It is estimated that 4 million British women suffer an attack of cystitis each year.1 The incidence of urinary tract infections (UTIs) is highest in women; in younger adults there is a 50:1 female to male ratio, while in patients over the age of 70 years of age the ratio is around 2:1.2 Incidence in both sexes increases with age and can be asymptomatic – it is estimated that up to 30% of people living in nursing homes and other institutions have asymptomatic bacteriuria.2,3
A UTI, or urinary tract infection, is caused by microbes, the majority of cases being caused by Escherichia coli a bacteria that is a part of the normal gut microflora but is regarded as an ‘opportunistic pathogen’. This means that levels will normally be kept in check by friendly gut bacteria but factors such as stress or poor immunity may allow it to overgrow and cause symptoms.
This blog discusses symptoms, risk factors and natural approaches that can be used to address the underlying causes and reduce the incidence of recurrent infections.
Symptoms of Urinary Tract Infection
The NHS website4 lists symptoms of UTIs as including:
- needing to pee suddenly or more often than usual
- pain or a burning sensation when peeing
- smelly or cloudy pee
- blood in pee
- pain in your lower tummy
- feeling tired and unwell
- in older people, changes in behaviour such as severe confusion or agitation
Children with UTIs may also:
- appear generally unwell – babies may be irritable, not feed properly and have a high temperature (fever) of 37.5C or above
- wet the bed or wet themselves
- deliberately hold in their pee because it stings
A urinary tract infection can result in an infection of the bladder (cystitis), urethra (urethritis), epididymis (epididymitis), prostate (prostatitis) and kidney / renal pelvis (pyelonephritis). Diagnosis is made on the basis of the presence of bacteria in the urine together with clinical symptoms.
There can be serious complications of urinary tract infections, including dehydration, sepsis, kidney stones, kidney failure and death. Antibiotics are frequently prescribed and UTIs are the most common reason for antibiotic use in older adults.5
Risk Factors for UTIs
As urine passes down the urethra to the outside it flushes bacteria away with it – reducing the time that bacteria can colonise and multiply within the urinary tract. Reduced urinary flow due to factors such as enlarged prostate, kidney stones or anatomical abnormalities increases the risk of a UTI. Catheters, diaphragm, anticholinergic agents, inflammation and use of spermicides may also increase risk (spermicides alter the balance of microbes in the vagina because they kill friendly bacteria).
Anatomy may be the reason for increased risk in females – a shorter urethra with its exit being close to sources of potential pathogens, the anus and vagina. The risk increases post-menopause and low oestrogen levels have been identified as another risk factor.
During pregnancy bacteria overgrowth may occur as the acidity of urine decreases and the pressure from the uterus may prevent complete bladder emptying. Pregnancy predisposes women to more kidney infections than bladder infections.
In addition, there may be some element of genetic susceptibility because UTIs often run in families.
How do these infections develop?
Up to 90% of UTIs are caused by E coli6, a bacteria that is a part of the normal gut microflora. However, there are several categories of E. coli strains that cause pathogenicity leading to symptoms and infections both within or outside of the gut. For example, the uropathogenic strain of E. coli (UPEC) is able to survive the conditions of the urinary tract and is thus associated with UTIs.7 To cause infection, pathogenic E. coli attach to and, in some instances, invade the epithelial cells. Bacterial adhesion and/or invasion of host cells is enabled by proteins called adhesins, secreted by E.coli, which enable it to stick to the lining of the bladder, kidney or urethra using their fimbrae, hair like projections.8
After invasion of host cells the E coli proliferate and grow as dense clusters, secreting a polysaccharide rich matrix. These clusters, referred to as ‘intracellular bacterial communities’ (IBCs), have some protection from the innate immune system within the intracellular environment. Eventually invaded cells rupture, releasing the bacteria which can then infect surrounding cells.
Biofilms can develop – these are accumulations of microorganisms and their extracellular products which attach to a surface such as the lining of the urinary tract. The biofilm provides some protection to the bacteria from treatment by antibiotics and if the biofilm is not completely eliminated then infection will eventually return.
Other significant pathogens that can cause UTIs include Candida, Proteus mirabilis, Staphylococcus saprophyticus, Staphylococcus epidermidis and Klebsiella pneumonia.2,5
Preventing Urinary Tract Infections
This is an important consideration in particular for people who experience recurrent infections – defined as at least three episodes in one year or two episodes in six months.6 For these people, prevention is important to avoid endless rounds of antibiotics which also destroy beneficial flora allowing pathogenic bacteria to selectively overgrow – thus potentially exacerbating the problem. In addition there is concern about increasing antibiotic resistance and NICE has identified UTI infections as a key area, in terms of how infections can be managed, with the purpose of tackling antibiotic resistance.8
A key priority for prevention of UTIs should be supporting the immune system – and thus considering the need for nutrients such as vitamins A, B12, B6, C and D, folate, zinc, copper, iron and selenium, along with a diet that is low in sugar and which contains adequate protein. Sugar has been shown to suppress the immune system; protein is needed for antibody synthesis.
