Urologist
Not just a "men's doctor"
Many women regularly visit their GP and gynecologists. When it comes to the urologist, many think that this is purely a "men's doctor" who only deals with men's health.
This is a misconception because the field of urology is responsible for all diseases of the urogenital tract and treats men, women, and children.
However, the unfortunate reality is that women usually only consult a urologist after long-term or seemingly hopeless urinary tract infections, even though it should be the first place to go if there are problems with the bladder.
It wasn't until I had gone through a long series of bladder infections that I realised I could make an appointment with a female urologist. Hindsight is always clearer ā I should have gone much earlier.
What's also unhelpful is that bladder problems are generally a taboo topic, and no one really likes talking about them. People happily discuss all kinds of health issues, but when it comes to urinary tract infections, overactive bladder, or incontinence, rarely do people ask for advice.
The Heart in the Lower Abdomen
I think this term for the human hollow organ, coined by Prof. Dr. med. Stephan Roth, is simply brilliant. The bladder truly is the heart of the lower abdomen, particularly the inner mucosal layer.
The so-called urothelium acts like a flexible filtration system. It has to withstand enormous stretching forces for decades, all while remaining sealed at all times to prevent urine from leaking back into the bloodstream.
No engineer in the world could design something like this!
The inner protective layer of the bladder is made of glycosaminoglycans (GAG). When needed, it activates white blood cells (leukocytes), stimulating the local immune system.
Today we know (although the exact benefits are not yet fully understood), that this inner membrane functions more like a Goretex material. It doesn't allow liquids to pass through, but still enables substance exchange.
The urothelium has a relatively slow renewal rate. The lifespan of a urothelial cell is 200-500 days. For this reason, if the urothelium is damaged, rapid healing (as with other mucous membranes) is not to be expected.
Also, due to this slow renewal, deeply embedded, hidden bacteria can resurface during the regeneration process, entering the bladder and causing recurring bladder infections. For this reason, and when all other measures have failed, long-term prophylaxis (continuous use of antibiotics in a reduced dose over 3-12 months) may be necessary.
How is it examined?
A bacterial bladder infection is one of the most common diseases worldwide. The correct balance of diagnostics & treatment is difficult (as little as necessary but as much as needed).
This is why the distinction between uncomplicated and complicated urinary tract infections was made.
A recurrent bladder infection (at least 2 infections in 6 months or at least 3 infections per year) is considered a complicated UTI and therefore requires thorough diagnostics to initiate targeted therapy.
Urine Diagnostics: Rapid Test
For a quick initial diagnosis, a urine test is carried out using midstream urine (the last toilet visit before should be at least 3 hours ago) with test strips. A urologist may also collect the urine using a catheter to ensure that no contamination occurs during the collection process. The test strip result evaluates the fields for nitrite (by-product of bacteria), leukocytes (white defense cells during inflammation), and blood. A urinary tract infection (UTI) is unlikely only if no nitrites, leukocytes, or blood are found. You can read more about it in my article on Urine test strips.
Urine Diagnostics: Microscopy
An experienced eye can detect a lot in a urine cytology under the microscope: leukocytes, bacteria (sometimes even bacterial strains), a fungal infection, or tumour-suspicious cells in a cancer form that grows flat on the top cell layer of the bladder (Carcinoma in situ).
Urine Diagnostics: Urine Culture
To initiate a targeted therapy for the infection, the urine is placed on a nutrient medium and incubated at 37Ā°C in a culture chamber.
If enough bacteria are present, they will grow and can be identified. Subsequently, an antibiogram is tested to see which antibiotics are sensitive (or resistant) to the bacteria and can eliminate them.
Additional information: 10^5 (100,000) bacteria per ml of cleanly collected midstream urine is a sign of a clinically significant urinary tract infection.
Until the result is available, a so-called "calculated" therapy is often initiated, as a urine culture takes at least 48 hours. This means that until the pathogen is known, your doctor will weigh which antibiotic to prescribe (ideally effective and with few side effects). Once the results of the urine culture are available, the therapy can be adjusted if necessary (e.g. different antibiotics).
