Download URINARY TRACT INFECTIONS Tieraona Low Dog, MD

URINARY TRACT INFECTIONS
Tieraona Low Dog, MD
The urinary tract of otherwise healthy individuals is relatively resistant to bacterial
infection. The urinary system has multiple, redundant systems to help protect itself from
microbial invasion. Normal bladder-emptying mechanisms impede bacterial
multiplication. The low pH and high organic acid concentration of urine make it capable
of inhibiting the growth and proliferation of numerous microorganisms. Urinary
frequency experienced during a UTI is, in part, a physiologic attempt to “flush” out the
microorganisms via increased diuresis. The epithelial cells of the bladder are coated with
a type of mucus (uromucoid) that helps to prevent the adherence of bacteria to the
bladder wall. Tamm-Horsfall protein (THP), produced in the kidney and secreted into
the urine, is a urinary protein that binds specifically to type 1 fimbriated E. coli, the main
cause of UTI of women.1 Research has shown that the kidney produces defensins-antimicrobial peptides that play a pivotal role in nonspecific host defense.2
In spite of these mechanisms, urinary tract infections (UTI) are one of the most common
bacterial infections in humans, accounting for more than eight million patient visits per
year.3 Acute urinary tract infections (UTI) are primarily a disease of young, sexually
active women. Approximately one in three women will experience at least one diagnosed
UTI necessitating antibiotic treatment by the age of 24, and 40% to 50% of women will
experience at least one UTI during their lifetimes.4 The annual cost to healthcare services
reaches $2 billion in the United States alone.5
UTIs have been traditionally classified according to the anatomical site of the infection.
Examples of lower urinary tract infections include cystitis, urethritis, and prostatitis,
while pyelonephritis and perinephric abscess are examples of upper urinary tract
infections. Cystitis and urethritis are considered superficial mucosal infections, while
pyelonephritis, abscess and prostatitis demonstrate a much greater degree of tissue
invasion. We will focus on cystitis in this section.
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Risk Factors for Urinary Tract Infections
Gender:
Women
Being a woman certainly increases the risk for a urinary tract infection (UTI). A short
urethra (approximately 4 cm.) combined with close proximity to the anus provides a setup for migration of gram-negative organisms from the bowel to the urethra. Intercourse
massages the urethra allowing the infective organisms to gain access to the bladder. The
use of spermicides shifts the healthy flora of the vagina and increases the risk of urinary
tract infection. Normally, the high concentration of urea in the bladder, the presence of
leukocytes in the bladder wall, and the dilutional effect of urine serve to prevent
infection, however, many women still become symptomatic. Voiding after intercourse
and avoiding spermicides are often recommended but studies have failed to show that
these measures are seldom effective for reducing recurrent UTI.6
In middle-aged and elder females, relaxation of the pelvic support muscles can lead to
prolapse and descent of the uterus, pulling the floor of the bladder along with it. The
bladder then protrudes into the vagina, creating a pouch - cystocele - that fails to empty
during voiding. Urinary stasis can then lead to recurrent infections.
Men
Acute bacterial infection is unusual in a man less than fifty years of age, however,
prostatitis and obstruction from an enlarged prostate can both lead to a UTI. There is a
small increased risk in non-circumcised males.
Pregnancy:
Pregnancy causes a decrease in ureteral tone, peristalsis and function of the vesicoureteral
valves leading to an increased risk of upper urinary tract infection during this time.
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Approximately 20-30% of asymptomatic lower urinary tract infections will lead to
pyelonephritis during pregnancy. It is important to be watchful for urinary symptoms
during pregnancy and to test for nitrites and leukocyte esterase during routine prenatal
visits.
Low Estrogen:
Decreasing serum estrogen levels in women alter the stratified squamous epithelium of
the vagina. This altered epithelium is not a friendly environment for the adherence and
proliferation of Lactobacilli, probiotic organisms that helps maintain a low vaginal pH.
