Urinary Tract Infections after Bladder Cancer

July 11, 2022

With Krisztina Emodi, NP

Year: 2022

You can read the full transcript of Urinary Tract Infections after Bladder Cancer at the bottom of this page.

Part 1: Diagnosing Urinary Tract Infections

Video (20 min) | Transcript (PDF)

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Part 2: Working Up Urinary Tract Infections

Video (16 min) | Transcript (PDF)

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Part 3: Preventing Urinary Tract Infections

Video (8 min) | Transcript (PDF)

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Part 4: Question and Answer Urinary Tract Infections

Video (14 min) | Transcript (PDF)

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Full Transcript of Urinary Tract Infections after Bladder Cancer

Stephanie Chisolm:

Hello, and welcome to Urinary Tract Infection After Radical Cystectomy. This is a Patient Insight Webinar from the Bladder Cancer Advocacy Network, and is supported by our sponsors. An untreated urinary tract infections can turn into very serious problems and need immediate care, so BCAN is delighted to welcome nurse practitioner, Krisztina Emodi, from the University of California San Francisco, for a discussion of UTIs after bladder removal. Welcome, Krisztina, it’s so nice to have you. I know you work with a lot of patients who have UTIs, and this is a really important topic for us, and we’re really delighted to have you with us.

Krisztina Emodi:

Thank you so much, Stephanie, and thank you to BCAN for having me. I feel like as a nurse practitioner, I’m really bridging between our fabulous nursing team and our incredible surgeons, and I have a unique role and opportunity to interact, really with our patients and see the full spectrum of recovery, and all the challenges that come up over time. I would like to address in the next 45 minutes to an hour, just some basic anatomy of what a diversion looks like, distinguishing between an infection versus having asymptomatic bacteria in the urine, understanding some of the diagnostics and treatments as it relates to infections found in bladder cancer patients.

I will have some information on patients who have non-muscle invasive bladder cancer undergoing either BCG, but I think, really the bulk of this presentation will focus on people after diversions, and how to work around this. Identifying situations when antibiotics absolutely should be used, have to be used. Identifying clinical situations when suppression is beneficial, and many of you might have heard of antibiotic suppression on shorter or longer term to control urinary tract infections. Then I think, ultimately, really the main goal is how to prevent these infections, what are the helpful supplements, and how do we work the magic in your gut, so to speak, because they’re all connected to the gut at some point.

When we’re looking at definitions of infections in a regular urinary system, they’re divided into simple and complex infections, just by the nature of our bladder cancer, whether you have invasion, no invasion, diversion, BCG injection, we are all in the complicated urinary tract infection domain. What this implies, is that generally people have some sign of infection, whether that’s a low grade fever, you might have some systemic illness, chills, fatigue, malaise, maybe some flank pain, nausea, vomiting, but I think the overlying arch after cystectomy, is that people just wake up and the very next day they feel like you have a cold or a train hit you, and the day before there was absolutely nothing went on with you. I oftentimes see that people overlook this symptom, and so you may have had a few infections on board, and then you start to recognize your own symptoms. Oftentimes not a single symptom is really coming by itself, meaning generally people would feel, “There might be some smell and change in my urine. There might be more mucus. I feel more tired. I had some low grade fever a few days ago.”

Krisztina Emodi:

When we are looking at recurrent infections, and this talk will focus on that also, sorry, it’s really … the clinical definition, although some people disagree with this, clinically, two episodes of an infection in six months or three episodes of symptomatic infection that needed treatment in 12 months. I’m going to just touch base on a very basic idea of pathogenesis of having a UTI in women, and obviously this is prebladder removal, but it still will have applications post-removal. So the colonization of the vaginal wall and the area between the rectum, your vagina and the bladder, is basically full of uropathogens, predominantly E.coli. E.coli is obviously coming through the rectum, most of the time with food, and there has been a lot of research linking, predominantly poultry and turkey, how those E.colis, the bacterial colonization is passed from animal product to humans. When you excrete this E. coli there is usually colonization between the vaginal wall and the bladder.

There are very particular little arms of pili that this bug gets attached to, and basically gets internalized into these highly specialized cells in the bladder or the bladder wall, creating symptomatic infections. When we are looking at studies, there have been 12 different strains of E.colis that have been found that share common genetics, common microbial resistance, or antibiotics susceptibility between meat, poultry, and human strains of E.coli. I do believe personally that what you eat, either pre cystectomy, post cystectomy is really important, and it should generally help you to decrease some of the colonizations, however that is E.coli specific.

