Beaver Dams (it's all about the flow/urinary health)

In infectious diseases there are seasons. Traditional flu season, the many seasons of Covid,  Lyme season, cellulitis season. Specific viruses and bacterial infections show up in summer, specific pathogens to worry about with floods, excess pools of rainwater. Parasites from food or travel. Mosquitoes. And then sprinkled into every day of every week are things that are seasonless– pneumonia, heart valve infections, gall bladder infections, surgical site complications and urinary tract infections.

This last month can only be summed up as urology season. And that isn’t a typical thing. But as I wandered through the weeks I found myself teaching urologic anatomy and physiology; water flow strategies multiple times each day. And many patients wished they had understood this before their hospitalization. 

Why do we pee? Because as our blood travels through our bodies, bathing and feeding our organs, cleaning up messes and keeping us finely balanced. (Humans have a pH that they can exist in, like many other life forms). Maintaining that pH is the job of the lungs (oxygen in and carbon dioxide out) and the kidneys. Our kidneys are two beans that are in the back of our abdomen (in what many refer to as the flank or retroperitoneal area) where they filter the blood and that removed waste becomes urine. 

Each kidney drains to the bladder via its own ureter and then from the bladder the urethra takes the urine from the bladder out– either through the penis or just adjacent to the vagina in the perineum. Neither of these areas are sterile; therefore when urine is collected– even by sterile techniques or catheter- we are not surprised at times when there are bacteria in the specimens. What matters for most immunocompetent beings is the question are there any symptoms of infections. With these we treat cultures.

However in almost all of our older patients- if a urine specimen is obtained there will be some bacteria– asymptomatic bacteriuria is the proper medical term. And because we are not sterile but we didn’t know this— urine cultures are treated all of the time when they shouldn’t be treated. They select for antibiotic resistance; they cause clostridium difficile infections and diarrhea. Studies have well demonstrated that we completely over prescribe antibiotics. 

So when do we need to treat the urine? When do things become a problem? Since urology is plumbing it is fairly straight forward– when the plumbing backs up. Everyone has seen a creek or lake that flows with some scummy stuff around the edges but clear water where the water moves. If the water is flowing, a little stuff around the edges isn’t a problem. But when the beavers come in and build a dam then all of a sudden a smelly stagnant pond develops.  

So what can the metaphorical dam be? In men it is the prostate. The prostate lies downstream of the bladder; it surrounds the urethra below the bladder.  So as the urethra travels with urine out of the body via the penis– it passes through the prostate. As men age– their prostate grows. As it grows, it puts some pressure on the urethra and makes urinating more difficult. (Inability to start the stream, dribbling, inability to fully empty the bladder). Then the bacteria that might have been in the urine in the bladder but were just “hanging out” as the urine flowed through are able to replicate in higher numbers and the pond becomes a bit stagnant. As well they can travel up the ureters to the kidneys (causing pyelonephritis) and sometimes jumping into the very blood stream that the kidneys are cleaning. (Bacteremia is the term for bacteria in the blood— from any site; urine is a common source)

Location. Location, Location. Stones also can become the metaphorical dam. In the kidney they can fit (they can be painful while passing but if they are moving, there might not be infection) but they can also get stuck. A stone in the ureter can block the ability for urine to drain from kidney to bladder and cause a swollen kidney (hydronephrosis) and require stenting to open up. A stone in the bladder can be much like a lily in the pond, unless it becomes lodged in the urethra as it exits the bladder. If the creek can flow then the stone or prostate doesn’t become a problem– but it is when the flow ceases.

Volume. Again looking to creekbeds– when the volume of the creek is low– what were once rushing clear pools can become cloudy. At times patients stop drinking water, become dehydrated and all of a sudden there is a fever and the positive urine culture requires treatment.

Many patients think that as long as someone is peeing/voiding/urinating that all is well but as I explained to a number of men last week— sometimes the prostate is so big that it is only when the bladder is stretched and almost overflows that the patient is able to pee. But they never empty their bladder. We often check this in the hospital by doing a bedside ultrasound (checking a post-void residual) after someone has urinated to see how much urine remains in the bladder and when it continues to be a significant amount, we start talking to urology about how to help a patient better empty their bladder.

This can happen to women as well- as our bladder and pelvic floor ages we can be plagued with different kinds of incontinence. Ultimately some women cannot control when their bladder empties and with this, not always empty their bladder. And of course women get kidney stones as well. They don’t have prostates (so we have that going for us….) Medications can interfere with the ability to pee, muscle tone issues, neurological disorders, previous surgeries and multiple vaginal deliveries….. 

If you are a woman and are having issues with incontinence– talk to your doctor. Exercises, topical estrogen creams after menopause, medications and many strategies can be attempted to improve control. And if you aren’t fully emptying your bladder, a bedside ultrasound can be done for us as well. 

If you are a man, talk to your doctor about your prostate. It will grow and get bigger. It might hamper your urinary flow and there are options. But if you ignore it— you can create a high pressure system, blow your bladder out like a balloon and contribute to kidney failure.

Ultimately knowing your body is key. Keep the creek beds flowing; avoid the beaver dam. And talk with your doctor/PA/CRNP etc. Because urosepsis can be life threatening.