Jennifer Nevels, NMD

Tolle Causam

The #1 cause of infection in women living in long-term care facilities is urinary tract infections (UTIs), and overall, UTI is the second most common infection in the female elderly population.¹ These statistics make it extremely important to be familiar with the varied symptomology that our elderly patients may present with, as well as the underlying contributing factors to UTI.

Symptoms of UTI

As physicians we can all identify the common symptoms of a typical urinary tract infection, eg, dysuria, polyuria, hematuria, pyrexia, low back pain, and suprapubic pain. It is important to understand that our geriatric patients are more likely to experience mental status changes as their expression of a UTI. Confusion, delirium, lethargy, and behavioral changes are examples of symptoms that can occur rapidly and with no clear causation to family members or caretakers. Clearly, there are other diagnoses that may also come to mind with such symptomology, which should be pursued after a negative work-up for UTI.

Predisposing Factors of UTIs

There are several factors that can cause our geriatric patients to be more vulnerable to UTIs. A weakened immune system, lack of activity, catheterization, obstacles to maintaining a healthy diet, dehydration, poor hygiene, and other concurrent medical conditions can all play a role.

Impaired bladder emptying, vaginal atrophy, and digestive disturbances can also be present in patients with recurring UTIs, and in this article I will delve into specifics on these. A thorough history and physical exam can help discern whether these are underlying factors involved in patients’ chronic or recurrent UTIs.

Impaired Bladder Emptying

Incomplete bladder emptying causes stasis of the urine, allowing bacteria to multiply. This often leads to an infection. Neurological conditions, such as cerebrovascular disease, Alzheimer’s disease, and Parkinson’s disease are associated with impaired bladder emptying.² Because patients with these conditions are especially vulnerable, they should be monitored more closely. Examples of medications that can cause urinary retention include anticholinergics, tricyclic antidepressants, antihistamines, and decongestants. A cystocele, rectocele, or uterine prolapse can also structurally alter the position of the bladder, compromising urinary flow.

Vaginal Atrophy

Postmenopausal women are more predisposed to UTIs due to a reduction in circulating estrogen. Estrogen deprivation leads not only to atrophic vaginal tissue, but urethral as well.³ A lack of estrogen causes a decrease in glycogen production within the vaginal tissue. The glycogen is utilized by vaginal lactobacilli to make lactic acid and hydrogen peroxide. These byproducts are responsible for promoting an acidic pH, which creates an inhospitable environment for the overgrowth of pathogenic, and even commensal, bacteria. Thus, without the presence of local estrogen, the urogenital tract becomes more vulnerable to infection. This can be further impacted by sexual activity. Vaginal and urethral atrophy is one of the more common causes of recurring UTIs seen in my practice. When vaginal estriol is administered to the patient for at-home use, the UTIs often cease.

Maldigestion

As naturopathic physicians we are always evaluating for digestive issues, whether they are our patient’s chief complaint or not. An assessment of digestive health is particularly crucial in a patient with recurring UTIs. Our geriatric patients may be even more vulnerable to digestive issues, given the prevalence of fecal incontinence, nosocomial infections, and poor diet and lifestyle. We know that a UTI most commonly arises from the migration through the urethra of gram-negative organisms in the perineal region from the bowel flora.⁴ This bacterial migration underscores the importance of treating any dysbiosis or the underlying cause of digestive disturbances in order to treat the patient comprehensively. Intestinal flora imbalances can predispose to the development of food intolerances, which can then lead to further issues including bladder irritation and inflammation.

Diagnosis of UTI

Accuracy of testing for a urinary tract infection is especially challenging in the geriatric population. Contamination due to improper urine collection can be a factor in these patients. In a review of roughly 4000 papers examining UTI diagnostic accuracy, diagnosis based on a typical patient history was found to be only 50% to 80% sensitive.⁵ In a study of nursing home residents, change in the character of the urine, dysuria, and changes in mental status were associated with the outcome of bacteriuria plus pyuria.⁶

Urine dipsticks are not conclusive on their own. An elevation in leukocyte esterase (indicating the presence of white blood cells) can occur without bacteriuria, and may coexist with the presence of a urinary catheter, bladder stone or tumor, or lower genital tract infection; hence, the presence of white blood cells alone may not be conclusive of a UTI.² The detection of nitrite on the urine dipstick significantly increases the probability of UTI; however, the sensitivity is still low.⁵ Urine culture is more diagnostic, but since there is a delay in obtaining results and potential treatment, it can be hard to wait on this.

To complicate testing further we have the diagnosis of asymptomatic bacteriuria (AB), which relates more to commensal colonization than infection.⁷ AB strains have been thought to actually protect the bladder, and treatment with antibiotics may increase the risk of subsequent symptomatic UTI episodes.⁸

In the end it is perhaps best to initially base the diagnosis on the patient intake and urine dipstick test results gathered at the time of the appointment, and to then determine if urine culture is necessary based on the severity of symptoms and/or health of the patient. If UTIs are recurrent in a patient, then conduct a physical exam to rule out pelvic prolapse and vaginal atrophy, and also consider ordering a stool analysis to evaluate for dysbiosis. In general, it is important, when treating any elderly patient with behavioral changes or uncharacteristic alterations in mood and mental status, to rule out a UTI with a urinalysis, at the very least.

