a

Recurrent UTI (Urinary Tract Infection) Lecture

[Music]

I'm dr. Kass person I am a

board-certified neurologist I work at

Pacific Northwest neurology specialist

most common infection in the United

States of America is a urinary tract

infection so everybody sees it and deals

that or has one in their lifetime so I

think I was talking to Sheila like a

year ago and I'm like I'm gonna give a

recurring UTI talk because it's one it's

like one in eight diagnoses in primary

care

I see recruit you guys all of the time

in our training you're all just they're

surgeons and so we got this much

training on what to do with recurrent

UTI is because there it's usually not

surgical right so you kind of have to

develop what you're gonna do at your

practice with recurring guys because

they will come to your ologists and

people come to the urologist and they

say I would like to not ever have a UTI

again so I've gotten to the point of

saying well let's adjust expectations

majority of them are women and studies

are over 50% in one lifetime 8 to 1

ratio women to men and kind of setting

the expectations of I can never promise

you you will never get a UTI again

unless you are dead because when you're

dead you can no longer have a UTI and I

see a little bit nicer than that but

just that we're living breathing human

organisms and other organisms are

attracted to us and therefore infections

do happen as long as we're living I

think what patients are looking for is

how can I never have one again can you

give me that and I say I cannot give you

that but I can have a conversation of

how you can improve it yourselves and I

think a lot of people just if they can

empower themselves say the choices I

make are the things I do are gonna

decrease my risk everybody's in the

death

she'll maybe give you three objectives

I'm sure they were somewhere but up for

CMU but my objectives are to empower you

because I think through you when I

started out you're like oh the Suzy's

coming in for recurring BGI and you're

like oh because she's gonna be like

makes me never have a UTI again and

you're just gonna kind of feel like you

don't want to have that to that

conversation with people that's how I

felt I'm like I can't make you never

have a UTI in so people you know Susie's

coming in again for another recurring

UTI and she's got allergies the bathroom

and penicillin and cipro and blah blah

hear your heart kind of stinks right and

so she's coming in she's angry because

she's got a UTI and it keeps happening

and why why why and so my goal is to

empower you to now say okay I think I

get this UTI thing enough that when

Susie comes back into my clinic I know

what to ask Susie I know how to optimize

Susie I know if I need to order some

tests for Susie and to help her decrease

UTI so my goal is for you guys to not

moan as much when Susie's on your

schedule because I've owned for a long

time until I figured it out and now I

don't mind them like I don't recruit UTI

here's my spiel it's usually successful

and it's sometimes it's not but when

it's not successful and they get another

UTI is not your fault so it's not your

fault you are a good doctor it is not

your fault when other people get UTIs

so how do you diagnose the UTI is it's

not an imaging diagnosis you know you

see these cats can literally consistent

with cystitis and pyelonephritis and the

patient's like I feel fine it's like

that is not how we define a UTI it is

not how it looks on a cat scan is not

how it looks on a read all over yourself

so I want I want a clean catch and going

to go and try it women go and try to do

a clean catch it's freaking tricky

you're like read the instructions are

over there right and then you've got the

cuff and the wipes now over there and

you're like oh it's meat minced red and

now you've got pee on your hands like it

is actually kind of tricky to do it on a

hedge let alone now I have an extra 75

pounds of my body or I have macular

degeneration or now I have rheumatoid

arthritis all of these things make for a

very crummy clean you a so take the dip

with a grain of salt knowing that yes

we're trying to get urine straight from

the bladder but there are a lot of

challenges I don't think everybody has

catheters in their clinic if you do and

you have a recurrent UTIs patient it

might be a nice time to say hey you

actually get a cast that's something to

know if this is a UTI or not because a

lot of again that older population is

not going to give you a clean catch and

if you kind of want to get sciency get

get a catheterized specimen especially

my elderly female population a lot of

them unlike I know they are not giving

me a clean catch and you get a

catheterized specimen others false

