Naturopathic Management of Urinary Tract Infections: A Retrospective Chart Review

Abstract

Introduction: Antibiotic overuse is a significant driver of bacterial resistance. Urinary tract infections (UTIs, cystitis) are the most common condition for which antibiotics are prescribed in the ambulatory setting. Many complementary and integrative approaches to cystitis have been proposed, including probiotics, D-mannose, and several herbal therapies. Trials comparing such therapies with placebo or antibiotics showed mixed, but promising, results. Naturopathy is a system of medicine that has potential to avoid antibiotic use for UTI because of its affinity for nonpharmacologic therapies and its theory that infection is a result of both the immune system's vulnerability and the pathogen's virulence.

Methods: The authors conducted a retrospective chart review of cases treated at four naturopathic clinics in the Portland, OR, metro area, where naturopathic doctors (NDs) have a scope of practice consistent with their license as primary care providers. The primary aim was to characterize how NDs treat UTIs in a real-world setting. Secondary aims were to gather preliminary evidence on the types of patient cases receiving such treatments, outcomes of treatments, and associations between presentation and treatment prescriptions.

Results: The authors found 82 distinct treatment regimens among 103 individual patients diagnosed with UTI. Most patients received a combination of herbal medicine and behavioral modification (e.g., increase fluid intake), whereas the most common monotherapeutic regimen was antibiotics. Of the 43 patients who were followed up, 15 had no success with nonpharmacologic therapies and required antibiotics. The sample was comparable with national data regarding composition of public versus private insurance, acute versus recurrent/chronic UTI, and percent of cases related to uropathogenic Escherichia coli.

Conclusions: NDs practicing in a primary care context frequently prescribe antibiotic and nonantibiotic multimodal therapy for uncomplicated UTI. These results may guide future studies testing complementary and integrative therapies for uncomplicated UTI.

Introduction

Antibiotic overuse is a significant driver of bacterial resistance. Urinary tract infections (UTIs; or cystitis) are the most common bacterial infections seen in the outpatient setting in the United States¹ and a primary reason for outpatient antibiotic prescription.² According to the Centers for Disease Control and Prevention (CDC) National Health Care Survey in 2007, 84% of UTI cases encountered in the ambulatory setting were women.² By the age of 32, half of all women self-reported as having had at least one UTI in their lifetime.³ Approximately 20%–30% of women with UTI experience recurrence, most commonly within 6 months of initial infection.⁴

Our present functional understanding of the urinary tract suggests that host factors may be equally significant to bacterial factors in facilitating UTI.^5–7 The urinary tract has its own microbiome (urobiome) that experiences characteristic shifts in health and disease states.^8–10 Lower urinary tract symptoms, including urge incontinence and dysuria, can present similarly in UTI and noninfectious urological disorders such as overactive bladder and interstitial cystitis. Similar to functional gastrointestinal disorders, lower urinary tract symptoms are subject to central sensitization and can have a variety of triggers, especially when recurrent or chronic.⁶ Some triggers can act synergistically, such as negative psychological affect and dysbiosis of the urinary tract. Moreover, changes associated with age, including menopause, can influence the urobiome and the etiology of cystitis, thus indicating different treatment approaches for older versus younger females (Jung et al. 2019).¹¹ Because lower urinary tract symptoms and their variable etiologies can be difficult to distinguish clinically, many patients receive unnecessary antibiotic prescriptions, further driving bacterial resistance.¹²

Trials that have compared antibiotics with placebo or no treatment have demonstrated that >50% of cystitis cases resolved spontaneously, although bacteriuria takes longer to clear in placebo-treated females and the length of time to symptom resolution is not tolerable for many patients.^13,14 Some trials have compared ibuprofen alone with antibiotics and other therapies, hypothesizing that reducing inflammation and palliating symptoms will make natural UTI resolution more tolerable and avoid antibiotic usage.¹⁵ One such trial demonstrated that antibiotic use was indeed lower in the ibuprofen group, but the symptom burden and incidence of pyelonephritis in these females were higher.¹⁶ For patients with suspected or confirmed UTI, both managing symptoms and combating infection remain clinically important.

