IG Live Recap: Bonafide Speaks with MyUTI on Bladder and Urinary Changes

Bonafide’s Chief Medical Officer, Dr. Alyssa Dweck, sat down with MyUTI co-founder, Megan Henken, and Women’s Urologist, Dr. Tami Lewis, during our 6th episode of Bonafide Talks, our IG Live series, to talk all about bladder health and urinary changes that may be experienced during perimenopause, menopause and beyond.

Check out the full recording and summary from the session below, where this panel of experts discusses things like urinary tract infections, overactive bladder, and dietary supplements, along with treatments that can help manage these changes in urinary health.

Video Summary

Dr. Dweck: As most of you know, I am Dr. Alyssa Dweck. I am the Chief Medical Officer here at Bonafide. And I am so excited for this conversation all about urinary health. And I will first introduce Megan, who runs the platform, MyUTI, so please do us the honor and tell us a little about yourself, while we're waiting for Dr. Lewis to join us.

Megan Henken: Sure thing! So yes, I am the co-founder of MyUTI. A little bit about me, is that I am, I guess what I sometimes coin as an “industry veteran.” So, I have been on the industry side of healthcare, really managing products and testing in the women's health and infectious disease side of things. And so, that's really where I was introduced to advanced testing for urinary tract infections. And then also I have a personal experience with urinary tract infections. So, this is pretty much a culmination of both my personal and professional experience.

Dr. Dweck: Great! So, I've been a gynecologist for 29 years, which predates my position at Bonafide. And I still practice gynecology. And I have to say, one thing that really has come up over and over, in my practice, are very squeamish urinary complaints and concerns – because we've gotten really good at talking about menopause. And we've gotten really good at talking about vaginal health and even vaginal dryness. But when it comes to urinary symptoms, particularly symptoms of overactive bladder, symptoms of leakage, in particular, we're still seeing a lot of very shy people who really almost don't even want to talk to their gynecologist about it.

Are you getting a lot of interest in discussing these subjects?

Urinary Changes and Menopause

Megan Henken: Yeah, absolutely. And I think before the call, we put feelers out there really trying to see what questions individuals may have, whether it's advice that they received from friends, advice that they've received at urgent care, or a primary care physician's office, to really demystify what can happen during many different phases of a woman's life, but especially around menopause and perimenopause, where you're getting a combination of symptoms that often do involve urinary issues –  anything from UTIs to maybe OAB [overactive bladder].

And then you're also looking at some other vaginal concerns, right, where people start to talk about vaginal dryness. We also got questions – this is more about urinary health, but about their urine smelling different than it did previously. I think there's so many questions about what's going on down there. And then when do you talk to a urologist? And when do you talk to your gynecologist and kind of how do you step through that process together? So, I'm excited to have the conversation.

Dr. Dweck: Oh, and hello, Dr. Lewis! Good to see you - you know, the tech is always the hardest part. Like we can practice medicine and take care of complex issues, but sometimes Instagram can be a little challenging. So, welcome and thank you so much for joining.

Dr. Lewis: Yes, thank you for inviting me.

Dr. Dweck: You're so welcome. We were just doing some very quick introductions. So, please let our audience know where you are, who you are, and, and let us get to know you better!

Dr. Lewis: Thank you for inviting me. I'm Dr. Tamra Lewis. I'm a urologist with specialty training in female pelvic medicine and reconstructive surgery. I work in private practice urology, in the Chicago suburbs. I’m part of a medium sized group here and since joining the group about 17 years ago, I’m really the only female urologist in the practice. And with specialty training, my practice has become primarily composed of incontinence, recurrent urinary tract infections, and then you know, a peppering of the other urologic conditions.

It really behooves me to get really good at understanding these conditions and, a lot of it's incontinence, but it's also urinary tract infections, and there's just seems to be so much of an overlap between, both the symptomatology, the patients who fall into that group there, and also some of the recommendations that we're giving them. So, I found myself having sort of two parallel conversations with patients, just regarding overall good, bladder, vaginal, and pelvic health, and everything that goes into it. So, this is, I think, a very timely conversation, no question about it.