A higher vaginal pH allows gram-negative bacteria to multiply in the vagina and
periurethral area, allowing easy access to the urethra. With restoration of the stratified
squamous epithelium, Lactobacilli become prevalent once again. A Cochrane review of
four randomized controlled trials concluded that the use of oral estrogen did not reduce
the risk of recurrent UTI,7 though vaginal estrogen has been shown to reduce recurrent
UTI in elder women.8
Obstruction:
Obstruction of the bladder outlet can be caused by a number of conditions - enlarged
prostate, tumor, stone, or stricture. When the free flow of urine is prevented, infection is
more likely to occur and ascend upwards into the kidney. If the obstruction is severe,
hydronephrosis can develop, possibly impairing renal function. If obstruction is
suspected, a thorough evaluation of the urinary emptying system must be undertaken, as
well as determining kidney function (e.g., serum creatinine).
Vesicoureteral Reflux:
This condition is found more frequently in children than adults. Reflux, or the retrograde
flow of urine from the bladder back into the ureters and possibly the kidneys, occurs
when there is increased pressure in the bladder, such as during urination. While a small
amount of reflux can occur in normal healthy individuals, anatomic abnormalities can
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cause the retrograde flow to be more marked. Children with severe urinary reflux often
go on to develop renal damage and scarring. Urine should always be checked in young
children who have a fever with no obvious foci of infection. Recurrent UTI in a child
should prompt a thorough evaluation by a qualified practitioner (e.g., urologist).
Neurogenic Bladder:
A number of conditions can interfere with the bladder’s nerve supply - multiple sclerosis,
diabetes, spinal cord injury, tertiary syphilis, etc. When normal voiding signals are
impaired, urine remains in the bladder for extended periods of time. Urinary stasis can
lead to infection. If a urinary catheter is used to empty the bladder, bacteria can easily
gain access into the urethra and bladder. Indwelling catheterization should be reserved
only for those individuals with sacral ulcers, those with urinary retention that cannot be
managed surgically or with medication and who cannot do intermittent catheterization,
and in those who are severely impaired where intermittent catheterization or frequent
change of bedding would cause discomfort.
Medications:
Urinary stasis can be caused by a number of medications including anticholinergic and
sympathomimetics. Over the counter cold remedies and antihistamines can make
urination more difficult, especially amongst elders, and increase the likelihood of
infection.
Symptoms of a Urinary Tract Infection
Most of us are familiar with the symptoms of a bladder infection in a healthy adult,
however, symptoms may vary between age groups and it should be kept in mind that a
number of individuals with significant bacteriuria may be totally asymptomatic.
Pediatrics:
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Cystitis can by asymptomatic or present with symptoms of dysuria, urgency, bedwetting,
suprapubic pain, or frequency. Vomiting is also common. If a urinary dipstick indicates
infection, a clean catch midstream urine sample should be obtained, refrigerated, and
submitted for culture. In toddlers and infants, sterile in-and-out catheterization should be
used to obtain the specimen.
Pyelonephritis usually presents with a high fever (greater than 102 F), flank pain,
costovertebral angle tenderness, and an ill-appearing child. Pyelonephritis is much more
common in children with urinary reflux. Urinary specimens and blood cultures should
both be obtained before initiating any antimicrobial therapy.
Adults:
Many women will present with the common symptoms of a bladder infection - frequency,
urgency, and dysuria. It is generally recommended that those with classic UTI symptoms
be treated empirically, and telephone consultation is increasingly being seen as an
acceptable method of identifying and treating women with a UTI. Women who are
pregnant, who have a history of recent UTI, recurrent UTI or vaginal symptoms should
be seen for evaluation.
A urinalysis by dipstick should be done to determine if an infection is present. Urine
cultures are not needed in non-complicated, non-pregnant women with cystitis.
However, women should be counseled to return to the clinic if symptoms worsen or are
not relieved within three days.
Pyelonephritis typically presents with fever, flank pain, costovertebral angle tenderness,
and an ill-appearing individual. Pregnant women with pyelonephritis are generally
admitted to the hospital for intravenous antibiotics and observation. Healthy individuals
who present with pyelonephritis should have a urine culture sent before starting
antimicrobials and then carefully followed. Hospitalization is not usually necessary in
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this group of individuals. Evaluation for the cause of the infection should be undertaken
(e.g., reflux, enlarged prostate, etc.)
