| Interview with the Medical Team at the Artemis Cystitis Clinic in London (Part 1)
We had the opportunity to speak directly with the medical team — about diagnostic procedures, treatment protocols, and the safety of long-term therapy for chronic urinary tract infection.
● Introduction and Expertise
1. Please introduce yourself and tell us how many years you have been working in the field of urology, specifically focusing on chronic UTIs. Treatment Protocols and Outcomes
Ed Harvey - GP with Special Interest in chroinic urinary tract infection. He developed his expertise under the training and supervision of Professor James Malone-Lee. He has worked at the Clinic since 2020.
Ed’s passion for this particular field of medicine was sparked by the work Professor Malone- Lee was doing in the field of chronic cystitis, and the breakthroughs that have been made in understanding the pathophysiology of the disease in recent years.
Matthew Malone-Lee – GP with specialist interest in chronic urinary tract infection. As a medical student I assisted with my fathers research and worked at his NHS LUTS clinic during the summer months. My medical school dissertation focused chronic urinary tract infection. After working for several years as a GP, I trained further at the NHS LUTS clinic and at 10 Harley Street. In 2018, I began treating patients with chronic urinary tract infection at Artemis Cystitis.
Sheela Swamy – Consultant Obstetrician and Gynaecologist with special interest in Urogynaecology and Medical education, worked for Prof Malone-Lee as a Senior Research Associate from Dec 2011, started my PhD in 2012 - 2016 and started working again with Prof at Artemis Cystitis clinic from Oct 2018 to date. Sheela has worked at Whittington LUTS clinic and completed her PhD titled: Missed UTIs in patients with chronic recalcitrant LUTS.
● Treatment Protocol
2. What is the current treatment protocol used in your clinic?
At our clinic, we treat chronic urinary tract infections using a combination of treatment- dose antibiotics and a medicine called methenamine Hippurate. We prescribe antibiotics carefully, selecting narrow-spectrum options whenever possible to minimise disruption to the body’s natural microbial balance and reduce side effects. Methenamine Hippurate is an antiseptic that slowly cleanses bacteria from the extracellular spaces while the infected cells clear.
There is no “one-size-fits-all” treatment. Our aim is to identify a plan that each patient can tolerate and that is both safe and effective. A small proportion of patients are able to manage on methenamine Hippurate alone, but most require antibiotics in combination with hiprex to gain control over the infection.
We monitor bladder inflammation by performing microscopy on freshly collected urine specimens, counting white blood cells and epithelial cells, and plotting these results over time. The antibiotics target bacteria that emerge from infected cells, preventing them from spreading to new cells. However, antibiotics have limited effect on bacteria already inside the cells, so we must wait for those cells to naturally shed. This process can take up to 18 months or longer, which is why extended courses of antibiotics are sometimes required. Patients are reviewed every three months to assess treatment response, repeat microscopy, and ensure that therapy remains both safe and effective.
3. Have you made any changes to your treatment protocol in the past couple of years? For example, were adjustments necessary during the pandemic, when international patients were unable to attend in-person visits, or for other reasons?
Yes. We offer remote appointments via Microsoft Teams for patients who live far away or unable to attend in person. Where possible, we advised patients to arrange for a local laboratory that can provide fresh, unspun urine samples for microscopy. These results can then be reviewed and discussed during each virtual appointment. We provide Urgent Telephone or video reviews to deal with emergencies 6/7 days per week.
4. With more patients being treated and thus more data available, what is the current average duration of treatment? Have you observed any patterns between the length of treatment, the number of years a patient has lived with the condition before seeking treatment, and the number of red and white blood cells present at the start of treatment?
The average duration of treatment is around 18 months. We do not believe that the length of time a patient has experienced symptoms is directly related to how long it takes for them to improve.
5. Are there any success stories or particularly memorable cases that you could share (anonymously) to inspire patients considering treatment?
I am afraid that GDPR does not allow for this type of data to be shared even if anonymized especially with a patient group. Any medical presentation we do , we have to gain patients written consent. Patient support groups have patient testimonials and stories and you can provide your patient group a link to these. We do have patient biographies that we would like to publish and we have a book of case studies that we are currently writing up and this will provide good material for reference for patients and clinicians.