Urinary Tract Infections and the Menopause Connection

Dr. Dweck: So, let's talk first about the obvious, which would be urinary tract infections. I mean, these are incredibly common; most women have experienced at least one in their lifetimes, if not more than one. And what I'm seeing and what I'd like to focus on is obviously UTIs that have to do with sexual activity, because that seems to be a really common issue that people are coming into the gynecologist for. But also as they relate to the menopause transition and menopause in general. So, could you speak a little bit about what we call “post-coital UTIs”, or urinary tract infections that develop as a result of or after intercourse, specifically?

Dr. Lewis: Yeah, so I mean in terms of what discussions I have with the patient, obviously regarding the frequency of infections, but the symptoms that go along with it, confirming that they really are dealing with infections due to bacteria.

There are a lot of other conditions where women can have burning, urgency, or frequency after intercourse that may actually have nothing to do with bacteria in the urine. And so, confirming the presence of bacteria in these specific episodes with culture, advanced urine testing, such as a PCR, I think, is critical to make sure that we're addressing the right condition. And then understanding, it's not just what happens around the time of intercourse - but rather it's what happens in the other 24 hours of the day and seven days in the week, and things like that.

How much fluid are people drinking? Are they holders, you know, are they emptying their bladder right after intercourse? And so, sort of understanding some of the behavioral things that go into it, I think are a few critical places to start, and then we obviously want to make sure that there's nothing anatomic that we're overlooking – meaning it's not a kidney stone or something going on in the bladder that could be causing some flares of the symptoms as well. So, it kind of starts with a full anatomic/ functional evaluation, just to make sure we're not missing anything –  and we go over some behavioral interventions. And then, we kind of move down the line, depending on what the complaints are and how they respond to some of the conservative therapies.

Dr. Dweck: Yeah, more and more, we see people who really just want to be treated for what they think is a UTI over phone or via telehealth, quickly, while they're sitting in their office. So, I'd love to get your take on treatment before a culture returns, since oftentimes, people are too uncomfortable to wait for the two or three days, and then Megan, I'd love for you to weigh in on how your platform is helping people who are dealing with these issues.

Dr. Lewis: I think that's a good question. It's to me, as a physician, it's important that we treat patients based on data; we assess the urine, we put that together with what the patient's symptoms are, because for it to be an infection, you have to have bacteria, and you have to have some symptoms. So, I think, on a urinalysis, you can get some initial evidence of does this look like an infection versus something else?

Is there blood in the urine or white cells? Are there nitrates in the urine? If there's blood and no other indications, then maybe I start thinking more along the lines of kidney stones, on the other hand, if they're super dehydrated, or if the urine just looks completely normal, or if it's a patient who's had a history of symptoms that aren't necessarily consistent with bacteria, those might be patients to who we send the test, and say let's do some symptomatic therapy, let's wait until we get the confirmation. And then go ahead and treat based on that.

What I like to do is build a sort of a database of what did your last test look like? And so that way, I can have some sort of predictive guidance – if it's something that looks like it's susceptible to my go to antibiotic, which is Macrobid, then, do we do a couple of days of that, where we wait for the culture to come back? There are some cases where I wouldn't do that, if it's somebody who's running a fever, or if I really have a high suspicion of stones, I'm going to get that patient evaluated quick; I'm going to get them started on an antibiotic and really kind of move forward with it.

So, it really kind of depends on the patient's scenario. And a lot of this is having somebody who is managing your bladder care, your urologic care, who knows more about your history, and it's not just like urgent care, trying to treat the symptoms or things like that. I mean, it's really that we're trying to treat the patient and make sure that in the long run, we're addressing the underlying condition and not just finding a quick fix for the patients all the time.

Dr. Dweck: Yeah, you know, it’s more “I want to do what's right for you, the patient,” because you're the specialist that people are going to probably see after they’ve had more than their first UTI.

Megan, how do you manage this, because I'm sure people are hitting your website before they're getting the care of a gynecologist or a urologist, so, what is first line at MyUTI?