Vaginitis, or vaginal infection, should be considered in women who present with burning
and pyuria. Cervical cultures should be obtained if one is suspicious of infection and a
microscopic examination of the vaginal discharge performed. In uncircumcised men,
rule out contaminated smegma as a cause of pyuria. All adult men with symptoms of a
urinary tract infection should be evaluated by history and physical for sexually
transmitted diseases and prostatitis.
Elders:
The detection of a urinary tract infection in elders is often missed. Place of residence
matters. UTI is the second most common infection in elder women living in the
community, whereas in residents of long-term care facilities and hospitalized, it is the
number one cause of infection.9 Asymptomatic bacteriuria is transient in older women,
often resolves without any treatment, and is not associated with morbidity or mortality. 10
Symptoms can include changes in mental status, decreased appetite, and somnolence, as
well as the usual symptoms of dysuria, frequency, and urgency. Elders may have a mild
fever or be hypothermic. Fever cannot be relied upon to determine the presence or
absence of infection in elder individuals. Consider a urine culture if the dipstick is
suspicious, as numerous species of both gram-negative and gram-positive bacteria are
responsible for infections amongst elders when compared to young adults. Blood cultures
should be obtained to evaluate for urosepsis if indicated.
More severe cases of pyelonephritis, and infection in pregnant women, elders or children
may require hospitalization and intravenous antibiotics.
Diagnosis
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The evaluation of the urine diagnostic purposes has been used since at least the time of
Hippocrates. The color, amount of sediment, smell, and sometimes even the taste of
urine assisted ancient healers in their understanding of illness. With the invention of the
microscope, urine examination became more sophisticated starting in the 1830s. In 1957,
the first urine dipstick that could detect glucose and protein in the urine became available.
Dipstick urinalysis is now capable of testing for pH, ketones, protein, glucose, specific
gravity, bilirubin, urobilinogen, nitrite, leukocyte esterase, and hemoglobin.
A dipstick analysis is conducted on a “clean-catch” midstream urine sample. A positive
nitrite and/or leukocyte esterase test is indication to begin treatment. A positive nitrite
result indicates the presence of at least 100,000 bacteria per ml however, the test is only
able to detect bacteria which are capable of reducing nitrates in the urine to nitrites;
Escherichia coli, Klebsiella, Proteus, Staphylococcus, and Pseudomonas. Some grampositive bacteria and yeasts may give a false-negative result. Those who are taking large
doses of ascorbic acid can also receive a false-negative nitrite test because nitrate is
converted to ammonia, nitric oxide and nitrogen in the presence of ascorbic acid, not
nitrite. If the specific gravity and urine urobilinogen are high, a false-negative test can
also result. A positive LE, especially in the present of blood, strongly suggests a UTI and
the absence of LE means one should consider an alternative diagnosis.
The European Association of Urology recommends dipstick urinalysis to detect pyuria,
hematuria, and nitrite if UTI is suspected.11 The absence of pyruia strongly suggests an
alternative diagnosis. The American College of Obstetricians and Gynecologists states
that dipstick urinalysis for LE or nitrite is a rapid and inexpensive screening test, with a
sensitivity of 75 percent and specificity of 82 percent.12
Urine cultures are indicated in pregnant women, infants, children, elders, and anyone in
whom pyelonephritis is suspected. The urine culture should be obtained before initiating
antimicrobial therapy.
The Organisms
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There are a variety of organisms that can infect the urinary tract. The gram-negative
bacteria are the major offenders with Escherichia coli accounting for approximately 80%
of infections in patients less than fifty years of age. Other gram-negative organisms
include Proteus, Klebsiella, and Enterobacter. Proteus and Klebsiella are more common
in those with urinary tract stones. Serratia and Pseudomonas are most often found in
those individuals with urinary obstruction or from manipulation of indwelling catheters.
