On July 4th at 5 a.m., I'm loading the family into the car and driving very far away, where cellphones, pagers, and most critically the internet, do not work. Blogging has been very hard for me lately. I love writing, but due to work and family mishegos it's been hard to keep up with the posting. I'm hoping a stint up in the woods providing medical supervision to 400 souls will be rejuvenating. While I'm gone, I'll leave you with some of my favorite posts about the human side of medicine. I hope you enjoy reading them again, or for the first time. --PalMD
Urinary tract infections (UTIs) are a very common problem, especially in women. The link provided offers some very good information, but briefly, women's urethrae (the tube the urine comes out of), are closer to the rectum than those of men (who have a built-in "spacer"). This allows bacteria from the colon to creep over to the urinary tract and cause burning, pelvic pain, frequent urination, etc. I treat UTIs daily. Most are uncomplicated, but some are quite serious (usually in the elderly and chronically ill). As medical problems go, I love UTIs. When a healthy, young woman comes in with the usual symptoms, a quick test can confirm the diagnosis, and, usually, three days of inexpensive antibiotics fixes it. The patient is happy, I'm happy, everyone's happy. But then there's the orange stuff.
A few years back, a medication called "phenazopyridine" became more widely available as an over-the-counter drug. It is marketed to treat the symptoms of UTIs. It turns urine and other body fluids bright orange. This medication is useful for reducing the symptoms of UTIs, but does not cure them. The FDA does mandate certain labeling for the OTC preparations, but I can tell you from experience, the subtlety of this distinction is, well, subtle. Fortunately, you don't have to rely on my experience. Someone bothered to study the question. Most patients do not realize the difference between treating the symptoms and treating the disease. This leads to delay of treatment, and the infection can become more serious. To add insult to injury, phenazopyridine's orange pigment interferes with the most common tests we use to diagnose UTIs.
In discussions of medical ethics, the concepts of "paternalism" and "patient autonomy" are often thought of as being in opposition to each other. It is sometimes in the name of autonomy that medications are made more easily available to patients by skipping the physician prescribing process. (Also, over the counter meds are quite profitable). This can be very useful for medications such as ibuprofen, or Plan B (post-coital contraception), but any time you cut out the expert, certain risks accrue. Paternalism isn't the opposite of autonomy. The two work together. Patients see me for my expertise. They don't consult me about movies, art, or (thankfully) religion---just medicine. They do this because I'm the one with the training. Giving a patient knowledgeable advice is not paternalistic---it's what they came here for. I don't paternalistically command my patients to do anything. I dole out advice, and they are free to follow it or not.
Orange urine not only removes the expert, it fools the patient. It does not increase autonomy, it actually decreases it by deceiving the patient, perhaps causing them to become more ill.
<End of rant>
"Most patients do not realize the difference between treating the symptoms and treating the disease."
Drug advertising, and doctors as well, actively work to keep the confusion going. And when have you heard any journalistic coverage of this problem in the mainstream media?
OTOH ... when you are 12-15 hours away from a doctor, or on a cross-country trip, it and a huge bottle of cranberry juice are a godsend.
"To add insult to injury, phenazopyridine's orange pigment interferes with the most common tests we use to diagnose UTIs."
Not in my experience. I spent two years as the Princess of the Pee Lab in a large hospital, doing many dozens of UAs a day for inpatients and outpatients.
It's like looking at a colored picture through orange or red ski goggles.
It tints the color of the pads on the test strip some shade of unnatural orange, yes, but it doesn't obscure the results completely. Any RBC or WBC are still there in the scope, the blood, glucose and ketone pads will darken, and you can do the sulfosalycilic solution test for protein if you really need to.
A lot of this comes down to money and time. Often one and the same thing.
The thinking is that most infections will clear on their own. Possible helped along with copious amounts of water, some cranberry juice and being extra careful cleaning up. The OTC orange stuff just buys you time and keeps you sane at work by controlling the itch. Bottom line is about $20 for fruit juice and OTC medication and two weeks of moderate discomfort and you don't miss work.