Naturopathy may be an untapped resource in the effort to better understand and treat UTI. According to the naturopathic philosophy, infection is a result of both the immune system's vulnerability and the pathogen's virulence. The science evaluating UTI mechanisms and treatments appears to support this philosophy, as outlined above. As licensed primary care providers in several U.S. states, naturopathic doctors (NDs) learn standard-of-care medical practice, including minor surgery and the appropriate use of legend drugs, in addition to advanced training in botanical medicines, dietary supplements, physical medicine, homeopathy, clinical nutrition, and behavioral/lifestyle modification. Many of these natural approaches have been theorized and tested for cystitis treatment and prevention, including probiotics and botanicals,^17–24 with some showing noninferiority to antibiotics.²⁵

In light of the harm associated with antibiotic overuse, there may be a nonpharmacologic approach currently used by NDs that is appropriate for treating patients with cystitis. However, the authors are not aware of any past clinical studies evaluating naturopathic management of cystitis, nor of any other bacterial infection. It is possible that observation of naturopathic practice could yield a novel approach to cystitis that is worth further investigation. Such a study may also yield important information about the types of patients with urinary tract symptoms who seek care from NDs with a broad scope of practice. Thus, in the present study, the authors aim to gather preliminary evidence on the real-world naturopathic management of UTI through a retrospective chart review.

Methods

The authors used a retrospective chart review design to identify cases of UTI diagnosed and treated by licensed NDs. The authors' primary aim was to describe the patients who present to NDs for UTI and the treatments they received. Secondary aims included the following: (1) to evaluate UTI treatment outcomes with naturopathic care; (2) to identify any associations between patient characteristics and treatment prescribed; and (3) to evaluate for clear naturopathic treatment patterns of UTIs.

The authors contacted administrators and providers at seven clinics in the Portland, OR, metro area, by e-mail, seeking participation in the study (Fig. 1). Clinics were considered for inclusion if they were staffed by general practice or women's health NDs and used electronic medical records (EMRs) that could be queried by ICD-10 codes. Due to the legal structure of clinics and the frequency of NDs working as independent contractors, the authors gained individual signed consent from each ND at these clinics who agreed to grant access to their patient records. The study design was approved by the Institutional Review Board at the Helfgott Research Institute (National University of Natural Medicine, Portland, OR), which granted a waiver of authorization to release protected health information. One investigator (L.G.) was granted access to EMRs at each clinic. Each clinic's EMRs were queried systematically by ICD-10 codes to identify all possible cases of uncomplicated UTI seen by each consented ND—a full list of ICD-10 codes used is depicted in Appendix A1.

FIG. 1.

Flowchart of clinic/ND enrollment and patient chart inclusion. ND, naturopathic doctor.

Participants

Charts were considered for inclusion if they were of cis-female patients, aged 18 to 65 years, who were diagnosed and treated for UTI anytime since 2013. Exclusion criteria included characteristics of complicated UTI, including male anatomy, pregnancy, urologic tract abnormalities (anatomical variants and surgical alteration), catheter use, and immunocompromised status (e.g., HIV positive and corticosteroid or other immunosuppressant use). For each chart that met criteria, the patient's initial UTI clinical encounter was selected for data abstraction. Any UTI encounter within 1 year following the initial encounter was reviewed for data pertinent to the secondary aims mentioned above.

Measures

To characterize patients who sought naturopathic care for UTI, the authors collected data on age and type of payment (cash, insurance, or Medicaid) as a proxy for socioeconomic status. The distance between the patient's residence and the clinic was noted to illustrate some of the context of care, for example, specialty or primary. Using all relevant information from the chart, the authors attempted to identify each UTI occurrence as either acute or recurrent and to determine whether it was associated with recent antibiotic use. They adopted the standard definition for recurrent UTIs—two or more infections within a 6-month period or three or more infections within a 1-year period.²⁶ Individual UTI risk factors were recorded when available, including diaphragm or spermicide use, withholding of urine, and postmenopausal status. Any self-treatments that the patient disclosed were recorded and categorized, including antibiotic use within 30 days before presentation. All available urinalysis, urine culture, and antimicrobial sensitivity results were collected.

