High Urine pH and Recurrent UTIs: The Ammonia Connection | Ruth Kriz, Part 2

Ruth Kriz, MSN, APRN, is a nurse practitioner who specializes in chronic UTI and interstitial cystitis, with 35 years in the interstitial cystitis community. She's becoming more and more convinced that ammonia is a huge player in why people have some of these infections.

What ammonia does to your bladder overnight

While you sleep, antidiuretic hormone concentrates your urine. That's why it's darker first thing in the morning.

Ruth describes three things high ammonia may do while it sits there. It raises the pH of your urine, which may favor the growth of many of the pathogens behind chronic UTIs. It damages the GAG layer, the layer of the bladder wall that takes the hit, which can crack and bleed when the bladder is filled during a cystoscopy. And it stabilizes biofilms.

Her line for it is blunt: leaving ammonia sitting in your bladder all night long is a really bad idea.

Why some people make too much ammonia

Some of it is genetic. Variations in the CBS gene, cystathionine beta synthase, can mean some people make too much ammonia. Clearing it takes several enzymes, and some people have genetic problems there too.

Genes aren't the whole picture. Ammonia can also come from bad bugs in the gut, as in SIBO, and from Lyme disease. Ruth thinks that's one reason she sees so many urinary issues in the Lyme community.

Having a CBS variation doesn't mean you have an ammonia problem, the same way a genetic predisposition for diabetes doesn't make you diabetic.

How to check your first morning urine pH

That's why Ruth tests function, not genes. Your first morning urine shows whether your body is clearing the ammonia well enough.

If your first morning urine pH is above 6.0, she reads that as a sign your body didn't clear the ammonia well enough overnight. Her goal for that first morning urine is 5.75 to 6.0. Measuring your urine pH first thing in the morning is where you start.

Where it runs high, she may use an ammonia scavenger that gives the body more ornithine or citrulline to help clear it. That's one possible tool for some people, and it's a conversation for your practitioner. I'll admit I went looking for mine in the closet while she was talking.

Why cranberry juice can stop working

E. coli is fussy about pH. Its favorite is 7.0 and its second favorite is 5.5. Cranberry has a pH of 2.6, so for an occasional UTI, cranberry juice can help by bringing the pH down.

Keep drinking it and push your urine down to 5.5, and the cranberry may stop helping, because now you've landed on the pH E. coli likes second best. More isn't better here.

Why your antibiotics might not reach the infection

If you've had round after round of antibiotics and you're still suffering, you're not imagining it.

The macrolides may work on many of these pathogens, but only 6 to 8% of the dose makes it into the urinary tract. Macrobid needs an acid pH to work according to its product insert, and urine running high on ammonia isn't acidic.

Timing may matter too. A twice a day dose taken at breakfast and dinner may be running low by bedtime, before the long overnight stretch. Ruth has been asking practitioners to schedule the second dose at bedtime. Talk to your prescriber before you change how you take anything.

The hopeful part is her point that the same old antibiotics can still work once the biofilms are broken down.

Testing that looks further than a culture

I watched this with a woman I care for, who's about to turn 80. Six months of UTIs, cultures and contamination results. I asked her urologist's office about MicroGen DX testing, it found what was going on, and after a round of antibiotics she was one of the lucky ones.

Ruth recommends that women testing for the first time use a kit that tests both urine and the vagina. For most men with UTIs, she says the source of the infection is the prostate, so the men's test checks semen as well as urine.

BV, vaginal pH and the bladder

Ruth thinks BV is a misnomer. In her testing, Gardnerella often isn't the big player. Other pathogens colonize the vagina too, and the usual tools may not work on them.

Antibiotics can wipe out the healthy lactobacilli that keep the vagina acidic. Without them the pH rises, pathogens that like a higher pH move in, and it can become a vicious cycle.

She puts the ideal vaginal pH at 3.8 to 4.2, and for many women, simply acidifying the vaginal tract may be enough to discourage the bad guys and let the good bacteria grow back. Your vagina isn't a self-cleaning oven. It depends on those lactobacilli.

If you missed Part 1 of my conversation with Ruth Kriz, we talked about why chronic UTIs may keep returning, how bacteria can hide inside biofilms, and why standard urine cultures may not always reveal the full picture. Visit the Part 1 episode page here.

So if you're in this cycle, start with what you can see. Check your first morning pH. Ask what your antibiotic can actually reach. Find someone who'll test further than a culture. You're not dirty and you're not doing it wrong. There are answers, and there is hope.