Lower urinary tract infections (UTIs) or bladder infections (cystitis) are infections caused by a bacterium, virus, or fungus; the latter two are rare except in hospitalized patients who have catheters in their bladders. Almost 50% of women have a urinary tract infection in their lifetimes. Recurrent UTIs (rUTIs) are more common after menopause. Upper urinary tract infections involve the kidneys and ureters and can lead to dangerous sepsis or infections of the blood stream. The only safe way to treat a lower UTI is with a prescription oral antibiotic. Most infections are cleared with antibiotics in 3-7 days. 

UTIs are very painful and people who have them report frequency of urination, urgency, dribbling, burning or stinging with urination, cloudy or blood-tinged urine, and incomplete emptying. The good news is that they can often be prevented and treated quickly. 

“ So, Dr. Kim, why do women in menopause get them more frequently than others?”

For one, the lower estrogen levels in the menopause affect the lining of both the urethra, bladder, and vagina. These changes can affect the microbiome, likely by altering the pH. While most commonly thought to be a sterile environment, the urobiome, is just recently becoming a topic for research. 

Urine is normally sterile (no bacteria or other pathogens) unless someone has been catheterized or has a catheter in their bladder, in which case, bacteria from the skin around the urethra get pushed into the bladder. For young women, this is commonly caused from sexual intercourse or wiping back to front rather than front to back. However, in postmenopausal women, sexual intercourse is a less likely scenario. 

New studies are emerging that the bladder has its own urobiome and has different compositions in both healthy and unhealthy bladders, and could play a role in bladder disease, including rUTI.

Reasons why menopause can cause recurrent UTIs

1. Estrogen levels are low
2. Altered microbiome
3. Impaired immune response
4. Resistant bacteria due to the over prescribing of antibiotics
5. Change in the anatomy due to vaginal atrophy from low estrogen levels
6. Other diseases like diabetes
7. Urinary incontinence
8. Dropped bladder
9. Immobility
10. Prior surgery on the region
11. Accidental bowel leakage
12. Unable to completely empty the bladder
13. History of UTIs before menopause

Smokers have decreased vaginal lactobacilli which raises the pH, vaginal moisturizers, personal lubricants, douches, and spermicides also suppress the growth of Lactobacillus.

Why UTI symptoms persist after antibiotics

The pain or residual discomfort in the bladder can linger long after the bacteria is cleared by the antibiotics. The reason for this is because the damaged lining of the bladder must regenerate because of all the inflammation. Inflammation is the immune response that releases white blood cells that try to clear the bacteria. When the infection is severe, biofilms can form that prevent the immune response from working right and the antibiotics may not penetrate the biofilms very well. Biofilms are a conglomeration of bacteria, cells, and sugars that create a ‘surface slime’. They are responsible for treatment failures, especially in the immunocompromised and are a continual source of resistant bacteria. 

Because the bladder gets no rest since you must continue to urinate, the bladder wall muscle contracts and triggers the nerves to fire—and that is painful. Of course, the residual pain could be an incomplete treatment (lack of cure) or a recurrent infection, possibly due to antibiotic resistance.

Like any infection or trauma, the tissue takes time to heal and the nerves take time to settle down. Until then, you may continue to experience discomfort. The key is to keep well hydrated. Don’t avoid fluids for fear of pain when urinating because that keeps the bacteria concentration high and they will continue to multiply until killed or washed out of the body with urination.

Conclusion:  What can menopausal women do to help prevent UTIs?

Since women with recurrent UTIs often show alterations in their vaginal or urethral flora or microbiome, probiotics, especially Lactobacillus, have been extensively used as alternative approaches to reduce recurrent UTIs. One of the major roles of Lactobacilli is their ability to reduce bacterial reservoirs, thus preventing recurrences. D-Mannose, an over-the-counter sugar helps by decreasing bacterial adherence to the bladder mucosa, which is a factor in poor treatment outcomes. The key is to keep well-hydrated and empty your bladder frequently. Hydration acts to dilute the bacteria and the process of urination pushes the bacteria out.  Of course, a daily intake of quality cranberry extract has been shown to help reduce the risk of UTIs in women. 

Read part two of Dr. Kim series on Menopause : 
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