Wednesday, March 25, 2009

Cranberry Juice: Does It Really Help Prevent Urinary Tract Infections (UTIs)?

This is a very common question I get from my female patients, both young and old. Many seem convinced that cranberry juice or pills can stop a urinary tract infection (UTI) in its tracks when they feel it coming on, or take cranberry to prevent them. Well…they may not be wrong.

After many years of grandma’s advice, in 1994 a study was done on elderly women who consumed 300 ml of cranberry juice for three months and showed less bacterial counts in the urine.This is where the whole cranberry-UTI link picked up some steam. But there is more...

I used to tell patients that cranberry juice or pills can improve the acidity of the urine, and acid is a natural defense against bacteria. Common sense would dictate that more acid is better, and cranberries are a good source. Correct? Cranberry juice however may contain a lot of sugar, and it may require drinking A LOT of it to get the effect. This isn't necessarily good for diabetics or those watching their weight. Cranberry pills may be helpful, but how many should you take to get the desired effect?

Not too long ago, a well designed study showed a trend, but no significant improvement in preventing UTIs with cranberry, and cranberry products, however, have not been shown to significantly reduce acidity. So now what?

Cranberry is seen as a natural element people can take, in order to prevent overconsuming antibiotics. Antibiotics help, but they must be tailored to the infection, and be given at the right dose, for enough period of time to prevent recurrence, persistence or development of resistance by the bacteria. However, there are women who are most susceptible to bacterial adherence, and certain bacteria are more likely to stick to the body surfaces than others.
So, what’s so special about cranberries?

In raw cranberries there are at least six chemical compounds that can interfere with bacterial adherence to the body. These compounds modify the surface properties of the bacteria to make them less sticky to the lining of the bladder. When someone consumes cranberries, the bacteria itself are actually altered by the cranberry products that dwell in the urine, changing how the bacteria express certain proteins on their surfaces leading it to cling less effectively to the bladder. This is how cranberries reduce infection. If the bacteria are less sticky, then the bladder is more capable of washing out the bugs with good urine flow. Drinking more fluids helps to create a better flow.

Interestingly, once the bacteria are removed from exposure to cranberries, they regain their “old ways” and their adhesive properties return. A recent study showed that just 6 hours of exposure to cranberry products resulted in an 84% decrease in bacterial attachment to bladder cells. Continuous exposure resulted in the continued inability of the bacteria to attach!

Now everybody go out and get some Ocean Spray!!!

Sunday, March 22, 2009

Kegel Muscle Exercises aka Pelvic Floor Muscle Training

“If you don’t you use it, you lose it” principle also applies to the muscles in the pelvis. Age, menopause and childbirth can cause weakness and looseness to the pelvic floor muscles known as the levator ani. They wrap around the anus, urethra and vagina in the female pelvis and support the organs in the pelvis: the bladder, vagina/uterus and rectum. When pelvic muscles and their connective tissue covering (fascia) weaken or tear, women may experience urine leak when coughing, sneezing, laughing or exercising (stress incontinence), or have the sense that the bladder or other pelvic organs are dropping or pushing into the vagina. Overactive bladder symptoms can also occur with a dropped bladder, such as urgency , frequency and urine leak (the “I gotta go and I can’t hold it any longer” feeling). Importantly, weak pelvic floor muscles can give a woman the feeling of vaginal looseness, and decreased sensation and/or satisfaction during sex.

Strengthening the pelvic floor muscles (PFM) by performing Kegel exercises helps to improve the tone, essentially, of these muscles. Imagine trying to stop the flow of urine during urination, or holding in poop, well, these are the sphincter muscles that can be strengthened by Kegel exercises. The main challenge is figuring out for yourself how to isolate and squeeze these muscles. But once you have, it’s easy.

Repetitive exercises can reduce stress incontinence, help with mild bladder drop, and improve tightness and sensation during sex and orgasm.

One should always begin by emptying the bladder, then relax. Tighten the PFMs and hold it for a count of 10 seconds. You should feel a sensation of lifting around the vagina or pulling around the rectum. Another way to do PFMs is to tighten and hold the PFMs tight for 10 seconds straight and then relax. Do this 10 times and repeat 3 times a day.

