Renowned IC researcher Dr. Curtis Nickel (Queens University Kington ON) gave a groundbreaking lecture (AUA 202o Annual Meeting) on the importance of beneficial bacteria in the urinary tract and just how dangerous and disruptive antibiotic therapy can be. He said “You are your microbiome. While it might only weigh 3 to 4 pounds, your body has more microbial cells than human cells. You exist as a vessel, albeit a fragile vessel, that provides a world for your personal microbiome population.”

Our microbiome keeps us alive. They are allies that support your health, assure balance, homeostasis, genetics, digestion, as well as controlling your mood and energy level. Tragically, the use of antibiotics has placed great pressure on the biome, and is causing an ecological imbalance in the human body (aka dysbiosis).

While the urinary tract was long thought to be sterile and was, surprisingly, left out of the human microbiome project, new state of the art PCR Next Generation DNA sequencing has changed that perception. He said “The bladder and to the lesser extent the prostate and kidneys are a veritable microbial jungles.”

The first study, released in 2019, found 330 bacteria associated with infection in the urinary tract. Microgen Diagnostics gave him access to the data of 70,000 urine specimens, which revealed more than 4,000 species in our urine.

They aren’t sure what a normal urinary microbiome is because antibiotics have changed our biome over time but he believes that it is very diverse with clear differences between men and women. In fact, the MAPP Research Network found significant diversity between genders, ages and hormonal status. They are continuing that work with a new study that will follow 600 subjects.

Where urine is sampled is important. Researchers Alan Wolfe and Elizabeth Mueller at Loyola found differences between microbiota found in voided urine, catheterized urine, the urethra and peri-urethra. They also discovered fungi (aka the micobiome) and viruses (aka the virome) in the urinary tract. IC flares were more painful in patients who had more fungal species found in their urine.

Dr. Nickel had hoped that research would reveal a hidden pathogen like the H. Pylori found in stomach ulcers that led to a Nobel Prize. In the MAPP studies, there was no clear pathogen but there were differences between men with chronic prostatitis and those without. One bacteria, burkholderia cenocepacia, emerged as a likely suspect. They found 78 total species.

The link between microbiota and female lower urinary tract symptoms has been extensively evaluated. Urge incontinence and OAB have notable differences though they do not yet understand cause vs. effect. Men with lower urinary tract symptoms have shown clear differences in the microbiota.

Patients who are deficient in one species of bacteria, oxalobacter formigens, are more at risk of kidney stone development. This bacteria helps metabolize calcium oxalates. When it is missing, stones develop. When it is present, the risk of stones is reduced by 70%. Dr. Nickel said “Dysbiosis/ imbalance in the gut, urine and the stone leads to urinary stone disease.”

Bladder and prostate cancer may be linked to dysregulation caused by dysbiosis resulting in an environment that can promote tumor growth.

Caring for our biome

Dr. Nickel said that we have to eat better, exercise more, stay away from antibiotics and avoid environmental pollutants to support our microbial buddies. Fecal transplant is viable because it introduces good bacteria to protect patients from having UTI. Urine transplant may also protect against UTI by recolonizing the bladder with healthy, non pathogenic bacteria from a healthy host. He said that “this shows great promise especially in patients with neurogenic bladder.”

One of the most exciting products under development is a sublingual vaccine that confers an innate and adaptive immunity to the bladder mucosa for patients with recurring urinary tract infections. The European Clinical Trial is complete but the data has not been published. It provides immunity against: Klebsiella pneumonia, Ecoli, Proteus vulgaris and enterococcus facecalis.

Embracing Change

Dr. Nickel encouraged doctors to start with PCR and Next Generation Sequence microbiome reports instead of urine culture reports. He said that interpreting the data is difficult but studies are now attesting to the benefits and pitfalls of this approach. He said “I predict it will not be long before we abandon the petri dish for the PCR test.”

First Printed: IC Optimist Late Summer 2020