Why we Can't Blame an "Embedded" Bladder Infection for Symptoms
With how the symptoms of interstitial cystitis resemble those of a UTI, it's always been tempting to assume the symptoms are simply an undetected bladder infection.
Recent (and exciting) advances in the field of urine testing are allowing us to better understand the natural microbiome of the bladder. We are learning that everyone - both those with and without symptoms - have natural bacteria in the bladder. This is similar to how we have a natural microbiome in the gut or vaginal canal.
We know that all people have this natural microflora in the bladder, but we have no evidence that it is harmful or the cause of IC symptoms. From early testing, it appears there is no major difference between the bacteria in the bladder of IC patients and asymptomatic people.
Unfortunately, being able to find and identify all the bacteria that have always been in the bladder has led some to re-assert the old notion that IC really is just an undetected bladder infection.
While this is an interesting area of study and more research is absolutely needed, currently there is no evidence that IC is the result of a previously-undetected infection. Long-term antibiotics - the treatment that would be indicated for a bladder infection - have been shown to be ineffective and are specifically not recommended by the American Urological Association.
Even the CEO of Microgen, the testing company at the forefront of these advances, has specifically stated their testing cannot be used to diagnose an embedded infection.
There is absolutely no evidence that interstitial cystitis symptoms are due to a previously undiscovered bacterial infection. In fact, there’s significant evidence that long-term antibiotic treatment is ineffective, and the American Urological Association specifically
states antibiotics should not be used in the absence of a clear, demonstrated bacterial infection.
New testing techniques are now able to detect the natural microflora in the bladder. These bacteria are present in everyone – whether or not you have any symptoms. In fact, in women who have absolutely no pelvic pain, symptoms or problems, an average of 21 different types of bacteria can be found.
For decades doctors treated interstitial cystitis as if it was a bacterial infection they just couldn’t see. They prescribed long-term antibiotics and even IV antibiotic treatment. It was proven to be ineffective. Our new ability to see these bacteria which have always been present – and are present in all people – does not change the way we treat interstitial cystitis.
What is MicroGen Testing?
Traditional urine cultures work by putting bacteria into a place where they can thrive (culturing) and seeing what grows. Unfortunately, it can be difficult to get bacteria to grow using a culture, and the test can be inaccurate and miss a potential infection. It can also be inconclusive, and doesn’t typically identify if a bacteria is drug-resistant.
Microgen testing actually finds and tests the DNA of bacteria in a sample. It doesn’t require the bacteria to be grown, so it can find bacteria that wouldn’t be picked up with a culture. It also has the ability to test for fungal infections. In summary, it’s a more sensitive test which is able to pick up microorganisms in urine (and other areas of the body) that we had previously not been able to detect.
“All urine has microorganisms and that the “micro- biome” within the urinary tract is going to vary by patient. It’s very difficult to say what a quote, “normal microbiome” is.”
-Rick Martin, CEO of MicroGen
What does it mean for IC?
First, this is exciting new technology. It should be able to reduce the number of ‘phantom UTIs’, where patients with IC are treated again and again with antibiotics for urinary tract infections that don’t exist. It may also help understand the complex urinary microbiome and what role (if any) it plays in urinary symptoms or pelvic pain.
However, no research at all has been done that changes our underlying understanding of the condition. We have no evidence that IC is due to bacterial infection, and a lot of evidence that it isn’t the case. Long-term treatment with antibiotics has repeatedly proven to be ineffective for interstitial cystitis and is specifically not recommended by the American Urological Association IC guidelines.
“The key point is you have to combine our test with other markers of infection or inflammation. If all other indications, whether it’s patients’ symptoms, burning urgency, whether it’s white blood cells count or leukocyte esterase assessment, whatever said rate CRP, whatever test you’re using, if all markers and symptoms point to infection, we are going to tell you with precision exactly what species are at the site.”
-Rick Martin, CEO of MicroGen
We would love to see additional research in this area. A few studies would tell us a lot more about the role (if any) of normal microflora and bacteria within the urine.
Is there any difference between the bacteria in urine of a patient with IC versus people with no symptoms? The first major research question will be to determine if we can detect any pattern at all to the bacteria found in the urine of individuals with and without symptoms. No testing has yet been published in this area, but it would let us know if we should conduct more research into the microbiome of the bladder.
·If there is a difference in microbiomes, does it dictate an effective treatment? After we learn if there is a difference in the bacteria found in the bladder of IC patients, the next step will be to learn if targeted antibiotics or another intervention are able to provide symptom relief.
Until those two main questions are answered, none of our understanding of the condition has changed. While more sensitive testing is always important, it’s equally important to learn how to interpret the findings and not chase after test results that don’t mean anything in terms of practical symptom relief.
At PelvicSanity, we support patients beyond the walls of our own clinic in Southern California. We offer an Out-of-Town program, remote consultations, and a Facebook support group for patients called Finding Pelvic Sanity.
Dr. Nicole Cozean is the founder of PelvicSanity Physical Therapy in Orange County, CA. PelvicSanity treats patients from all over the world with remote consultations and the Immersive Out of Town Program. She also runs Pelvic PT Rising, training other pelvic PTs to better serve patients.
Named Physical Therapist of the Year, Dr. Nicole is author of the award-winning book The Interstitial Cystitis Solution and the first PT to serve on the ICA Board of Directors, Her passion is helping those with pelvic health issues - regardless of where they live - find lasting relief.