Urinary tract infections

Bechorot 44 (Part II) ~ Urinary Tract Infections, Infertility and Other Dangers of Long Sermons

When you’ve got to go, you’ve got to go

בכורות מד,ב

אמר רבי אבא בריה דרבי חייא בר אבא משתינין מים בפני רבים ואין שותין מים בפני רבים ותניא נמי הכי משתינין מים בפני רבים ואין שותין מים בפני רבים ומעשה באחד שביקש להשתין מים ולא השתין ונמצא כריסו צבה

urinal.jpeg

Rabbi Abba, son of Rabbi Ḥiyya bar Abba, says that Torah scholars may urinate in public and they need not be concerned with issues of modesty, [because holding back from urinating causes bodily harm]. But they may not drink water in public, as such conduct is unbefitting a Torah scholar. And this is also taught in a baraita: Torah scholars may urinate in public, but they may not drink water in public. And there was an incident involving one who sought to urinate, and he did not urinate, and his belly was found to be swollen.

This is one of those delightful passages in which we learn that Talmudic manners were sometimes the very opposite of our modern ones. Because of the perceived dangers of not urinating when necessary, Torah scholars were permitted, or rather encouraged, to urinate whenever the urge arose, even in public. Drinking in public, however, was not allowed, since this was considered uncouth behavior. And then we read a couple of stories in which the urgent public urination of a Torah scholar is described.

שמואל איצטריך ליה בשבתא דרגלא נגדו ליה גלימא אתא לקמיה דאבוה א"ל אתן לך ד' מאה זוזי וזיל אהדר עובדא את דאפשר לך דלא אפשר ליה ליסתכן

Shmuel needed to urinate on the Shabbat [when everyone came to hear halakhot relating to the impending Festival. In order to afford him privacy], they spread a sheet for him. Shmuel then came before his father, who said to him: I will give you four hundred dinars if you will go and retract this incident, [i.e., if you will state publicly that one may not hold back from urinating even at the expense of one’s privacy.] Since you are an important man, you can have others spread a sheet around you. But with regard to one who cannot have others spread a sheet for him, should he endanger himself by seeking privacy? You must therefore teach that no-one should hold back from urinating even in public.

Shmuel’s father was willing to pay him the massive sum of 400 dinars for Shmuel to clarify to the public that “one should not hold back from urinating even in public.” Then comes another story, (describing what must be one of the weirdest incidents in the Babylonian Talmud). While walking over a bridge, Mar Bar Rav Ashi had the urge to urinate. As he was micturating, he was told that his mother-in-law was on her way, which was presumably a suggestion that hurry up and finish. To which he replied, with a most memorable turn of phrase, emphasising just how important it was to urinate when the urge is felt: “I would have even urinated in her ear”(באודנה).

But what was it that the rabbis feared might happen if you delayed micturition? Infertility. They believed that failing to urinate frequently enough would render a person sterile. And they tell a chilling example of this happening in the tractate Yevamot.

The lecture that went on for too long

רב גידל איעקר מפרקיה דרב הונא רבי חלבו איעקר מפרקיה דרב הונא רב ששת איעקר מפרקיה דרב הונא

Rav Gidel became sterile on account of Rav Huna’s lectures, Rav Chelbo became sterile on account of Rav Huna’s lectures and Rav Sheshet became sterile on account of Rav Huna’s lectures...
— Yevamot 64b

Rav Huna had a lot to answer for.  His lectures went on, and on, and on, and on and on and on.  Rashi (Yevamot 62b) explained the relationship between these lengthy classes and infertility:

איעקר מפרקיה דרב הונא.שהיה מאריך בדרשיו וצריכים למי רגלים ומעמידים עצמן ונעקרים כדתניא בבכורות 

Rav Huna would give lengthy sermons and [his students] would need to urinate. But they held it in, and as a result became sterile, as we read in Bechorot.

The suggestion here is that holding-it-in can lead to problems of fertility, and there is a least a theoretical scientific reason why Rav Huna's lengthy classes had the unintended consequence of lowering the reproductive rates of his students.  

Urinary tract infections and infertility

As it turns out, there is a clear relationship between male infertility and repeated infections of the genitourinary tract. Here, for example, is  how one urology textbook opens its chapter on male genital tract infections and infertility:

Male Genital Tract Infections and Infertility. Neal, DE, Weinstein, SH. In Male Reproductive Dysfunction ed Kandeel FR. Informa Healthcare 2007

Male Genital Tract Infections and Infertility. Neal, DE, Weinstein, SH. In Male Reproductive Dysfunction ed Kandeel FR. Informa Healthcare 2007

Any male GU infection such as prostatitis, urethritis or epididymo-orchitis can reduce both sperm count and the quality of the seminal fluid. OK, but what does that have to do with not urinating when you feel the urge? Well here's the thing: that not-going-when-you-need-to is really not a good idea.

It's quite a challenge to determine scientifically the effect of holding-it-in (and hereafter referred to as delayed micturition, because it sounds nicer) on the risk of getting a urinary tract infection.  You can't very easily randomly assign one large group of healthy volunteers to urinating whenever they want, and a second to urinating only three times a day.

However, there are a couple of observational studies that may be able to tell us something about the risk of delayed micturition.  A 1968 study of 112 women with a documented UTI reported that further UTIs could be reduced by voiding  every two hours during the day (which sounds rather too good to be true). And a 1979 study from the (not-very-widely-read-but-it-really-is-a-journal) Scandinavian Journal of Urology and Nephrology reported that the frequency of UTI was significantly higher among women with three or less voidings per day compared with those who have to go four or more times per day. (Whether this is true for women outside of northern Jutland where the study was conducted remains unclear.)

