Addressing Common Urinary Health Questions

In this podcast, I answer frequently asked questions about urinary health, touching on the efficacy of D mannose for preventing urinary tract infections, the impact of vitamin D deficiency and supplementation on bladder health, the role of vaginal estrogen in treating urinary symptoms, and when to treat asymptomatic urinary tract infections. 

I'll also cover how to differentiate between urine leaks and sweat during exercise, the relationship between bladder issues and pelvic floor health, the benefits of pelvic floor physical therapy postpartum, and managing bladder symptoms in the third trimester of pregnancy. I address misconceptions about the pelvic floor's role in urinary health and offer practical advice for women experiencing these common issues.

00:00 Welcome to the Q&A Session!

00:55 Exploring D Mannose and UTI Prevention

04:03 Vitamin D Deficiency: Impacts and Solutions

05:59 The Role of Vaginal Estrogen in Urinary Health

06:45 Addressing Asymptomatic UTIs: To Treat or Not to Treat?

08:27 Distinguishing Between Urine Leaks and Sweat

09:44 Bladder Issues vs. Pelvic Floor Problems

11:52 Postpartum Physical Therapy: Is It Ever Too Late?

14:22 Managing Bladder Symptoms During Late Pregnancy

15:18 Closing Remarks and Invitation for More Questions

Transcript

Hi there. I'm going to do something a little bit different today. I've been getting a lot of questions online and so I am just going to put those all together in this podcast and answer some of the questions that  I have frequently been getting asked. Because You know, I always figure if one person is asking the question, it's just the tip of the iceberg.

And there are a lot of people out there that have these  same questions. So the first question is about D mannose. So D mannose is a natural sugar that is used to prevent urinary tract infections. So this is really important. It is used to prevent urinary tract infections. It is not used as a treatment for urinary tract infections.

So if you have symptoms of a urinary tract infection, that's something that you should talk to your provider about, and that should be treated with an antibiotic.   But D mannose is something that we have traditionally used to prevent urinary tract infections. And for women who get recurrent urinary tract infections, it's, you know, a pretty devastating problem that impacts your quality of life and keeps happening time and time again. 

So the question about D mannose was how well does D mannose actually work? And the truth is that we don't actually know. So there was just a Cochrane review that came out and a Cochrane review is when they go into the literature and they look at all of the different studies and they pull all of the studies and there have been a lot of studies on D mannose, but,   they, in this review, they felt that the quality of the studies were actually, was actually very poor.

 And so it was really hard to come up with a conclusive   Recommendation. And, you know, a Cochrane review is one of the most rigorous  reviews that we have.  Right now, I would tell you there is no data.  There was one study, and they talked about this in the review, where they looked at D mannose versus nitroferantoin, which is an antibiotic.

And in that study, they did find that D mannose worked better than the antibiotic in terms of prevention. But they felt that that study had a lot of limitations. So,  the, clinically we still use D mannose to help prevent infections.  There aren't a lot of risks with it. It's very well tolerated. And, it anecdotally does seem like there, there is some benefit.

There are multiple studies. There are about six ongoing studies right now.  And so we should hopefully have  more data soon. If these more rigorous studies show that it doesn't work, then I would stop using it. And one of the things that we're really trying to do with recurrent urinary tract infections is to prevent giving prophylactic antibiotics.

So prophylactic antibiotic is a small amount of antibiotic that you take every day to prevent something.  And the risks of that in terms of developing bacteria that are very resistant to things  to, of getting side effects, the risk of that is much higher. So that's what we're really looking to avoid.

So with D Mannose, I would tell you we still clinically use it. There isn't a lot of data to support it.  There aren't a lot of risks with it.  And there will be more data that's coming out soon. And we'll see what the bottom line is at that point in time.  So the next question that I got asked was, 

And I think one of the important things to look at is  vitamin D deficiency. So vitamin D deficiency is really common. I live in the Pacific Northwest and we joke that we think everybody has it.  You get your vitamin D by sun exposure. You get it in food supplements and vitamin D promotes calcium absorption in the gut.

So It's needed for bone growth  and for your bone to be able to remodel. It's also needed for muscle function.  It can decrease inflammation and it modulates a lot of  pathways that control cell growth in your neuromuscular systems and your immune systems as well. It also impacts glucose metabolism.  So, there have been a couple of studies that have shown that there is an increase of overactive bladder and urgency urinary incontinence with vitamin D deficiency, and that if you take supplementation,  right, so if you take vitamin D, that it reduces that risk.