Due to the multimodal treatment approach that is typical in naturopathic medicine, the authors expected a wide array of treatments for UTI to be captured. They abstracted as much detail as possible for each treatment modality (e.g., botanical, antibiotic, and home care advice) that was recorded in the chart, including dosage, duration, and brand name. For the secondary aim of evaluating treatment outcomes, data from any follow-up visits within 30 days of initial presentation were extracted. Natural treatment success was defined as the stated resolution of symptoms without requiring an antibiotic prescription within this 30-day window, as stated in follow-up chart notes. Natural treatment failure was thus defined as the addition of antibiotic therapy within 30 days after the initial encounter. When neither success nor failure, so defined, was indicated, the authors considered determination of treatment success to be missing. These terms defining treatment success are similar to several past trials comparing UTI treatments.^16,25,27 Of note, this definition depended on a written positive or negative assertion in a follow-up encounter note. If a patient was self-treating with any natural therapies that the ND recommended the patient continue or modify, this was also recorded as a prescribed treatment to capture any signal of nonpharmacologic treatment success. In concert with the primary aim of describing naturopathic practice, including charting, data were collected if and only if stated explicitly in the chart; no missing variables were inferred for the sake of analysis, and chart entries were treated as valid unless internally inconsistent. All data were abstracted into a standardized form built with REDCap software (Vanderbilt University).²⁹

Analysis

The authors generated descriptive statistics for patient demographics, including range, mean, variation, and distribution, as well as frequencies and rates of clinical presentation and treatments prescribed. They calculated both frequencies with which particular treatment combinations were prescribed and frequencies of major categories of treatment, such as antibiotics, probiotics, or cranberry products, regardless of whether they were prescribed in combination with other treatments. The authors evaluated associations between patient characteristics (demographic and clinical) and prescribed treatments using chi-squared tests of proportions. Any follow-up data that were available were used for exploratory analysis of outcomes, including estimates of time to cure and rate of symptom resolution associated with each treatment. All statistical tests were considered significant if p < 0.05. All statistics were generated using R software (Boston, MA).

Results

Our primary aims are represented in Tables 1–3. Providers from four of the seven clinics that were contacted agreed to participate. A total of 21 NDs from these clinics gave individual consent for chart review and data abstraction. Patient ages spanned the full range of inclusion, with a median age of 37. The median distance between a patient's residence and the clinic was 6.85 miles. Most patients (90%) had some form of private insurance to pay for at least part of their office visit. Ten patients (9.7%) paid fully in cash for their office visit and 15 patients (14.6%) were Medicaid recipients.

Table 1.

Clinic and Patient Characteristics

	Clinic 1	Clinic 2	Clinic 3	Clinic 4	Total
No. of NDs included	4	9	5	3	21
No. of patients included	17	57	22	7	103
Patient age (years)
Median (range)	45 (20 to 63)	35 (18 to 65)	35 (19 to 60)	33 (25 to 37)
Distance of patient residence from clinic (miles)
Median (range)	6.2 (0.7 to 166)	6.4 (0.1 to >1000)	10.3 (1.1 to 35.8)	9.7 (2.7 to 42.7)
Payment type
100% Insurance	0	1	0	0	1
Cash	4	5	0	0	9
Insurance+copay	13	51	9	5	78
Medicaid	0	0	13	2	15

NDs, naturopathic doctors.

Table 2.

Description of Patients' Clinical Presentation and Workup

Presentation	Frequency (%)
Recurrent UTIs	23 (22)
Single previous UTI	5 (5)
Symptoms present
Dysuria	76 (74)
Frequency	61 (59)
Urgency	59 (57)
Hematuria	10 (10)
No. of days with symptoms
<3	29 (28)
3–10	33 (32)
>10	13 (13)
Nonspecific	28 (27)
Recently failed antibiotics	19 (18)
Used self-prescribed natural productsa	42 (41)
Urinalysis performed (n = 63)
Positive result	60 (95)
Urine culture performed (n = 46)
Escherichia coli	17 (37)
Other organisms	7 (15)
Negative	22 (48)
Treatment presumptive	35 (34)

^a For example, D-mannose, cranberry products, and other botanicals.