So a decreased voiding frequency is associated with an increased number of infections, and urinary tract infections are associated with decreased fertility. Thus by the rule of transitive relations (or something clever like it) decreased voiding may indeed be associated in a causative way with decreased fertility.  

All this is highly speculative, and it would certainly be unusual for male sterility to directly result from delayed micturition.  But here's the weird thing: teachers are slightly more likely to suffer urinary tract infections when compared with the general population. Is that because they too, like their students, hold-it-in? (Yes, I know it didn't reach statistical significance, but the authors thought it was important to note, and so do I.)   

Kovess-Masféty, V. Do teachers have more health problems? Results from a French cross-sectional survey. BMC Public Health 20066:101;1-13

Kovess-Masféty, V. Do teachers have more health problems? Results from a French cross-sectional survey. BMC Public Health 20066:101;1-13

Poor Rav Huna, talking on and on and on, while his miserable students had to sit there with their legs crossed and could likely only think of only one thing. We will give the last word to Rav Acha bar Yaakov, another hapless student of Rav Huna. 

אמר רב אחא בר יעקב שיתין סבי הוינא וכולהו איעקור מפרקיה דרב הונא לבר מאנא

Rav Acha bar Yaakov said, we were a group of sixty students, and all of us became sterile because of Rav Huna's lectures - except me (Yevamot 64b).

Students be warned.

[Partial repost from here.]

 

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Yevamot 64 ~ Urinary Tract Infections, and the Class That Went On For Too Long

יבמות סד,ב

רב גידל איעקר מפרקיה דרב הונא רבי חלבו איעקר מפרקיה דרב הונא רב ששת איעקר מפרקיה דרב הונא

Rav Gidel became sterile on account of Rav Huna's lectures, Rav Chelbo became sterile on account of Rav Huna's lectures and Rav Sheshet became sterile on account of Rav Huna's lectures...

Rav Huna had a lot to answer for.  His lectures went on, and on, and on, and on and on and on.  A couple of pages prior, on Yevamot 62b, Rashi explained the relationship between these lengthy classes and infertility:

איעקר מפרקיה דרב הונא.שהיה מאריך בדרשיו וצריכים למי רגלים ומעמידים עצמן ונעקרים כדתניא בבכורות 

The suggestion here is that holding-it-in can lead to problems of fertility, and there is a least a theoretical reason why Rav Huna's lengthy classes had the unintended consequence of lowering the reproductive rates of his students.  There is a clear relationship between male infertility and repeated infections of the genitourinary tract. Here, for example, is  how one urology textbook opens its chapter on male genital tract infections and infertility:

Male Genital Tract Infections and Infertility. Neal, DE, Weinstein, SH. In Male Reproductive Dysfunction ed Kandeel FR. Informa Healthcare 2007

Male Genital Tract Infections and Infertility. Neal, DE, Weinstein, SH. In Male Reproductive Dysfunction ed Kandeel FR. Informa Healthcare 2007

Any male GU infection such as prostatitis, urethritis or epididymo-orchitis can reduce both sperm count and the quality of the seminal fluid. OK, but what does that have to do with not urinating when you feel the urge? Well here's the thing: that not-going-when-you-need-to is not a good idea.

It's quite a challenge to determine scientifically the effect of holding-it-in (and hereafter referred to as delayed micturition, because it sounds nicer) on the risk of getting a urinary tract infection.  You can't very easily randomly assign one large group of healthy volunteers to urinating whenever they want, and a second to urinating only three times a day.

However, there are a couple of observational studies that may be able to tell us something about the risk of delayed micturition.  A 1968 study of 112 women with a documented UTI reported that further UTIs could be reduced by voiding  every two hours during the day (which sounds rather too good to be true). And a 1979 study from the (not-very-widely-read-but-it-really-is-a-journal) Scandinavian Journal of Urology and Nephrology reported that the frequency of UTI was significantly higher among women with three or less voidings per day compared with those who have to go four or more times per day. (Whether this is true for women outside of northern Jutland where the study was conducted remains unclear.)

So a decreased voiding frequency is associated with an increased number of infections, and urinary tract infections are associated with decreased fertility. Thus by the rule of transitive relations (or something clever like it) decreased voiding may indeed be associated in a causative way with decreased fertility.  

All this is highly speculative, and it would certainly be unusual for male sterility to directly result from delayed micturition.  But here's the weird thing: teachers are slightly more likely to suffer urinary tract infections when compared with the general population. Is that because they too, like their students, hold-it-in? (Yes, I know it didn't reach statistical significance, but the authors thought it was important to note, and so do I.)   

Kovess-Masféty, V. Do teachers have more health problems? Results from a French cross-sectional survey. BMC Public Health 20066:101;1-13

Kovess-Masféty, V. Do teachers have more health problems? Results from a French cross-sectional survey. BMC Public Health 20066:101;1-13

 

Poor Rav Huna, talking on and on and on, while his miserable students had to sit there with their legs crossed and could likely only think of only one thing. We will give the last word to Rav Acha bar Yaakov, another hapless student of Rav Huna. 

אמר רב אחא בר יעקב שיתין סבי הוינא וכולהו איעקור מפרקיה דרב הונא לבר מאנא

Rav Acha bar Yaakov said, we were a group of sixty students, and all of us became sterile because of Rav Huna's lectures - except me (Yevamot 64b).

Students be warned.

 

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