Try to do 10 sets of PFMs in the morning, 10 in the afternoon, and 15 at night. Or you can do it for 10 minutes 3 times a day. In the beginning, you may not be able to hold the contraction for the complete 10 count or do 10 full repetitions. However, you will slowly build to this over time. The muscles may start to tire after 6 or 8 contractions or sets. Take a break then and do some later on.

These exercises can be practiced anywhere and anytime. Most women seem to prefer doing them in bed while lying down or while sitting. Women can also try to do them during sex. Tighten the muscles to grip your partner’s penis or finger and then relax. Your partner should be able to feel the increase in pressure.

Never use your stomach muscles, legs or buttock muscles. Rest your hand on your abdomen during PFMs to see if you tense up here. Eventually, they will become effortless and part of your lifestyle. You may do them while walking, before you sneeze, or on the way to the bathroom.
After 4-6 weeks of consistent daily exercise, most women will see results. Women will notice less accidents, and feel more confident. Sex may feel better as well. After 3 months the results will be even more noticeable.

Kegel muscle exercises are not harmful and most women find them easy and relaxing. If your stomach or back muscles feel tense, then you’re probably not doing PFMs the right way. Breathing during any exercise is important, including these. Headache or neck ache can be from holding one’s breath. Breathe easy like in Lamaze or yoga.

Tuesday, March 10, 2009

Urinary Tract Infections- More

I had my article on UTIs in women posted to the Sun Times Online:

Monday, March 9, 2009

Free Upcoming Events on Female Pelvic Health

The following is short list of free educational events given by me this month and next in the East Valley.

March 25, 2009, 2:30pm: Pelvic Floor Prolapse: United Methodist Church, Chandler, AZ

April 8, 2009, 1:30pm: Female Urinary Incontinence: Ahwatukee Women's Club, Ahwatukee, AZ

April 29, 2009, 6:00pm: Female Urinary Incontinence: Chandler Regional Hospital, Morrison Building, Chandler, AZ

More pelvic health topics

Please see my blog page at's website

“Why do I keep getting recurrent urinary tract infections, and how can I prevent them?”

This is a reprint of an article of mine on urinary tract infections (UTIs) that ran in a local paper several years ago. It's worth posting it again here:

Recurrent urinary tract infections (UTIs) are defined as two or more UTIs within a twelve month period. They are bacterial infections that typical involve the bladder. Classic symptoms include lower abdominal pain or ‘pressure’, urinary burning, urgency, and frequency. If the kidney is also involved, back pain and fever may be present as well. The majority of UTIs in women are uncomplicated and involve only the bladder. Complicated UTIs are those involve the kidney or occur in pregnancy, diabetics, transplant patients, frail elderly, in weakened immune systems, or with urinary tract structural or anatomic abnormalities.

Common risk factors include: sexual intercourse, diaphragm/spermicidal jelly containing nonoxynol-9, fecal soilage of the vagina/groin, constipation, tampon use, menopause, urinary catheter use, diabetes, urinary stones, incomplete bladder emptying, anatomic abnormalities such as obstruction or reflux, neurological diseases such as multiple sclerosis or spinal cord injury, incomplete antibiotic usage, bacterial resistance.

Other urogenital problems that may mimic symptoms of UTIs include: urinary stones, vaginal infections, urethral infections from sexually transmitted diseases (STDs), interstitial cystitis.

Medical workup may include: determining a pattern of infection (intercourse, menses), prior antibiotic usage/compliance, prior catheter use, gynecological history, physical exam, urine culture, x-rays or endoscopy of the bladder (cystoscopy) if warranted.

Potential treatment options include: Longer or different course of antibiotics, proper daily hygiene, post-intercourse voiding/showering or antibiotic use, alternative contraceptive use, panty liner instead of tampons, bladder retraining for inappropriate habits, low dose antibiotic suppression, self-start therapy, and correction of anatomic problems.

Follow-up may include: monitoring for symptom resolution, re-culturing urine if symptoms recur, identify other potential risk factors, perform x-rays or cystoscopy, re-evaluation every six months.

Friday, March 6, 2009

Slings: what are the risks, benefits and recovery?

Mid-urethral slings have become the most common method to treat stress urinary incontinence (SUI). They are typically placed in under 30 minutes in an outpatient setting and are popular with both physician and patients due to the high cure rate, relative ease of placement, low complication rate and quick recovery.

