It can start with a constant “Gotta go!” feeling that’s accompanied by knife-like pain when urinating, followed by the terrifying sight of pee the colour of cranberry juice. But what makes a miserable urinary tract infection (UTI) experience even more miserable is when it happens again and again and again. This is recurrent UTI, defined as two or more infections in six months or three or more infections in one year.
UTIs occur when bacteria, most commonly E. coli, reach the urethra and then travel up to the bladder. A lot of bacteria hang out around the anus and surrounding tissue, and the distance between the anus and the urethra is much shorter in women than in men, as is the length of the urethra itself.
While any woman is at risk (thanks to that short urethra), clearly some women are more prone to recurrent UTIs than others. If your mum suffered from them or you had your first one before you were 15, you may have a genetic pre-disposition that makes E. coli bacteria more likely to “stick” to the walls of your urinary tract than to get flushed out.
Intercourse is often the culprit, since it facilitates the journey of E. coli from the rectum to the urethra no matter how many showers you take, how often you pee or how well you wipe.
Diagnosing the problem
Perimenopausal and post-menopausal women are particularly prone to getting recurrent urinary tract infections, since a lack of oestrogen not only makes the urinary tract tissue more susceptible to infection but also changes the genital microbiome.
The only way to diagnose a UTI is with a urine test. After you hand in that sterile cup of wee at the doctor’s office, it takes 24 to 48 hours to determine whether bacteria are growing and, if so, what kind of bacteria and which antibiotics will work.
Most doctors will give you antibiotics without yet having culture results, not only to relieve your misery but also to prevent the infection from travelling up to your kidneys. The downside to treating right away is that you may not actually have a UTI, or the antibiotic you’re taking may not be the right one. But if someone is getting recurrent infections, it’s important to identify the bacteria and determine what antibiotics will kill them. In some cases there may be more than one kind. So what strategies are and aren’t effective in preventing recurrent UTIs?
Things that don’t work
Urinating before and after sex: Despite what your mother, Dr Google, or even your actual doctor might have told you, studies have not shown that weeing right before and right after intercourse makes a difference.
Wiping techniques: Likewise, the way you wipe really makes no difference! Just wipe your anus separately if you have had a bowel movement.
Probiotics: Don’t bother.
Cystoscopy: This is a procedure in which a scope is inserted through the urethra and into the bladder to see whether there is a reason for recurrent infections. In a 2022 study, nearly 400 women with documented recurrent UTI had cystoscopies, and the procedure provided a reason for the UTIs in only a handful of cases.
D-mannose: Despite testimonials on websites selling products containing D-mannose (a type of sugar) claiming it will prevent UTIs, there is no convincing scientific evidence that it works.
Things that do work
Methenamine: This daily pill stops bacteria growth in the bladder by making the urine acidic. It’s not used to treat infections, but a 2022 study showed that it worked as well as antibiotics to prevent recurrent infections.
Drinking more water: In a 2018 study, young women with recurrent UTIs who increased their daily intake of water by one and a half litres cut their recurrence rate in half. Again, this isn’t a treatment for a current UTI.
Cranberries: There’s mixed data on this one, but a number of plausible studies support the use of cranberry juice and cranberry products.
Prophylactic antibiotic with sex: If the only time you get a UTI is after you have intercourse, taking one antibiotic pill when you have sex may dramatically decrease the chance of a postcoital UTI.
Local vaginal oestrogen: If you are perimenopausal or postmenopausal, the number one thing that will prevent frequent urinary tract infections is the use of a local vaginal oestrogen.
Oestrogen ensures a healthy microbiome so that good bacteria will hang around instead of the problematic kind. Local vaginal oestrogen comes in the form of a cream, a long-acting vaginal ring, a vaginal insert or a vaginal tablet. This treatment is among the most under-used, and it can be life-changing.
When it’s not a UTI
In some postmenopausal women, the classic symptoms of a UTI are due to genitourinary syndrome of menopause (GSM), which causes vaginal dryness and painful sex and also affects the urinary tract.
If the urine culture is negative for a UTI, a vaginal and vulvar exam is needed to diagnose GSM, but all too often that exam never happens, so if this is your situation, bring it up with your doctor.
If you’re having bladder urgency, frequency and discomfort that is not from an infection, a local vaginal oestrogen will likely eliminate those symptoms. Non-oestrogen options that treat GSM (such as DHEA and oral ospemifene) will also reduce recurrent UTIs.
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