positives there are false negatives but

in 2018 national guidelines and

infectious disease guidelines it's not

an asymptomatic diagnosis so a person

goes in there doing their well adult

exam clinic calls on two days later and

they say you have a UTI here's some

antibiotics

that's no there's no now if there's a

systemic bacteria 10% of all bladders if

we took all the bladders in this room

and we put you on a petri dish 10

percent of you are gonna grow something

out so that that old wives tale now of

urine is sterile no longer exists

there's a certain amount of us that just

carry our or our normal flora and the

thing is if you kill that normal flora

that you might be finding that's when

the recurrent UTIs will come because now

you just killed all the healthy guy

and you just opened up the field for new

growth and and pathogenic bacteria so I

feel a lot of recurrent UTIs and the you

know one of the first thing I do is

what's your symptom with a UTI

what's your symptom well the doctor has

told me that I have UTIs it's like great

your beauty is that's wonderful just

because you grow out something

don't take a drug for it and then the

physical exam I don't I I don't think

you need to look at genitals every time

somebody comes in for a UTI

it's way overkill but if you have a

woman who's coming with recurring UTI

and nobody has looked at her vulva and

her urethra on her vagina you're not

doing your service and my thought is

where else on the body when a when a

person says it hurts do we not look at

it right my shoulder hurts oh that's

great here's here's some here's some

antibiotics look at the hell we we do

that for every other body part we're not

doing it especially as a postmenopausal

women where there's tons of vulvar

pathology men do get UTIs - I've kind of

gender bias on women because they're 80%

of the recurrent UTIs literature but men

that do get UTIs -

three things under urinalysis nitrates

leukocyte esterase in blood nitrates two

nitrates only bacteria make nitrates we

don't always have nitrates so it's the

food that we gets converted in our

bladder you are not going to detect that

positive nitrates if you're just super

hydrating and pee all the time because

you got a UTI right so you might get a

false negative and somebody that truly

has bugs in there because they're just

emptying their bladder a lot is super

dilute because of their burning and just

trying to get rid of it your the

nitrates are actually they say like the

urine should be stored in the bladder

for four hours before trusting the

nitrate and it's like who is a UTI you

just haven't peed for four hours so it's

kind of like they're miserable there

Pete right so nitrate together it's not

wonderful but it is when you have it

it's pretty specific because a bug made

that happen

Hugh Metiria you can one of the most

common reasons for blood in the urine is

UTI but it's just a color-changing strip

if I can teach anything like other of

urology today is I don't need to see

people with trace on a UA that's not one

your urine and don't tell people that

they have blood in their urine because

now they're obsessed of like blood in my

urine when it's a trace dipstick trees

dipsticks are pretty much negative if

you then send them for microscopy but

somebody comes in they've got moderate

to large blood in their urine they got

symptoms a UTI that helps you say yeah

it's probably a yes we've got some

inflammation that's dropping someone

down leukocyte esterase not specific at

all that's just a white blood cell

so imagine itis atrophy kidney stones

cancer anything inflammatory response

so anything that makes a white cell will

cause that so again more sensitive less

specific cuz lots of things can can call

that so if you have a totally negative

one about 20% of people can still

culture a UTI be symptomatic so the

dipstick is helpful but just understand

that it's not a perfect test

I'm acute UTI treatment get the story

when where what are your symptoms urine

culture infectious disease Society the

now is nitro parenting for five days

bactrim for three names and then

fosfomycin is kind of the old drug

that's new again because of the

resistance patterns that's nice it's

just once a big dose thing it's in a

little powder form but depending upon

insurance coverage can be expensive or

not expensive blackbox warning on the

fluoroquinolones now and they do not for

uncomplicated urinary tract infection

fluoroquinolones are no longer

recommended what do you do obviously

what I do well you got a patient that

comes in she said I have recurring UTIs

and by the way doctor I'm allergic to

penicillin the cephalosporin

ciprofloxacin Backstrom and I had Mac

repair once and I just really didn't

