The urinary tract is typically sterile and fairly resistant to bacterial colonization, mediated by the constant discharge of urine, which dilutes and washes away any potential pathogenic organisms, and through the secretion of IgA in the urinary mucosa. Urinary tract infection (UTI) however is a common condition seen in all age groups, and generally speaking, is more prevalent in females due to a shorter and wider urethra, providing less resistance against microbes that naturally occur in or colonize the vaginal mucosa. Alterations in the vaginal flora can also occur with frequent vaginal intercourse, the usage of synthetic-fiber underwear, contamination with fecal material, frequent douching, and the usage of spermicides. While the incidence of UTI is more common in girls and women of reproductive age, as men age they become much more susceptible to infection due to an increased frequency of prostate disease. UTIs in otherwise healthy men are often seen as a sexually-transmitted disease, either from contact with pathogenic organisms in an infected vaginal mucosa, or from unprotected anal intercourse. Immunosuppression (e.g. chemotherapy, AIDS) in either men or women can also predispose UTI.
Most UTIs are related to gram-negative aerobic bacteria that ascend from the vaginal mucosa and urethra (urethritis) to the bladder (cystitis) and up the ureters into the kidneys (pyelonephritis). Infections in otherwise healthy individuals are most often caused by Escherichia coli (80%), and to a lesser degree Staphylococcus saprophyticus (10%). In hospitalized patients however E. coli accounts for only 50% of cases, with gram-negative species such as Klebsiella, Proteus, Enterobacter, and Serratia accounting for 40%, and gram-positive bacteria such as Enterococcus faecalis and Staphylococcus spp. (e.g. saprophyticus, aureus) comprising the remainder. Non-gonococcal urethritis is usually related to infection with Chlamydia trachomatis, Ureaplasma urelyticum or Mycoplasma genitalium, usually as sexually-transmitted infection that is difficult to detect with current testing procedures, and thus often goes undiagnosed. Other infectious agents the herpes simplex virus (usually as an STD), and Candida albicans in women and in the immunosuppressed. (Berkow 1992)
There are a variety of factors that predispose patients to UTI, beyond simple infection. The most common factor relates to an impairment in micturation and an incomplete emptying of the bladder. This includes the presence of calculi, prostatic enlargement, a prolapsed uterus, diabetic neuropathy, pregnancy and anatomical abnormalities. The introduction of medical instruments such catheters into the urethra are another frequent cause of UTI. In fungal infections such as candidiasis alterations in the vaginal flora are usually at play. (Berkow 1992)
Urethritis
Urethritis refers to the inflammation of the urethra, most often the result of a bacterial infection, and is frequently associated with an STD. Urethritis with a characteristically “frothy” urine however may be a symptom of renal failure (the “froth” relating to excessive proteins from an increase in glomerular permeability). In a bacterial urethritis onset is gradual, and symptoms are mild. In men urethritis usually present with urethral discharge, which is purulent when due to N. gonorrhoeae and whitish mucoid when nonspecific. In women urethritis usually present with dysuria, frequency, and pyuria. Candida can also cause symptomatic urethritis, with dysuria, a watery discharge, and urethral itching, more common in women and in the immunosuppressed. (Terris 2005; Berkow 1992)
Cystitis
Cystitis refers to the inflammation of the urinary bladder, once again, usually due to a bacterial infection. Onset is usually sudden, with frequency, urgency, and burning or painful voiding of small volumes of urine. Nocturia with suprapubic and/or low back pain is common. The urine is often turbid, with hematuria occurring in about 30% of patients. In elderly patients UTIs are often asymptomatic. In women cystitis is often preceded by sexual intercourse, whereas in men, generally results from an ascending infection of the urethra or prostate, or secondarily from urethral instrumentation. With Candida infection the symptoms are more or less similar to a bacterial UTI, and often predisposes the patient to secondary bacterial infection. Treatment with antibiotics usually clears up the symptoms but only for a few weeks or months, and thus recurrent UTIs are sometimes caused by an untreated, underlying candidiasis that is made worse through repeated antibiotic treatment. (Berkow 1992)
Pyelonephritis
Pyelonephritis refers to a bacterial infection of the kidney parenchyma, and can be either acute or chronic. It often occurs secondarily to cystitis as an ascending infection (facilitated by bacterial endotoxins that inhibit peristalsis), or some kind of obstruction in urine flow including pregnancy, strictures, calculi, tumors, prostatic hypertrophy, or a neurogenic bladder. Pyelonephritis frequently occurs after medical instrumentation or bladder catheterization. (Berkow 1992)