6. Why do some patients continue to experience pain despite being on antibiotics? The embedded bacteria do not cause acute pain, correct? Symptoms are typically triggered only when the bacteria are released and cause an acute bladder infection. However, in theory, the antibiotics (if appropriately chosen) should immediately prevent these bacteria from adhering to the bladder mucosa and triggering a new infection. Could you clarify why this pain persists?
Antibiotic treatment only eliminates the bacteria that are released. The bladder tissue itself remains inflamed and colonised with bacteria, which continue to cause irritation. Any stretch or contraction of the bladder, or even the act of opening the urethra, puts strain on this inflamed tissue, resulting in pain, discomfort, or heightened awareness.
In addition, infections are often mixed, and some organisms may not be fully suppressed if the antibiotic dose is insufficient. This can explain the fluctuating nature of symptoms, as well as the recurring presence of pus cells and epithelial cells seen under the microscope.
It takes considerable time for bacteria to be cleared and for inflammation to settle. The process is similar to peeling layers of an onion gradually and stepwise. Bacteria have survived on earth for billions of years and are highly skilled at adapting to and persisting in their chosen environments.
● Microscopic Examination of Fresh Urine.
7. When examining urine under a microscope, why do you prefer using fresh urine that has been in the bladder for a while, rather than sedimenting the urine first, as is commonly done in German laboratories? What exactly can you observe through the microscope in its fresh state?
When we obtain a urine sample form our patients we examining immediately under a microscope using a haemocytometer. It is important that the sample is immediately fresh to maximise sensitivity of the test because the pus cell counts will fall to 60% of the starting result within two hours of collection as they are really delicate an lyse with time. Bacterial overgrowth can also cloud the field so that no useful information can be obtained. A stale sample can be misleading. This is why the patients have to attend this centre in order to have this examination.
We report the fresh urine microscopy per microliter, Sedimenting the sample involves putting urine in a pot through a centrifuge at 2000 rpm per minute, removal of supernatant fluid and using the thick cell mass at the bottom of the tube. This is really counterproductive when doing microscopy and leads to clumping of all cells together making it impossible to sperate and count and causes significant cell lysis. We do use this technique for urine cultures to try and capture the bacterial species for science experiments.
● Patient Concerns and Safety
8. Many patients feel uncertain about beginning long-term treatment involving high doses of antibiotics. Could you provide more information on its safety, how you manage side effects, and any preventative measures you recommend for your patients?
The bacteria are embedded in the lining of the bladder and we have to use high oral antibiotic doses to get sufficient concentrations in the urine to have a beneficial effect. Because the infections are often by more than one bacterium we sometimes have to use more than one antibiotic. All deep-seated indolent, intracellular infections whether in the bladder or other tissues require protracted courses of treatment to achieve clearance.
The antibiotics we use in this clinic are generally well tolerated, but side effects may occur. How we manage the side effect depends on the type/severity. We maintain an emergency email service that is monitored every day of the year, so that patients can report any concerns about side effects and they will receive prompt advice from one of the doctors in the team.
We aim to spot any complications early, and recommend monitoring liver and kidney function and liver function by way of blood tests, usually every 3-4 months whilst taking long term treatment.
We can reassure that antibiotics will not affect immunity and will not cause anyone to become susceptible to bacterial attack or resistant to antibiotics. The regimes that we use here have been developed over 20 years. Safety has always been a huge concern to us and we have tested for that meticulously. We do not use heavy duty modern broad spectrum antibiotics but favour the older simple drugs that have been around for many years.
The bacteria that we are treating divide little and so they are not able to evolve resistant forms readily. This results in the fact that most urinary infections we see in this clinic prove sensitive to a wide range of antibiotics.
Probiotics are worth taking and studies have shown them to reduce the incidence of antibiotic associated diarrhoea. Increasing levels of resistant starch in the diet is also recommended. Resistant starch is not fully broken down and absorbed. Intestinal bacteria feed on this and thrive. The starch of grains, seeds and legumes are bound to the fibrous cell walls. The crystalline structure of starch in potatoes and bananas resists digestion. If you cook potatoes, rice and pasta and then let them cool they will form resistant retrograded starch.
We would like to express our sincere thanks to the physicians at the Artemis Cystitis Clinic in London for taking the time to answer our questions.
Their dedication, expertise, and many years of experience in treating chronic urinary tract infections are a valuable source of hope and guidance for many patients.
| Read Interview Part 2