Gram-positive bacteria can also cause infection, especially Staphylococcus
saprophyticus, which is frequently found in the urine of young women. If
Staphylococcus aureus is found in a urine culture, one should maintain an index of
suspicion for a kidney infection. Chlamydia trachomatis and Neisseria gonorrhoeae,
sexually transmitted infections, can also cause symptoms of urinary frequency and
urgency in women. Non-bacterial sources such as Ureaplasma urealyticum and
Mycoplasma hominis account for a small number of urinary tract infections.
Bacterial adhesion allows the organism to gain a foothold into the bladder. Most of the
gram-negative bacteria that are responsible for urinary tract infections express a number
of molecules on their surface, which allow them to “attach” themselves to the bladder
mucosa. Type 1 fimbriae, produced by E. coli and several other cystitis causing
Enterobacteriaceae, are able to attach to mannose residues on cell membranes.1 These
fimbriae allow bacteria from the gut, E. coli primarily, to attach to the perineum and
vagina - making their way to the urethra. Once the bacteria have attached to the bladder
mucosa - inflammation and clinical symptoms appear.
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Treatment of Acute Uncomplicated Cystitis and Recurrent UTI
The goals of treatment are to relieve symptoms, eradicate the offending organism, avert
damage to the kidney, and prevent recurrences. Antibiotics are the mainstay of therapy.
Patients with more severe illness or who cannot maintain oral hydration are typically
hospitalized for administration of IV antibiotics and fluids, especially children <1 year of
age, the elders, immune-compromised patients, and pregnant women.
D-Mannose
D-mannose is a naturally occurring sugar present in numerous fruits that is excreted in
the urine virtually unchanged where it acts as a decoy in the bladder, binding to the
fimbria of gram negative uropathogens, preventing their ability to attach to mannose
receptors embedded in the bladder and urethral mucosa. A study of 308 women with
history of recurrent UTI and no other significant comorbidities were randomly allocated
to three groups after being treated initially with antibiotics for acute cystitis.13 The first
group (n = 103) received prophylaxis with two grams of D-mannose powder in 200 ml of
water daily for six months, the second (n = 103) received 50 mg nitrofurantoin per day
and the third group served as control and received no prophylactic therapy. Overall 98
patients (31.8%) had recurrent UTI: 15 (14.6%) in the D-mannose group, 21 (20.4%) in
nitrofurantoin group, and 62 (60.8%) in no prophylaxis control group, with the rate
significantly higher in no prophylaxis group compared to active groups (P < 0.001).
While the dose of antibiotic was lower than what is typically used (100 mg per day), this
was a very useful study in showing the effectiveness of D-mannose, a substance that has
no adverse effects and is very well tolerated.
Probiotics
Researchers continue to evaluate the role of probiotics in the prevention of recurrent UTI,
especially in women, as specific species appear to inhibit the growth of uropathogens
within the vagina. Lactobacillus rhamnosus GR-1, L. fermentum B-54, L. reuteri RC-14,
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and L. crispatus all show significant potential act as a potential barrier to the ascension of
uropathogens into the urinary bladder.
A 12-month double-blinded double placebo study randomized postmenopausal women
with recurrent UTI to either 480 mg per day of trimethoprim–sulfamethoxazole (TMPSMX, Bactrim) or L. rhamnosus GR-1 and L. reuteri RC-14 twice daily.14 After 12
months, the antibiotic was found superior. An intention-to-treat analysis showed a
between-treatment difference of only 0.4 UTIs per year, which while statistically
significant is rather meaningless clinically.
Vaginal application of probiotics might be particularly useful. In a randomized placebo
controlled trial, premenopausal women who received intravaginal suppositories
containing L. crispatus after antimicrobial treatment had a high vaginal colonization rate
and significantly lower (15%) recurrence of UTI than the placebo group (27%).15
T’s Take: The questions of species selection and optimal administration route continue
to plague researchers, complicating recommendations made by clinicians. At this time, I
generally recommend Femdophilus by Jarrow, which contains 5 billion CFU L.
rhamnosus GR-1 and L. reuteri RC-14 per capsule. I instruct women to insert one capsule
per day for two weeks intravaginally before bed and then twice per week, along with the
use of a panty liner to collect any discharge.