The GAG layer is an important, very cool layer in the bladder, so to speak. Again, this is focusing on people with bladders. The GAG layer is a very specific, very thin, and mucus-like layer that protects the epithelial cells in the bladder. It is having a specific permeability to kind of let good things through, and block out pathogens or block out toxins that are in your urine. Once this GAG layer gets disrupted, again, people undergoing BCG treatments, intravesical treatments, people having these treatments, and now they’re dealing with cystitis or bladder pain syndrome. Generally, we focus on the rebuild of this GAG layer. I think this idea has been around for quite a long time. There have been some intravesical therapies to rebuild the GAG layer, however some of it, I think, is questionable, looking at data and safety. There is one … basically, this is to protect, a supplement that people are using to help with this rebuilding. In my personal experience, when people actually need to rebuild tissue, hyperbaric oxygen has been the most successful long-term solution, because you can’t rebuild these layers very fast. It takes time and patience.

Krisztina Emodi:

Now, to launch into diversions, and I really want you to have a good understanding what your diversion looks like. I will be focusing on both the ileal conduit and neobladders, along with the Indiana pouch. However, I think ultimately the understanding is about the same, once you have had bladder cancer, leading to removal of your bladder, we are needing to utilize the small bowel to reroute your urinary system. I really like this picture from some of the Core Curriculum Ostomy Management trainings that we did, because I feel like a lot of patients don’t have a clear understanding what’s connected where, and why are we getting infections oftentimes. For us to reroute your urinary system, we need to go upstream from the terminal ileum. This is basically the end of the small bowel, so the end of that curve connecting into the large bowel, and there’s a valve that blocks the flow of stool going backwards in the small intestine basically. It is really important because your small intestine’s job is to produce mucus, absorb nutrients, and we have trillions of bacteria living in our gut.

Once we make this triangular resection, and we suture the bowel back together, so this is your anastomotic site from surgery, the triangular shape, which kind of looks like a pizza here, is brought to the surface area via your stoma. Your stoma is sitting in the right lower quadrant of your abdomen, the bowel mesentery, lymphatics, vascular structure, blood flow, again, your gut microbiome is a 100% connected to the rest of your small bowel and GI function. This is the first point of needing to understand that without having a healthy gut, it’s very difficult to avoid ongoing infections because your urinary system now, as you can see on the bottom portion on the right of the first picture, your ureters are directly sutured into this terminal ileum in a form of your conduit, and now we are all connected.

Krisztina Emodi:

In the neobladder it’s very similar. We are removing nearly four to five times more bowel tissue for us to reconstruct a neobladder. Your ileum is approximately an inch. We are needing to reconstruct the sphere from cylinder. There’s lots of surgical clips for us to reconstruct. On the right side, you see the chimney of the neobladder, and the ureters are connected to this chimney. Bottom line is, between these two systems, there is no valve to block the reflux of urine into the kidneys, into your ureters, both of these systems produce mucus, and the stagnating mucus is a very high infection risk if people not empty properly.

The clinical considerations that I always have, and these are just questions in my head when I see my patients, if you have had no cystectomy yet, but again, you’re under bladder cancer treatment or intravesical treatment, “Have you had any cystoscopy recently? Instrumentations? Any tumor resection? Have you had any cystitis? What have you worked with? Have you had any pelvic floor evaluations leading to urinary tract infections? Any urodynamic studies that are very helpful oftentimes when we are not knowing what to do, and we keep having issues?” GI management and constipation. People who are constipated because your bowels are interior very … much more likely to develop basically urinary issues over time versus people who are not, or who have, again, healthy GI flora. After diversion, if somebody keeps having infections, the very first question in my head, “Have you ruled out actually any structural abnormalities? Have you spoke to your clinician if you haven’t had a recent renal ultrasound, or you haven’t had a recent scan?”

Post-COVID, I feel like a lot of people … unfortunately, everything has gotten pushed out along the block further. We need to evaluate that you don’t have any strictures, so where the ileal conduit and the ureters are reconnected, you want to be sure that nothing is strictured down there, and the actual mechanics of the conduit is intact. Have you formed any stones? Your bladder is impermeable, and basically you’re not absorbing or reabsorbing any electrolytes or toxins from the urine. When you had diversion, unfortunately, your bowel is functioning just like a bowel tissue, it would be absorbing things, and potentially forming stones. Sometimes there’s potentially a stone sitting in the back of the conduit, or very close to where the ureters are connected into the conduit. This is very easy to see, even in clinic, we don’t necessarily need a cystoscope. Sometimes I can just actually use a tube that we use for blood draw, and I can put the curvy end of the tube inside the conduit, shine a light, and I can actually see, mostly all the way to the conduit.