UTI, urinary tract infection.

Table 3.

Frequencies of Treatments Prescribed for Urinary Tract Infection

Treatment prescribed	Frequency (%)
Botanicals (total)	52 (50.5)
Commercial product 1	14 (13.6)
Product 2	14 (13.6)
Product 3	12 (11.6)
Product 4	5 (4.8)
Othera	21 (20.4)
Increase fluids	48 (46.6)
Antibiotics (total)	46 (44.7)
TMP-SMX	10 (21.7)
Nitrofurantoin	22 (47.8)
Fosfomycin	1 (2.1)
Ciprofloxacin	10 (21.7)
Amoxicillin/clavulanic acid	2 (4.3)
Azithromycin	1 (2.1)
Prescription to hold	14 (30.4)
Probiotics	29 (28.2)
Diet counseling	29 (28.2)
Cranberry juice or extract	24 (23.3)
D-mannose	24 (23.3)
Hygiene counseling	18 (17.5)
Homeopathy	15 (14.6)
Hydrotherapy	3 (2.9)
Phenazopyridine	2 (1.9)
Referred out	2 (1.9)

Most recommendations were prescribed in combination with others. Of the 103 patient visits analyzed, 82 distinct treatment combinations were found. The majority (>70%) of treatment plans that appeared more than twice were antibiotics used as monotherapy. The most frequent treatment pairing was an herbal compound combined with counseling to increase fluids (n = 26 [25%]). See Table 5 for commercial botanical product constituents.

^a Various single or custom herbal preparations—for example, chamomile and pipsissewa—whole or in liquid extract.

A description of patients' clinical presentation and diagnostic workup is shown in Table 2. Roughly one-quarter of patients with UTI who sought naturopathic care were described as having experienced recurrent UTIs. Nineteen percent of patients (n = 20) had recently failed one or more courses of antibiotics for UTI, while 41% had tried natural treatments such as D-mannose (n = 11), cranberry products (n = 20), and other botanicals (n = 7). Other stated UTI risk factors such as having multiple sexual partners or poor hygiene-related practices were rarely recorded. About two-thirds of case records included urinalysis reports, most of which (60/63, 95%) showed positive indicators of infection such as leukocytes or protein. Of the limited number of cases in which urine culture was obtained (n = 46), roughly half (52%) were positive for uropathogenic bacteria. In roughly one-third of cases, UTI treatment was given presumptively based on symptoms and history.

Table 3 depicts the frequencies of treatments that NDs prescribed. Most treatments were given in combination with others, and 82 distinct treatment combinations across 103 patient visits were detected. Half of all cases were prescribed botanical treatments, most of which were commercially available herbal blends (see Table 4 for constituents; brand names undisclosed due to lack of manufacturers' consent). The most common treatment pairing was a botanical compound in addition to the advice to increase fluid intake (n = 26). An antibiotic was prescribed in slightly less than half of all cases (44.7%), with 30% of these given as a backup to natural modalities in the event that the patients did not improve in 2 or 3 days. Medicaid recipients were significantly more likely to receive an antibiotic prescription, relative to all other patients (14/15, 93%, vs. 32/88, 36%; p < 0.001). Frequently prescribed nonpharmacologic treatments included probiotics, dietary counseling (e.g., abstaining from sugar and alcohol, which are associated with more frequent UTIs), unsweetened cranberry juice, and D-mannose. Other naturopathic modalities such as homeopathy and hydrotherapy/balneotherapy were less common. As their primary aim was oriented toward the patient experience of naturopathic care for UTI, the authors did not conduct analyses at the level of individual providers or clinics. While some clustering of treatments within clinics likely exists, the authors did not record other data on clinics, which could allow them to explain differences in patterns between clinics.

Table 4.

