By Steve Hodges, M.D.
This week I saw a 7-year-old patient who’s had four urinary tract infections in the last six months and was referred to me by her pediatrician. The girl also wets the bed, but her parents didn’t consider the issues related and were baffled by their daughter’s UTIs.
“I don’t know why she keeps getting them,” her mom told me. “She wipes from front to back, she takes showers instead of baths, and she doesn’t drink soda.”
There are a lot of myths bundled into that one sentence!
I ordered an abdominal X-ray for the girl, as I always do for recurrent-UTI patients, and was hardly surprised at what the film showed: Her rectum is clogged with stool.
I explained to the mom and her daughter that the two main causes of UTIs are holding poop, aka constipation, and holding pee. The usual preventive measures families take — wiping front to back, avoiding baths, avoiding soda — won’t help.
Urinary tract infections in children (primarily girls) are more common than most parents realize, accounting for more than 1 million doctor visits annually. Eight percent of girls contract a UTI during childhood, and the recurrence rate is high. Huge numbers of these girls also struggle with bedwetting and accidents — no surprise, given the causes are the same.
In this post I explain why UTIs are so common in young girls and how to keep your daughter infection free.
What Exactly Is a UTI?
Here’s a fact that may surprise you: urine is sterile. You could literally drink it and be fine, although I don’t recommend it as a beverage.
Urine is mostly water, with a small percentage of harmless waste products. My point is, urine, unlike poop, should be bacteria free. But sometimes certain types of bacteria access the bladder and grow in the urine. The upshot: a bladder infection, also known as a urinary tract infection.
To get a UTI, you need a source of bacteria, a pathway for this bacteria to enter the bladder, and a bladder full of urine for the bacteria to grow in. UTI-causing bacteria sometimes live on the skin of the perineum, around your bottom, but all these bacteria come from the stool itself. They enter the urinary tract by crawling up the skin between the anus and urethra into the bladder, where they set up shop and multiply, causing pain and irritation.
You can prevent these infections by getting rid of the source of bacteria, keeping the bladder empty, and making the path to the bladder inhospitable. Young girls typically do none of these things, which is why they’re perfect candidates for UTIs.
Young boys have the same unhealthy toileting habits as girls, but girls are much more prone to infection because they have shorter urethras, so bacteria have a shorter trip from the anus to the bladder. (A boy with a UTIs should be evaluated for a congenital anomaly that prevents him from fully emptying his pee.)
Diagnosing a UTI
In young girls, UTI symptoms are excessive and/or painful peeing and the sudden onset of pee accidents. In rare cases the child also has a fever above 101.5, accompanied by nausea, vomiting, and belly or side pain. These are signs the infection has traveled from the bladder to the kidneys, called a “complicated” UTI, a more severe situation that may signal a type of anatomical problem.
We diagnose UTIs by examining a urine sample under a microscope. If the child has a UTI but no fever, we treat it with three days of antibiotics. A UTI with a fever needs seven to 10 days of antibiotics.
But antibiotics won’t stop these infections from coming back, because medication doesn’t attack the root of the problem: pee and poop holding.
Why Children Get UTIs
Each year I treat thousands of uncomplicated, or “simple,” UTIs (only in the bladder, not in the kidneys). Do you know how often I see a simple UTI in a child who isn’t toilet trained? Never. Do you know how many simple UTIs I see in girls who recently have toilet trained or are in the process of training? A ton.
That’s because newly trained kids, especially those trained as toddlers, typically lack the judgment to heed nature’s call in a timely manner. For reasons I explain here, they tend to hold both pee and poop as long as they can.
How can holding pee cause a UTI? Well, the bladder almost always has some pee in it, except right after it’s emptied. When you’re not peeing, the bladder neck, the part that connects to the urethra, stays closed. But the rest of the urethra is an open tube that always houses bacteria, some of which may have come from the poop. These bacteria are always trying to climb up into the bladder, looking for unexplored country.
Women rarely get UTIs because they pee regularly, washing bacteria out of the urethra. But young girls pee less often, giving the bacteria more more opportunity to creep up to the bladder.
Worse, they actively suppress the urge to pee, which ratchets up the risk of infection. Let’s say you need to pee really badly. What you are feeling is the bladder contracting because it’s reached a certain volume level. The bladder neck automatically opens because it thinks you are going to pee.