Krisztina Emodi:

Stone stenosis, this can happen both for ileal conduits, or it can happen in Indiana pouch. This is basically the real narrowing of the stomal OSS, to the point where urine is sitting in the back of the conduit, unable to drain properly, leading to urinary reflux through the ureters, potentially causing dilation of your ureters, and the dilation of your renal pelvis, because urine is no longer “sterile,” and you are now having mucus mixed with this urine that is refluxing. Think of it like pond with algae, instead of having a beautiful river floating and having trouts jumping at you, really important to know that the actual flow is proper. If we have a basic ultrasound, and we are thinking that there is actually stricture or hydronephrosis, or hydroureter, your clinician needs to rule out that it’s actually a real stricture. Your kidneys need to function 50/50, and the next step is renogram, which is a special nuclear scan for us to answer that question.

I think bottom line of this slide, once the mechanics are rolled out, then we can move on and discuss why do we develop these infections, and what needs to be happening with your workup and prevention. In the conduit, your main thing, again, is drainage, so this is your simple stuff, that I still run into patients occasionally from who had surgery 15 years ago, not connecting religiously to their overnight bag, not emptying your ostomy bag on time below the level of the stomas. Again, once urine goes above it, we are back-flowing into that conduit, refluxing into the ureter. Is your skin intact? How are you doing your ostomy care? For example, if you are having major dermatitis or moisture-related yeast on the skin, that can also affect your urine and potentially people can come down with a massive yeast infection, both on the skin and within their urinary system. Again, are we taking any supplements, diet, probiotics, et cetera?

Krisztina Emodi:

The neobladder is slightly different, because once the bladder is resected we are removing all nerves connected to the bladder. The formation of this information from your bladder to communicate to your brain, when you have a bladder, when to pee, is actually very complex. Once it’s resected, your neobladder is basically a pouch inside, if you’re not emptying that pouch properly, again, with stagnating urine and mucus, you are at a very high infection risk. Do you self-catheterize? What is your catheterization routine? How often do you catheterize? Do you know how much residual urine do you have? At night, do you get up at night? A lot of times people get very tired from getting up, I think more so within the first six months of surgery. I’ve had patients using condom catheters because they were so exhausted, and over time, this again, led to having not only a urinary tract infection, but massive pyelonephritis. I think the equation that I sort of came up here with combination of mucus, and stagnating urine, leading to bacterial overgrowth, leading to an infections.

Probiotics have been shown effective in multiple clinical trials. Again, I think a lot of it has been targeting E.coli specimens that are particularly colonizing rectal and vaginal areas. However, I think the bottom line is that having a healthy microbiome in your gut will be affecting the rest of the health of your conduit, and the neobladder, how everything is connected.

Some of the foods that can affect your conduit or your neobladder. I’ve had a few questions regarding smell. Smell is not necessarily an indication in itself whether or not you have an infection. I think, when I said at the beginning, usually symptoms don’t come by themselves, so if you just have really, really bad smell, but no other symptoms, you might have some over colonization, but also there are very specific odor-producing foods that are affecting your urine smell 100%. These are from the United Ostomy Association site for food chart, and you can download it. They have their PDF reference for all kinds of additional information, and I find it very helpful, and then just some simple ideas of how to control odor if it’s truly regarding odor.

As far as diet goes, I usually get a lot of questions how to prevent things. The book that we use at the UCSF Cancer Center is called The Cancer Fighting Kitchen from one of our local authors, Rebecca Katz, from the North Bay here. Although this is not specifically plant-based, it does have some meat that she incorporates. It is very heavily focused on cancer prevention, and just really getting mostly plant-based diet, along with different methods of controlling chemotherapy or immunotherapy related side effects that patients potentially experience. I think this is a fabulous gem that I found over the years, and I use it pretty much every day in my clinical practice. So I have a … Stephanie, I have a few questions?

Krisztina Emodi:

Okay, perfect. Again, when I meet my patients we like to go from here, and what our workup should look like, and how do we think about this from a systemic standpoint. People with a bladder, generally we want to have a very detailed history of any previous infections. I want the microbiology of those infections, the susceptibilities from your physician, whether or not you are post-menopausal, this is very, very important, and I think oftentimes overlooked, because women responds to vaginal estrogen very nicely. Generally, there is atrophic vaginitis as we age, especially postmenopausal women. Once we withdraw estrogen there is a significant decrease in volume of the muscular structure and the wall of the vagina. There is some pelvic floor instability. There’s increased, basically the connective tissue and this looseness in the ligaments in the pelvic floor. Estrogen stimulates the proliferation of lactobacillus, which is your kind of, sort of your best friend. It allows for vaginal pH to drop, and really allows … and prevents colonization of different pathogenic bacteria. Again, these are folks with having a bladder.

