Q. I am in my 60s and I have been suffering from UTIs for a couple of years. I also suffer from dryness down below and after years of getting no answers I am considering changing GP as a friend of mine who was a nurse suggested that I might be suffering from vaginal atrophy. Could this be the case? If so, can you tell me a bit about it and the treatments please?
A. The definition of recurrent urinary tract infection (UTI) refers to ≥2 infections in six months or ≥3 infections in one year and are typically acute simple cystitis (presumed to be confined to the lining of the bladder) rather than a complicated UTI infection. A complicated UTI generally has evidence of upper urinary tract infection and/or presence of systemic symptoms such as fever, rigor and chills. But yes, your friend could be right in suggesting vaginal atrophy may be a predisposing factor for your recurrent UTIs.
In fact, the new medical term in use is called the Genitourinary Syndrome of Menopause (GSM) and incorporates vaginal atrophy. Overall, GSM is thought to be caused by low oestrogen levels and exacerbated by the normal aging process. GSM symptoms include genital dryness, burning, and irritation, sexual symptoms such as pain, discomfort or lack of lubrication, impaired sexual function and urinary symptoms of urgency, dysuria, and recurrent urinary tract infections.
Other structures within the pelvis are susceptible to similar changes as they also contain oestrogen receptors. Namely, the bladder, urethra(urinary tube from the bladder to the outside), pelvic floor muscles, and the fascial support within the pelvis are affected by low oestrogen levels. Pelvic organ prolapse (falling down) into the vaginal wall may also be a contributing factor, with vaginal childbirth being associated with an increased risk of prolapse.
There are a few different types of prolapse. A cystocele is when part of the bladder falls into the anterior (forward facing)vaginal wall. This may lead to urinary stasis and increased risk of UTIs. A rectocele is when part of the rectum falls into the posterior vaginal wall. Enterocele is when part of the intestines fall into the vaginal wall. Uterine prolapse or vaginal vault prolapse is when part of the uterus falls, and lastly, uterine procidentia is worst case scenario when the uterus, cervix and vaginal vault are falling through the entrance to the vagina.
When making a diagnosis of GSM, laboratory blood tests are not usually necessary as there is usually characteristic symptoms and findings during pelvic examination. In your case, recurrent UTIs is your only complaint. Therefore, you should have urine culture and microscopy and be evaluated for other possible causes including interstitial cystitis. Given your age, something very low down on the list of potential causes is the very small possibility of a genito-urinary tract cancer.
General advice on preventing UTIs include increasing your daily fluid intake, aiming for approximately 2 litres of plain water per day, passing urine shortly after sexual intercourse, wearing cotton underwear/clothing that is not tight fitting and wiping from front to back to avoid perineal contamination with faecal flora. If after these simple measures things fail to improve, it is reasonable to start topical vaginal oestrogen therapy as this has been shown to effectively reduce the incidence of cystitis.
There are several formulations of vaginal oestrogen on the market and it is often trial and error, in finding the one that works best for you. Typically a vaginal oestriol cream is applied every night for two weeks then twice weekly for the eight month course. Obviously, referral to a consultant gynaecologist is preferred as they can assess cancer risk-related safety and optimal dosing. Lastly, some women need to take daily low dose antibiotic medication as a way to prevent recurrent cystitis or UTIs which is known as antibiotic prophylaxis therapy.
Dr Jennifer Grant is a GP with Beacon HealthCheck