.” But I don’t wait necessarily till Monday if someone’s really uncomfortable. Also, if it’s very obvious, I kind of want to get them treated sooner. I don’t, you know, want them to then wake up Monday and be even sicker.

Dr. Fox: Right.

Dr. Kostant: So definitely making contact with some medical professional, and if you don’t have any established care with a gynecologist or a primary care doctor, go to an urgent care. Like, this is the bread and butter of one of the things that they deal with. And you know, they’ll send a urine culture, and they’ll also, you know, start you on something if it looks like from the urine dipstick test that you obviously have an infection. So that’s definitely the first thing I would do.

Dr. Fox: Right. So let’s play that out. So someone, let’s say they call on the phone and they have an option to come into the office, get a urine culture. What is the advantage to having a urine culture, having a dipstick, seeing someone before starting antibiotics versus, “We’re really sure it’s a urine infection, just treat me?” Like, how do you balance that?

Dr. Kostant: Even though you may know someone for sure has a bladder infection, I don’t know for sure what bacteria it is. I can guess, like, most of the time, it’s this E. coli bacteria, but it could be a different bacteria. Also, it could be E. coli that just isn’t sensitive to the typical antibiotic. Like, in overwhelming majority of the time, I can prescribe one or two antibiotics, and it’s going to completely, you know, cover the bladder infection and they’ll feel better. But leaving a urine culture before starting treatment is helpful because, let’s say, two days later, I get another call that this patient is on the antibiotic, no improvement at all, they’re not feeling better, and they’re still peeing blood and still running to the bathroom every 10 minutes. I can then look back at that urine culture, which hopefully will at least have an early result, and check and see, maybe it was a bacteria that I didn’t expect or maybe the bacteria that I thought was there is there, but it’s one of these multidrug-resistant bacteria or it’s resistant to Bactrim, which is what I had prescribed.

So knowing that, I can then switch them to an antibiotic that would work for them. This is definitely much more important in someone who has recurrent bladder infections. It’s unlikely. If it’s the first bladder infection they’ve ever had in their life, most likely, the typical antibiotic course will help. But I insist more on getting a urine culture if I know someone has had at least a couple of other infections in the last few months, because there’s more of a chance that whatever they have now could be resistant to something that I typically prescribe.

Dr. Fox: Yeah. I mean, it’s sort of like a little bit of a gamble. I mean, on the one hand, someone calls, and they have a typical presentation, typical symptoms, whatever it is, 8 out of 10, 9 out of 10, whatever kind, and you say, “All right, I’m gonna prescribe this antibiotic.” They’re gonna get better. They’re gonna be done, problem solved, in which case, they never needed a culture, and they never need to see anybody. But every now and again, someone, we think they have a urine infection, and in fact, they don’t. We’re wrong, right? It’s something else. They have a vaginal infection, or they’ve got some other problem going on, or whatever it is. Or they do have an infection, but it’s with kind of a wonky bug. It’s a different bacteria than we expected. And then you’re a little bit behind the eight ball. We’re trying to treat it because…to then having to come in two days later and, you know, send a culture.

Number one, the culture might be off because you put them on some antibiotic. Number two, it’s not to come back for another day or two. So it’s one of these things, like, on a Saturday or Sunday, if there’s no option, okay, you take the gamble because you want them to get better. And 8 or 9 out of 10, it’s pretty good, you know. Those are pretty good numbers. But if it’s really not that difficult to come in and, you know, get checked, let’s make sure it’s an infection, send a culture, start on treatment, again, 8 or 9 out of 10 times you didn’t need to do that, but the 1 or 2 times out of 10 you did, you’ll be happy that you already did that. So that’s why people sometimes hear different things from doctors about what to do. Sometimes it’s like, “Oh, yeah, I treat everyone over the phone, and others, I always want them to come in.” And it’s probably some balance of the two that, you know, you have to be a little more practical with this as well, you know. If someone’s, you know, two hours away from, you know…if they’re near a pharmacy but there’s no urgent care within 15 miles of them and whatever it is, I’d rather just treat them than have them suffer. But if they can, you know, drop off a culture, it’s usually better if it’s not too difficult to achieve that.