But suppose you’re nowhere near a toilet at that moment you feel the urge. The only way to stop leakage at that point is to squeeze your urethral sphincter (a different muscle from the anal sphincter, the one you squeeze to hold in poop, though they often act in concert). This signals the spinal cord to make the bladder stop contracting. The urge goes away, but the pee stays put.
Kids tend to make the situation worse by sitting on their heels or dancing around. (Yes, this actually helps keep the pee in!) So, pee enters the urethra, where the bacteria are hanging out, but instead of getting flushed out, the urine picks up bacteria. Then the urge to pee goes away and the bladder neck closes. The bacteria pick up an expressway into the bladder, riding the urine back into the bladder. Next stop: UTI.
The fact that babies almost never get UTIs suggests pee holding is a major cause of these infections in girls. But it’s not the only cause.
The Poop-UTI Connection
Peeing more often prevents the offending bacteria from entering the bladder, but how do you stop the bacteria from taking hold to begin with — how do you cut off the supply line, so to speak?
You poop as soon as you feel the urge, and you empty fully.
Kids who are constipated carry around a hefty load of poop, primarily in the rectum. Well, guess what’s in a ton of poop? A gazillion bazillion bacteria — about a gazillion times more than when the rectum has been emptied of poop.
What’s more, studies have shown that when you have a pile of poop sitting in the rectum, bacteria mutate and you end up with more of of the offending bacteria and fewer of the harmless variety.
And you know what, in girls, is a couple of inches from the rectum? The bladder. The offending bacteria crawl over the perineal skin and into the vagina and the area around the urethra. The way to make it hard for the offending bacteria to journey to the bladder is to fully treat constipation.
For my UTI patients who do not have daytime or nighttime accidents, I generally recommend a daily dose of osmotic laxative, such as MiraLAX or lactulose, to keep poop mushy and make pooping less painful. For my patients who also have accidents, I recommend M.O.P., the Modified O’Regan Protocol, a regimen that includes daily enemas as well as osmotic laxatives.
Clearing the rectum is an almost surefire way to stop chronic UTIs, as Dr. Sean O’Regan — for whom M.O.P. is named — demonstrated back in the 1980s. In one study, Dr. O’Regan followed 47 girls who had recurrent UTIs and were severely constipated. After three months on an enema-based regimen, 44 of the girls stopped getting infections.
Staying Clean, Dry, and Infection Free
More frequent peeing and pooping will prevent UTIs from taking root. But keeping the vagina clean and dry is important, too.
This does not mean a child’s wiping technique will do the trick. Virtually every mom of a UTI patient has told me she makes sure her daughter wipes from front to back. Most moms are shocked by my response: There is absolutely no evidence that wiping from front to back helps prevent UTIs. I don’t go around promoting back-to-front wiping, but I actually feel confident it wouldn’t do any harm.
Let me put it this way: Remember when your daughter was a baby, and she’d poop in her diaper and the poop would squish all over her entire genital area? Did she ever get an infection?
Nope. It’s not the direction of wiping that matters. What does matter (besides peeing and pooping regularly, which babies always do) is keeping the area clean and dry, especially the area between the labia where skin is touching.
Taking soothing baths helps. Yes, baths! Many parents have their 3-year-olds taking showers because they worry baths will cause a UTI, but that’s just not true. You simply need to avoid irritating soaps, which strip off the protective coating of the skin.
Instead, choose gentler, pH-balanced soaps, the brands you’d use on your face. I also recommend little girls soak in Aveeno, made from very finely ground oatmeal. As I explain in detail in It’s No Accident, you can get a similar effect from homemade baths using ground-up supermarket oatmeal, baking soda, or apple cider vinegar.
Girls should always pee with their legs spread — I actually recommend sitting on the toilet backward — so the area doesn’t stay so wet. They must also wipe well on the inside. Dr. Soother’s Healthy Wipes, a steroid-free, antibiotic-free product I designed with colleagues, can help with that.
Finally, let’s attack one of the strangest yet most pervasive UTI myths: soda causes infection. In reality, it doesn’t matter what you drink; it all comes out as pee. Soda is an empty source of calories and lousy for teeth, and the caffeine may irritate the bladder, but there’s absolutely no connection between soda and UTIs.
So that covers it. If your daughter pees on time, keeps her rectum clear of poop, and her genital area stays clean, dry, and free of irritation, she can’t get a UTI. It is against the laws of nature.