like it so don't give me them like these

people exist right and you're like

really

what do I do I got a call a picture see

it you know earned a Penniman where do I

get the IV and then what if this happens

again like you don't want to see these

people because it's stressful send them

to allergy allergy Lou if there's any

out of you people here but the allergy

people life sentence who they love it

because the allergist are like let's

figure out what you're not allergic to

and they love it they're like nope not

that yeah you just had some diarrhea

with that not an allergy you can use

cipro they will they will shorten your

list for you and you're like yes so

you've got this person coming in and

you're just like I don't want to deal

with Mary and then you send it out and

they don't talk to them though they well

a sensitivity is different than an

allergy and GI side effects arc they do

all that so like use your team members

and the allergist are awesome with this

they'll be like I will figure out that

penicillin was not to thing for you

so recurring UTI is three UTIs within a

year or two within six months culture

proven symptomatic that by definition is

a recurring yet so behavioral prevention

strategies fluids there's two randomized

control trials now looking at fluids and

recurrent UTIs

so they took premenopausal women

randomize them to regular behavior or

one and a half liters of fluid a day

follow them for an entire year and those

women had at least three urinary tract

infections a year control group that

you're got three urinary tract

infections they stay in the exact same

1.5 liters a day decrease their UT iris

by more than half so it's like 3.30 or

1.5 0.7 a year so just drinking alone

and urinating and getting the bugs out

of there decreases your UTI wrist so

there's great randomized trials for both

kidney stones and recreate UTI as far as

just fluid production diet constipation

is the big one because any poop that's

there longer is old poop all 12 just

dirty poop dirty poop has more bugs that

are going to walk up to the urethra

sorry did you lose me at poop people

should poop and that's the part of the

microbiome too is if your e.coli doesn't

if you and your eco light there it's

infecting you exchange recoiling we're

gonna change recall by getting it out of

there more by drinking or getting your

eco light out of there by pooping more

we're getting you're changing your eco

lie defending you against e.coli by

giving you a vaginal estrogen and then

there is something to it I think we

don't know enough about fiber about a

healthy diet and how it changes our GI

floor and for the better and you know

this is all prelim stuff on let's study

the gut microbes of the American diet

with not the things that girl in the

ground and then the the diet and Wisman

plant-based things that go in the ground

and people have different micro biomes

and I think we're gonna start seeing a

lot as far as you know obesity weight

loss metabolism infection risk so I

think there's absolutely something to

fiber if only it's gonna make you poop

more it's probably will change your

e.coli for the better there's data

things like glucose diabetics get it

optimized metal that'll help stop trying

to fashion the Bajau

because that's the stop scrubbing waxing

them again if I go over here then this

is a paradox the vulva the labia it's

the National Guard okay and when you

when you mess with your National Guard

you're gonna let in other things that

you don't want to be into your your

house so especially the premenopausal

woman I'll see him could we do an exam

look at the following where it hurts and

if they're waxing a lot there's actually

studies now that waxing and removing the

hair number one increases your vaginal

discharge so if a woman's complaining

about your discharge because it's not

being trapped in our natural hair and

number two it's it's not it's allowing

buds to go up the urethra a lot more

because you're just you're you're

interfering with your natural barrier so

I'm usually pretty you know I tried to

be funny because it's like I'm gonna be

that doctor that tells people don't

spend your money how you want to spend

it and look the way you want to look

like go freaky so my mom owns to waxing

studios oh I totally but I'm like you

know what my mom owns to waxing studios

you do what you want but if you want to

not get recurrent UTIs just consider

maybe trimming instead of ripping just

consider it the micro trauma will be a

lot less and it might be better so I'm

never kind of you know I kind of just

educate on Anatomy and let people make

the decisions but it's like if you want

and not get recurrent UTIs let's talk

about optimization and then