Other immune system support may be considered – for example honey bee propolis which has a long traditional history of use for immune support and beta glucans. Beta glucans prime both the innate and adaptive immune system to help the body defend itself against viral and bacterial invaders.9-11
With 70% of the immune system being located in the gut – poor gut health may result in poor immunity. In addition, E coli the primary pathogen involved in UTIs spreads from the rectum to the vagina and then to the urinary tract (a normally sterile environment). Research has shown that improving the gut or vaginal flora reduces recurrent UTIs.
Probiotics could help prevent recurrent infections via several mechanisms (see our recent blog on Probiotics). A healthy vaginal microbiota is mainly dominated by Lactobacillus species and probiotics containing Lactobacilli are being investigated as a potential therapy for reducing UTIs – several reviews have shown them to be safe and effective. However, they are not yet being recommended as a mainstream treatment due to the lack of large clinical trials.6,8,12
Cranberries contain compounds called proathocyanidins (PACs), specifically proanthocyanidin-A, which reduce bacterial adhesion at the appropriate dose; bacteria are thus unable to invade epithelial cells – they are flushed out of the urinary tract. There is limited or mixed evidence concerning cranberries ability to prevent UTI infections. A 2012 Cochrane review concluded that there was some evidence that cranberry juice may decrease the number of symptomatic UTIs over a 12 month period particularly for women with recurrent UTIs. One major limitation in many of the studies included in the Cochrane review is that many participants were unable to ingest the amount of cranberry juice required to show a potential benefit.13
However a Cochrane update published this month (August 2018) concluded that
“Given …. the evidence that the benefit for preventing UTI is small, cranberry juice cannot currently be recommended for the prevention of UTIs. Other preparations (such as powders) need to be quantified using standardised methods to ensure the potency, and contain enough of the ‘active’ ingredient, before being evaluated in clinical studies or recommended for use.”14
In addition there are problems with cranberry juice; firstly it is high in sugar and (along with other disbenefits) sugary foods suppress the immune system, and secondly it is necessary to drink large quantities (not easy for people with swallowing difficulties).
Low sugar varieties are available but these are loaded with artificial sweeteners which have been linked to contributing to a number of health conditions, including negative effects on the immune system.
D-mannose again reduces bacterial attachment to the walls of the urinary tract.15 The bacteria are then flushed out during urination.
A 2014 study published in the World Journal of Urology tested whether D-mannose powder is effective for recurrent urinary tract infection prevention. In the study, 308 women with a history of recurrent UTIs were divided into three groups: one that received D-mannose power in water for six months, the second received nitrofurantoin (an antibiotic) daily and the third did not receive treatment. Overall, 98 patients had recurrent UTIs: 15 in the D-mannose group, 21 in the nitrofurantoin group and 62 in the group that received no treatment. D-mannose powder significantly reduced the risk of recurrent UTIs, and patients in the D-mannose group had a significantly lower risk of side effects compared to patients in the nitrofurantoin group.16
One caveat with D-mannose is that it is only effective with UTIs caused by E. coli infection. While this accounts for up to 90% of cases, some people will not benefit from using it.
Vitamin C makes urine more acidic which inhibits the growth of E. coli and vitamin C contributes to normal immune function. A 2007 study evaluated taking 100mg of vitamin C during pregnancy. Researchers found that vitamin C for a three-month period was able to reduce the incidence of urinary infections.17
Allicin, one of the active principles of freshly crushed raw garlic, has a variety of antimicrobial activities and has been found to exhibit antibacterial activity against a wide range of bacteria, including multi-drug-resistant strains of E. coli. Garlic also has antifungal properties, particularly against Candida albicans, another microbe which can cause UTIs.18
A 2012 study evaluated the antibacterial activity of oregano oil. Researchers found that oregano was active against all of the clinical strains of bacteria that were tested, and it successfully inhibited the growth of E. coli, the bacteria most commonly seen in UTIs, with no reported side effects.19
Caprylic acid, a natural dietary acid found in high levels in coconut oil and some other foods, has been found to assist in the maintenance of normal micro-flora. Studies have shown that caprylic acid helps inhibit the growth of Candida albicans and other opportunistic fungi and bacteria in both the small and large intestine while having a positive effect on the growth of beneficial gut flora. Alone, or in combination with organic acids, it is being researched for its effects on and ability to disrupt bacterial biofilms.20,21
Finally bromelain, from pineapple has anti-inflammatory and anti-microbial properties that may be useful for UTI symptoms and as part of a gut support programme.22
Other prevention strategies are:
- Increasing fluid intake: this may work by flushing out organisms and giving them less time to adhere to the urinary tract.