Megan Henken: Yeah, we do see a lot of individuals that come to us out of frustration of what I call like the classic symptom, where they're frequent fliers at their urgent care, they can't get in to see their PCP. They're frustrated, because they've been given the same antibiotic over and over and their symptoms don't seem to resolve. So, that's generally how people end up finding us.

And so, we really want to understand the patient journey - meaning you're uncomfortable, you want answers, you're frustrated. So, first and foremost, I think speed for us is very intentional. We do ship kits overnight, if that is something that you would like to do, and then it goes overnight to our lab, and then they report results, about 96% of the time, within 24 hours or less. So, that is one of the benefits of PCR testing, is that it is quick, but it's also robust. So, we look at the top 12 UTI symptoms caused by bacteria. This isn't just your classic E coli, right? We can look at some of the other pathogens and multiple pathogens that can cause symptoms.

And I think for us, also, it's really important to make sure that you get these comprehensive answers. So, then you can go to somebody, like Dr. Lewis, to say, “hey, this is more complicated than I thought”. Because we do also give an antibiotic overlay, which enables you to then have a robust conversation.

And if it's negative, and you're still having these symptoms, that's even better information for you and your clinician to have to explore – is it something that's going on with menopause and you need to talk about hormone replacement? Do you need, you know, is there a product like Revaree® for dryness, that could work for you? So, you can kind of work through all those different options instead of just assuming that it's always an antibiotic that is going to fix what's going on.

Supplements, Vaginal Health and Urinary Health

Dr. Dweck: You know, with that in mind, Dr. Lewis, what are your thoughts on supplements like cranberry or d-mannose? I get asked these questions day in day out in practice.

Dr. Lewis: Thank you for that question. I think that's a really important thing, because you know, patients are searching for something that they can do for prevention and to help manage some of the symptoms and I think focusing on things that are going to promote good vaginal health, good bladder health, good bowel health, are helpful. So, you know, the typical supplements I would recommend for someone who's peri or postmenopausal and working on vaginal health, may include estrogen, but a lot of times it's just the need for a good moisturizer if things are dry and itchy and irritated, because that can mimic the symptoms of an infection and can actually lead to infection.

So, what are we doing to maintain good vaginal health? What are we doing to maintain good bladder health? Are you drinking enough fluids? There is some evidence that cranberry supplements, not all of them, but cranberry supplements that are standardized, to help flush E.coli and other bacteria out of the bladder. So, I think there's some good evidence that's actually mentioned in the AQa guidelines of including cranberry as a preventative agent. And it's very safe and simple and well tolerated. Designing a bowel regimen, putting patients on probiotics, making sure they're eating enough fiber, I think those are the things that have a lot of good evidence. And the number one “supplement” that I think patients need to take more of is just water.

Dr. Dweck: Okay, that's a very good point, because so many women are just not well hydrated at all. So, I just want to switch gears a little bit, because I guess as I as my practice ages, they have different complaints. And something that I'm really seeing so much of now, are symptoms of overactive bladder. So, to your point, you know, these are symptoms of constant urination, maybe up to eight or nine times in a day, the urgency, the occasional leakage because of that urgency, feel free to fill in the blanks there with overactive bladder.

But occasional leakage can also really be an issue. Can you speak about this a little bit and your experience with some of the treatment options out there and what you think is missing in the field?

Dr. Lewis: I mean, overactive bladder is an extremely common condition, and it gets more common with each decade of life, too. So, it’s extremely, extremely prevalent. Urgency, frequency, having to rush to the bathroom after pulling into the garage, and I can't make it in time – limiting places that you go because there isn't a bathroom or I can't use the bathroom on a right interval; meaning I’m getting up at night more than once. I mean, those are some of the typical concerns. And I think a lot of women just feel like, “oh, it's just part of getting older,” I go to the bathroom all the time, and I have to stop. And it's common, but common doesn't necessarily mean normal, and that you have to live with it. So, you know, it's how many times a day. I mean, there's different strategies for how manage this, but it's really how bothersome it is for you. If it bothers you to the point where you limit the things that you do or you adjust your day, then I think it's worth talking about some options of things that we can do to help.