Men with bladders are slightly different, because if you have a man with a bladder, with an infection, it’s automatically considered to be a complex infection, which I think it’s a different topic. The questions I have for my patient’s status post cystectomy, again, “What are your symptoms?” Because you’re not going to have the regular, “I have maybe a lower abdominal pain. It burst when pee, I pee every hour,” because you either have a neobladder or you basically have urostomy on your abdomen. So status post cystectomy, we might observe the low grade fever, increased mucus, foul-smelling urine. I think again, the biggest observation over the years from my practice is having generalized fatigue, and by far this is the most common symptom, and overlooked. Personally, I will always get, depending on where we are, if I’m not a 100% sure what we are doing, I will get a UA and microscopy with what we call a reflex culture. Important to be reflex culture because this way, if there’s enough abnormality or enough white cells or bacteria picked up on this, the lab is automatically culturing the specimen so nothing gets lost.

Krisztina Emodi:

Oftentimes when I deal with bladder cancer status post cystectomy, I don’t need the dip, a UA microscopy, in real life, is not very helpful because we are not dealing with sterile urine. Your UA and microscopy was developed for people with bladders, and we are looking at very particular values, whether you have hemoglobin in your urine, whether you have bacteria in your urine, so none of these things are applicable. I always tell my folks living, especially further from us, “Anytime your clinician orders a UA/microscopy, just ask what are they looking for.” If they’re ordering it for your annual visit, because they want to be sure if you have diabetes, you’re not spilling sugar, you’re not spilling protein, you’re not in ketosis, those are very valid reasons to order a UA/microscopy. However, if you’re just looking for an infection, we need to go straight to culture.

Unfortunately, what ends up happening oftentimes, asymptomatic post cystectomy bladder cancer patients end up getting a UA and microscopy, goes to culture, comes back positive, and guess what? You are put on cycles and cycles of antibiotics and treatment, which is at this point really unnecessary. This clearly would foster potentially antibiotic resistance and overtreatment, to a point where we might be knocking out an entire class of antibiotics in a clinical scenario when you actually are asymptomatic.

I also look for any kind of shifts in your blood work. I will get blood work. Usually I want my CBC to have what we call a differential, the differential is this little tiny information, breaking up the different cells in your blood. Even if before your white count gets high, I can see from the differential if something is brewing up. To me, it gives enough information, especially if it’s a Friday afternoon and I need to have someone on treatment over the weekend. I want to see your creatinine. I want to see your filtration, again, this can indicate dehydration if you’re not feeling well. If your creatinine is significantly different from your baseline, let’s say your baseline is 1.1, now your creatine comes back 1.9, you’ve hydrated, then I would be getting a renal ultrasound to be absolutely a 100% sure that I’m not dealing with a stricture, or something mechanical that needs to be addressed.

Krisztina Emodi:

I got lots of questions about collection. Collecting from the stoma directly is a must, or from a brand new bag. So, if you have a two-piece system, you can detach the bag, leave the flange on if you just changed it the day before, and your bag must be brand new. Anytime you have hours of urine in that bag there is bacterial overgrowth, and whatever else I’m going to get is not going to be accurate. If this is not possible, if you have a one piece bag, obviously you have to take the bag off and change it to collect the stoma directly, or if you have stenosis or unable to collect for some reason from the bag, or I really want the “cleanest catch of urine,” which I will do it in clinic if I need to.

There is a very tiny red rubber catheter that people can use for self catheterizing. I will insert a red rubber catheter without any lubrication. I don’t want anything disrupting my sample. You can insert this directly into the stoma, and just have the end of that red rubber to drip into a urinary collection cup. The red rubber is not going to hurt your stoma, if you push it in too far it’s literally going to hit the back wall of that conduit, and turn around and come back at you on the other end.

Krisztina Emodi:

I generally also check Vitamin D levels in all my patients, although this is not necessarily UTI-related, partly because so many people are deficient, but vitamin D also enhances some antimicrobial peptides that are produced in the urinary tract. The theory goes that this potentially helps protecting from microbial invasion, basically helping the bladder epithelium. I absolutely want all my patients to have high normal D levels, and I would say when I check D levels, maybe 60% of my patients are actually deficient, thinking they get enough D from the sun, which is not the case.

General workup for both diversions. If you’re asymptomatic I will start your treatment based on your renal function, based on any previous culture-resistant patterns that I’m able to identify on your reports, your allergy profile, and what medication have you treated with last potentially. This is called treating empirically, which means it’s a Friday afternoon, you don’t feel great, I am suspicious that you are coming down with an actual infection by tomorrow, but it’s a Saturday. As long as you collect your urine, which takes two to three days to finalize with your culture and susceptibility, I’m able to start you on treatment. Generally, I will send in whatever the best medication I think, it is generally Septra, or Augmentin, Macrobid. I try to stay away from Fluoroquinolones, this is your Ciprofloxacin, Levaquin, these are the medications with the black box warning, and can actually be very harmful even in therapeutic doses.

