Narrator 0:00
The information provided in this podcast is not a substitute for medical advice or treatment. If you’re concerned about your health in any way, we encourage you to consult your GP.

Hannah Paterson 0:12
People don't like talking about it, but incontinence can affect anyone. You may have a friend or relative who lives with it every day, or maybe you're worried about your own incontinence. Incontinence Talks is here to make us all feel more confident about continence, hosted by former Olympian Rower and Coloplast Ambassador Pete Reed. In this episode, Pete talks to consultant microbiologist Dr. Carmel Curtis to find out more about urinary tract infections. Dr. Curtis is an expert in UTI's, something which affects a lot of ISC users.

Pete Reed 0:45
Carmel, nice to see you again, and I've been looking forward to this enormously. Why are we talking about UTI's and why are they such a big deal?

Dr Carmel Curtis 0:53
Thanks, Pete. Thanks for inviting me. Um, we're talking about urinary tract infections because they affect so many people. And I think they are a, an under-talked about subject. I think they're something sometimes people are embarrassed about. And I think some people really struggle with diagnosis and treatment. So for me, they are extremely common, about 3% of all GP interactions. They're about a fifth of all hospital infections. So they are, you know, quite a high priority, I would say, for certain members of the healthcare profession.

Pete Reed 1:30
How long have you been working in the UTI space, in microbiology?

Dr Carmel Curtis 1:34
Yeah, so I've been a consultant in the NHS for 13 years. And I've had an interest in UTIs, particularly in patients with neurological issues for at least the last 10.

Pete Reed 1:44
Is there anything you think you haven't seen in this space?

Dr Carmel Curtis 1:46
Oh, there's always something you haven't seen, I would say.

Pete Reed 1:49
Uh, seen, smelt, monitored, uh, all the things I have suffered from UTIs in the past. I'm recurring UTIs. I've heard you speak on this subject, um, twice actually, and I was just dropped jawed fascinated because the science that you were communicating and showing data about was what I'd been feeling in myself as I got to know my new body post injury. But I had, I didn't have the skills to understand what was going on. Is this something that our listeners who perhaps have never had a UTI? Is it something that they should be aware of and thinking about? Why should they be listening into this as well?

Dr Carmel Curtis 2:29
Because I think particularly in people who have cord injuries or who use urinary catheters, UTIs are very real fear even if they haven't had one themselves. So I think from the perspective of a person who thinks, well, why should I care about it if I haven't had one yet? But I still think for many patients that I speak to, the worry is will I get one and what will I do and how will I know and will someone diagnose me and will someone offer me treatment? And if I have that treatment, will I get better? So I think it's significant because it's common because people have worries about it and I think people worry about how they access diagnostics, treatment, prevention. So I think those for me are the main issues for patients.

Pete Reed 3:15
Do you think that there's a stigma?

Dr Carmel Curtis 3:18
I don't think it's so much a stigma, I think people can be quite flippant about it.

Pete Reed 3:22
Okay. So there's a public perception.

Dr Carmel Curtis 3:25
Yeah. So the thing, and I include healthcare professionals in that. So it's just a UTI, it's just the cystitis. What's the big deal? You know, drink loads of water, drink cranberry juice, get some antibiotics. Don't worry about it. So I think in actual fact, it's the opposite, I think in many cases we don't take it seriously enough.

Pete Reed 3:46
So that's kind of reassuring for me to hear because that's been my experience as well. So my spinal cord injury was in 2019. There's clearly a lot of change, there was for me, but anyone that has a spinal cord injury to a lesser or greater extent has to learn their body again. And lots of people externally, they just see the wheelchair or just see whatever that is visible. And wrongly assume that legs not working or arms not working is the biggest part and there are scores of things that I would like to have back. But the tippy top of my concerns is UTIs. So I self-catheterise, which will come to my bladder, my renal system doesn't work so that's the bladder, kidneys. I'm just going to say pipes, but you're going to say, urethra and give us all of the big names. The plumbing doesn't work for me, so I need to put something foreign up inside my body to drain the bladder. And bladders weren't designed for that, they're designed for sort of filtering and out.

Dr Carmel Curtis 4:53
They are self-voiding.