Going to the doctor means taking at least half a day off work, $70 to $150 for the visit and the time and cost of getting a prescription filled.
That's how it works for the poor and middle class women in the US. I wonder what the situation looks like in nations with national health care. Where going to the doctor is less of a burden.
What about Cystex (tm)? It contains "the antibacterial methenamine as well as sodium salicylate, a pain reliever." I have used that in the past when visiting the doc was inconvenient for all the reasons mentioned above. It seemed to knock down the minor infections (in concert with cranberry juice, extra water, going commando, etc.)
Art: Even with semi-national health care in Australia, it's still time off work unless you can get an out or hours or Saturday appointment.
There are fewer free out of hours clinics now than there were 10 years ago (the result of a combination of a slight shortage of doctors and possibly an anti-national health government for a decade)
It is sometimes in the name of autonomy that medications are made more easily available to patients by skipping the physician prescribing process. (Also, over the counter meds are quite profitable).
You need the third category of drugs that we use in the UK, Pharmacy Only. This allows the pharmacist (who is more than just a pill counter) to assess and advise the patient in regards to what they're buying and if needed point them at their doctors.
Now, I'm a vocal opponent of antibiotic misuse, but surely there must be some way for a doctor to pre-Rx 500mg levofloxacin BID for 3 days so that when people get caught off-guard by an uncomplicated UTI.
(uncomplicated? if that beast was uncomplicated, I'd hate to to find out how complications feel!!!)
How about a Honeymoon Prep Kit? Three-days of pretreating with cranberry extract tablets, and three days of Levaquin if needed. And maybe birth control and condoms if you want to work that angle.
Doctors most certainly can pre-Rx a course of whatever antibiotic. I have a diverticulum in my bladder, so I get a lot of urinary tract infections. They are an old friend of mine. My doctor has given me refillable antibiotics prescriptions, to be filled if/when needed. She usually gives me three refills. While I was nursing, it was a sulfa prescription; now it's Cipro. ;-) Fortunately, I haven't needed one in a while, and I think my current prescription will probably expire before I need to get the last refill.
I know phenazopyradine well; when it was prescription-only, my doc would give me two prescriptions, one for the antibiotic and one for the pain reliever. Now that it's OTC, I am very happy. ;-) I was quite irritated when my grandpa got an infection after a hospital stay (not an uncommon complication of a catheter, but he was too shy to tell anybody about his symptoms) and nobody told him about phenazopyradine. I had my mom swing by the pharmacy and pick some up. The annoying part is that it's in the feminine hygiene aisle, as if only girls get UTIs. Yeah, we get 'em more than men, but men suffer more when they get them because of their longer urethras.
More recently, I've started using it for a burning that I get sometimes during part of my menstrual cycle. I've had it checked out; it's not a UTI. I always give it a few days; if it doesn't get any worse, it's not a UTI, and I take the phenazopyradine for a few days. I discontinue at that point to check symptoms and decide whether or not I need to see a doctor or whatever. It's hormonal; recently I went back on the Pill and that seems to have controlled it, though I'll be more confident in that conclusion in a few more months.
BTW, as far as birth control and condoms, my experience is that they make no difference as far as preventing UTIs. Since the UTI is usually caused by the woman's own commensal bacteria, it really doesn't help. Might help avoid combining a pregnancy with an antibiotic which is contraindicated, but that's about it.
And now for my big pet peeve about phenazopyradine -- it has inadequate labeling. It does mention the fact that it treats symptoms only, but it does not mention any contraindications. And my doctor was pretty adamant that it should NEVER be taken during pregnancy, especially the first trimester, as it can cause a nasty birth defect. This is not mentioned anywhere on the packaging for Azo-Standard, the brand carried at Walgreens.