I feel like the further we get from major hospitals, smaller clinics, very often treat patients with Ciprofloxacin. Important to know when to use Ciprofloxacin or Levaquin, and predominantly we want these medications to be brought on board, but I’m suspicious of pyelonephritis. I have had questions about pyelonephritis. Basically the difference between having a “urinary tract infection risk of pyelonephritis,” is now this bacteria that is colonizing your neobladder or your conduit is ascending through those ureters, ascending into the kidney and causing a massive potentially infection. Pyelonephritis presents usually with tenderness in your back and mid back, that’s called a CV tenderness. You will have a higher grade fever, so if your fever, 102 chugging towards 103, that is definitely pyelonephritis versus just a standard UTI. Adults do not spike high fevers like that. The differentiation, again, I’m trying to avoid an admission to the hospital here. I will start somebody on Fluoroquinolone, because those are the only medications actually that can treat pyelonephritis outside.

If a neobladder, similar situation, you might have decreased urine output, difficulty with stream, difficulty emptying, there is a clinical situation which is called hypercontinence, simply you’re unable to avoid, and you have to self-catheterize. Sometimes people developing upper respiratory infections, because histologically some of these cells develop similarly from long tissue versus urinary tract. Oftentimes, I will see people with the neobladder having upper respiratory issues, and their neobladder can go haywire literally. We want to be mindful of respiratory infections. Again, any stenosis, any stones, this is predominantly important for the Indiana pouch.

Krisztina Emodi:

If I have had multiple workups, complex infections, nothing’s working, I’m working with a company called MicroGenDX, and this is … I’m not part of any of these companies, it’s just I’m using their urine PCR. It’s a very cool test in a way that when you look on the left side I see all the bacteria, all the colonic counts and everything, whether you’re resistant to oral and IV compatibilities, when I’m really hitting the end of my road trying to figure out what is happening to someone. The most common bacteria we find are gram-negative, so this is again your E.coli, Enterococcus, Klebsiella, Pseudomonas. Again, if your skin is not intact, like my most recent patient here, if I’m needing to treat yeast on the skin, this yeast can crawl through back into the stoma, and potentially we have a yeast UTI along this. Your skin absolutely must be a 100% intact, along with not having infections.

I wanted to present a few cases. These are all my patients who I’ve treated over the years. I have a 71-year old university professor, status was cystoprostatectomy node dissection, January of 2018. Later, we all said to remove the urethra because of cancer, and just in the side notes, if there’s any discharge from the urethra, especially for men, that has to be addressed with your clinician to be sure that there is no cancer recurrence in the urothelium. In men, generally the urethra is left behind after your surgery. This patient had ongoing infections, all symptomatic, started about a month after his surgery, ongoing fatigue, foul-smelling urine, low grade fevers between January of 2018 to October of 2018. We had eight different infections that I had to treat.

Krisztina Emodi:

When you’re looking at a dip from an ileal conduit, and this is from a new bag or from the stoma directly, it is very inconclusive. I’m expecting a positive nitrate. None of this is really making or breaking what I’m doing, but again, some labs require the dip before we culture. When you’re looking on the right side, there is three different pathogen growing along with yeast. This person actually had probably fairly intact skin along with Enterococcus, and I think … here it is, Klebsiella. So, susceptibility for your clinical team is really important so I can actually look at this, and determine what medication you need to be on, and for how long.

Second person is a 44-year old female with a neobladder, August of 2018. Her postoperative course was very complicated, multiple readmissions, multiple infections, IV antibiotics, oral antibiotics, nothing really worked. Over time we figured out that she had fairly poor neobladder management, not getting up at night. She was a very deep sleeper, slept through three alarm clocks, but at the end of the day, these infections were ongoing, leading to hospitalizations every time. So I sort of run off the clinical pathway here, and I started what we call Gentamicin instillations into her neobladder.

There is clinical evidence that in high-risk situations you can reduce ongoing infections that are not systemic, meaning your Gentamicin is instilled into the bladder, so she’s using basically a catheter. Using a syringe you’re putting in this Gentamicin mixed with normal saline. We clamped the catheter, she sleeps with it for four hours then she drains it. She still has some infections, however, every time, I guess, susceptibility, she’s still responding to Augmentin, which is the first medication. She will have Augmentin on hand just because, I’ve known her for so many years, she still will have some fevers over time. Thank God this regimen actually has worked for us. If anybody has some of these complex infections, Gentamicin and how to use this is in the link that I have sourced here.