Pete Reed 4:55
Yes, self-watering, thank you. Is the bladder, is the renal system a very delicate organ? Is it in a fine balance?

Dr Carmel Curtis 5:02
Well, it isn't a fine balance because it's obviously connected to the kidneys. So the whole point is that the kidneys filter the blood, generate waste products, send those down to the bladder. So it's robust in the sense that it's got to work every single minute of every single day of your life pretty much to be efficient and to keep you in good health. And when it goes wrong, you feel the impact and that's part of what you were describing. So you're not in renal failure as such, but you have a bladder implication of what has happened to you with your spinal cord injury.

Pete Reed 5:34
So the bladder implications aren't just, there drink some cranberry juice, I have plenty of water. You'll flush it out. They are the worst aspects. So I need to ask you some questions about my medical care which is really indulgent, but I've got an audience with you. It's because when I have a UTI, firstly when they start off I'm in denial, I think that's probably not a UTI. Maybe it's some sort of trauma, maybe pushing something up inside me is irritating, some lining and causing a few spasms. What I noticed quite soon after that, how mine presents is, actually my wife, Jeanie, she notices that I start to get smelly. So, like a body odor armpit smelly, and I noticed that I get physically weak, so my just power using my arms drops by half. I get very fatigued as well, and sweaty, shivery, fevery, I seem to sleep and sleep. And then the part that I was unsure of is, I don't know if this is psychosomatic, but I think differently. My speech is even less coherent than it is now, and my thoughts are as well. It's the only time in my life that I feel any sort of despondence where can a bacterial infection affect the way you think?

Dr Carmel Curtis 6:53
Well it can, I suppose, in the sense that it can the normal balance of your electrolyte. So those are things like the salts in your blood and in your urine. Things like your glucose, how much sugar you have. The bacteria can do things like disturb those effects, particularly if they get into the bloodstream. Now not everybody who has a urinary tract infection gets a bloodstream infection, thank goodness. But I think it can affect you in the form that you can be dehydrated, therefore you get light-headed, you don't feel quite well. Particularly in older patients, they can get something called delirium where they're very confused and they almost forget where they are, they can become to the point where they need to be hospitalised. So I think one of the things with urinary tract infections is it affects people in very different ways. And so when you see it in a child, it will present very differently to an adult, to a person of older age, to a person who might have a spinal cord injury or a person who might have something like MS. And I think that's why it's for me quite important that you recognize it in yourself because you or your close family members like Jeannie will know you better than a lot of other people. And when you say, "I don't feel quite right, I think I might have a UTI", it has been my experience that particularly patients with MS or Parkinsonism where I had sort of started my interest in this, would report that nobody believed them. Right. They would describe a very unique symptom, I'm just going to give an example in an MS patient that I saw where they would drag their leg. So the spinal lesion they had would cause a leg drag and they usually knew that that meant they had a UTI. That was how they presented.

Pete Reed 8:31
But when they told that story to their GP or someone, they might just naturally--

Dr Carmel Curtis 8:41
Yeah, might get dismissed or they might think they were having a relapse of their MS, for example. They might think actually that leg dragging sensation was a neurological deterioration, a deterioration of their nervous system. But actually it was a UTI in their case and over time that patient that I looked after would say, "Oh, I always know when they're coming on because I get the leg weakness.” So what you're describing is not an uncommon scenario, particularly people who have cord injury or neurological causes for their UTIs.

Pete Reed 9:07
So there's a massive spectrum.

Dr Carmel Curtis 9:09
Massive.

Pete Reed 9:10
Which means that somebody's on the left hand edge of the spectrum where they've got a UTI but it's not bothering them too much. So we don't want to be all doom and gloom. No, exactly. Kind of reassuring that ok, it’s not normal to have recurring UTIs that are making you bedridden, but also we shouldn't live in fear too much. Correct. And it's a normal thing if you get a UTI, doesn't mean you're dirty, it doesn't mean you should be ashamed and it can be that it just hurts to pee and you need to drink more.

Dr Carmel Curtis 9:38
Absolutely. And you've just been unlucky. So if you think that 50% of all women will get a UTI at some point in their life, which is an enormous number. And a lot of that will be associated with intercourse, with childbirth, with being pregnant, with postmenopausal also. And a lot of people have no real issues with that they get two or three days of antibiotics. They feel great. So I agree with you completely. I think there are certain people for whom it causes more problems than others. And I think it's that spectrum exactly as you describe.