Treatment Outcomes

Follow-up data available: n = 43 (42%) Lost to follow-up: n = 60 (58%)
Nonpharmacologic treatment success	28 (65%)
Nonpharmacologic treatment failure	15 (35%)

Our secondary aims are represented in Tables 4 and 5. Forty-three cases (42%) had at least one follow-up visit within 30 days following initial presentation and treatment. Of the cases where follow-up data were available, 65% achieved resolution of their UTI without antibiotic therapy, while 35% required antibiotics after failing nonpharmacologic modalities (Table 5). Because botanical therapies were common, the authors evaluated whether the three most frequently prescribed commercial products were associated with treatment success (Table 5). Although patients who received one of these three commercial products were more likely to have recorded treatment success relative to other cases in the data set, available data on success versus failure were very limited. Only one product had significantly better results, compared with those who did not receive the product (Product 3—Fisher's exact p = 0.03). Of several herbs included in each compound, the only commonality was the presence of the uva-ursi leaf. It is important to note that like most other treatments, botanicals were usually prescribed in combination with other modalities or behavioral modification. Interestingly, patients who were prescribed one of these three most common botanicals were more likely to have a follow-up visit than patients who were not prescribed them (Fisher's exact p = 0.003). The explanation for this close relationship between botanical compound prescriptions and higher likelihood of having a follow-up encounter can only be inferred due to these limited data.

Table 5.

Efficacy of Herbal Blends for Urinary Tract Infection

Herbal blend prescribed	Success	Failure	Lost to follow-up	Total	Fisher's exact p
Product 1—solid extract	4	3	7	14	0.56
Contents: buchu leaf extract; uva-ursi leaf extract; pipsissewa aerial parts; cranberry fruit extract; and marshmallow root
Product 2—solid extract	4	3	4	11	0.16
Contents: buchu leaf extract; Echinacea angustifolia root; Indian barberry root extract; and uva-ursi leaf extract
Product 3—liquid extract	6	4	4	14	0.03*
Contents: goldenrod flowering top; corn silk; horsetail whole plant; uva-ursi leaf; and juniper berry

^*p-Value is significant (<0.05).

Discussion

The authors were unable to identify any consistent naturopathic treatment protocols for UTI based on patient chart data. It is apparent that multimodal therapy is the norm since over 80% of patients in the sample received more than one treatment recommendation. Previous surveys of U.S. naturopathic practices show that not only are botanicals and behavioral modification commonly recommended^30,31 but antibiotics are also commonly given for UTI in the observed practice setting. The authors could not determine any predictors of therapy selection based on patient presentation, other than the increased likelihood of giving an antibiotic prescription if the ND was billing Medicaid. The high variability in UTI treatments is likely due to several factors, the most notable of which are individual patient and physician preferences. Patients of NDs have disclosed that they enjoy receiving holistic and multimodal treatment, they enjoy collaborating with their ND to determine treatment, and they often have a preference for nonpharmaceutical options.^31,32

The association between antibiotics and Medicaid recipients raises an interesting question about the interplay between the naturopathic clinical gestalt and scope of practice. In the context of treating UTI, NDs in Oregon were amenable to using antibiotics almost as frequently as botanical medicine, which could suggest that they are patient centered in their consideration of treatment cost and patient preference, rather than being dogmatic about using only natural products; or treatment variations may derive from an incentive to code a visit for treatments that result in higher reimbursement. Relatedly, the nonprescription products that NDs recommend to patients are often sold in office with some degree of price markup, which could influence the practice patterns observed. There may be other factors influencing the observed practice patterns of NDs in Oregon not measured in this study, such as heterogeneity between training institutions. These potential influences on clinical practice need to be disentangled to determine the generalizability of naturopathic treatment patterns observed herein, if indeed any pattern exists.

There is a background of traditional use and scientific evidence to support the herbs that were prescribed—for example, Arctostaphylos uva-ursi, which contains hydroquinones and tannins that concentrate in urine when given orally, discouraging bacterial adherence and growth.²⁰ From the follow-up data that were available, there was some evidence of antibiotic-sparing potential associated with botanical therapies, but this should be interpreted with caution. Over 50% of patients did not have a follow-up visit, and those that did were much more likely to have been prescribed a botanical compound. This raises the question of possible confounding factors related to these patients' clinical success, such as having greater overall health or more health care utilization in general. Nevertheless, the authors did find conclusive evidence of success of nonantibiotic treatment in 28/106 cases, with the actual count likely larger since patients are just as, if not more, likely to decline follow-up with treatment success as with failure.