As far as prevention goes, it is not as complex, I think, as people think, because your GI tract, again, and the gut microbiome is containing trillions of organisms, bioactive substances, neurotransmitters controlling your immune system produces serotonin. I think it’s one of the most incredible systems that we have that we didn’t know so much about. Because of how your conduit, again, is connected, it’s very important trying to keep this gut microbiome as healthy as possible. Over the years, and again, I have no association with any companies, my question was, “Probiotics, are they all the same?” Because people will tell me, “Well, I’m taking Probiotic X from the store, and I don’t want to be paying a little bit more for what you would like me to take.” I don’t think all probiotics are created equal. There is a fantastic site through the International Scientific association, you can see their little logo on the right side. This is an organization, professional organization of pro and prebiotics. You can actually look at tables clinical trials. You can look at the data, what it treats, what trial was done on what particular system.

Krisztina Emodi:

I chose Visbiome seven years ago because this was the only probiotic coming back with documented trial information, helping with what we call pouchitis. Pouchitis is when you would have inflammation technically in the Indiana pouch. Now, because we are using small bowel in the other two diversions also, I made my own deduction that, well, Visbiome should be working, I think, for everybody else. Because lactobacillus is one of the most important probiotic strains in the gut to not allow the overgrowth of the rest, it has very particular strains, very particular quantities. The company sends them on dry ice. This has to be refrigerated. They come in a box with temperature control. This is the highest quality probiotic I’ve seen. I would like all my patients to take one per day, and generally people have been doing really well on this. The first case study that I mentioned, where my patient had eight months of symptomatic infections, when something is really inflamed or we are really trying to increase the concentration, there is a powder formulation that is 900 billion organisms per pouch, that needs to come from your provider as a prescription because it’s considered to be a treatment. So long story short, after the last positive culture, we kind of threw all hands on deck, he was taking for 30 days the very high concentration, and eventually I put him on suppression.

Antibiotic suppression is done after your last negative culture, and it is very particular what we use. It can be a single-strand structure, which is Bactrim, Keflex, or Macrobid. People who have had ongoing infections, once you have had a negative culture, and you don’t have any of the structural strictures or mechanics that need to be dealt with, there was an 80% risk reduction in recurrence. I think that’s a really important number to know. If things are not draining properly, or you have stenosis at the opening of your stoma, oftentimes I will see that again by worsening creatinine because you’re backing up. I will be inserting a red rubber into the stoma, not only to now collect urine for culture, but actually we can have the red rubber sitting in your stoma, the end of that goes into your urostomy bag, and you’re actually draining properly. I have lots of patients who have red rubbers in the stoma, who catheterize a few times a day to empty properly, and it’s a very well accepted method.

Krisztina Emodi:

Hiprex, you might have heard of this. This is an antiseptic supplement. It basically kills bacteria. There has been over 13 randomized controlled trials and studies looking at how this medic … not medication, supplement works. Basically, it inhibits cell division, and these pathogenic bugs sticking to your urothelium, not necessarily specific for having a conduit or a neobladder, or having a diversion. However, there is still urothelium within your ureters, in the kidney, and acidifying the entire system has not been harmful. Let’s put it that way.

Probiotics, again, I use Visbiome particularly, also BioK+, which is a liquid form. You can buy capsules, but I would highly recommend getting on a site from what I referenced, actually look what’s available and clinically proven. D-Mannose doesn’t have that many trials, there is one randomized trial with really good results. It’s very similar to sugar, and it’s basically blocking the little arms and pili of the E.coli to stick to urothelial receptors. There’s also suppression or … sorry, not suppression, but basically some supplements that they’re able to use. People who have a bladder, again, Uqora has been successful for some of my patients, and it has kind of a similar composition that we would have in different supplements. Obviously, the dosing and their concentration is a proprietary information, but I have patients with bladders with frequent infections, who do well on Uqora.

Krisztina Emodi:

Neobladders, if you are catheterizing, very important not to reuse any catheters, trying to use hydrophilic catheters. These are your catheters that come, there’s a little sleeve, everything is sterile and it’s lubricated, depending on the concentration. But basically when you are pushing the catheter through, no part of the catheter is touched by your skin, and everything is as clean as possibly could be. Sometimes people with neobladders or the Indiana pouch, you need to irrigate. You need to irrigate your neobladder to irrigate the mucus out. You need to irrigate your Indiana pouch for better maintenance.

Gentamicin again, I’ve currently only installed for a neobladder, and currently I’m thinking of how to do this with an ileal conduit, with some of the complex scenarios I have. You can actually install the Gentamicin using a cone that they use for colostomy irrigations. Last but not least, this is not available in the United States, available some parts of Europe, the Uro-Vaxom, which is basically a preventive immunotherapy capsule that has been very, very successful. Again, study people in bladders, however I think there’s a lot of deductions that we are coming to over time, and when and how this will be available, I’m not sure. But the data I’ve seen from Europe is very, very promising with nearly an 80% reduction in recurrent UTIs in people. Thank you.