This review that  showed this was in nutrition reviews in 2024 by saying, and then there was also in 2023 randomized controlled trial where they gave postmenopausal eight weeks of   Vitamin D supplementation in women who were low, right? Whose vitamin D levels were less than 30 nanograms per milliliter.

And they found that  by replacing them, the severity of the urinary incontinence got much, much better and that they got up at night less. Right, so there was less disruption in their days, so it improved their symptoms. So I think looking at your vitamin D levels and then supplementing can help your bladder, bladder.

But it's also something that's good for your overall health as well. And so that is an important thing to check.  And then the other natural supplement would be vaginal estrogen. So vaginal estrogen can help with with recurrent urinary tract infections. It can help with urgency urinary incontinence and overactive bladder symptoms  as well as  vaginal symptoms like vaginal dryness.

And that is something that we give frequently to help prevent these symptoms and to treat overactive bladder symptoms. So, you know, if you're someone who has developed a lot of urgency, You've recently gone through menopause, or you're in a perimenopausal period, so that timing of decreased estrogen seems right.

I think trying vaginal estrogen  makes a lot of sense.  So I, I seem to be getting a lot of questions about urinary tract infections, and one of the questions was, if you have an asymptomatic urinary tract infection, do you have to treat it? So that means you don't have any symptoms, but for whatever reason, someone looked in your urine and said, yeah, there's some bacteria in here. 

 And you know, this probably happens to about 45 percent of women. It happens to more than 50 percent of women who are in long term care facilities. You know, if you're someone who has. a device, a stent in your ureter because you just had a procedure, a Foley catheter  almost all of these people are colonized with bacteria.

And the recommendations are that you don't treat. There's a low probability that it's getting worse. We used to think that the bladder was a sterile environment, and it is not. There are bacteria in  blood. The bladder. And so if you're not having symptoms, then we just kind of leave that alone. There are some exceptions.

So during pregnancy, we will frequently treat because the  risk of you're getting more sick or developing a kidney infection is greater.  Renal transplant patients, so people who have had a kidney transplant,  or someone who's having a urological procedure. In the near future. Those are all patients that that should be treated.

So in general we don't treat a urinary tract   we don't treat bacteria in the urine if you're not having symptoms, unless, you know, there are some special considerations.    So one of the next questions that I got asked is, how can you tell  when you're exercising, if you're leaking urine or if it's just sweat?

 And this may seem like a really simple question, but sometimes it is really, really hard to tell, especially if your body's changing over time, maybe you sweat more than you used to.   Things can feel different to you. And the way that we usually test that in the office is I will give patients peridium.

So peridium is basically advil for your bladder. It's something that we give patients to control symptoms if they have  an uncomfortable urinary tract infection. But it also turns the urine orange. Right. And so I will give that to patients. I will say, go exercise. And if the discharge is orange, then it's urine.

And if it's not orange, then it's sweat. And that's, you know, how we figure that out. The one thing that I always try to remember to warn people is that peridium is super, super staining, right? And so you want to wear a white pads. You're not staining your underwear. And so that it's easy to see.  If you wear black underwear, it's hard to see.

 And  you just, you know, the stains are hard to get out, so that's an important thing to, to think about. 

The next question that I got asked is, is a bladder issue always a pelvic floor issue? And I would tell you, you know, your pelvic floor, so those muscles are right there by your bladder. They support the bladder.  I think of them as a very close neighbor. And pelvic floor issues and bladder issues do often go hand in hand.

But there are definitely situations where you could have a bladder issue that has nothing to do with your pelvic floor. Pelvic floor, right? And so, you know, an example of that  is sometimes patients can get.  A bladder stone, right? So a kidney stone is really painful because it's blocking the flow of urine.

If you have a stone in your bladder, it's not usually painful because it's not blocking anything because you're, you know, your bladder is bigger,  but that stone can cause a lot of irritation. So you could get urgency, you could get frequency, maybe you're getting urinary tract infections and you know, that's an example of something that is in your bladder and has absolutely nothing to do with your bladder.