Treatment, Management & Prevention

Treatment recommendations may vary and depend on the overall health of the patient. If a patient has been dealing with chronic and/or recurrent urinary tract infections, we must determine the underlying factors and treat accordingly. The uncertainty of a UTI diagnosis can make it more challenging for physicians to know when and how to best treat, especially with geriatric patients. Empirical evidence may be the best way to assess the presence of an infection. By using herbs, we don’t add to the over-treatment with antibiotics. This is not to say that antibiotics are not sometimes necessary.

Protocols can be designed for both acute infection and prevention. The approach would be similar, in terms of herbs and nutrients, but of course aggressive dosing would be reserved for an acute UTI. An important aspect of prevention is identifying and treating any underlying condition that is causing the infection. For example, if UTIs accompany sexual intercourse, then prescribing herbs the day of and perhaps several days following intercourse can be helpful. Vaginal estriol might be prescribed in these circumstances, as estrogen deprivation may be driving the infection. Estrogen therapy provides additional benefits for urethral function by increasing urethral pressure and ameliorating stress incontinence, which is very prevalent in postmenopausal women.⁹

Treatment Recommendations

Key Supplements:

Botanicals: Oregon grape root (Berberis aquifolium), uva ursi (Arctostaphylos), cranberry (Vaccinium macrocarpon), pipsissewa (Chimaphila umbellata)
D-mannose, for both treatment and prevention of recurrent UTIs
Probiotics: Lactobacillus salivarius and L acidophilus have specifically been shown in a recent study to significantly inhibit the adherence of 5 uropathogens (Escherichia coli 53503 and 10791, Enterococcus faecalis 04-1 and 08-1, and Staphylococcus epidermis 08-3).¹⁰ Other studies showed similar results using additional Lactobacillus probiotics: L gasseri, L rhamnosus, L plantarum, L paracasei, and L acidophilus.¹¹

Miscellaneous:

In cases of prolapse, pessaries and/or pelvic floor rehabilitation based on the overall health of the patient
In cases of vaginal and urethral atrophy, vaginal estriol 1 mg/g inserted vaginally every night for 2 weeks, followed by 2-3 times per week
Balanced diet low in refined sugars and processed foods; consider food sensitivity testing
Education on proper hydration; consider hydrating IVs if necessary

Summary

Urinary tract infections are common in our geriatric patient population, which underscores the importance of recognizing different presenting symptoms. The most important tool in assessment of a UTI is obtaining a thorough history. We may sometimes have to rely on information from caretakers or family members in cases where other diagnoses such as dementia can result in less-than-accurate information from the patient. In our patients with recurring UTIs, it is important to establish the underlying causes and to treat accordingly. In my practice I often see elderly patients that are under-cared for by the general medical field; hence, it is our job to investigate properly and to get them the help that they need and deserve.

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References:

Matthews SJ, Lancaster JW. Urinary tract infections in the elderly population. Am J Geriatr Pharmacother. 2011;9(5):286-309.
Beveridge LA, Davey PG, Phillips G, McMurdo ME. Optimal management of urinary tract infections in older people. Clin Interv Aging. 2011;6:173-180.
Elia G, Bergman A. Estrogen effects on the urethra: beneficial effects in women with genuine stress incontinence. Obstet Gynecol Surv. 1993;48(7):509-517.
Grabe M, Bjerklund-Johansen TE, Botto H, et al. Guidelines on Urological Infections. European Association of Urology. 2010. Available at: https://uroweb.org/wp-content/uploads/Urological-Infections-2010.pdf. Accessed May 15, 2017.
Schmeimann G, Kniehl E, Gebhardt K, et al. The diagnosis of urinary tract infection. Dtsch Arztebl Int. 2010;107(21):361-367.
Juthani-Mehta M, Quagliarello V, Perrelli E, et al. Clinical features to identify urinary tract infections in nursing home residents: a cohort study. J Am Geriatr Soc. 2009;57(6):963-970.
Cai T, Mazzoli S, Mondaini N, et al. The role of asymptomatic bacteriuria in young women with recurrent urinary traction infections: to treat or not to treat? Clin Infect Dis. 2012;55(6):771-777.
Lutay N, Ambite I, Grönberg Hernandez J, et al. Bacterial control of host gene expression through RNA polymerase II. J Clin Invest. 2013;123(6):2366-2379.
Bhatia NN, Bergman A, Karram MM. Effects of estrogen on urethral function in women with urinary incontinence. Am J Obstet Gynecol. 1989;160(1):176-181.
de Llano DG, Arroyo A, Cardenas N, et al. Strain-specific inhibition of the adherence of uropathogenic bacteria to bladder cells by probiotic Lactobacillus spp. Pathog Dis. 2017 Jun 1;75(4).
Shim YH, Lee SJ, Lee JW. Antimicrobial activity of lactobacillus strains against uropathogens. Pediatr Int. 2016;58(10):1009-1013.

Jennifer Nevels, NMD, graduated from Southwest College of Naturopathic Medicine (SCNM) in 2003 after receiving her Bachelors of Science in Psychology at the University of Arizona. Following completion of her degree, Dr Nevels did a year-long residency specializing in women’s health. She became a faculty member at SCNM and acted as Interim Chair of the Women’s Department, where she taught gynecology and was a supervising physician at the school’s medical clinic. Dr Nevels is a co-owner of East Valley Naturopathic Doctors in Mesa, AZ, where she currently treats patients.

Urinary Tract Infections (UTI) in Female Geriatric Patients