Pete Reed 10:13
If we dig into the mechanics, the female Urethra is still part of, inside your anatomy, and very It's very, very short. I didn't really realise. But what are we talking?

Dr Carmel Curtis 10:25
Three or four centimeters long.

Pete Reed 10:27
Okay, and a male Urethra has got a long way to go.

Dr Carmel Curtis 10:31
Correct. Which is why men are less prone to UTIs in general.

Pete Reed 10:33
It's important that we do bring up male and female differences because there might be a societal thing as well. Is there any difference in stigma or getting treatment for females than males?

Dr Carmel Curtis 10:45
Yes, so UTI should be rarer in men. So often when a doctor or a specialist nurse sees a man with UTI they actually take it more seriously because they shouldn't really be seeing it. Which I think is quite interesting. So if a young man came in with the urinary tract infection who had no other medical history, there would always be quite a serious thought. What could be going on here? Is it related to something else? Could there be a, for example, a kidney stone there? There'd be a different thought process. I think my personal view is because they're more common in women you may need to have a couple of extra UTIs before somebody goes, you know, I wonder if you have a problem. And of course, some loads of women won't. It'll just be, I've just had a baby or I'm pregnant or I'm postmenopausal. So I think there is a difference in that sense. And we also treat them slightly differently. Men get longer courses of antibiotics than women because they're considered more complicated.

Pete Reed 11:41
That's interesting. Could we talk about the dipsticks as well? We haven't mentioned those yet, but... a someone with a spinal cord injury, who catarizes. So I've got a predisposition, I suppose. What are the dipsticks that I'm talking about that we put some pee on to? What are they showing?

Dr Carmel Curtis 11:56
So they show different things. They're not all the same. But generally when you are considering whether somebody might have a UTI, you're looking at a couple of things on the dipstick. One is the white cell. So when you're bladder encounters bacteria, it produces white cells. Which are to sort of protect you from the bacteria, to if you like, chomp them up and remove them. And then the second thing they often test for the dipsticks is something called nitrates. And that's something relating to bacteria. So those are the two classical things we would look at.

Pete Reed 12:28
And these are normally used by healthcare professionals. Correct. Maybe a urology nurse in the GP surgery, so you'd go and they'd ask you to produce a sample and then in the first instance, dip it. So let's say the dipstick is lit up, high in leukocytes and nitrites, maybe some blood in the urine as well.

Dr Carmel Curtis 12:46
Yeah, sometimes.

Pete Reed 12:48
So the sample go off to a lab. Would it come to somebody like you?

Dr Carmel Curtis 12:52
Well, it would come to my laboratory. So we're a place like a hospital, an NHS laboratory typically. It would be put through a laboratory process. So it would have a more sophisticated level of a dipstick, which is essentially a microscope would look to see, can I see the leukocytes? Can I see any bacteria or yeast floating around? Then it would get cultured and then it would get antibiotics tested against it. And then it would come to me for what you'd call medical authorisation. So I look at the name of the patient. I look at whether they're male or female. If they could be pregnant, are they a child, and then I would look at what bug they've isolated. And then what antibiotics I'm going to release to the GP or to the specialist nurse who will then decide what antibiotic to give you. And of course, I would, you know, I don't know whether you're allergic to an antibiotic, so that would be for them to assess.

Pete Reed 13:44
Well, actually, I don't mind sharing, but I am. So I'm allergic to penicillin, which is a little bit of a personal problem because it halves the number, ish of antibiotics I can use. And we will come onto that. I'm desperate to ask, is there a threshold? So once the analysis has been done and the cases come to you, you said you have to make a decision, and these are quite tough decisions sometimes, because there must be a threshold where you say sometimes it's there or there abouts. So it's a yes or no. What are the parameters that you're considering, of whether or not you prescribe or say, yeah, this is a positive test or a negative test.