Stephanie Chisolm:

Krisztina, this has been fabulous. I know that everybody is submitting a lot of good questions so I’m going to ask you to stop sharing your screen for a minute, and then we’ll just get to have you so that people can see you. We just need to turn off the screen share. There we go. Hang on one second. Let’s try to get to as many questions as we can. There was one that came in very early about traveling, and if you’re not able to carry everything that you need to like the vinegar and water, can just rinsing out the night bag avoid or reduce the risk of developing a UTI, if you don’t have all of the supplies to really clean it well?

Krisztina Emodi:

I think, actually as long as your overnight bag is connected below the waist, it’s draining to gravity, nothing should be ascending back into the urinary system. I think white water … white vinegar and water mixture, that is my go to, and I think rinsing it with just about anything. You can honestly squeeze lemon juice into your water and have some acidic rinse of that tubing, but generally it should not require anything major. It is not a sterile system, and as long as it’s rinsed and air dried, and draining below gravity, I think you should not have any issues.

Stephanie Chisolm:

Here’s a related question. Does urine backflow from the ostomy bag into a conduit ever, or sometimes? From the ostomy bag back into the ileal conduit itself, and could that lead to problems?

Krisztina Emodi:

Yes. So, it can, because even though it’s a low-pressure system by definition from surgery, if you keep emptying your ostomy above the level of the stoma, so we are going continuously above, instead of you emptying your bag half-full or three quarters full, the moment we get above the level of the stoma there’s nowhere else to go besides that flow. Once you have that stagnating urine in the conduit, because it’s not a continent reservoir like the neobladder, it will a 100% reflux back through the ureters to the kidneys.

Stephanie Chisolm:

Okay, and that does put you then at increased risk for developing infection?

Krisztina Emodi:

Yes. The outflow of your plumbing needs to be very precise, and as … flow as possible, this is where when I do my preop preparations, I try to present things in what’s negotiable and what’s non-negotiable. Connecting to your overnight bag is a non-negotiable, because over time you are going to make your renal function worse, you are back-flowing. We potentially put you in a much higher risk for infections, but also, I’m trying to look at in 10 years, how is your renal function going to be when we’ve had maybe 10 infections that I needed to treat?

Stephanie Chisolm:

Okay. Well, here’s a question about prebiotics, probiotics, do you need both? Are you thinking people should take them even if they don’t experience UTIs just to reduce their risk?

Krisztina Emodi:

I think so. The benefit of probiotics is not only linked to bladder health. I think there’s a lot of studies coming out of immune response, antigen production. I think the healthier you can keep your gut, the better off you are. Now, I think obviously if you have not experienced any infections, and probably your diet is good, and your body is responding in that matter, do you have to take it? I don’t know. I don’t want to say you have to. Obviously you’ve been doing well, but that would be certainly the first thing I would be thinking of.

Stephanie Chisolm:

Okay. A few people that were curious about where you can get Visbiome, and they wanted to know do you need a prescription for it?

Krisztina Emodi:

No, so Visbiome needs to come from the company directly, it’s visbiome.com. If you go on their site you just click on under products, and you click on capsules. Once you place your order, they ship Monday, Tuesday, and Wednesdays, again, on dry ice with the temperature control. That product does not need prescription. The higher colonic count powder, which is 900 billion instead of 112, that I use for very severe situations, that needs a prescription, but other than that, you do not.

Stephanie Chisolm:

There’s somebody on here that uses a condom catheter at night, and is able to sleep through the entire night undisturbed. Are you saying that condom catheters can cause bacterial infections in the neobladder? Or is there something that, from the other elements that you were just talking about, with gravity and other things, that he should be paying attention to?

Krisztina Emodi:

I see, Mr. Pearlman. Condom catheters, it’s a slippery slope, let’s put it that way. I would challenge to ask a question, if you are leaking urine through the neobladder inter condom catheter, do you empty your neobladder? I think the answer to that is no, because you still have stagnating urine in your neobladder with mucus. Leakage is not empty. Leakage is related to incontinence. The moment you fall asleep, and all those sphincters and all your nice muscles relax in a situation with neobladder, we know that nighttime continence is one of the most challenging parts of long-term survivorship and recovery. I think condom catheters are fine as long as, let’s say, you actually do get up once a night to physically sit on a toilet, and empty that neobladder.

Krisztina Emodi:

Rule of thumb that Dr. Porten and I use at UCSF, you should never go more than six hours without emptying her neobladder. It’s okay to get up once a night, if she, let’s say, go to bed at nine and you wake up at two, and then you get up at 6:30. Generally speaking, ideally twice a night. So I think condom catheters, with this stagnation mucus, what’s coming out is leakage, it’s actually not residual urine, is definitely, in my clinical experience, have put patients at a higher risk.

Stephanie Chisolm:

Okay. Is changing a pouch only once a week increasing the chance of the UTI?

