Studies underway at Duke are evaluating the effects of aging on the female urinary microbiome, leading to a deeper understanding of recurrent urinary tract infections (UTI) and other pelvic floor disorders, and introducing possibilities for new treatments and protocols.

Urogynecologist Nazema Siddiqui, MD, MHS, is board-certified in pelvic reconstruction and is the principal investigator of a new study on aging and recurrent UTI. She discusses why and how Duke is exploring changes to healthy bacteria in the bladder and ways in which they influence certain conditions, as well as some of the treatments for pelvic floor disorders.

Question: What led you and your colleagues to explore age-related changes in the urinary microbiome?

Siddiqui: At Duke, treating bladder conditions is a big part of our practice, and we’ve found that there’s a high prevalence of recurrent UTIs that spike after menopause and in the years leading up to it. We’ve suspected that part of what’s at play are changes in healthy bacteria as a woman ages, so we’re initiating studies to learn how the urinary microbiome changes with normal aging and whether these changes are different in menopausal women who develop recurrent UTIs.

Question: What is your long-term vision for applying study results to patient care?

Siddiqui: Recurrence of UTIs is defined as three infections in a 12-month period or two in a six-month period; at that rate, these infections can seriously impact a woman’s quality of life. But treatments for UTIs haven’t changed much in 50 years; we’re still using topical hormone creams and prophylactic antibiotics. We want to better understand what should be living in the urinary microbiome and how to help “the good stuff” in a woman’s body, hoping our research will lead to new medications and new treatment protocols to optimize what’s healthy, rather than just knocking out the "bad bugs" with antibiotics.

Question: Why do women sometimes avoid seeking treatment for pelvic floor disorders?

Siddiqui: Sometimes women are embarrassed to speak with their provider about symptoms; sometimes they feel it’s just a normal part of aging and they can handle it; sometimes they’re unwilling to engage in therapy such as performing exercises at home. And, many women simply aren’t aware that we have an arsenal of effective surgical and nonsurgical treatments available. I think more women are beginning to seek treatment because we’re all living longer, we’re an active population as a whole, and we want to maintain an excellent quality of life into our later years.

Question: What are some of the treatments Duke offers for these conditions?

Siddiqui: For prolapse care, Duke has many leaders in the field who are familiar with the various surgical and nonsurgical techniques available. In the midst of the current controversy over the use of vaginal mesh, our group deeply understands all of the available evidence and information, and we’re very thoughtful about when to do this type of surgery using the FDA-approved types of vaginal mesh. For other pelvic floor disorders like overactive bladder, we use a combination of therapies, including medications and behavior management, but we also have nerve stimulation procedures that can improve bladder function by changing how nerves “talk” to the bladder. One of these nerve stimulation procedures can be done with small accupuncture-type needles in the office. Another nerve stimulation procedure involves a small nerve stimulator placed under the skin. We can also inject botulinum toxin directly into the bladder to relax the muscle response to excessive nerve signaling. Some of these treatments are effective for both urinary and fecal incontinence.

Our group also actively studies new ways to treat pelvic floor disorders. For example, we have noticed that prediabetes and diabetes affect bladder control and we have an ongoing study seeking to better understand how and why this happens.

Question: What are your recommendations for clinicians who have patients with recurrent UTIs and other pelvic floor disorders?

Siddiqui: I strongly encourage primary care physicians and gynecologists to ask their patients whether they are experiencing symptoms. Often, there are simple therapies that can be started at home. If those efforts aren't working, we hope that patients are referred to a center that offers specialized care for pelvic floor issues. At Duke, we have a team of highly experienced urogynecologists with nursing staff and pelvic floor physical therapists who are dedicated to caring for patients with these conditions. Our membership in the NIH-sponsored Pelvic Floor Network and our active clinical research program ensure that our patients receive the most current, evidence-based care.