In acute pyelonephritis the kidney usually is enlarged in due to the infiltration of leukocytes and edema, the infection is focal and patchy in the renal pelvis and medulla at the outset, extending outwards into the cortex as the condition progresses. Within a few days medullary and subcortical abscesses may develop. The onset of symptoms is rapid, characterized by chills, fever, flank pain, nausea, and vomiting. Symptoms of a lower UTI such as frequency, and dysuria occur in about one-third of patients. Upon abdominal palpation a tender, enlarged kidney may be felt. In children acute pyelonephritis is frequently associated with renal scarring, which is often a cause for subsequent surgery, although in adults this is not usually the case. Upwards of 20% of cases in women result in bacteremia. (Berkow 1992; Govan 1991, 643; Rubin and Farber 1990, 477-78; Gupta and Stamm 2005)
In chronic pyelonephritis the bacterial infection is chronic and bilateral, eventually producing atrophy, deformity and scarring of the kidney. It usually occurs only in patients with some kind of anatomic abnormality or obstruction, such vesicoureteral reflux (VUR), chronic prostatitis, or calculi. VUR is usually seen as a congenital defect that results in incompetence of the ureterovesical valve, but can be acquired in patients with a spinal cord injury. Signs and symptoms are vague and inconsistent, including flank pain, fever, malaise, anorexia, and weight loss. Upon examination a unilateral renal mass can usually be palpated. (Berkow 1992; Govan 1991, 643; Rubin and Farber 1990, 478-80; Gupta and Stamm 2005)
Medical treatment
The medical treatment of UTI consists of the eradication of the pathogenic organism(s) and the prevention or control of bacteremia. In recent years proper testing was considered unnecessary but since that time many of the pathogens commonly involved in UTI such as Escherichia coli and Staphylococcus saprophyticus have demonstrated resistance to commonly used antibiotics, including ampicillin, cephalothin, trimethoprim and sulfamethoxazole. Given this problem newer guidelines now suggest that the urine be tested with reagent strips and cultured to determine the presence and type of pathogen(s) involved in UTI. Given the prevalence of resistance antibiotics are typically used in combination, such as trimethoprim with sulfamethoxazole (TMP-SMX), but these too are increasingly associated with bacterial resistance. Nonetheless, a TMP-SMX combination is often given as a first line therapy for 3 days, followed by the more expensive fluoroquinolones (e.g. ciprofloxacin) over a 7-14 day period if these fail. In acute pyelonephritis the regimen may consist of the oral or parenteral administration of TMP-SMX and/or a fluoroquinolone for 14 days, ampicillin plus gentamicin, or advanced-spectrum cephalosporins. Ofloxacin, azithromycin, erythromycin, and the tetracyclines are used in non-gonococcal urethritis, with treatment given to both the patient and the sexual partner(s). In pregnancy oral ß-lactams, sulfonamides, and nitrofurantoin are considered safe, but sulfonamides specifically are avoided near parturition because of a possible role in the development of kernicterus, an abnormal toxic accumulation of bilirubin in the fetal central nervous system. Fluoroquinolones are avoided specifically because of possible damage to fetal cartilage. In obstructive uropathies and anatomic abnormalities surgical correction is often recommended. (Terris 2005; Berkow 1992; Gupta and Stamm 2005).
Holistic treatment
Given the prevalence of antibiotic resistance in UTI herbal medicine has much to offer in the way of treatment. A great many herbs are used not only to correct the ecology of the UT, but also to relieve the pain and inflammation associated with infection. Perhaps the most well known of these herbs in the Western herbal tradition is Bearberry (Arctostaphylos uva ursi). This herb contains the glycoside arbutin which upon exposure to an alkaline urine undergoes hydrolysis to yield the antiseptic compound hydroquinone, which has a broad-spectrum antimicrobial activity against many pathogens including E. coli, Staphylococcus, Proteus, Klebsiella, Proteus, Citobacter and Pseudomonas. Arbutin is an otherwise harmless compound unlike hydroquinone which is a fairly toxic: it is only when arbutin reaches the urinary tract however that it undergoes hydrolysis, thus providing a unique mechanism for the delivery of this bioactive compound. The caveat however is that hydrolysis of arbutin only occurs in an alkaline urine, and given that many pathogens thrive in an acidic urine, a half a tsp. of sodium bicarbonate thrice daily is taken as part of the herbal regimen to alkalize the urine. Although hydroquinone is often taken as the “active” constituent in Uva ursi (Arctostaphylos uva ursi), this herb contains other constituents that also display antimicrobial properties and act synergistically, such as the aglycone of the glycoside piceoside, p-hydroxyacetophenone, or the breakdown