The prototype of modern day slings is the TVT (tension-free vaginal tape), and many similar ones exist on the market that are placed in a similar fashion, but ultimately perform the same function. TVT has been around for approximately 15 years and is used worldwide.
The sling is made of a thin strip of polypropylene mesh weave, a common and safe type of mesh used for surgery in a variety of body locations. The width is 1 cm and the length left in the body is usually between 6-8 inches long. There are various methods for placing slings, but ultimately, it must rest under the mid-urethra.

It is placed through a small incision in the vagina, usually under general anesthesia, and women can go home the same day without a urinary catheter after urinating in recovery. Vaginal stitches to close the skin dissolve, but the sling is permanent. It becomes incorporated into the body tissue. The body lays new collagen and scar within the sling and around it, and it becomes a new firm ligament under the urethra replacing the one that had become weak. The sling acts like a backboard and supports the urethra during straining maneuvers such as coughing, sneezing, laughing, jumping and exercise. It prevents it from descending, thereby preventing urine loss.

Slings are durable to about 10-15 years but longer term data does not exist simply because it hasn’t been around that long. It is less invasive than the next most popular procedure for SUI, the Burch colposuspension, which requires a bikini line abdominal incision and then the bladder neck is raised up and stitched close to the back part of the pubic bone. Despite equivalent cure rates, surgery time and recovery time is longer. It has generally fallen out of favor as a modern approach to curing SUI. If a woman is undergoing other pelvic surgery such as a hysterectomy or bladder lift (cystocele), a sling can be done concomitantly and adds only a few extra minutes to these procedures.

For those women who desire cosmetic vaginal surgery, sling surgery can be done as well at the same time.

The expected cure rate for slings is approximately 89-91% where the female patient is dry. There is about a 2% failure rate, and the rest can be considered improved. Improvement from soaking 6 pads a day to 2 thin liners is a success for severe cases of incontinence.
Durability is important and most (85%) will still be dry in the long term. There is an expected drop off (recurrence) rate which is inevitable given changes that occur to the body with age, menopause, weight loss or gain, etc. Women who are still considering another pregnancy should not undergo a sling till childbearing is complete.

Preoperative evaluation with a history, physical exam, urinalysis, and urodynamics help to make the appropriate decision as to whether: 1. A sling is appropriate and, 2. which type of sling to use. Other factors taken into consideration when deciding if/when/and how to place the sling include age, prior surgeries, body habitus, overall health, and other considerations. Bladder function, capacity, and sphincter function as determined by urodynamics helps to tailor the sling to the individual patient.

Common risks include: infection (low), bleeding (low), injury to bladder (low), mesh exposure in the vagina (low), and post operative urinary dysfunction. Vaginal spotting is expected for 1-2 weeks after the surgery.

Recovery is usually straightforward. Typically, being a “couch potato” for 72 hrs is recommended. Women can return to work thereafter (if non-physical). Exercise and exertion should be delayed about 2-3 weeks, but no pools, baths or sex for six weeks.
Slings will usually work right away even though most scarring isn’t complete for several months. In the first several weeks, occasionally the stream may seem a little slower than usual, or may split or deflect. These usually self correct after a few weeks.

There are women who experience leakage of urine with penetration during sex, and others who experience leakage of urine with orgasm. Several studies have shown that penetration-related leakage is treatable with TVT type slings. Orgasm-related leakage can be treated with overactive bladder medication, but one study did show TVT to help this as well. Urodynamic evaluation is important to verify the correct type of sex-related incontinence prior to treatment.

Despite the fact that TVT and other slings are placed in the vagina under the urethra, it has an overall beneficial effect on female sexual dysfunction when it is related to incontinence. Women may be embarrassed to have sex if they fear a urine leak or odor, and will avoid it or have decreased pleasure. Surgical correction of SUI with TVT has been shown to improve sexual function domains such as desire, arousal, lubrication, orgasm, satisfaction, and pain. As a result of the surgery, women report reacquiring self confidence and greater sexual interest after resolution of sex-related incontinence. The consensus in the literature concludes that there is a positive, not negative, impact on female sexual health.
Most women are motivated to cure SUI and will often first perform Kegel muscle exercises and restrict fluids, or urinate frequently to keep the bladder empty and avoid a leak. These can be successful strategies but are tedious and frustrating to many. Once these conservative options have been exhausted, evaluation for a sling can be performed.