- Not delaying in emptying the bladder (urination): again this will reduce contact time that microorganisms have in the urinary tract.
- A UTI, or urinary tract infection, is caused by microbes, the majority of cases being caused by E coli a bacteria that is a part of the normal gut microflora. Some UTIs can lead to serious life-threatening complications.
- Factors which reduce urinary flow increase the risk of a UTI e.g. enlarged prostate, kidney stones and anatomical abnormalities. Pathogens attach to the cells of the urinary tract and replicate – increasing urinary flow can help flush them away so is an important part of prevention.
- The rectum and vagina are close to the urinary tract and pathogenic bacteria may reach the bladder from these areas, thus a healthy gut and vaginal microflora are important.
- Antibiotics are frequently prescribed but these contribute to the underlying problem by destroying friendly bacteria in the gut and there is also the issue of antibiotic resistance. It is therefore important that those who suffer from frequent UTIs address the underlying causes
- Those who suffer recurrent UTIs may benefit from supporting their immune system and improving gut health – nutrients important for the immune system include vitamins A, C, D, zinc and selenium.
- Research has shown that improving the gut or vaginal flora reduces recurrent UTIs – probiotics and anti-microbials such as caprylic acid, garlic and oregano may be used.
- Another strategy in preventing recurrent infections is reducing the ability of E. coli to attach to the epithelial cells lining the urinary tract. D-mannose reduces the ability of infectious agents to attach to epithelial cells and in one study performed as well as an antibiotic at preventing recurrent UTIs in women.
- Staying hydrated and not delaying urination are also an important part of a strategy to prevent UTIs.
If you have any questions regarding the topics that have been raised, or any other health matters please do contact me (Clare) by phone or email at any time.
firstname.lastname@example.org, 01684 310099
Clare Daley and the Cytoplan Editorial Team
Relevant Cytoplan Products
D-Mannose Plus – D-Mannose is a natural sugar that is not metabolised by humans (non glycaemic) that binds to E.coli and prevents adhesion and replication.
Cyto Biotic Active – A live native bacteria powder comprising 9 strains plus a small amount of prebiotic inulin which stimulates the growth of bifidobacteria and other healthy native bacteria in the gut.
Caprylic Acid Plus – Provides a mix of anti-microbial and anti-fungal agents. This formulation is designed to help, as part of a programme, to address systemic candida and to promote digestive health. Beneficially combined with garlic powder, oregano, grapefruit seed extract and green tea extract.
Immunovite – Contains Beta 1-3, 1-6 Glucan along with vitamin C, selenium and zinc, which contribute to the normal function of the immune system.
Pregna-Plan – specifically formulated for all stages of pregnancy and breastfeeding. It’s also suitable for preconception planning for women too.
CoQ10 Multi – Adult only formula and to composition includes CoQ10, Beta 1-3, 1-6 Glucan and vitamins B12 and D3.
Vitamin A – In the form of Retinol Palmitate and is a vegan product. Vitamin A has been shown to be essential for the integrity of mucosal membranes and therefore plays an important role in supporting the digestive and immune systems.
Cherry C – Rich in vitamin C and carotenoids, with the cherry-like fruits being one of the richest-known natural sources of vitamin C.
Vitamin D3 – A wholefood supplement from lichen ideal for vegetarians and vegans. Vitamin D3 is the most bioavailable form of this nutrient.
Vitamin D3/K2 – Vitamin K2 is synergistic with vitamin D, and you need both in adequate amounts to ensure optimum biological activity of both vitamins.
Vitamin D3 drops – Ideal for vegetarians and vegans this vitamin D supplement comes in the form of vitamin D3 drops and is designed to elevate levels of Vitamin D3 (2 drops = 5mcg)
Zinc citrate 30 mg – A non-food form of zinc; as a citrate it is readily absorbed into the bloodstream. Zinc is involved in the functioning of over 200 enzymes in the body.
Honey Bee Propolis – Propolis is a complex food, and over 180 natural compounds have been identified including vitamins, minerals, fatty acids and amino acids. Propolis is one of nature’s richest sources of bioflavonoids and this is one of the reasons that it is considered to be an excellent and natural antioxidant.
Bromelain – A natural extraction from high quality pineapple fruit to provide a suitable and constant strength of dose and action. The only good source of bromelain is from the pineapple stem or core.