Herbal Medicine
Herbal medicine can be used to both treat and prevent urinary tract infections. Some
herbs have been clinically evaluated through scientific means while others have been
used since historical times to relieve the symptoms of cystitis.
Cranberry (Vaccinium macrocarpon)
A member of the heath family, cranberry grows in marshy areas and is commonly found
throughout the northeastern part of the United States where the indigenous peoples used
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the berries for food and medicine. It was said that the plant could be used to treat fever
and other “pestilent” disease.16 Modern research has focused primarily upon the plant’s
benefit to the urinary tract, especially for the prophylaxis of recurrent UTI. The
proanthocyanadins (PACs) present in the fruit inhibit the adherence of bacteria to the
uroepithelial cells lining the urinary tract. 17 Research has shown that the PACs in
cranberry cause E. coli rods, including those that are multi-drug resistant, to lose the
expression of P fimbriae, thus preventing adherence and attachment to the uroepithelial
cells.18 While most of the research has been focused on cranberry, these effects have
actually been found to be stronger in lingonberry (Vaccinium vitis-idaea). More research
is needed to determine if these two species may be used interchangeably or if one species
is superior to another in preventing recurrent UTI. 19
While the use of cranberry for the prevention of bladder infections is widely accepted by
the both the public and medical communities, a 2012 review failed to find cranberry
effective in the prevention of UTI.20 One must look critically at the totality of the
evidence, however, as several studies included in the review had very high dropout rates
due to the inability of participants to consume large quantities of the juice over extended
periods of time, while several small studies showed the tables/juice as effective as
antibiotics for prophylaxis.
T’s Take: I am still a fan of cranberry tablets (500 mg 1-2 times per day) for otherwise
healthy women for the prevention of recurrent UTI, especially when combined with Dmannose.
Uva Ursi (Arctostaphylos uva ursi)
Bearberry leaf preparations have long been used for the treatment of lower urinary tract
infection and inflammation. The leaves contain arbutin at 6-12%, with a small amount of
methylarbutin and free hydroquinone.21 The metabolites of arbutin are considered to be
the primary constituents responsible for the herb’s urinary antiseptic activity. Although it
was originally thought that hydroquinone could only be liberated from arbutin in alkaline
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urine,22 newer research has challenged this hypothesis. After undergoing hepatic
conjugation, hydroquinone is further metabolized by intracellular enzymes present in
bacterial cytoplasm. Alkalization of the urine does not appear to be a prerequisite for
improving the antiseptic properties of hydroquinone released from arbutin.23
The urinary excretion of arbutin metabolites was examined in a randomized crossover
design in 16 healthy volunteers after a single oral dose of bearberry leaves dry extract
(BLDE), either as film-coated tablets (FCT) or aqueous solution (AS). With FCT, 64.8%
of the arbutin dose administered was excreted; with AS, 66.7% was excreted (p = 0.61).
The maximum mean urinary concentration of hydroquinone equivalents was a little
higher and peaked earlier in the AS group versus the FCT group, although this did not
reach statistical significance. No significant differences between the two groups were
found in the metabolite patterns detected (hydroquinone, hydroquinone-glucuronide, and
hydroquinone-sulfate).24 It appears that tea, tincture or tablets are all appropriate dosage
forms for uva ursi.
When urine was collected from healthy volunteers three hours after the ingestion of 1.0
gram of arbutin, it was subjected to in vitro antibacterial testing. Antibacterial activity
against E. coli, Pseudomonas aeruginosa, Proteus mirabilis and Staphylococcus aureus
was noted.25 Uva ursi had a prophylactic effect on recurrent cystitis in a double-blinded,
prospective, randomized study of 57 women who had experienced at least three episodes
of cystitis in the year preceding the study and at least one episode in the previous six
months that had been successfully treated with antibiotics. Patients received either three
tablets of UVA-E (containing a hydroalcoholic extract of uva ursi leaves with a
standardized content of arbutin and methylarbutin and of dandelion root and leaves) or
placebo three times daily for one month. After 7 and 12 months the patients were
examined and during the year any occurrences of cystitis were treated with antibiotics. At
the end of the year none of the patients in the uva ursi group had had a recurrence of
cystitis compared to 23% of the placebo group (p < 0.05).26
In spite of the lack of controlled clinical trials, bearberry leaves are endorsed by the
European Scientific Cooperative on Phytotherapy (ESCOP), the British Herbal Medicine
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Association and the German Commission E for minor infection/inflammatory disorders
of the lower urinary tract. The dose recommended by these authorities is that which
provides 400-800 mg/d arbutin, divided into 2-3 doses. This is equivalent to 1.5 – 3.0
grams in infusion or cold aqueous extract or 2-5 ml of a tincture (1:5) 3 times daily.
