Gynaecologist
Connection Between Vagina & Bladder
When dealing with recurrent urinary tract infections, it is worth taking a closer look at the (female) reproductive organs.
It's no coincidence that we talk about the urogenital tract, which includes both the urinary organs and the genitals. Although the urinary and reproductive organs have different functions, they are considered together due to their shared embryological development and their close functional and topographical relationship. Diseases in one system can quickly affect the other system.
Since almost every woman regularly visits a gynaecologist for routine check-ups, there's no need to fear the unknown, unlike the typical anxiety before visiting a urologist.
Sexually Transmitted Diseases (STDs)
In particular, urethral discomfort without evidence of a bacterial urinary tract infection can indicate sexually transmitted diseases.
You can learn more about STDs in my article Partner Check.
When Is the Vagina Healthy?
The vaginal environment contains good bacteria like lactobacilli and harmful bacteria or fungi. A healthy vaginal flora is made up of 95% lactobacilli (lactic acid bacteria), has no strong discharge, and is odor-neutral. The key to the healthy microbiome of the vagina are the lactobacilli, which perform a variety of defensive tasks against bacterial infection.
Hero No. 1 - Lactobacilli
Lactobacilli help in 3 ways to defend against infections through:
- Acid production (pH value of 3.8 - 4.4)
- Formation of local defensive substances
- Release of hydrogen peroxide (H2O2)
Lactic acid is responsible for the acidic environment, an important factor in combating harmful foreign germs.
The inhibitors produced by lactobacilli act like natural antibiotics. They prevent foreign bacteria from attaching to the vaginal epithelium.
Hydrogen peroxide (H2O2) is the chemical wonder weapon, like a natural disinfectant, because its corrosive effect can destroy harmful pathogens.
Hero No. 2 - Estrogen
The sex hormone estrogen is also a hero. Estrogens...
- cause a multiple protective effect (protective proteins) on the urethral mucosa against inflammation.
- increase the production of natural proteins that can combat bacteria.
- provide a sufficient nutrient base (glycogen) for the formation of the essential lactobacilli in the vagina.
- affect the tissue firmness and blood circulation of the vaginal and urinary mucous membranes.
The Hostile Opponents
Now that we know that lactobacilli and estrogens are our most important defenders against infections, the question arises: What, for heaven's sake, threatens this balance?
Lactobacilli deficiency can occur due to:
- Bacterial vaginosis (vaginal infection)
- Antibiotics
Estrogen deficiency can occur due to:
- (Post)-menopause
- Modern, low-dose pills that suppress too much estrogen
Which Deficiency Should Be Addressed First?
This can be logically and simply explained with a comparison: When a plant isn't growing, you must first fix the "soil".
In other words, before correcting a lactobacilli deficiency by supplementing with additional lactobacilli, you should first make sure that the following are either excluded or treated:
- Bacterial vaginosis
- Estrogen deficiency
Bacterial Vaginosis
When the bacterial colonisation of the vagina is in imbalance, it is called bacterial vaginosis or vaginitis. Due to a lack of lactobacilli, "bad" bacteria overgrow, and the vaginal environment suffers from a microbiological disturbance.
If the vagina is infected, the risk of ascending bladder infections is also increased. So how does your gynaecologist recognise that you have a vaginal infection?
- Symptom itching and burning
- Increased discharge with a fishy smell
- The microscope shows many bacteria on the vaginal cells (clue cells)
- The measured pH level is no longer acidic (over 4.5)
In most cases, treatment is with an antibiotic local treatment, such as Metronidazole (e.g. Clont® vaginal tablets) or Clindamycin (e.g. Sobelin® vaginal cream).
Fungi can also cause vaginal infections (vaginal mycosis). After microscopic and cultural diagnostics, targeted therapy is also applied here (antimycotics).
Additionally, you should enrich your vaginal flora with lactobacilli. Treatment proposal by Professor Mendling (leading gynaecologist in treating vaginal infections):
- Treatment duration: 6-12 weeks
- Phase 1: A total of 10-14 vaginal suppositories every 1-2 days before bedtime
- Phase 2: 2x per week, one vaginal suppository
One bacterium - Gardnerella vaginalis - deserves special attention due to its connection with the bladder. This germ is found in many women in the vagina. It only becomes a problem in the vagina when it overgrows.