Dr. Dweck: Yeah, I find people are really shy to bring up the symptoms. They always think they have a UTI. And that's why I really wanted to bring them up next to each other.

What about the medications that are traditionally thought of to treat overactive bladder symptoms, because in my gynecologic world, you know, what my patients will complain about is, “oh, my God, no matter where I'm going, I need to map out the bathrooms so that I always know where I can stop if I'm having a symptom or concern.”

What are some of the treatment regimens that you are finding to be successful?

How to Manage Overactive Bladder

Dr. Lewis: So, there's kind of three tiers in the stages of management of overactive bladder, and we call it management more than a treatment or cure, because you're not going to cure overactive bladder, it's like diabetes, or high blood pressure, you're going to come up with a good management strategy. And that management strategy may include a combination of things. It's not just a pill or just physical therapy or things like that.

So, first line therapies, behavioral modification, physical therapy, and I throw in restoring vaginal health into that category as well, too, because you're sort of creating a healthy framework for it. So, keeping bladder diaries, are they drinking too much, too little, are they drinking the wrong things at the right time? You'd be amazed at the things that I learned by simply having people track their fluid intake and output and it gives patients good awareness about the things that they're doing.

Sometimes, I find people overdoing it, sometimes I find people underdoing it and getting up at night, but a lot of times, that's just a timing issue. And so, you don't know that unless you track it. So, behavioral modifications based on the bladder diary and physical therapy, I think are still some things I utilize that a lot. But I think overall, it's a very underutilized therapy and working on the muscles that you use for bladder control, I think there's a role for that, and UTI prevention, too. Because if you're not holding and releasing urine effectively, that's going to have an effect on infections, as well as bladder control.

And so, I teach patients to use what they have more efficiently before we go on to more complicated things like pills and procedures and tests and things like that. There are medications called second line therapy, but there's side effects to them. There are some cost considerations to it as well, too. I think there's a place for it. But I think you want to start with the simplest things and then move down the line until you have someone saying, “you know what, I don't think about my bladder so much anymore.”

Dr. Dweck: And the question that somebody had asked was, is there a “normal” amount that you should be urinating a day? I think everybody's trying to figure out like, what is normal? And so, what I'm hearing you say is, it's something that’s not interrupting your quality of life and your day to day living?

Dr. Lewis: Yeah, how would you really know what's normal? There are actually some research groups going on that are trying to define what is normal, because that probably changes with age, it changes with condition. I can give you averages, but averages don’t necessarily mean normal. And so, I think really, the degree of bother is important. If your bladder is causing health conditions, you know, incontinence, leakage, difficulty emptying, things like that – or if you're having urinary tract infections, or if your bladder control is limiting the things you do – those are bothersome things; those need to be worked out. If you're someone who just says I'm going to go bathroom a lot, but I don't really care. That's not someone who's going to be too motivated to do something about it. So, it's really, if it's bothersome, then let's try to define it and see what we can do to help.

Lifestyle Changes to Manage Urinary Frequency or Overactive Bladder

Dr. Dweck: I find my patients are most bothered by, number one, having to map out bathrooms. But number two, the nighttime awakening, because then their sleep is interrupted sometimes two, three times a night. And that really affects their day-to-day lives. So, I get asked this question a lot, and I see one in the in the chat as well, and I'm hoping you can just take us through your simple instruction to do Kegel exercises. I think a lot of people maybe find that it's a big mystery. How do we how do we really do a Kegel?

Dr. Lewis: Oh, and to be honest, that is the hardest thing to tell a patient without some hands-on feedback because I don't know if they're doing it right. I see patients squeeze all sorts of crazy things and they’re not things that are going to help the bladder. What I will tell you 100% what to not do is don't try to do a Kegel exercise when you're emptying the bladder because that will make you a dysfunctional voider, and it will cause more trouble down the line.