postmenopausal you know it's interesting

because just the postmenopausal State

you actually do have a hair loss down

there and there is an increased risk of

your area tract infection so you kind of

as you get into that - go now - goes

away and that increases their risk

avoiding prolonged courses of

antibiotics which is ironic because one

of the gold standards for recurrent UTIs

is up for a long course of antibiotics

so but a lot of patients if you say

what's your trigger what's your trigger

for you yet knowing I had this dental

procedure and they put me on this big

kharsa antibiotics

or I had bronchitis or as long as and

then they start getting recurrent UTIs

because they killed their microbiome and

now they've just got this opportunity

for all these pathogens to come in

spermatocyte is a known killer of

healthy bugs so that just basically

again waits out your natural defenses

how acid your urine is makes you

susceptible UTIs we want to Ella

our urine we can do that with you know

prescription potassium citrate we can do

it with vitamin C or we can do it with

again the healthy diet alkalinize is

your urine also super important in your

kidney stone formers so acid urine will

give you more uric acid stones and

kidney stones so it's that healthy diet

that ELCA one eyes is a urine that

decreases both UTIs and kidney stones so

therapeutic intervention what do you

know you've counseled them about all the

things they can do but they're like ah

doctor give me something so gold

standard is you can offer them

suppressive therapy six to 12 months low

dose antibiotics there's a couple of

different choices that you can do most

of my ladies don't want to be on it and

I talked to them about listen there are

severe risks with antibiotics I actually

been dot phrase dbx because I always

want it documented that I've told

somebody that their choice to take

antibiotics might result in a side

effect from an antibiotic so suppressive

therapy it does work but as soon as you

stop that person their risk is just the

same as if they did it before yeah it

might be a nice break but there if their

risk factors haven't changed and now

they're six months are done and you

don't want them to be on antibiotics

forever they're just back to baseline

you haven't improved their life

trajectory on that you just kind of gave

them a break from it and your risk is

you put them on that low-dose sulfur

that low-dose macro bed next time they

have a UTI get a urine culture because

they might not be resistant to that one

macro Bennett has the quickest kind of

I'm not gonna say like the infectious

disease people want me to but the

quickest kind of returned from

resistance is Madeleine um self-start

therapy is good for a motivated patient

especially if they're like I'm sick I'm

sick of coming in you know it's always a

Saturday can they just have an egg you

know a couple of courses I think if

you've got good cultures to say yes this

is usually e.coli and it's sensitive the

back term here's for you know three

refills of bactrim especially if we're

gonna travel like give them a break they

don't want to find antibiotics in

Lithuania or ever they're going but I

have the ladies and they're like I get a

UTI on Saturdays

all these satirizes Saturdays and you're

like bugs don't know it's Saturday like

what's with a Saturday right and so

really working into what are you doing

what are you changing that

to your bladder on on the weekend

because the eco light does not know that

seven days have passed cranberry

super mixed reviews on that I have a

handout for a brand name one that's done

a lot of research I think people like to

think they're doing something so I refer

them to the brand name one that actually

did studies I think at the co-op it's

not it's not FDA approved it's not

regulated are they taking a high enough

dose of cranberry I don't know it's not

regulated so there's some studies that

say it helps their subsidies and say it

doesn't vitamin C again alkalinize is

the urine taking the vitamin C with miss

enamine which is a prescription makes

the urine more favorable for miss that I

mean and how miss enemy works is it

turns into a formaldehyde component into

the bladder do you don't think there's

any long-term damage with that it sounds

kind of but I've got lady thing ever

since I started than the Senate mean I

haven't had another recurrent UTI

so these are all options you're just

like hitting a wall and there what else

what else you can just keep offering

because I think everybody's different

somebody's a vitamin C and a drinking

more fluid somebody's a vaginal estrogen

and low-dose suppressive therapy there's

all these different possibilities

how does acupuncture work to prevent

