Correspondence

Urinary Tract Infections in Young Women

N Engl J Med 1997; 336:381-383January 30, 1997

Article

To the Editor:

The study by Hooton et al. (Aug. 15 issue)1 of risk factors for urinary tract infections in young women was very interesting and informative, but what about the contraceptive methods they used? I was surprised not to see any mention of condoms. With the current concern about AIDS and the transmission of the human immunodeficiency virus, I would expect some of these young women to have used condoms as an adjunct to safe-sex practices. I believe other studies have shown an increased incidence of urinary tract infection with condom use. Did the authors look at that? If so, what did they find?

Charles A. Winterling, M.D.
264 Pleasant St., Concord, NH 03301

1 References

1. 1

   Hooton TM, Scholes D, Hughes JP, et al. A prospective study of risk factors for symptomatic urinary tract infection in young women. N Engl J Med 1996;335:468-474
   Full Text | Web of Science | Medline

To the Editor:

In his editorial on sex and urinary tract infections,1 Dr. Ronald mentions a variety of methods for the prevention of postcoital cystitis. There is no suggestion that the couples should simply wash themselves with soap and water, as is the practice among Muslims.

Is there any proof that washing with soap and water helps? No. But, if washing one's hands before and after seeing a patient makes a difference in the risk of transmitting infections, then washing must also decrease the bacterial flora of the skin of the genital area and the risk of infection.

Ismat U. Nawabi, M.D.
Maimonides Medical Center, Brooklyn, NY 11219

1 References

1. 1

   Ronald A. Sex and urinary tract infections. N Engl J Med 1996;335:511-512
   Full Text | Web of Science | Medline

Author/Editor Response

The authors reply:

To the Editor: As Dr. Winterling noted, we did not evaluate condom use in our study of risk factors for urinary tract infection in women. However, the association between condom use and urinary tract infection has been evaluated in several recent case–control studies. Remis et al. found no association,1 whereas Foxman et al. demonstrated an increased risk of first-time urinary tract infections in women whose sexual partners used condoms.2 Neither study delineated the role of spermicides. In a large case–control study, Fihn et al. recently found a significantly increased risk of urinary tract infection in women in association with the use of spermicide-coated condoms but not with the use of uncoated condoms.3 The association of urinary tract infection with use of spermicide-coated condoms is most likely due to an adverse effect of the spermicide on vaginal flora, favoring colonization with uropathogens.4 It appears unlikely that the use of condoms not coated with spermicide increases the risk of urinary tract infection beyond that associated with sexual intercourse.

Dr. Nawabi suggests that having sexual partners wash with soap and water would decrease the risk of genital infections. However, studies that have examined hygienic practices and the risk of urinary tract infection have not shown an association.1,5 For women, bathing with soap and water is unlikely to affect the quality or quantity of uropathogens, which are thought to originate from fecal flora colonizing the vagina and periurethral area. Although uropathogens may be harbored under the foreskin of uncircumcised men, these organisms are unlikely to have a substantial impact on vaginal and periurethral colonization in women. Although there is no evidence that bathing reduces the risk of urinary tract infection, we would certainly agree that good hygiene is desirable before intimacy between couples.

Thomas M. Hooton, M.D.
Walter E. Stamm, M.D.
University of Washington, Seattle, WA 98195

5 References

1. 1

   Remis RS, Gurwith MJ, Gurwith D, Hargrett-Bean NT, Layde PM. Risk factors for urinary tract infection. Am J Epidemiol 1987;126:685-694
   Web of Science | Medline

2. 2

   Foxman B, Geiger AM, Palin K, Gillespie B, Koopman JS. First-time urinary tract infection and sexual behavior. Epidemiology 1995;6:162-168
   CrossRef | Web of Science | Medline

3. 3

   Fihn SD, Boyko EJ, Normand EH, et al. Association between use of spermicide-coated condoms and Escherichia coli urinary tract infection in young women. Am J Epidemiol 1996;144:512-520
   Web of Science | Medline

4. 4

   Hooton TM, Hillier S, Johnson C, Roberts PL, Stamm WE. Escherichia coli bacteriuria and contraceptive method. JAMA 1991;265:64-69
   CrossRef | Web of Science | Medline

5. 5

   Strom BL, Collins M, West SL, Kreisberg J, Weller S. Sexual activity, contraceptive use, and other risk factors for symptomatic and asymptomatic bacteriuria: a case-control study. Ann Intern Med 1987;107:816-823
   Web of Science | Medline

Author/Editor Response

Soap and water markedly reduce the transmission of microorganisms carried on our hands. Common sense would argue that it should also reduce microbial flora on the perineum and reduce the opportunity for pathogens to gain entry into the urinary tract. However, no prospective studies of this intervention have been carried out. Douching, a practice similar to perineal cleansing, has been shown to be harmful with regard to bacterial vaginosis and pelvic inflammatory disease.1 A well-designed study is necessary before we can recommend the routine use of soap and water to prevent recurring episodes of cystitis.

Allan Ronald, M.D.
St. Boniface Hospital, Winnipeg, MB R2H 2A6, Canada

1 References

1. 1

   Wolner-Hanssen P, Eschenbach DA, Paavonen J, et al. Association between vaginal douching and acute pelvic inflammatory disease. JAMA 1990;263:1936-1941
   CrossRef | Web of Science | Medline