Nutrition News and Views July/August 2013 Vol.17, No.4 for Health Professionals
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Nutrition News and Views July/August 2013 Vol.17, No.4 For health professionals URINARY TRACT TISSUES AND ISSUES, Part 1 By Judith A. DeCava, CNC, LNC Cystitis (also called Urinary Tract Infection or UTI) is an inflammation of the urinary bladder. The lower urinary tract consists of the urethra (the tube that carries urine from the bladder) and the bladder. The upper urinary tract includes the kidneys and ureters (tubes that carry urine from the kidneys to the bladder). Where inflammation occurs determines whether the condition is called cystitis, pyelonephritis or urethritis. Not everyone with cystitis develops symptoms. But the most common symptoms include a burning sensation or discomfort during urination, more frequent urination, the urge to urinate even when the bladder is not full, urinary incontinence (leakage), pain or pressure in the pelvic area, dark-colored or cloudy or malodorous urine. If not resolved, cystitis can lead to more serious symptoms including blood in the urine, fever, nausea, vomiting, backache in the kidney area, pain in the pubic area, occasional discharge of pus in the urine or from the urethra—signs of pyelonephritis (kidney inflammation) or urethritis (inflammation of the urethra). In most cases Escherichia coli (E.coli) bacteria are involved, although other types of bacteria or yeasts (like Candida) have been found. These bacteria or yeasts do not belong in the urinary tract and are ‘foreign’ to it. The E.coli or other bacteria come from feces; Candida comes from the vagina. They can adversely affect an irritated or compromised urinary tract, particularly if the bacteria are ‘sick’ (having engulfed wastes or toxins). The bacteria from feces make their way through the urethra into the bladder, or rarely, to the kidneys. In men, the ‘sick’ bacteria may stress the prostate. Although the tendency is to blame some microorganism, inflammation of the bladder can occur without ‘infection’ from bacteria foreign to the urinary tract. And, even if there are foreign bacteria or yeasts involved, it does not mean that they cause the problem. A healthy urinary tract flushes out any toxic or foreign substances through the urine. The underlying cause would more likely be an unhealthy urinary tract lining which is more susceptible to insult or irritation from foreign bacteria or yeasts. 1, 2 Cystitis is much more common in women (1 in 5 women will have cystitis during her lifetime). One reason is the female urethra (the tube that carries urine from the bladder) is shorter than a male’s. Also, the urethral opening is near the perineum (region between the vulva and anus) which tends to harbor fecal matter including ‘sick’ bacteria that may contribute to cystitis. In men, the urethra is much longer, making it harder for bacteria to migrate; there is a greater distance between the opening of the urethra and the anus; and prostatic fluid has antibacterial properties. When foreign bacteria, toxins or other substances that don’t belong in the urinary system are not flushed out quickly enough, irritation or injury to the lining of the bladder and urethra can occur. Sexual intercourse (including ‘honeymoon cystitis’), delayed urination after intercourse, use of diaphragms with a spermicide, spermicides alone, oral contraceptives, obesity, incontinence (urinary or fecal), and a history of recent cystitis all increase risk. Intercourse that is rough or frequent can cause irritation or push bacteria up into the bladder. Spermicides induce colonization of E. coli and alter vaginal flora. Exposure to irritants such as perfumed soaps or scented douches can also contribute to the tendency for cystitis. Men experience a higher prevalence of cystitis starting in their mid-50s and 60s when an enlarged prostate and obstruction of the urinary tract are more probable. In older women, reduced estrogen can cause marked changes in the bacteria living in the vagina and the area around the urethral opening as well as weaken the vaginal lining. Estrogens also help maintain the muscle and ligament structures in the pelvic area. Postmenopausal women tend to have lower levels of lactobacillus in particular. This type of healthy bacteria help lower the pH of the vagina, making it less hospitable to ‘sick’ bacteria and thus help prevent their spread to the urinary tract. 