Hundreds of thousands of women with recurrent urinary tract infections (UTIs) are being misdiagnosed, according to some experts, who suggest that the majority of them don’t have a bladder problem at all, but rather, a vulvar problem, reports NPR.
Maria Uloko sees the same scenario in her urology practice in Los Angeles every day: a woman has been diagnosed with recurrent urinary tract infections (which means she’s had at least two in six months or three in a year), taken repeated rounds of antibiotics, and is confused because the infections keep coming back.
Then, Uloko tells these patients something that often feels both revelatory and frustrating. “Most of them don’t actually have UTIs, even though that’s been their diagnosis time and time again,” she says. “In fact, millions of women are being treated for UTIs they may not actually have.”
Uloko is the co-author of a recent study published in The Journal of Sexual Medicine that backs this up. She and her fellow researchers reviewed the medical records of 253 women with recurrent UTIs and found that just 15% showed evidence of problems that were limited to the bladder or urinary tract.
The remaining 85% had signs of hormonally driven inflammation of the vulvar region and 75% had pelvic floor dysfunction.
These conditions produce identical symptoms as UTIs – burning with urination, urgency, frequency, and/or lower abdominal pain – but require different treatment.
“What we found is that in women with recurrent UTIs, the majority didn’t have a bladder problem at all; they had a vulvar problem," says Uloko.
Uloko’s study provides insights that could help patients with urinary tract symptoms, says Melissa Kaufman, professor and chief of the division of reconstructive urology and pelvic health at Vanderbilt University Medical Centre, who was not involved in the research.
“These findings will accelerate our discipline’s investigations into a comprehensive unifying hypothesis to more precisely optimise care,” she said.
Why are these vulvar conditions getting missed?
One reason is the current diagnostic process for UTIs. When a patient presents with classic UTI symptoms, the first thing most clinicians order is a screening – or urinalysis – which detects the presence of inflammation, not bacteria. To determine whether there’s a bacterial infection, that urine must be cultured.
What’s more, that urine sample must be a “clean catch”, which requires thoroughly cleaning the urinary tract opening and surrounding areas and collecting only the midstream of urine, something not all patients are instructed on how to do, says Kaufman.
“But because patients are suffering in real time, clinicians often start them on a broad-spectrum antibiotic right away if that urinalysis comes back positive, and adjust the medication if needed once the culture comes back,” says Uloko.
There’s also a lack of training among medical professionals, with Uloko adding that doctors are taught that when a patient presents with classic UTI symptoms, it should be considered a UTI until proven otherwise.
“We do the urinalysis, send the culture, start the antibiotic, and for the patients who get better, it’s amazing,” she says.
For the patients who don’t get better, the cycle continues, “because the doctor, who hasn’t been taught how the vulva relates to urinary, colon, and sexual health, doesn’t know what else to do”.
Overlooked causes of UTI-like symptoms
The truth is that lower urinary tract symptoms that may look and feel like a UTI can be caused by things other than bacteria, says Lindsey Burnett, a urogynaecologist, assistant professor at the University of California-San Diego, and co-author with Uloko on the study.
For example, a loss of hormones to the vulvar tissue can cause inflammation, a condition called hormonally mediated vestibulodynia. This can happen due to natural physiological changes to hormones during breastfeeding and menopause. It can also happen if you’re taking medications affecting hormones.
For example, oral birth control is one of the most commonly prescribed anti-androgen medications that can disrupt the hormonal balance in the vulvar tissue and cause inflammation that prompts UTI-like symptoms.
Other commonly prescribed medications that can cause vulvar inflammation include medications for acne (like isotretinoin, sold as Accutane) and hair loss (such as minoxidil, sold as Rogaine); oncologic treatments for breast, ovarian, and/or uterine cancer (like aromatase inhibitors and selective oestrogen receptor modulators); and hormone therapies for endometriosis or fibroids.
The genitourinary syndrome of menopause, or GSM, a collection of symptoms caused by the decline in oestrogen and other sex hormones during menopause, can also affect the tissues of the vagina, vulva, bladder, and urethra and cause UTI-like symptoms.
Chronic inflammation due to GSM can also prompt the pelvic floor muscles to go into a state of reactive guarding, says Uloko, which can make them hypertonic (too tight) and can further disrupt bladder function.
Things get even more complex when you consider that these hormonal changes can also alter the balance of good and bad bacteria in the urinary tract and vagina. When levels of hormones like oestrogen and testosterone are disrupted, the good bacteria decline, which puts patients at risk for developing bacterial UTIs, says Uloko.
“So now you have a patient who is testing positive on urinalysis, sometimes growing actual bacteria on culture, receiving antibiotics, getting temporary relief mostly because of the anti-inflammatory properties in antibiotics, and then cycling right back into symptoms because the underlying hormonal and vulvar dysfunction was never addressed.”
What patients should ask their doctors
Women with recurrent UTIs that may be caused by a vulvar yet to be diagnosed should ask their clinician some key questions, including whether their urine culture positive for bacteria – bearing in mind that the first test typically given to patients who present with UTI-like symptoms is a urinalysis, which tests for inflammation, not a bacterial infection.
They should also check whether symptoms nay be due to hormone changes, due to medications they’re on, or the menopause transition.
“Getting an appropriate diagnosis requires that someone have the wherewithal and the care to screen and diagnose appropriately in women,” says Kaufman.
This can be surprisingly difficult to find.
Vulvovaginal health and pelvic health are just as important as bladder function and should be evaluated, notes Burnett. “I have so many patients who have spasms of their pelvic floor muscles, and that’s probably what's causing their urinary symptoms.”
Unfortunately, many clinicians aren’t comfortable doing even a basic physical exam of a woman’s pelvis, says Kaufman. “It’s a simple exam to look for diagnostic changes around the vulva and openings to the vagina and urethra – one that doesn't even have to involve a speculum or a pap smear. And it’s too often a barrier to treatment for many of these conditions with symptoms that mimic a UTI.”
If patients don’t think their primary care doctor is doing an adequate physical exam or answering their questions, they should make an appointment with a specialist, starting with a urologist, who has specialised training in treating UTIs and understands that the bladder is part of an interconnected genitourinary system.
Other good options include a urogynaecologist or gynaecologist.
Candidates for vaginal oestrogen or DHEA
The American Urological Association has published guidelines for multiple conditions that can all present with UTI-like symptoms – overactive bladder, recurrent UTIs, and GSM – and they clearly state that low-dose vaginal oestrogen or DHEA is an effective treatment.
“A number of randomised control trials and systematic reviews demonstrate that low-dose vaginal oestrogen reduces the risk for recurrent urinary tract infections in perimenopausal and post-menopausal women," says Kaufman, one of the authors of the guidelines.
“As urologists, we do a pretty good job of the urinary part of the evaluation – the bladder, ureters, and kidneys,” says Uloko.
“Where we fall short is the genital part, and that requires a much broader understanding of the pelvic ecosystem as a whole – the hormonal environment, vulvar tissue, and pelvic floor musculature, all influencing each other and all capable of producing symptoms that look exactly like a UTI.”
NPR article – Why too many women are prescribed antibiotics for UTIs they don't have (Open access)
See more from MedicalBrief archives:
Most women receive inappropriate treatment for uncomplicated UTIs
FDA approves new oral drug for UTIs, despite concerns
Antibiotics may increase, not reduce, risk of further UTIs – Harvard/MIT/Washington study
Crackdown in antibiotic prescribing blamed for increase in UTIs in the UK