product of ericolin, ericinol. There are many similar herbs to Uva ursi that contain similar compounds such as Pipsissewa (Chimaphila umbellata), or similarly act as antimicrobial agents including Buchu (Barosma betulina), Purple Coneflower (Echinacea angustifolia) and Goldenseal (Hydrastis canadensis). Useful Indian herbs used in Ayuredic medicine that act as antimicrobials include Gokshura (Tribulus terrestris), Kankola (Piper cubeb), Guggulu (Commiphora mukul), Varnua (Crataeva nurvala), and Guduchi (Tinospora cordifolia). Chinese herbs used as urinary antiseptics include Huang bai (Phellodendron amurense), Jin Qian Cao (Lysimachia christinae), Bian Xu (Polygonum aviculare), Huang Lian (Coptis chinesis) and Yin Chen Hao (Artemisia capillaris). In addition to antimicrobial herbs, botanicals that have antispasmodic, demulcent and vulnerary actions are important adjuncts. Of particular value is Kava (Piper methysticum) due to its potent antispasmodic effects as well as antimicrobial properties. Other antispasmodics include Wild Yam (Dioscorea villosa), Crampbark (Viburnum opulus), and Henbane (Hyocyamus niger), the latter reserved for severe pain and spasm. Demulcents and vulneraries that often have additional antimicrobial properties include Couchgrass (Agropyron repens), Plantain (Plantago lanceolata), Cornsilk (Zea mays), Ze Xie (Alisma plantago-aquatica) and Marshmallow root (Althaea officinalis). One important anti-inflammatory demulcent remedy in Ayurvedic medicine is Vamsharochana (Bambusa arundinacea manna), a concretion found in the hollows of bamboo stem that is mostly comprised of silica. Somewhat similarly used in Chinese medicine is Hau Shi (talc), comprised mostly of magnesium silicate hydroxide. Long standing or recalcitrant UTIs may also require trophorestorative botanicals such as Bilberry (Vaccinium spp.), Hawthorn (Crataegus spp.), Gokshura (Tribulus terrestris), Shi Di Huang and Horsetail (Equisetum arvense). Where candidiasis is suspected antifungal treatments are also employed, such as Purple Coneflower (Echinacea angustifolia), Barberry (Berberis vulgaris) and Pau D’arco (Tabebiua spp.).
Another important consideration in treating UTI, especially in recurrent infection, is to address the ecology of the body. Dietary changes in both chronic bacterial UTI and candidiasis benefit from dietary changes and synbiotic therapies. In a bacterial UTI that demonstrates a lowered pH, a short term vegetarian diet should be employed, whereas a bacterial UTI with an alkaline urine, or in candidiasis, carbohydrate foods should be temporarily removed from the diet. In all diets, an avoidance of reined foods including flour and sugar, as well as dairy, should be employed.
In pyelonephritis, especially in children, long term trophorestorative therapy should be undertaken to prevent fibrosis and surgery.
The holistic treatment of UTI is as follows:
1. Dietary changes
- vegetarian diet for a UTI with acidic urine
- increase meat intake and reduce carbohydrates in a UTI with an alkaline urine, especially where Candida is suspected
2. Antimicrobial botanicals.
- for bacterial infection: Uva ursi (Arctostaphylos uva ursi), Pipsissewa (Chimaphila umbellata), Buchu (Barosma betulina), Purple Coneflower (Echinacea angustifolia), Goldenseal (Hydrastis canadensis), Neem (Azadirachta indica), Gokshura (Tribulus terrestris), Kankola (Piper cubeb), Guggulu (Commiphora mukul), Varnua (Crataeva nurvala), Guduchi (Tinospora cordifolia), Huang bai (Phellodendron amurense), Jin Qian Cao (Lysimachia christinae), Bian Xu (Polygonum aviculare), Huang Lian (Coptis chinesis), Yin Chen Hao (Artemisia capillaris).
- for Candida: Purple Coneflower (Echinacea angustifolia), Barberry (Berberis vulgaris), Pau D’arco (Tabebuia spp.), Sweet Annie (Artemisia annua), Guggulu (Commiphora mukul)
3. Antispasmodic botanicals, e.g. Kava (Piper methysticum), Wild Yam (Dioscorea villosa), Crampbark (Viburnum opulus), Parsley root (Petroselinum crispum), Lobelia, Hingu (Ferula asafoetida), Skullcap (Scutellaria lateriflora), Hops (Humulus lupulus), Henbane (Hyocyamus niger)
4. Demulcents and vulneraries, e.g. Couchgrass (Agropyron repens), Plantain (Plantago spp.), Cornsilk (Zea mays), Marshmallow (Althaea officinalis), Slippery Elm (Ulmus fulva), Bala (Sida cordifolia), Water Plantain (Alisma plantago-aquatica)
5. Trophorestorative herbs and nutrients.
- botanicals: Gokshura (Tribulus terrestris), Bilberry (Vaccinium myrtillus), Hawthorn (Crataegus spp.), Haridra (Curcuma longa), Horsetail (Equisetum arvense), Amalaki (Phyllanthus emblica), Rosehips (Rosa sp..), Agnimantha (Premna integrifolia), Shu Di Huang (Rehmannia glutinosa)
- Shilajit, purified, 2-3 g daily
- Vitamin A, 20,000 IU daily, short term
- Vitamin C, 2-3 g daily
- Vitamin D3, 3000-5000 IU daily
- Vitamin E, 600-800 IU daily
- Zinc, 15-30 mg daily
- EPA/DHA, 1000 mg each daily
6. Synbiotics
- 6-8 billion bacteria (e.g. a mixture of Lactobacillus acidophilus, Bifidobacterium et al.), thrice daily, with meals
- live-culture foods, e.g. fermented vegetables, kefir etc