3 Generally, there is some tissue weakness or a lack of resistance to stress. Occasionally, kidney or bladder stones, catherization, and anatomical or functional abnormalities can increase risk in both men and women. But usually the lining of the bladder and/or urethra is somehow compromised and not as healthy as it should be. A bladder that has been irritated, has lax tissues, or is affected by reactions to toxins or drugs or food intolerances is more susceptible. Urine that stagnates in the bladder because the tissues have become so weak that the back of the bladder hangs lower than the opening means that the bladder never completely empties and urine sits there. This too can irritate the bladder and lead to inflammation. Symptoms, a urine dipstick, urine analysis and/or urine culture are usually used for diagnosis. Using a dipstick, however, is not always accurate. The US Preventive Services Task Force does not advise urine testing for people without symptoms. Why? The antibiotic regimen prescribed by many doctors is riskier than no treatment for people with symptomless UTIs. Adverse effects from antibiotics and development of bacterial resistance (from overuse) are reasons given. Medical treatment is almost always a prescription for antibiotics. Yet studies have shown that this does not decrease risk of recurrent UTIs and does increase risk of antibiotic resistance. Antibiotics become less effective with each episode of cystitis and stronger antibiotics are prescribed until they too are no longer effective. Plus the underlying cause is not approached. 4 Most people have heard how cranberry juice can help prevent the recurrence of cystitis. Yet study results have been mixed, evidently depending on the content, quality, additives, and processing methods of the juice. 5, 6, 7 Unsweetened juice—not the types with refined sugars—appears to be best. (Raw honey or pure maple syrup can be added to offset the tartness, if needed.) 8 Cranberries may interfere with the attachment of foreign bacteria to the lining of the urinary tract. 9 One component in cranberries that may do this is d-mannose. Isolated d-mannose has been used to prevent recurring cystitis. But cranberries contain many other ingredients including organic acids, natural fructose, vitamin C complex with flavonoids, anthocyanidins, proanthocyanidins (PACs), catechins, triterpenois, and more. There are indications that many of these can prevent foreign bacteria from sticking to the urinary tract wall. 10 Even though it’s thought that inhibition of adherence of bacteria is the main action of cranberries, the exact mechanism has not been established. A 2012 Cochrane review found a “small trend” towards fewer UTIs in people taking cranberry products compared to placebo or no treatment.” They concluded that “until there are more studies of products containing enough of the active ingredient [emphasis added], measured in a standardized way, cranberry products cannot be recommended for preventing UTIs.” This is the drug mentality, insisting on one measured active ingredient. Different dosages and product types were used in the studies, so a standardized dosage—as a pharmacological agent—was not employed. Another reason for their conclusion is the need for improvements in the design of studies. 11 Some scientists have questioned the validity of the Cochrane group jumping to conclusions. 12 Amy Howell, PhD, who has been researching cranberries for two decades, doesn’t agree with the Cochrane group’s basic dismissal of cranberries and their juice for prevention of cystitis. Her lab “has consistently found that cranberries effectively help prevent bacterial adhesion to bladder cells…They are washed out of the body in the urine stream.” 11 A 2012 review published in The Archives of Medicine, which included 13 clinical trials with 1,616 participants, found that unsweetened cranberry juice was more effective than capsules or tablets—the point is that cranberry juice was effective. It’s possible that some components in the juice are removed when making capsules or tablets, yet there are types that preserve the whole cranberry and are effective. 13 Many experts agree that more and better research is needed. 5, 6 Cranberry juice may prevent cystitis, but so far evidence is lacking to show it can be used to treat cystitis. Cranberries, blueberries, and other foods that may help prevent cystitis recurrence are rich in flavonoids (including anthocyanins and proanthocyanidins) plus contain mannose and a host of other components that may help. 14, 15 D-mannose is a naturally occurring simple sugar contained in cranberries, blueberries, other berries, and other foods. D-mannose adheres to the bladder epithelium and, in essence, interferes with the ability of E.coli or other bacteria that are not normal inhabitants of the urinary tract to adhere there. Then the bacteria or other foreign substances can be flushed out of the bladder with the urine. To date, research on the effects of isolated D-mannose is very limited. Little is known about the safety of long-term use of D-mannose supplements. There are some potential side effects such as bloating. When taken in excess doses, it may stress or damage the kidneys. Foods containing d-mannose (along with all their co-workers) may be the best choice. 16, 17 Lactobacilli bacteria are a normal component of the urinary and genital flora of healthy women. Various strains of Lactobacillus have been found to be helpful in preventing and treating cystitis and other genitourinary problems. In a double-blind trial, L. rhamnosus GR-1 and L. reuteri RC-14 were found to be not quite but nearly as effective as antibiotics for preventing UTI recurrence.