Bearberry is contraindicated during pregnancy.27 This may be due to the potential toxicity
of hydroquinone to the fetus. In bone marrow, hydroquinone produces microtubulin
dysfunction,28 while exposure of human lymphocytes and cell lines to hydroquinone has
been shown to cause various forms of genetic damage.29 Uva ursi is also generally
contraindicated during lactation.30 Gastrointestinal irritation, nausea and vomiting may
occur due to high tannin content.31
Most authorities recommend using uva ursi for no longer than 1–2 weeks at a time and no
more than five times a year due to concerns about the safety of arbutin and hydroquinone.
One case of Bull’s eye maculopathy secondary to prolonged use of uva ursi was reported
in the literature. 32 However, a recent review of experimental and human studies found
that uva ursi was safe when used at the aforementioned dose even for extended periods of
time.33
T’s Take: Uva ursi is absolutely my go to herb for uncomplicated UTI. I can’t even
remember the last time I prescribed an antibiotic for a young healthy woman. I generally
prescribe 3-4 grams/d leaf with ~400-600 mg arbutin for 48 hours and then 2-3 grams
and 200-300 mg arbutin for an additional three days. I like to use uva ursi with corn silk.
Clinical Pearl: Pipsissewa (Chimaphila umbellata)
Think of using pipsissewa when one has difficulty tolerating uva-ursi or perhaps when
one is choosing an antimicrobial for long-term use to prevent recurrent UTI. It contains
lower amounts of arbutin, tannins, as well as methylsalicylate.
Tincture 1:5 50 alcohol 2-3 ml four times per day for acute infection, or twice daily for
long-term use.
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Berberine Rich Plants (Goldenseal, Barberry, Oregon Grape)
Berberine, an alkaloid found in a number of plants including goldenseal (Hydrastis
canadensis), barberry (Berberis vulgaris), Oregon grape (Berberis aquifolium), and
goldthread (Coptis chinensis), has long been used for the treatment of UTI. Activity
against Staphylococcus aureus and Escherichia coli has been documented,34,35 while
crude methanol extracts of golden seal root and rhizome were shown to be very active
against multiple strains of Helicobacter pylori.36 A study found that when urine samples
were obtained from five volunteers after they taken berberine chloride orally 0.9 g/d for
three days, berberine and a number of its metabolites were recovered in the urine, 37
confirming its ability to exert its antimicrobial activity in the kidney and bladder.
Berberine containing herbs are contraindicated during pregnancy by almost all
authorities. The acute toxicity LD50 for berberine in rats was shown to be 713 mg/kg. 38
The dose is generally 2-3 grams per day for acute treatment.
T’s Take: I often use goldenseal or Oregon grape root in those with recurrent UTI for 6-8
weeks or when I was concerned that I need additional antimicrobial activity.
Juniper (Juniperus communis and other species)
Juniper fruit and leaves are used in many parts of the world as medicine. Oil of Cade is
made from the wood of Juniperus oxycedrus, which grows in the Mediterranean region.
This oil is used topically for a variety of skin disorders. The pounded fruit is used for
urinary difficulties, as well as diabetes.39 The berries (modified cones actually) are
excellent urinary antiseptics, though, there has not been much research conducted in this
area. They are rich in antiseptic volatile oils, which are excreted via the kidney. There is
some concern regarding its safety in those with diminished renal function. Most of the
adverse event reports have been due to the essential oil. Juniper is not safe in pregnancy.