UTIs doesn't increase immune response

and so you just have a stronger immune

system we don't know but it's out there

I don't recommend acupuncture because I

don't know that much about it or who's

the good new GI acupuncture person in

town I don't know but it's in the

studies probiotics again they'll I think

there is something to it

lactobacillus there are vaginal

probiotic formulations

I don't really push them but they're out

there and then vaginal estrogen is huge

so a complicated UTI is anybody with an

anatomic defect they do consider males

to be complicated in the UTI at

world-wide because they have a prostate

or they're more rare men sure to get

UTIs but they're certainly allowed to

get UTIs UTI symptoms

younger man to think chlamydia and

gonorrhoea check them for that UTI

symptoms and an elderly

seventy-year-old think about prostate

urinary obstruction urinary stasis

things that want to see a urologist for

and then immunocompromised people people

who just had urology surgery any sort of

kind of high-risk where your urine is

just not flowing as it is or your immune

spotting response isn't fighting as

strong as it should be it's complicated

and then there's you know you can do

longer courses of antibiotics for them

when do I do a cystoscopy that's me

looking really concerned so Dan Reza's

checking I started a YouTube channel for

our business about a year ago so just

because it's just us to be scary but

it's actually not that big of a deal I

do not do a cystoscopy for recurrence

guys and most urologist don't because

the yield is so incredibly low it's

usually not something in your bladder

that's causing a UTI so I'll do it if

you're if you're peeing blood like

cancer is let's do it history of

muscling anybody who's had a sling and

now his recurring UTI is I'm gonna scope

I want to make sure there's not mesh in

there I want to make sure there's not

scar tissue so if you've got a sling you

get a scope if you have recurrent II is

fistula story is malignancy and then the

worried well of like oh my cousin have

bladder cancer it might be that I don't

feel like you wanted let's just make

sure that it's not bladder cancer it's

easy to do a cystoscopy but I think it's

overkill and over procedure Eliza to do

a cystoscopy on people with recurrent

UTIs so I have a video on cystoscopy and

it has 9,000 views I know you can click

on it you can see where people are

viewing you from and I've got like

turkey people in Turkey there but it's a

cool and then there's lots of other

urology stuff on here so there's

prostate biopsy all that stuff I have

one on vaginal estrogen I have one on

condoms I have one on recurrent UTIs

when is a UTI not a UTI there's another

pearl when a woman comes in and tells

you she has a UTI

she might not have a UTI so when they

come in because in United States of

America anything between here and here

especially in a woman that's a UTI you

guys there it can be nothing else and

women know that everything between here

is a UTI so they come in and I have a

UTI

you're like oh how do you know you have

a UTI you know and getting this symptoms

so that's one big pearl just because a

woman tells you her diagnosed

it might not be her diagnosis just like

any other you know part of Medicine

asymptomatic bacteria again especially

in the elderly or in a nursing home they

have huge rates of asymptomatic bacteria

treating that

predisposes them to antibiotic

resistance in addition to now

predisposes them to recur a UTI is

because you just killed that healthy guy

that you found and now it's an open

field for all the pathogenic of people a

symptomatic bacteria pregnant people and

people who are gonna have urology

surgery those are the people you treat

everybody else who gets to leave alone

especially your people who have

catheters super pubic tubes in July

catheters if they're asymptomatic do not

treat it I don't like how it looks I

don't care you're not getting an

antibiotic I don't like how it smells

it's a waste product is it supposed to

smell good three pour water and vitamin

C changes smell of urine those are no

longer reasons to give people

antibiotics so I think the antibiotic

overuse and this D dip locations along

faxes right yeah I think they're taking

smelly urine again yeah yeah and I think

I think where that's going which is good

is hydrate them hydrate them hydrate

them fix that I think all these people

are super dehydrated because they come

into the hospital right they get all

these fluids they take care of them they

give them an antibiotic and they perk

right back up and it's like is that

actually an asymptomatic UTI that acts

like confusion which was what we were

all taught right we were also taught