Krisztina Emodi:

I wouldn’t say that increases the chance if your skin is intact. The important thing is when you take your flange off and you look at the back of that flange, which is hydrocolloid, that hydrocolloid really puffs up from moisture. You can see how far of that hydrocolloid goes to the edge of the tape, if you’re very, very close, you’re probably really at the end of the wear time of that pouch. Again, in an ideal situation, just for skin health and hygiene, generally it’s recommended to change the pouch every three to four days, just because your skin should see water. I encourage my patients to, first thing in the morning, take a shower, take the bag off in your shower, and have your skin deal with normal water situations like your normal skin. But I think in itself, as long as, again, you are not getting above the level of the stoma, it’s fine. If you use a two-piece bag, because you get so many supplies, 20 per month, which is a lot, you can also just change the bag in the front if you don’t want to change your flange, so that way your bag is actually uncolonized and clean.

Stephanie Chisolm:

Okay. Should a neobladder patient sleep on an incline to minimize reflux?

Krisztina Emodi:

I don’t think so. I mean, great question if positioning and whatnot, that helps, I haven’t seen any evidence that that would be an issue or helpful. It’s really more so emptying on time and catheterizing. If you have residual urine and we don’t know about it, self-catheterization is a tool, you need to think of, “I’m in a dark highway and there’s no triple A, and I need to change my tire.” So that’s your catheter, it’s a tool, it’s a tool to use and make your best friend.

Stephanie Chisolm:

Okay. Here’s somebody who’s had a UTI every two months, sometimes very bad and became septic. “I take back Bactrim three times a week, probiotics, D-Mannose, cranberry pills, drink three quarts of water a day and eat Activia. What else do you recommend? One doctor wanted to put me on Bactrim every day. They come on very quickly and I become very weak, sometimes I get the chills.” Is there something they could be doing prophylactically beyond all the other things that they’re doing?

Krisztina Emodi:

I assume that you have been ruled out for any of the structural things I mentioned at the beginning of the talk, and again, a very simple renal ultrasound can do, before jumping into a CT or MRI, or a renogram, or any of these things. My first question is, are you draining properly? Because if there’s any mechanical issue, no matter how many times you’re treated it’s not … it’s a bandaid, you’re not addressing the flow problem. So if that hasn’t been done, that should be done. If that is addressed, then I think the moment you have a negative culture, I would ask my clinician, or if they’re not as well-versed, to potentially get an infectious disease consult from an ID doctor, where they can literally look at all your cultures as susceptibility side to side, see what the common bug was, and oftentimes I find antibiotic suppression helpful, so to kind of get you over that hump. Whether or not, what will I choose will depend on, again, your renal function, allergy profile, what do you tolerate.

I prefer to put people on Keflex or Macrobid versus Septra, because Septra can actually influence and make your creatinine worse. I’m kind of cautious when I use what, I think suppression is definitely … I would be having a conversation with you about that. Also, I would try to see if this probiotic would be helpful for you, and if there’s potentially any backing up in the system. If you have a two-piece urostomy, you could ask for a red rubber catheter, depending on the stoma opening, which would be a smaller one, like a 14 French or 16. If you’re able to have a two-piece system, I will ask my patients, “Let’s try catheterization. Let’s take your bag off three times a day. You insert the catheter and there’s a bunch of urine coming out that has been backing up.” So those would be my initial suggestions.

Stephanie Chisolm:

So there’s a whole bunch of good next steps to follow through to see what’s happening.

Krisztina Emodi:

Yeah. I think suppression has a very valid point, but I only start suppression when you are fully treated. We have what we call a test of cure, so then your culture is actually negative, again, from the stoma directly from brand new bag, or your clinician can call you into office, insert the red rubber, collect as clear as possible and clean into a cup. If that comes back negative, then I actually go back on the previous susceptibilities, and look at which antibiotic did not show any resistance that I could suppress with. Again, those three that we talked about, and I would give it a try for three months initially and see how you do. Ciprofloxacin though is not my go to, as I said before, it’s a black box warning from the FDA medication. UCSF has taken it off from our clinics for biopsies. It has to be used with a very good reason in your head, “Why am I using Ciprofloxacin?” If there’s anything else available, I physically document in my notes why am I taking this over that, when it’s a lot more, potentially harmful than … Even in treatment doses, you don’t need to overdose on Ciprofloxacin. In simple doses Ciprofloxacin can be harmful if you have any heart abnormalities, any tendon issues, it can cause tendon ruptures, et cetera. I would not wanting you to be a Ciprofloxacin every six weeks or every other week. That’s that’s not my … that would not be my management.

Stephanie Chisolm:

Okay. Well, I think that you’ve really addressed all of the questions, because the last question was dealing with how dangerous is Cipro every other week, and we are at time, so Krisztina, thank you so much.