So, I think it is a very difficult thing to really instruct patients how to do this without some sort of hands-on therapy. I mean, there's some guidance out there as to how to find the right muscles. And how many do you do; there's some over the counter biofeedback devices that can help to show that you're squeezing, but there really is no substitute for a urologist or gynecologist or physical therapists, checking to make sure that you're squeezing the right muscles, and then you can go on from there and know that you're helping yourself and not causing yourself some additional trouble.

What Does the Microbiome Have to Do with Urinary and Bladder Health?

Dr. Dweck: Yeah, all of us gynecologists are thrilled when we have a really good, go-to pelvic floor physical therapist. It really is so nuanced. Okay, so I'm getting a question. And people ask this all the time, and it’s about the microbiome. So, the microbiome of the vagina, the microbiome of bladder, are they similar? If you correct the vaginal microbiome, will the urinary microbiome automatically benefit? Speak about that a little bit if you could?

Dr. Lewis: So, it's a really interesting area of research. I think the bottom line is what we're finding is none of these environments are sterile. Certainly, we know that the bowels are not sterile, the vagina isn't sterile, and the bladder is probably not sterile – so what you really want is biodiversity of appropriate organisms. And so even an infection, it's not the presence or absence of bacteria, it's when one gets out of control, and it upsets the balance. And so that's where E coli, or something like that can kind of take over.

But the vaginal microbiome certainly affects the bladder microbiome as well because I mean, they're literally next-door neighbors, they're three centimeters apart from each other. So, if the vaginal microbiome is upset by, menopause, excessive cleansing, douching, things like that, things that you're doing that can disrupt the normal, healthy preventative environment, then yes, that is definitely going to have an effect on the bladder as well.

There's no quick fix to this, unfortunately, and what disrupts microbiomes, as much as anything, is antibiotics. And so being judicious about the use of the correct antibiotics for the correct condition is key. You can certainly restore some of that with probiotics; trying to tailor the vaginal pH back to a normal vaginal pH, trying to just create a healthier environment so that this diversity can regrow. But it's an easy thing to break it down and it's hard to build it back up.

Dr. Dweck: That makes perfect sense. Megan, do you get questions about the microbiome on your site? And Kegel exercises? I'm guessing it's a sort of a one stop shop other than the just PCR testing that you offer.

Megan Henkel: Yeah, on our education content, and Blog area, yes, we do address pelvic floor physical therapy. And we had an interview with Don Sandal Chiti. She's a pelvic floor physical therapist who has been doing it for many, many years, and we just discussed how she works with patients, and the bladder retraining, and what Dr. Lewis is talking about – making sure you're not excessively holding it. And, other treatment modalities that they may use to help you relax your pelvic floor, so that you don't have urinary retention either. So, we do address that. And then I think the microbiome is certainly something that everybody is very, very interested in understanding, like, how can I be eating the right things? People are very familiar with the gut microbiome, there's some talk about the vaginal microbiome. And I think as we evolve in this area of research around women's health and pelvic health, especially, it’s really about understanding that everything is connected. And that, you know, our hormones play a massive role in what we experience throughout life as women.

I'm excited about the direction that research is going because I think there's been so little talked about or done about perimenopausal and menopausal phases of life, where the majority of us women spend more time and that area of our life. And we’re not really aware of how it changes the vaginal pH and how it changes the way that sex will feel; that your urine may smell differently, all these things that are going on are impacted by your hormones and how that shifts and shapes that that phase of your life.

Dr. Dweck: And is that something that you also see with your patients [Dr. Lewis]?

How Managing Vaginal Dryness May Help with Urinary Changes

Dr. Lewis: I mean, absolutely. To your point of whether it's related to UTIs, related to overactive bladder symptoms, you know, we find that out. Managing the vagina and the dryness that comes along with diminished estrogen levels really is almost a real help for many of these ailments or at least benefits day to day symptoms.

Dr. Dweck: And I would suspect you agree, Dr. Lewis, I mean, we always had vaginal estrogen cream, we've always had other forms of vaginal estrogen. We recently did a study with our moisturizer Revaree®, which is a hyaluronic acid-based insert, as a head to head trial that was done at NYU, against vaginal estrogen. And in fact, Revaree performed really well. So, for those women who can't or don't want to use estrogen for these reasons, they can try a really good vaginal moisturizer, like Revaree, which has been clinically studied and can be super helpful.