The sample appeared to be representative of a typical U.S. primary care practice. The authors observed that 90% of patients had insurance to cover their visit to an ND, of which 14.6% was Medicaid and 65.7% was private insurance. This is comparable with data from the 2019 National Census, which indicated that 92% of the U.S. population had health coverage, of which 68.0% was private and 19.8% was Medicaid.²⁸ The proportion of patients with recurrent UTIs was 22%, falling within the 20%–30% range that has been observed in nationwide sampling.⁴ They also observed that the ratio of Escherichia coli to other bacteria that grew in culture (17 of 24 positive results; 71%) was similar to a larger compilation of nationwide data—for uncomplicated and complicated UTIs, E. coli has been isolated in 75% and 65% of cases, respectively.³³

Our study had several limitations that are inherent in retrospective chart reviews. The limited clinical setting and geographic area are potential sources of sampling bias. As the aims of the present study were primarily descriptive, the authors elected to have only one reviewer for chart selection and data abstraction, but this is another potential source of bias. Charting practices were inconsistent among the NDs included. Few conclusions can be drawn about the effectiveness of specific nonpharmacologic therapies prescribed by NDs due to limitations of the data.

Future directions

In light of the growing public health threat of antibiotic resistance, the evidence to support nonantibiotic treatments for UTI should encourage one to continue studying their mechanisms and effectiveness. For UTI patients at low risk of sequelae, it appears safe to postpone antibiotic therapy and try a nonantibiotic approach before resorting to antibiotics, which carry their own risk of complications. Future research should pragmatically evaluate these most promising nonpharmacologic treatments prospectively through head-to-head studies in real-world clinical settings. Regarding naturopathic medicine, there have been relatively few studies evaluating NDs under the broad scope of practice they currently have in states such as Oregon and Washington. The number of NDs who are licensed as primary care providers is relatively small, but growing. Idaho and New Mexico became the most recent states to license NDs in 2019 and both included a broad scope of practice to equip NDs to work in primary care. As NDs continue to adopt a larger role in the primary care workforce, it will be important to observe their practice patterns and patient outcomes.

Conclusions

Based on this retrospective chart review, NDs primarily use multimodal and individualized treatments for UTI. They most commonly recommend herbal blends, behavioral modification, and antibiotics when treating UTI in a primary care setting. NDs are much more likely to prescribe antibiotics when billing Medicaid than when billing private insurance. Patients may have success with herbal medicines in place of antibiotics for UTI, but this may be mediated by other factors. Considering the increasing public health threat of antibiotic resistance, more research evaluating herbal medicine for acute and recurrent UTIs is needed.

Appendix

Appendix A1. International Classification of Diseases (ICD) Codes for Chart Inclusion

ICD-9:

 599.0—Urinary tract infection, site not specified

 788.1—Dysuria

 788.41—Urinary frequency

 788.63—Urgency of urination

ICD-10:

 N39.0—Urinary tract infection, site not specified

 N30.00—Acute cystitis without hematuria

 N30.01—Acute cystitis with hematuria

 N30.20—Other chronic cystitis without hematuria

 N30.21—Other chronic cystitis without hematuria

 N30.80—Other cystitis without hematuria

 N30.81—Other cystitis with hematuria

 N30.90—Cystitis, unspecified without hematuria

 N30.91—Cystitis, unspecified with hematuria

 R30.0—Dysuria

 R35.0—Urinary frequency

 R39.15—Urgency of urination

Disclaimer

The contents of the article are the authors' sole responsibility and do not necessarily represent official NIH views.

Authors' Contributions

L.G. conceptualized and designed the study, collected and analyzed the data, and drafted the manuscript. D.H. participated in study conception and design and drafting and revision of the manuscript. H.Z. and R.B. participated in study design and revision of the manuscript. All authors have approved the manuscript as submitted.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

Writing of the article was supported by a grant, number T90 AT008544, from the National Center for Complementary and Integrative Health (NCCIH) at the National Institutes of Health.