Birch (Betula pendula. B. alba)
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The bark, buds, and leaves of the silver and white birch tree have been treasured in herbal
medicine for centuries. Rich in betulin and betulinic acid, both of which exert antiinflammatory and diuretic activity. Betulinic acid is also being investigated for possible
anti-cancer properties, particularly in melanoma. Birch leaves and bark have long been
used topically for the treatment of warts, atopic dermatitis and other skin conditions. It
can easily be made into salve or added to the bath.
The German Commission E monograph approves the use of birch leaf “for irrigation
therapy in bacterial and inflammatory conditions of the lower urinary tract and renal
gravel; as supportive treatment in rheumatic complaints.”40 It is a urinary antiseptic and is
effective against urinary tract pathogens. All tested concentrations of birch leaf extract
significantly decreased the growth and replication of E. coli,41 as well as blocking its
adhesion to uroepithelial cells.42 It is also an effective anti-spasmodic, easing painful
urinary spasms. The dose is generally 2-3 grams per day for acute cystitis, or 3-5 ml
tincture -2-3 times per day.
Of interest: xylitol, a type of sugar, is sometimes made from birch and has been approved
by the FDA for use in food. Betulin, present in large quantities in the bark was shown in
an open non-randomized study in Germany to be effective for treating actinic keratosis. A
larger clinical trial found some benefit, as well, though not to the degree seen in the open
study.
Corn Silk (Zea mays)
The use of corn and corn silk for “affections of the kidney and bladder” can be traced
back to the Incas. Corn silk (CS) is made from stigmas, the yellowish-thread like strands
from the female flower of maize. It continues to be used for the treatment of cystitis,
edema, kidney stones, prostate disorders, urinary infections and bedwetting. It soothes
and relaxes the lining of the bladder and urinary tubules, hence reducing irritation. ParkeDavis introduced a corn silk product in the 1880s for the treatment of urinary pain and
spasm. Physicians of the time felt that corn silk was useful for minor urinary complaints,
though many debated whether it was more of a urinary demulcent than a diuretic agent.
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These physicians of old may have been right according to modern research. Though
tradition and some older data supported a diuretic activity, the aqueous extract did not
result in significant diuresis when given in oral doses of 5g/kg to guinea pigs,43 nor did it
increase 12-24 hour urine output in dogs.44 Pharmacological studies (in vitro and in vivo)
have confirmed that corn silk has antioxidant, hypoglycemic, and antibacterial
properties.45 Corn silk was shown to decrease E. coli adhesion by interacting with the
bacterial outer membrane proteins.46
The British Herbal Compendium lists corn silk as both a mild diuretic and urinary
demulcent. The former German Commission E also recognizes the use of corn silk as a
mild diuretic. Corn silk is quite benign and is often included in herbal formulae designed
to ease the pain of cystitis. No contraindications are found in the literature. The dose is
generally is 1-3 grams for relief of acute cystitis but I recommend just drinking it freely
for the first couple of days.
T’s Take: great urinary demulcent to reduce dysuria.
Java Tea (Orthosiphon stamineus)
The leaves and stems of this member of the mint family has long been used in folk
medicines of subtropical Asia and Australia as a treatment for urinary tract disorders and
gout. It is used in modern times for similar conditions plus the treatment of high blood
pressure and diabetes. It contains a number of compounds including diterpenes (e.g.,
orthosiphols), rosmarinic acid and rather significant quantities of potassium. The German
Commission E listed its approved use for, “ Irrigation therapy for bacterial and
inflammatory diseases of the lower urinary tract and renal gravel.” The European
Scientific Cooperative on Phytotherapy gives a similar indication, “Irrigation of the
urinary tract, especially in cases of inflammation and renal gravel, and as an adjuvant in
the treatment of bacterial infections of the urinary tract.” There have only been a small
number of human studies and these all suffer from short duration and very small numbers
of participants. A review by the European authorities concluded that due to its longstanding use and based on the available documentation (e.g., review of animal data and
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small human studies of short duration) that a traditional use can be granted. They found it
acceptable as an adjuvant diuretic in the treatment of minor urinary tract infections.