Pelvic floor. So when I'm evaluating patients who have bladder issues, I'm always thinking about the pelvic floor. Is this involved? Do we need to treat this as well? Right? How, how could this be impacting you? And it frequently is a component, but definitely not always, right? And I think, you know, the opposite happens as well.

Sometimes a pelvic floor issue gives you bladder symptoms. Right, so a tight public floor can cause urgency, frequency, leaking,  pain.  Right.  And you may think that those issues all start in your bladder, but they're really starting with the pelvic floor. Right. And so in that situation, we treat the pelvic floor.

So, you know, it's a little nuanced. It's important to, you know, think about all of these different things.  Pelvic floor issues can absolutely impact the bladder.  But you know, not always, sometimes the pelvic floor is innocent and all of this.   I had a woman who was four months postpartum, right? So she had delivered her baby four months ago, and she was fine after her delivery.

But at about four months after her delivery, she started leaking. And she was wondering if it was too late for physical therapy.  So that was her question. You know, if I have a four month old, I haven't been to physical therapy yet. Is it too late? Too late.  So this is a little bit of an unusual scenario.

Usually, if you're going to leak, you leak  right after delivery, and then it, you know, hopefully gets better. Maybe not 100 percent better. It, it's a little unusual to not leak at all for four months, but there are reasons why. You may not notice it, right? I mean, maybe at four months she started running and that's when she noticed it and she hadn't been active before then.

 Maybe she'd had a lot of bleeding. You know, they're having a new baby is very distracting. She may just not have realized it, which. I know it sounds funny, but it's definitely true in that early postpartum period.   So sometimes, you know, this can happen, but I think the important thing to know is that, no, it's not too late for public floor physical therapy.

It's a great time for public floor physical therapy. So right after you deliver, your muscles frequently don't work very well for a while. So there's kind of a temporary.  nerve injury, I would say, and, and they really don't respond particularly well. There are a lot of reasons why that happens. And so sometimes doing physical therapy is really hard because your body just isn't responding for four to six months after delivery.

So going at four months is probably   You know, ideal for a lot of women,  the other thing I would tell you too, is that it is, it's never too late, right? If you have a 10 year old and you're leaking started after your delivery and you haven't been to pelvic floor physical therapy, it's still a reasonable idea and an excellent treatment.

So, you know, it is never too late to go to a pelvic floor physical therapy. Sometimes it's not the full answer, right? And maybe you need something else.  But it is almost always part of the solution, and so reasonable to start at any point in time.  And then, you know, the last question that I'm going to go over today is, you know, if you are in your third trimester of pregnancy, right, so you're getting towards the end of pregnancy, what can you do to address bladder symptoms?

Right. So urgency and frequency, feeling like your bladder just won't hold anything.  And I would tell you there's, there's really very little that you can do at that point in time. And the reason for that is, you know, your uterus and the baby is just taking up a ton of room. Your uterus basically sits on your bladder.

 And you're, you can't fill, there really is not enough room. It is.  Just the baby taking up much more space besides all of the additional fluid that's in your system.   And so unfortunately, that's something that you just kind of have to power through.  And wait for the pregnancy to be over. And then almost immediately after you deliver, right  once there is more room in your belly, your bladder will fill up again.

 And that urgency and frequency should go away.  There can be other things that happen at the time of delivery and some things that have to be assessed. You know, sometimes after a delivery, you can't empty for a while, you get super full. I mean, their bladder can get stretched out. I mean, there are all different kinds of things that can happen.

 But in general, I would say once the baby is gone, there's more room for your bladder. And so your bladder fills up and those symptoms go away. So it can be really uncomfortable, but unfortunately it's just the way it is. And I think for women who have.  bigger babies  they can have more bladder symptoms for women who have multiples, right?

So twins or triplets or more babies, there's just more stuff taking up room in your abdominal cavity and just less room for your bladder. So you're going to get temporary bladder symptoms that should resolve pretty quickly.  So I  love answering questions, if there are any questions that anyone has, you know, just send them to me and I am happy to address them to the best of my ability.

 And just know that if you have a question, I'm sure someone else has the same question  and so, you know, you're helping someone else out by asking your question. And sometimes, you know, really.  I mean, simple questions like, how do I know if it's urine or sweat? I mean, those are things that people wonder about all the time.

And, you know, that can be what I would call a diagnostic challenge, right? So it's a, it's a great question.  Don't be afraid to ask any little question because that's how we all learn.