Dr. Kostant: Brought up something else, which is besides leaving a culture, one benefit of being seen in person is, what if it is actually something completely different? You know, sometimes, over the phone, it sounds really obvious, but sometimes, you know, I’ll get calls where someone’s having some sort of new pelvic pain that seems like it’s in the bladder area, and it hurts when they urinate. But from what they’re saying, it’s not 100% clear to me, like, the pain seems to travel. And you know, could it be appendicitis? Could it be some other type of, you know, a ruptured ovarian cyst? Like, there’s so many things. So that’s why I’m totally fine giving antibiotics if it’s really, really obvious, but if there’s something that just seems a little concerning about what they’re saying, I’ll also want them to come in, just so I can make sure…besides just making sure I give them the right antibiotic, like, is it even something totally different?

Dr. Fox: Right. Okay, let’s talk about Pyridium for a second. So, what is Pyridium, and when do you recommend it?

Dr. Kostant: So Pyridium is a medication that is basically a bladder anesthetic. It’s a pill, and I think there are versions over the counter. I’ve prescribed it as well. And it’s meant to help with pain control during a bladder infection. It’s not meant to actually treat the bladder infection. It doesn’t have any role in that. It does turn the urine a funny color, I think more like orangey type color.

Dr. Fox: Yeah, I tell them it’s gonna look like Tang.

Dr. Kostant: Yeah, I tell them that too because I can be pretty dramatic.

Dr. Fox: Yeah. If you don’t warn people, they think they’re gonna die when they’re like, “Oh, my God, I have an infection, and now my pee is orange. What happened?”

Dr. Kostant: It’s like, first, it was bright red from blood. Now, it’s orange. So I’ll prescribe it to patients who, like, with treatment for a bladder infection or I’ll tell them to get it over the counter. But I think most people have felt that it’s helpful for the first day, especially as the antibiotics are just kicking in, because usually, within 24 hours of starting the antibiotic, if it’s an effective antibiotic, most people will start to really feel much better. But they’re still like that first, you know, 24 hours where it can be pretty uncomfortable.

Dr. Fox: Yeah. I mean, Pyridium works quick, and it essentially just, you know, numbs the inside of the bladder wall so you don’t have a lot of those symptoms. But like you said, it does not treat the infection, so we don’t typically say, “Take Pyridium and call me in the morning,” right? It’s usually, like, I’m gonna prescribe an antibiotic, and why don’t you pick up some Pyridium? So for the first day or two, you feel better while the antibiotic is kicking in, and it does not affect the efficacy of antibiotic. Antibiotic, you know, works whether you’re on Pyridium or not. So yeah, that’s a good thing, and yes, it is over-the-counter. I think it’s marketed as different things over the counter. Sometimes it’s called bladder something relief.

Dr. Kostant: Right, bladder relief.

Dr. Fox: Yeah, it’s usually, like, a brown tight pill that you swallow by mouth, and it turns your pee orange, which again I don’t know if they write that on the box, but I always warn people.

Dr. Kostant: But again, I also tell people like…

Dr. Fox: Don’t take the antibiotic, yeah.

Dr. Kostant: Their take-home message also is, like, if you’re having these symptoms, don’t just go get it and then go home and just take that and not do anything else. Still, again, go to the urgent care, call your doctor, at least look into this further.

Dr. Fox: Right. And then in terms of which antibiotic you choose, so let’s say this is before getting urine culture back. Again, the urine culture, we use it for two reasons. One is to sort of confirm the infection, and number two, it’ll say what bacteria it is and specifically what antibiotics this bug is and is not sensitive to versus resistance. So a typical result is it’s E. coli and it’s sensitive to everything. They list 10 antibiotics. But every now and again, they’ll say it’s sensitive to six of them and resistant to four of them. And so we just double-check on the right antibiotic. So if we have the culture, very easy for us to pick an antibiotic.

Let’s say you have pre-culture results, right? You send a culture and you know the results, or again, it’s over the phone and you’re not gonna have a culture. How do you choose which antibiotic to prescribe? Again, let’s take aside allergies in antibiotics. Assume no one is allergic to anything.

Dr. Kostant: Yes. So most simple bladder infections will usually respond to a sulfa antibiotic, like Bactrim, which is trimethoprim and sulfa together. And so that’s in nonpregnant patients who don’t have an allergy to sulfa, that’s obviously what I think about. That’s probably my starting antibiotic. It’s a three-day course, twice a day, so it’s easy to take. It doesn’t have a lot of extra, you know, side effects. And it’s most, most E. coli is sensitive to it. So that’s usually the first choice.

Dr. Fox: It does not tend to have a ton of side effects or other bacteria issues.