Dr Carmel Curtis 14:21
So we have national standards for this in the UK, which most laboratories will use. There a bit controversial at the moment and they're undergoing a review whether we're too strict, in other words more people have UTIs than we report. The standard is actually from the 60s, the 1960s. So we've been hanging onto this standard for a really long time. So I think laboratories will have a standard that they look at, they will decide this is, meets the threshold of we have enough bugs in this urine to call this positive. And then that comes for a medical review to assign the antibiotics you might want to give out. For example, there are certain antibiotics we wouldn't give out in pregnancy or in very small children, or in people with penicillin allergy, if we have that. So I think that is where the microbiologist looks and decides I'm going to release these five antibiotics to the GP and he will choose the one best fit for his patient or her patient.

Pete Reed 15:19
I'm getting to something here, which is what's the burden on the healthcare system of UTIs because you'll be prescribing something and I really want to hear your experiences and thoughts on prescribing antibiotics, pros and cons and resistances to antibiotics as well.

Dr Carmel Curtis 15:39
Yeah, I mean, that is the seminal question of our age really. How many antibiotics should we be giving out and why should we protect them? The burning question across the world, which you're hinting at is antimicrobial resistance. So in other words, every time we expose a member of the population to an antibiotic, we worry that the bugs that they carry in their gut or in their mouth or on their skin is going to change because we've given them an antibiotic. Now most of the time, that's not a very significant change. And when we choose our antibiotics, we're always trying to choose the antibiotic that will do the least amount of damage to the rest of you. So, we want an antibiotic that's going to concentrate in your urine that we're hoping it's not going to affect your gut or the bacteria you have in your mouth or in your skin. So, we try to choose things that will do the least amount of damage to your normal bacterial, because we're all covered in bacteria, head to toe, inside and out. And we need it too, right? We need So, we don't want to take away any of the bacteria that make you feel healthy to help you digest your food or metabolise your drugs that you might be taking for something else.

Pete Reed 16:49
Because the danger is if you gave me a wacking, great dose of a nuclear antibiotic... How wouldn't you expect me to feel?

Dr Carmel Curtis 16:57
Well, I think the issue is, you might not necessarily feel very different. But I think that what the microbiologist is doing is thinking about I want to least affect the rest of you. So, large doses of broad-spectrum antibiotics are unnecessary for a lot of people with UTIs. And we try to preserve them for the day that someone comes in when they are truly unwell and they need to be admitted to hospital and they need to have intravenous antibiotics. We try to keep those really broad-spectrum antibiotics for those moments, not give them out in the community unnecessarily.

Pete Reed 17:28
Camel, I've got a question about antimicrobial resistance. That's the right phrase in AMR.

Dr Carmel Curtis 17:33
It is.

Pete Reed 17:34
How worried should we be about this phenomenon globally? What is it? And what's your advice to listeners?

Dr Carmel Curtis 17:41
Yeah, so AMR is a global threat, I would say, to health care across the world. And in different countries, in different parts of the world, it has a greater or lesser presence. We are actually quite lucky within the UK that we have superb agencies that monitor this, that give us guidance on what antibiotics we should be prescribing for our patients and for people in the community to reduce the risk of AMR. So, we are fortunate that we have these excellent surveillance systems where we can look and see who might have resistant bugs. You're correct to highlight it as a wider issue, but for many people as individuals, they won't feel the impact of it themselves.

Pete Reed 18:25
So, your advice to individuals?

Dr Carmel Curtis 18:26
Is to take antibiotics when you need them guided by a health care professional. I think it's the key message for me.

Pete Reed 18:34
So, do you have peers around the world in various different laboratories where there's a network of and a decision making process with all of your joint brains of this is the direction and things we should be worried about?

Dr Carmel Curtis 18:48
No, it's something that has taken quite a high priority in health care systems around the world. We truly live in a global society, so we know that things don't stay in one country. They move around with tourism, with business, with food products, with agricultural products. So, we are very conscious of this movement of resistant bugs around the world. So, many countries who have the resources will have these surveillance systems, and these ability to pick up resistant bugs moving around the population. And we take all of that into account when we give advice about what antibiotics the person should have.

Pete Reed 19:23
Are we making any more antibiotics? Is there a finite number? If I said how many are available to treat a UTI?

