The Reply

Abstract

We thank Dr. Reid for his comments, and we want to clarify that we do not conclude that vaginal lactobacilli have no role in urinary tract infection (UTI). Our results, which demonstrated no association between the presence of vaginal lactobacilli measured at baseline and incident UTI,1Jackson S.L. Boyko E.J. Scholes D.. Abraham L. Gupta K. Fihn S.D. Predictors of urinary tract infection after menopause a prospective study.Am J Med. 2004; 117: 903-911Abstract Full Text Full Text PDF PubMed Scopus (120) Google Scholar pertain to our study sample of community-dwelling postmenopausal women. In this large population-based study, we measured a wide variety of environmental and behavioral characteristics, and describe the relative contributions of all of these exposures to incident UTI. Prior study results from our own research group, using similar methodology for assessment of Lactobacillus presence, have demonstrated an inverse relationship between the presence of vaginal lactobacillus and UTI.2Gupta K. Stapleton A.E. Hooton T.M. Roberts P.L. Fennell C.L. Stamm W.E. Inverse association of H2O2-producing lactobacilli and vaginal Escherichia coli colonization in women with recurrent urinary tract infections.J Infect Dis. 1998; 178: 446-450Crossref PubMed Scopus (207) Google Scholar, 3Pabich W.L. Fihn S.D. Stamm W.E. Scholes D. Boyko E.J. Gupta K. Prevalence and determinants of vaginal flora alterations in postmenopausal women.J Infect Dis. 2003; 188: 1054-1058Crossref PubMed Scopus (99) Google Scholar We do plan to use our data to perform additional analyses to describe in more detail the relationships among vaginal flora, estrogen, and UTI. This will also allow us to evaluate the role of vaginal flora among subpopulations, such as women with recurrent UTI2Gupta K. Stapleton A.E. Hooton T.M. Roberts P.L. Fennell C.L. Stamm W.E. Inverse association of H2O2-producing lactobacilli and vaginal Escherichia coli colonization in women with recurrent urinary tract infections.J Infect Dis. 1998; 178: 446-450Crossref PubMed Scopus (207) Google Scholar, 4Raz R. Stamm W.E. A controlled trial of intravaginal estriol in postmenopausal women with recurrent urinary tract infections.N Engl J Med. 1993; 329: 753-756Crossref PubMed Scopus (711) Google Scholar and, as suggested by Dr. Reid, urinary incontinence. We do not feel that the incidence of 0.07 UTIs per person per year should necessarily be considered low for community-dwelling postmenopausal women, because incidence data in this population are limited. The positive association demonstrated between estrogen cream use and incident UTI is adjusted for other risk factors in multivariable logistic regression models as shown in Table 3 of our article,1Jackson S.L. Boyko E.J. Scholes D.. Abraham L. Gupta K. Fihn S.D. Predictors of urinary tract infection after menopause a prospective study.Am J Med. 2004; 117: 903-911Abstract Full Text Full Text PDF PubMed Scopus (120) Google Scholar and we acknowledge in the discussion that confounding by indication may play a role in this finding. Of note, however, is that a history of 3 or more microbiologically confirmed symptomatic episodes of UTI during the previous year were required for inclusion in Raz and Stamm’s carefully designed placebo-controlled trial of intravaginal estrogen, which is quite different from our study population of randomly selected community-dwelling women.4Raz R. Stamm W.E. A controlled trial of intravaginal estriol in postmenopausal women with recurrent urinary tract infections.N Engl J Med. 1993; 329: 753-756Crossref PubMed Scopus (711) Google Scholar Moreover, quantity and frequency of exposure to intravaginal estrogen were carefully controlled in Raz and Stamm’s study, in contrast with our observational community-based study, potentially contributing to the differing results. Lastly, we concur with Dr. Reid that additional study of the relationship among vaginal flora, estrogen cream, and UTI is warranted. Predictors of urinary tract infection after menopause: A prospective studyThe American Journal of MedicineVol. 118Issue 8PreviewI read with interest the study by Jackson et al1 published in December’s issue of the Journal. This is another good article from an excellent research group; however, I must challenge their conclusions, particularly that they proved no association between the vaginal bacterial flora and urinary tract infection (UTI). Full-Text PDF