However, it can cause damage much earlier in the bladder. The path to the bladder is usually via sexual intercourse, where the bacteria from the vaginal secretion are "massaged" into the urethra. Once in the bladder, it dissolves the hiding places of bacteria embedded in the bladder wall and thus leads to a recurring bladder infection.
You can find more information in my article on Vaginal Flora.
Antibiotics
Most antibiotic treatments not only kill the "bad" but very often also the "good" bacteria. Even when the antibiotic is not taken to treat bacterial vaginosis.
Alongside or at the latest following antibiotic treatment, the vaginal flora should be rebuilt, see treatment proposal by Professor Mendling above.
Estrogen Deficiency
Estrogen deficiency in the vagina can be diagnosed quite simply:
- Sensitive & reddened skin in the vagina
- Dry vagina
- High pH level (over 4.5)
- Reduced cell renewal of the vaginal mucosa (less than 15% superficial cells visible under the microscope)
If a local deficiency is found, it can be easily corrected by replacing estrogen with creams (e.g. Ovestin®), suppositories, vaginal rings in the vagina. Unwanted side effects occur in 6-20% of women in the form of local irritation.
If the deficiency is caused by the pill, you should consider changing the pill or also locally supplementing estrogen.
Estrogen Replacement
Good to know: Even with a longer history of breast cancer, local estrogen replacement therapy does not pose a measurable risk. Preparations with ultra-low doses of estriol do not lead to a measurable increase in estrogen levels in the blood.
Interesting: Estrogen replacement also helps with overactive bladder (irritable bladder), leaky bladder (stress incontinence), and generally with prolapse symptoms.
You can find more on the topic in my article Hormones - Secret Messengers.
Proven and Unproven
Estrogen replacement in case of deficiency:
Large studies have shown that the local application of 0.5mg/day of estrogen reduces the rate of urinary tract infections.
Estrogen replacement without deficiency:
A small case series
with 30 young women who all took an oral contraceptive (the pill) and suffered from recurrent bladder infections (without a proven estrogen deficiency) came to the conclusion:
After a 4-week, local estrogen administration, 80% of the women had no relapse in the following 11 months.
Lactobacilli for UTI prevention:
Although a Cochrane meta-analysis, after evaluating 9 studies, concluded that lactobacilli did not provide a statistically significant advantage over placebos in preventing bladder infections, there is at least one single study that showed a reduction by half in the rate of urinary tract infections.
Many testimonials online also confirm the positive effect of lactobacilli.
Lactobacilli after fungal infection:
The claim that lactic acid bacteria promote the growth of Candida albicans is not supported by any study. On the contrary, certain strains can even inhibit the growth of Candida.
The Pill & UTIs:
There are many reports online of women who experienced an improvement in urinary tract infections after discontinuing the pill.
Progesterone:
The hormone progesterone has a relaxing effect and therefore widens the urinary tract. It is proven that this makes it easier for bacteria to enter and thus promotes infection.
However, there are also increasing reports online suggesting that a progesterone deficiency (and an estrogen dominance) can also lead to symptoms.
Those affected by recurrent bladder infections sometimes substitute progesterone when a deficiency is identified.
The relative ratio of estrogen to progesterone is crucial.
Prolapse Symptoms
Overstretched vaginal tissue, lax ligamentous support under the urethra, bladder prolapse, and uterine prolapse can promote UTIs or trigger symptoms similar to a bladder infection.
The constant urge to urinate, even with small amounts of urine, is a symptom also found in overactive bladder and urinary incontinence.
Vaginal tissue can become overstretched with age or after childbirth, which can reduce the stability of the urethra. The bladder can also drop into the front vaginal wall, which can lead to emptying disorders.
In such cases, pelvic floor exercises are primarily recommended (I have a separate article on this: Pelvic Floor).
Additionally, a (ring-)pessary can be inserted into the vagina, which can "push" the bladder/urethra back into the correct position.
Certain medications can also help improve muscle tone. Finally, surgical interventions can also be considered.