T’s Take: I often recommend Traditional Medicinals Back on Tract tea, which contains
per teabag: java tea 1050 mg, cornsilk 105 mg and 595 mg of a proprietary blend of
organic hibiscus, peppermint, cranberry and stevia. It is an excellent part of a preventive
strategy.
Clinical Pearl: Kava (Piper methysticum)
Don’t forget kava when it comes to more severe urinary spasm. Kava is stronger than
many other urinary antispasmodics and should be considered when the spasm is severe.
It combines nicely with cornsilk, goldenrod, birch, etc.
Nettle (Urtica dioica)
The roots of nettle are widely used for the treatment of enlarged prostate, while the leaves
have long been relied upon as a useful diuretic. The German Commission E approves
nettle leaf as a supportive therapy in patients with lower urinary tract infections and to
prevent urinary gravel. Research has shown that it has weak growth-inhibiting effects on
E. coli, which lends some support to its traditional use.47
Couch Grass (Agropyron repens)
The rhizomes of couch grass have long used to treat urinary complaints. You might be
more familiar with its common name, dog grass, as our canine friends often consume it
when feeling sick. Studies have shown that couch grass impairs E. coli adhesion to
bladder mucosa by interacting with bacterial outer membrane proteins.48 Couch grass
may also be of use in those with uric acid stones. The combination of 24 mEq/d
potassium citrate and 100 mg/d couch grass dry extract along with appropriate
pharmacological and dietary treatment, decreased number and size of urinary stones and
statistically significant reduction in urinary uric acid excretion.49
Copyright Tieraona Low Dog, MD. 2014. All Rights Reserved.
Golden Rod (Solidago canadensis, Solidago virgaurea)
The aerial parts of golden rods have long been used medicinally both topically and
internally. Its very name suggests that it was highly regarded as a medicine, solidago
means, "to make whole." Golden rod is widely used as a folk medicine to reduce allergies
and is included in numerous traditional formulas for pain and arthritis.
More than a few herbalists believe that golden rod has a place in any chronic urinary
condition. It increases the amount of urine while reducing inflammation in the bladder,
probably secondary to its flavonoids and saponins. It is also an excellent urinary
antispasmodic. A study found that when combined with Orthosiphon and birch, solidago
reduces the recurrence of UTI in women who had been treated with antibiotics.50 This
same combination, with the addition of cranberry extract, was shown in a pilot study to
reduce microbial colonization in patients with indwelling urinary catheters.51
Some Suggestions for Clinical Use:
Acute Treatment
•
Nature’s Way purple top (965 mg uva ursi and 132 mg arbutin per 2 capsules)
take 2 caps 3-4 times daily for 48 hours and then 2-3 times daily for 72 hours. OR
•
Eclectic Institute Urinary Tract Support each capsule contains extracts equivalent
to:
o
500 mg uva ursi, marshmallow root, corn silk and
o 400 mg goldenseal root
o Take 2 caps 3-4 times per day for 48 hours and then 2-3 times daily for
48-72 hours OR
•
Could consider Swanson Birch Leaf extract 400 mg taken 4 times per day for 3-4
days AND
•
Traditional Medicinals Back on Tract tea – 1 cup three times per day.
o Each teabag contains
§
Java tea
1050 mg
§
Cornsilk
105 mg
Copyright Tieraona Low Dog, MD. 2014. All Rights Reserved.
§
Proprietary blend 595 mg of organic hibiscus, peppermint,
cranberry and stevia
For Recurrent UTI
o D-mannose – 1000 mg two times daily (Solaray D-mannose with Cranactin
provides 1000 mg D-mannose and 400 mg cranberry extract in 2 capsules) AND
o Fem-Dophilus – 2 capsules per day (if female) AND
o Traditional Medicinals Back on Tract tea – 1 cup daily OR
o Swanson Birch Leaf extract 400 mg taken 2 times per day OR
o Herb Pharm Golden Road extract – 25 drops twice daily
1
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Copyright Tieraona Low Dog, MD. 2014. All Rights Reserved.