Diaphragm Linked to Infection

Times Staff Writer

New evidence has emerged to validate the link--tenuous until now--between the diaphragm and urinary tract infections in women.

It isn't clear whether a different diaphragm design would help or even how the diaphragm happens to make it easier for urinary tract infections to occur. But a team of researchers at the University of Washington in Seattle has added new confirmation to conclusions by a Los Angeles urologist first published about three years ago that initially made the link.

The new research indicates that relative to other forms of birth control, a diaphragm user stands more than four times the chance of contracting a urinary tract infection.

Exacerbating Factor

The leader of the new study, however, said he worried that publicity about the research could prompt diaphragm users to become less vigilant in terms of birth control--a development he said would create far more problems for women than it could possibly solve. And while, despite the increase in risk, the diaphragm can scarcely be called the principal cause of urinary tract infections, a new study identifying this form of birth control as an exacerbating factor bears unwitting testimony to what many women have perceived as an uncomfortable reality.

That reality is that though urinary tract infections are seldom serious and almost never kill or maim, they are--occasionally or frequently--a nagging, tiresome and disquieting problem for most American women, yet physicians know surprisingly little about the extent of the problem or its toll in agonizing discomfort and are generally disinclined to find out more.

This is apparently true even though urinary tract infections are such a common part of being female that many women refer to them as the equivalent in women's reproductive health of either the common cold or sore throat.

It isn't even known, for instance, what proportion of women have experienced urinary tract infections and what fraction of those who have contract them chronically. Neither is it known how often women who come down with such infections simply tough it out, relying on home remedies and determination, as opposed to the number who seek the aid of their doctors.

How to Tough It Out?

There is even disagreement among doctors over how to tough it out. Some physicians find validity in the traditional folk treatment--drinking cranberry juice--and some don't. And doctors also disagree over how a woman can avoid getting an infection in the first place, though many doctors agree that drinking large quantities of water or fruit juice and emptying the bladder as soon as possible after intercourse are wise precautions.

Neither the federal government's National Center for Health Statistics nor any other organization questioned by The Times keeps records for the incidence or treatment of urinary tract infections. The federal agency does say that in 1980-81, the last 12-month period for which figures were assembled, there was an estimated total of more than 8.9 million physician office visits for symptoms common to urinary tract infections.

But those figures take no account of the number of times women seek treatment by telephone--an apparently commonplace response--or treat the infections themselves. A small and informal survey by The Times indicated that many women who contract urinary tract infections often--three or four times a year is enough to be called "frequent," doctors say--routinely keep stocks of antibiotics hoarded from previous prescriptions and treat themselves through self-medication.

Estimates of the incidence of urinary tract infections range from speculation like that in an article in a nursing magazine last year that 25% of women have a urinary tract infection at one time or another to the observation of a Planned Parenthood researcher that every woman will come down with one at one time or another in her life after sexual maturity.

Little is known about the dimension and severity of the problem apparently because, like the common cold and the sore throat, urinary tract infections seldom pose a threat to life or long-term health and lack the challenge and prestige of research in such glamour fields as cancer and heart disease.

Contrary to what women may believe, moreover, men aren't immune, either. Though urinary tract infections in males are comparatively rare--because of differences in urinary tract physiology between the sexes--they do occur, by some estimates at about 10% the rate of such infections in females.

Urinary tract infections apparently occur because bacteria that grow naturally in the intestinal tract somehow find their way into the vagina and, from there, into the urethra and bladder. It may be, according to literature in the field, that the bacteria originate near the woman's rectum or it could be that they come from somewhere on the man's body. On the other hand, it could be neither of these sources and the bacteria actually originate by some means that remains to be discovered.

Intercourse greatly aids and abets the travels of such bacteria, but it isn't really known how the bacteria start their journey in the first place.

The basic design differences between men and women are what make men immune--because women's urethras are very short in comparison to men's and the e-coli bacteria involved are very fragile and cannot easily survive a migration even of the length of a man's urethra.

A Vague Discomfort

However the bacteria make the journey, the end result often is what many women experience as a vague discomfort even before they start to experience specific bladder symptoms. After a day or so, the infection progresses to the point that the sufferer experiences a burning pain on urination.

Some women describe the onset as sudden, with the infection causing little, if any, pain at first. But at night, some women report the developing infections cause them to be restless. The frequent, urgent need to urinate is a common symptom. It is a frustrating feeling. "When one sets in," said one woman who has come down with three infections in the last year, "I feel like climbing the walls."

If the infection is ignored--doctors questioned said drinking large quantities of fluids and avoiding intercourse for a few days are good self-treatment steps--urinary tract infections can worsen markedly, and come to include back pain, fever, chills, nausea and vomiting. A bad infection left completely alone can even migrate to the kidneys, where dealing with it can be a major medical undertaking.

Against this backdrop of uncertainty emerges the new study in this week's Journal of the American Medical Assn. that identifies the diaphragm--the birth control method of choice of about 8.3% of American women, according to Planned Parenthood--as a major causative or exacerbating factor in urinary tract infections.

The new research was done by a team headed by Dr. Stephen Fihn, an internal medicine specialist at the University of Washington. Fihn and four other researchers analyzed two groups of women using different research techniques in an attempt to make certain the conclusions were accurate.

Four Times More Vulnerable

A total of 199 sexually active women participated. Fihn and his team reported that diaphragm users stood more than four times the chance of coming down with a urinary tract infection than women who used other methods of birth control including the Pill, the IUD, condoms and other types.

"It's a nagging problem," said Fihn, "but not one that's serious. It is one that's readily amenable to treatment (usually with antibiotics of one type or another) and it happens to women who don't use the diaphragm as well as to those who do."

Fihn said that, while predisposition to urinary tract infections could be a factor in a woman's choice of birth control, "it should probably be a small one, though even for a woman who does come down with urinary tract infections and uses the diaphragm, it would be (more) worthwhile to pay attention to how well the diaphragm is fitting."

Fihn and other researchers, including Dr. Larrian Gillespie, a Los Angeles urologist, believe the diaphragm may influence urinary tract infections if it is not properly sized and puts undue pressure on the urethra during intercourse.

In a study published in 1984, Gillespie even suggested an alternative diaphragm design that would eliminate much--if not all--of the extra pressure that may give diaphragms a role in causing urinary tract infections. But, she said, diaphragm manufacturers expressed little interest in her proposal.

A USC expert, Dr. Gerald Bernstein, said research is continuing into the factors that influence urinary tract infections. He said the new University of Washington study was an interesting addition to a limited body of medical literature in the field.

However, Bernstein said some preliminary research into infection incidence in diaphragm users comparing them to women using cervical caps has found little difference--a conclusion that, if it stands up to final analysis, would further complicate the question of what influences the infections and how.

Bernstein suggested that if a woman has "just an occasional episode"--perhaps once every three years or so--of urinary tract infection, she should perceive it as "no big deal." But, he said, a woman who is getting infections three or four times a year should certainly arrange to have a complete evaluation.

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