Dr. Kostant: Yeah, less than other antibiotics as far as, like, gut, you know. All antibiotics are gonna probably kill some, you know, gut bacteria. But I feel like I don’t have a lot of people having, like, nausea, you know, from taking Bactrim, at least in my experience.

Dr. Fox: Right.

Dr. Kostant: You know, if someone, let’s say, had a bad reaction to Bactrim or if they had an infection in the past that wasn’t sensitive, like, was actually resistant to Bactrim, you know, the other couple of options that I’ll try will be Macrodantin or Macrobid is another antibiotic that a lot many bacteria in bladder infections are sensitive to.

Dr. Fox: And that’s pretty much only used for bladder infections. I don’t think it’s used for anything else.

Dr. Kostant: Yeah, I’ve never seen it used for anything else.

Dr. Fox: Yeah, which is a good thing because it means it probably doesn’t do a lot else around your body. So that’s good.

Dr. Kostant: There’s another category of antibiotics called cephalosporins. Keflex or cephalexin is something that some people might be familiar with. That is not my first choice necessarily. There are more bacteria that may not be sensitive to it, but I’ll sometimes start with it if there’s multiple allergies. So that’s another option as well. Now, there are even stronger antibiotics that I don’t jump to right away, but in someone who their culture comes back with E. coli that’s resistant to Bactrim and, you know, Macrobid, Cipro or ciprofloxacin, what are called the quinolone antibiotics, usually many bacteria are sensitive to them. They’re very strong antibiotics, and they can have some pretty significant side effects. Definitely need to be used if someone has a bladder infection that is not sensitive to anything else. But I don’t just…that’s not the one, like, on the weekend, I’ll just say, “Okay, here take some, you know, Cipro.” I really want to have a culture that shows that I need to give that antibiotic before I just prescribe it.

Dr. Fox: Right. What about for a kidney infection? So the fancy word is pyelonephritis. What would you give for that?

Dr. Kostant: That’s kind of interesting. I’m assuming, again, we’re talking about someone who’s not pregnant because…

Dr. Fox: Not pregnant for now, yeah.

Dr. Kostant: Not pregnant, also, we’ll prescribe actually similar antibiotic choice but for a much longer period of time. So I’ve prescribed patients, I believe I’ve prescribed patients Bactrim before. I had someone recently who I treated, but it’ll be, like, a 10-day course of the antibiotic. And again, culture is really important. I would not give…Keflex would be, you know, again, you have a culture that shows it’s sensitive, that’s definitely…for pyelonephritis, I probably would not start with that. It’s just a little less likely to cover the bacteria. And that may be where also the quinolones, you know, might be a good choice. Because in someone who’s not pregnant, overall, not immunocompromised, relatively healthy, and is able to eat and drink, you know, they can take antibiotics and stay at home and not have to go into the hospital. But you do want to be a little more aggressive and treat them longer because if there’s no improvement, you definitely would want to bring them into the hospital. So you don’t want to set them down a road where they start something and it doesn’t work, and then they have to get admitted.

Dr. Fox: Yeah. I mean, a bladder infection pretty much never brings you into the hospital, and a kidney infection absolutely could. And so some people with kidney infections are very sick and do need to be hospitalized and given intravenous antibiotics and all those things. Nonpregnant often, like you said, not so bad, you can treat them as an outpatient, maybe a stronger antibiotic, maybe a longer course, this or that. This is another one where pregnancy is a big difference, right? If someone’s pregnant and has an infection in their kidney, I would say more times than not, they’re in the hospital because they tend to be much sicker and they tend to need, like, stronger antibiotics, intravenous. Like, they need a little bit more support. Again, there are pregnant women who have pyelonephritis and aren’t in the hospital, but much, much more likely to need to be in the hospital if you’re pregnant. It’s a much bigger deal.

Dr. Kostant: Yeah. I mean, I think if I ever see someone who’s pregnant and I think that’s what’s going on, I usually will just admit them, because I feel like just because of everything we talked about with the sluggishness of being able to clear any bacteria out of the kidney, I just want to get them on IV antibiotics right away. And usually, once there’s a significant improvement, like their kidney tenderness gets better, they’re not having fevers, like, you can actually have them leave the hospital. So it’s not like someone needs to stay there for 10 days, but pregnant patients can leave and then continue antibiotics just by mouth, and we’ll send them home with another week’s worth of antibiotics.