that you're in a sterile right so we

were taught that but now it's like no L

elderly people get dehydrated the

dehydration causes I think it's where

it's going is to teach people that not

jump on your and all the time and Penn

Barnes this infectious disease and I'm

like Penn I'm doing this talk I recur

UTIs and she's like tell him not to

check urine cultures on old people like

she's literally was that because they

get comes up and all the time in the

hospital's elderly person oh is this UTI

they didn't know that they had in

they're confused and I think the

differential for confusion is so much

bigger than a symptomatic

urinary tract infection Oh people just

go there people just go there I'll

you're dehydrated so now your urine

smells right

and so it's like a carthorse thing and

it's tricky but I think with this

antibiotic stewardship thing and you

know kind of teaching what we've been

taught I'm not saying don't do it but

just do it wisely and thinking about

other stuff postmenopausal pelvis oh my

gosh the pathology is huge it doesn't

look good down there people but nobody

looks nobody looks so I do probably

eight pelicans a day on the young women

because papsmear requirements are going

up in age right and then only perhaps

where your requirements are kind of

going like less and less over so I get

all I did all day long is I've never had

this done before or I thought it was

done during this 20 years ago right

nobody looks at the El we anymore and

the pathology down there which we're

calling UTI and we're drugging with

antibiotics is huge and if you can

optimize that women are gonna feel so

much better

I'm an overactive bladder interstitial

cystitis and chronic pelvic pain so I

keep getting recruiting UTIs what are

your symptoms I said the peel the time

you think you might have overactive

bladder yeah because the other backs

they just don't they don't work I just

keep having a peel at him and so there's

overactive bladder there's all these

other diagnoses that are here that

aren't recurrent UTIs so here's a

potpourri of all bird all buzz I don't

have a normal vulva you might have my

things so the first one this one simply

called really totally atrophic totally

irritated there is no s Truman there is

no rugae we've probably got a fissure

that hurts when it's pulled right here

so sex is not fun the urethra is right

here I it spread a little bit but what

happens is the external labia kind of

expand and puckers and the urethra cos'è

actually puckers out and people you'll

see this if you do more and where you

look you'll get some urethral prolapse

well now you've got your mucosal of your

cheek sticking out into the world that

e.coli is gonna love it and you don't

have any hair bearing in there and you

don't have a clothes to follow about

anymore and bugs love it

so the hell

of the vulva changes after menopause UTI

risk go way up so instead of just saying

oh this Nancy just keeps coming in for

current UTI it's like hey kids you can

feel better down here and get your

tissues healthier and those Ecola are

gonna not not going to this lady so

totally atrophic all you basically see

is really threat and right here you're

seeing totally red features that's

another thing on the history of

recurrent UTIs it only hurts when I'm

peeing and it's it's been four months

and I keep taking antibiotics and it

helps for a little bit but so it only

hurts when she's peeing is because she's

pouring acid on a wound and she got

vaginal estrogen a liver symptoms went

away so urines an acid and when you put

it on skin that's algae it hurts and

woman comes in she says I have recurrent

UTIs because it burns

that's like you've got pathology down

here if we can fix it you're not going

to keep going in and getting these

antibiotics on this lady so external

labia super red and irritated just I

will challenge I was out all the time

easily could be confused with a

recurrent UTI because it hurts down here

it hurts down here and so she was a kind

of a steroid cream estrogen cream to get

that kind of between you look down

so there's ton point being this is not a

UTI there's there's often Ella

especially in the postmenopausal woman

there's a lot more to it so how I do it

a little bit of time history to me of

everything it is like is it sudden onset

sudden frequency you were feeling fine

until your UTI or is it you know six

months of I pee a lot and it burns

sometimes so I kind of really figure is

this any acute UTI recurrent picture or

am I looking at overactive bladder

atrophic vaginitis chronic pelvic pain

all of those things records I always

look for urine cultures because to me

I'm like dip I don't you know I need I

need urine cultures to technically call