I do want to ask two pressing questions that I get all the time. And then I will let you go. First, can you comment on caffeine and bladder health? Because if there's one thing that women don't want to give up in my practice, and I think it even beats wine, it would be their coffee. So, how does caffeine really affect bladder health? The bladder? And what are your suggestions regarding that?

Caffeine and Bladder Health

Dr. Lewis: So, caffeine is a bladder irritant, it affects some people more than others. And the way I tried to frame that discussion is, look, I'm not the police, I'm not here to tell you what you can or can't have. But let's look at a diary. And let's see how what you take in affects your bladder; if you see that someone has three cups of coffee in the morning, that's all they drink, and then it's water the rest of the day, are there some compromises that you can make, maybe cut it down to one cup, maybe drink a bottle of water before your coffee, and that sort of dilutes the effect or protects your bladder against that. And you know, just kind of giving people more awareness.

And if some people say, I like my cup of coffee, and I'm going to go to the bathroom every hour for three hours afterwards. I'm like, that is a choice you're making based on data, rather than you looking at your bladder saying, “why are you betraying me like this?” So, I think it's empowering patients to understand what they put in, does affect their body. I mean, you know, putting in drinking a can of Coke, because it can have chemicals, you know, maybe your bladder doesn't like chemicals. And yeah, just kind of understanding what that relationship is, and then having a better management strategy.

Dr. Dweck: Yeah, my patients always choose caffeine over the frequency, that kind of thing. And the second question, which I'm seeing multiple times, is actually how much water should somebody drink? I know there is some information out there that you should drink as many ounces as half of your [body] weight. I don't know where that comes from. Is there any guideline that you suggest since, again, nobody knows what's normal?

Hydrating Efficiently to Address Urinary Changes

Dr. Lewis: Nobody knows what's ideal. I think there are a couple of conditions where certainly you want to increase your fluids. And sometimes when you want to limit your fluids. Like for people who are kidney stone formers, usually they want to be making around two to three liters of urine a day. So, that's 64 to 96 ounces of fluid intake. Okay, track your intake and output, make sure you're in the right space. For somebody who maybe has some cardiac issues or is on a fluid restriction, they can’t handle that much fluid, 48 ounces, may be as much as they can take in a day.

And so, not knowing what the right answer is – it’s somewhere between 48 to 64 ounces. For most women, I tend to go on the lower side if it's overactive bladder, and on the higher side if it's urinary tract infections, but the big thing is really having patients be aware of what they're actually doing. And I do think there's something into spacing it out during the day. The people who drink all of their fluids in the afternoon, that evening, are going to be getting up at night but are still going to be dehydrated for half of the day. So, understand that if you don't drink at night, you should already be making up for your fluid intake in the morning, and not waiting until the end of the day. And so, trying to get that into balance, I think is as important as what the actual number is.

Dr. Dweck: Wow, well, this was chock full of information!  Do you have any last thoughts that you want to impart on all of our listeners, you know, that’s important for bladder health month?

Dr. Lewis: I would just like to say thank you for taking the time to invite me on here and to talk about the things that I talk about every single day and, trying to create more awareness. These problems are extremely common. If you're out there suffering with one of these conditions, you are not the only one and you don't have to sit and just suffer with it. You deserve to have a conversation with somebody who really is interested in helping you move forward as a whole and not just giving you quick fixes for it.

Dr. Dweck: Fantastic. Fantastic. And thank you for all your information. Megan, any last words for us?

Megan Henken: I think Dr. Lewis covered it. I just want to say thank you for having us and giving us a platform to educate women and other individuals that there are options out there. And we're here for you.

Dr. Dweck: Yes, absolutely. And please! Urinary health is so important. Don’t be afraid to talk about it with your clinician, whether it’s an online community, your gynecologist or if you're lucky enough to see a urologist, like Dr. Lewis, it’s all-important stuff, so thank you.

Thank you both and we really appreciate everybody's time.