Dr. Fox: And plus, then, you’ll usually have a culture with the result of which bug and what it’s sensitive to. I would say, you know, the biggest difference between nonpregnant and pregnant women is number one, pregnant women, we will treat bacteria in the bladder if it’s over a certain amount even if they have no symptoms because they’re more likely to get a kidney infection. Number two, sometimes the antibiotics we choose are different if you’re pregnant and how far pregnant you are. Often not, they’re very, very similar, but sometimes there’s a difference. And then number three, kidney infections for pregnant women are much, much more serious on average than for nonpregnant. So those are, like, the big ones in when it’s different. How can someone potentially prevent a bladder infection? Like, what’s the business with, let’s say, drink a lot, have some cranberry juice, cranberry pills? What’s the deal with that? Does that work?

Dr. Kostant: So cranberry will not actually help. Like, when someone already has a bladder infection, it won’t treat the bladder infection. But it can have some effect on preventing infections, whether it’s drinking cranberry juice or actually taking, you know, cranberry extract in pills. So that is something that someone can do if they’ve tended to be more prone to bladder infections. And again, otherwise, you know, there’s no reason that’s been found. Because just to take a step back, if someone really keeps having recurrent bladder infections, I’ll sometimes refer them to a urologist to make sure there’s no structural abnormality with their urethra or bladders.

Let’s say that’s not the case. Someone just is more prone to get bladder infections, bad luck. Taking a cranberry supplementation, you know, is a safe way that it may, in some people, help prevent them from getting a bladder infection. Staying very well hydrated as well can help because it just helps flush any bacteria out before it really has a chance to latch onto the wall of the bladder. So that’s another preventative, another way to prevent bladder infections.

And some of the behavioral things I mentioned, again, we talked about earlier, just with hygiene and also just with, you know, if someone happens to notice that intercourse triggers a bladder infection, emptying their bladder after, also very relevant for healthcare workers who, you know, have long shifts and go to the bathroom once every 12 hours. Don’t do that. Try every few hours to, if you’re able to, empty your bladder. Everyone is different with how much they can hold, but sometimes we hold more than is good for us or we go longer than is good for us. And again, if you empty your bladder, you are flushing out any bacteria that happens to be, you know, hanging around there. And I’ve specifically had patients that are residents, nurses, PAs who will say they know when they have a crazy shift and they don’t pee all day, they’ll get home, and the next day, they’ll start feeling it. That’s how, if they don’t go, that’s how sensitive they are, so.

Dr. Fox: You know, there’s a “Seinfeld” episode about that.

Dr. Kostant: No, I didn’t know that.

Dr. Fox: Yeah, there was…I digress. I think we covered the medical part. There was an episode, one of the early seasons, where George and Jerry, they were in a parking lot, and they couldn’t find Kramer’s car, because, you know, like a parking garage, and they’re walking around and around and around, and they can’t find the car because they didn’t remember where they parked, because it’s before you could have a cellphone and take a picture of what floor you’re on. And then George ultimately had to pee, and he just went, like, in the parking garage against the wall, and he got…police got him, and they gave him a ticket for it, like, a whole fine. And basically, his excuse to them was that, “Well, I have a condition that if I hold it in too long, I get a problem.” And I think he said it was called like “hyperurotosis.” He made something up like that. And then I think Jerry got caught with the same thing, and he gave them the same excuse. Yeah, it was funny. So there you go. But it’s not false, not fake news, just probably not true for their situation.

Dr. Kostant: Yeah, exactly. Like, yeah, you know. You shouldn’t hold your urine too long. Still you should be, like, careful about where you urinate.

Dr. Fox: Just like Sara is in favor of the jury system, she is also in favor of not urinating publicly.

Dr. Kostant: Yeah, no judgment there, but just…

Dr. Fox: Excellent. Awesome. Thank you for coming to the podcast to talk about urine infections, bladder infections. If it hurts when you pee, give us a call.

Dr. Kostant: Absolutely.

Dr. Fox: Thank you for listening to the “Healthful Woman” podcast. To learn more about our podcast, please visit our website at www.healthfulwoman.com. That’s healthfulwoman.com. If you have any questions about this podcast or any other topic you would like us to address, please feel free to email us at hw@healthfulwoman.com. Have a great day.

The information discussed in “Healthful Woman” is intended for educational uses only and does not replace medical care from your physician. “Healthful Woman” is meant to expand your knowledge of women’s health and does not replace ongoing care from your regular physician or gynecologist. We encourage you to speak with your doctor about specific diagnoses and treatment options for an effective treatment plan.