Dr Carmel Curtis 19:31
This is an interesting question. We are doing better than we were I would say a few years ago. So, there had come, I suppose, a point, a hiatus at kind of full stop in antibiotic development, because for drug companies who would invest enormous amounts of money in the development of antibiotics, resistance was being acquired so quickly that they weren't making a return on their investments. So, they were very reluctant to produce drugs that people only needed for very short periods of time. So, if you think about high blood pressure, you're on a drug often for your whole life. So, that's very profitable. It makes sense for people to invest in, for example, cholesterol drugs, or anti-hypertensive drugs. But, of course, that's not really the case for antibiotics because you're not on them your entire life.

Pete Reed 20:18
That's heartbreaking for me to hear. Because I'm not making this political, but that's a little bit of capitalist mentality of what's making money, and I'm sure that's not the only problem in your industry as well. UTI's, renal systems, it's not a sexy topic of conversation, how is funding for everything? For scientific development?

Dr Carmel Curtis 20:40
Well, I'd have to say, of course I'm biased. I'm disappointed at how low-down the political agenda, things like urinary tract infections, often are. They affect large numbers of people, but as you say, compared to some other pressures on health care, I suppose, viewed less importantly, maybe lower down on the political agenda, which I think it's why it's so important that those people who suffer from UTIs and people who are interested in the treatment of UTIs continue to raise profile to do educational things like this, to discuss it, to discuss it with their GP, with hospital colleagues, in my case, trying to raise the importance to say that people who have UTIs can be affected to such a degree that their lives are changed by it. And I don't think that we really have done ourselves any favours in describing that particularly well in health care. I think we're much more aware of what to do if someone has cancer, if someone who might have dementia or HIV or tuberculosis or other things we’re very clear about what we're going to do, how we're going to treat them, how serious that is. So I think UTIs have somewhat suffered from that lack of scientific investment and interest.

Pete Reed 21:53
And if their individuals in the right hand edge of the bell curve with how debilitating UTIs can be, it will affect what work they can do, how they're able to contribute to society, work, pay taxes, be normal and functioning, and the big swing is, they could become an increasing burden on on the NHS and on health care systems. Again, I don't want to fearmonger at all. How much of your time is spent on podcasts, spreading awareness, on panels, speaking to government, speaking to health ministers, just to get the message across from the pointy end of science, what this phenomenon is now and going forwards.

Dr Carmel Curtis 22:33
Yeah, I mean, it's something I feel quite passionate about. I do what I can. I speak with various charities, I think have been very strong in this space.

Pete Reed 22:41
Can you talk about those?

Dr Carmel Curtis 22:42
Yeah, people like the MS society, Parkinson's charities, dementia charities are asking us all to not forget about their patients, their friends, their families. They're looking at, you know, for example, if a person with dementia gets a UTI, it can entirely cause them to have a significant deterioration. It takes what little quality of life they might have and diminishes it further. So from my perspective, I think the more we can do in terms of articles that people can read, podcasts, talks at events, charity events, in particular, I think is really key because this is not the easiest topic to get up the political agenda. So I think that's why I wanted to participate today and we've known each other a while, Pete, but I think we cannot allow people to feel like this is not a significant topic. Even though I couldn't go to work, I couldn't socialise, I couldn't go to my child's graduation or, you know, there could be some event that people scars them almost, feeling that they've been left, because they haven't been treated, they've been left out of what they consider to be the vital parts of their lives.

Pete Reed 23:51
So that's so well said and I think it's important that when we speak to the decision-makers that they're not making decisions out of charity for people, it's not just that they can't go to a wedding or a funeral. Those are the very real things that affect people's lives, but this is, it's every right to be top of a healthcare agenda alongside many other worthy causes and shouldn't be ignored or dismissed to cranberry juice and staying hydrated. Or not being hygienic when you have sex or other foolish taboos that are in the background of anything to do with UTIs. So thank you for your continued lobbying and support and talking and sharing about the subjects.

Hannah Paterson 24:34
On our next episode, Pete continues his chat with Dr. Carmel Curtis about the risks of urinary tract infections and how to minimise the chances of getting one as an ISC user. There are lots of amazing charities that can provide focus support depending on your particular needs as well as lots of information at coloplast.co.uk. Thank you for listening to Incontinence Talks. And remember to consult your GP if you have any worries about your own continence.