you or recurrent UTI by definition the

exam imaging

might go to imaging is a renal bladder

ultrasound that's gonna show any

obstruction any kidney stones they do

mandatory post-void residual when they

do unreal better ultrasound so you're

gonna pick up any sort of a symptomatic

retention on them and I say my jobs to

tell you my job is a urologist is to

tell you your anatomy is normal

once your Anatomy is normal now we work

on your environment and all the things

that we can change to not get infections

cystoscopy like I said pretty rare that

I do it except for a handful of cases

any woman who comes to me with recurrent

UTIs gets vaginal estrogen the data is

so strong that it does not increase your

breast cancer risk the data is so strong

that helps prevent recurrent UTIs and

this is how I have a YouTube video on us

so I tell women because it comes in an

applicator you're just to put one gram

up I have all these women coming in

wearing pads just because of their

freakin bad journal estrogen is falling

out of them all day long like

I would who would might have a bad

little extra doing that during I'm

wearing this pad just doesn't add

nitrogen it's like they stopped using it

because of the way it's prescribed so I

say small pea-sized amount on your

finger you spread your labia you put it

right where you pee in the inner parts

of the labia a little bit up the vagina

if you want to a couple times a week and

that too which is expensive if you don't

have insurance that's going to give you

a nice deal on that we'll ask you four

to six months that way so I'd like

you're saving money you're not gonna be

dripping out cream all day long and you

put it where you need that lactobacillus

to go and you put it in especially with

sex and dyspareunia pain on an entry

once once the partners inside and fine

paint on entry that estrogen cream can

help a lot with that complained estrogen

estradiol is now generic Medicare is

just starting to realize that so that

just went on Eric 2018 and Medicare's

just starting so I think we're gonna see

that price go down and that access pick

up a lot faster but a tube of primer

naresh trays will last you four to six

months if you do up in my way I've had

so many women come in and say yeah they

gave me that but it was a core it was

too expensive and ice you know give up

my schpeel and they get on it and it

does tend to work really really well we

have a clinic policy on urinary tract

infections we don't diagnose over the

phone she'll give you antibiotics over

the phone we we did

you know urine culture now where your

ologists and there's only so many of us

and it's kind of our policy but I think

it helps a lot just to say especially

our world is a cancer is it overactive

bladder there's all the things down here

that we see it's like if you want to

treat us with antibiotics you're gonna

be symptomatic and you're gonna have a

positive urine culture infectious

disease and allergy are you talking

about allergy for that big laundry list

of allergies that you just don't want to

deal with and then infectious disease

they are so on board and seeing eye to

eye with asymptomatic bacteria don't

overuse if you have a patient who's just

like no it's an infection can see there

it send them there and the infectious

disease will totally have your back and

be like yeah don't treat unless you're

it's like it's just another every once

in a while we have a patient we're like

you don't believe us fine infectious

disease and they talk to them about it

and they're like yeah I infectious

disease says don't treat it either okay

so they're kind of just there for backup

support and they're totally on board for

four lessons more on antibiotics so

takeaways you can live stress for you

and Nancy's on your schedule for

recurrent UTIs now you've got so much

stuff to talk to her about and to help

her out with ultimately it's up to Nancy

to get less UTIs it's not up to you so

don't take it personally and then

everything between here and here

especially in a women is not a UTI

that's all I have the funniest thing

about me which explains a lot of how I

got behind it she won't let me to have

any services for free she's like yeah

come on over here you get the friends

and family discount

and I'm like behavior get down because I

get to read all the stories and doctor

things

tendonitis from suppose Tony is Tony

trying really hard I'm being supportive

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okay well my slides aren't that

interesting because it's usually the

stool bacteria that that poisons the

urine right so you probably just do

another stool transplant gotcha nope

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