Warning: Some sexually transmitted pathogens, such as gonococci and chlamydia, cannot be cultured and require different diagnostics.
Ultrasound
An ultrasound of the bladder (after emptying) can determine whether the bladder is fully emptied. If the ultrasound shows remaining urine, this could be the cause of recurrent UTIs. Residual urine formation often occurs due to bladder prolapse (cystocele), e.g. after childbirth or in older age.
An ultrasound of the kidneys can rule out obstruction or kidney stones as the cause of recurrent bladder infections.
A vaginal ultrasound probe can detect rare protrusions of the urethra (urethral diverticula). Bacteria can collect in the cavities of these protrusions and cause repeated infections.
Urodynamics ("ECG of the bladder")
During bladder pressure measurement, functional disorders of the lower urinary tract can be diagnosed very effectively. It helps to clarify irritative states of the bladder, bladder emptying disorders, and various forms of urinary incontinence.
Cystoscopy
Cystoscopy allows the doctor a look inside the bladder and the urethra. During this possibly uncomfortable but typically painless procedure, a thin, flexible tube (the endoscope) is inserted through the urethra into the bladder, with a mixture of lubricant and anaesthetic. After the bladder is filled with sterile fluid to allow for better expansion, the video endoscopy (at the inserted end of the tube) allows the urethra and bladder to be viewed and assessed internally on an external screen.
During a cystoscopy, the doctor can remove bladder stones, eliminate strictures in the urethra, and remove small tumours, as well as take tissue samples (bladder mucosa biopsy). If a urethral infection (urethritis) is suspected, a urethral swab is taken, and the collected urethral secretion is sent to the microbiological laboratory for examination.
Normal findings in women: Urethra without narrowing, normal ureteral opening, bladder mucosa: no signs of inflammation and normal vascular pattern, no tumours, no squamous epithelium metaplasia.
Examples of pathological findings in women: Various forms of cystitis, ureteral stones, bladder stones, kidney congestion, schistosomiasis (Bilharzia - a parasitic infection caused by blood flukes), urethral diverticula, urethral strictures, fistulas, blood clots (coagula), squamous epithelium metaplasia, bladder cancer.
Rigid endoscope: Some practices and hospitals still use rigid endoscopes for cystoscopy in women, which can be definitely more uncomfortable and even painful. My tip: It's best to clarify in advance which device the urologist of your choice uses or to specifically request the flexible endoscope (which is usually used for men due to the longer urethra).
Good to know: A cystoscopy is not performed during an acute urinary tract infection.
Treatment examples for UTI
- Antibiotic therapy: Short-term therapy (1-7 days, depending on the substance), long-term prophylaxis (ongoing intake for 3-12 months or post-coital single doses), antibiotics directly into the bladder via self-catheterisation
- Acute & prophylaxis through acidification of the urine (it is known that acidic urine can enhance the effect of antibiotics), e.g. AcimethinĀ®
- Prophylaxis through vaccination / immunostimulation
- Instillations into the bladder to replace the protective layer of the bladder wall (solution administered via catheter into the bladder, e.g. InstillamedĀ®)
- Local estrogen therapy in the vagina for estrogen deficiency, e.g. OvestinĀ®
- Therapy plan for emptying disorders
If there is suspicion that the underlying cause of the condition lies beyond the bladder (e.g. endometriosis), other diagnostic methods must be used, such as CT, MRI, or laparoscopy.
"Today, I would definitely be wiser and would never wait so long for an appointment with a urologist. Back then, the pressure of suffering was so great that I suspected I might have bladder cancer. I found a private female urologist because I felt less anxious with a woman. Conclusion: The urine sample for the urine culture was painlessly taken using catheter urine. The post-void residual urine measurement was done via ultrasound. The cystoscopy was really not painful and was completed ultra-fast. The fact that my bladder was completely normal during the cystoscopy greatly relieved me and turned off the stupid question-mark constant head-cinema."
