What to do if you have recurring UTIs

Most of us use the bathroom throughout the day without much thought, but when you have a urinary tract infection, something as simple as peeing can suddenly become strenuous, smelly, and downright painful.

Your urinary tract is the system of “plumbing” that allows you to pee, and it includes everything from your urethra and bladder all the way up to your kidneys. A urinary tract infection, or UTI, occurs when any part of that urinary system becomes overgrown with bacteria that doesn’t belong there. This causes symptoms like pain or burning during urination, frequent urination or trouble voiding, cloudy or foul-smelling urine, and pain in the abdomen or lower back.

 While having one UTI in a lifetime is more than enough, some people cope with recurrent UTIs and don’t know how to handle them. If you have had more than one UTI in recent months, you might be suffering from recurrent infections. Here’s everything you need to know about the possible causes, treatment, and prevention of UTIs.

Why does my UTI keep coming back?

There are many different reasons why someone might have recurrent urinary tract infections. Although there are a few hygienic practices that can cause them (like not wiping front to back after a bowel movement if you’re female), the majority of infections are caused by factors completely out of your control.

According to Lauren Cadish, MD, urogynecologist at Providence Saint John’s Health Center, anatomical anomalies can put people at increased risk. This includes people born with a tendency for urine to go backward from the bladder back up the ureters, the tubes that bring urine from the kidneys down into the bladder. However, Dr. Cadish says this is typically diagnosed in childhood, so it shouldn’t come as a surprise to an adult suffering from recurrent UTIs.

Other common risk factors for recurrent UTIs include: 

• Bladder or kidney stones
• Nerve injury or disease of the bladder that prevents it from emptying fully
• Kidney disease and transplant
• Autoimmune disorders or other medical conditions that compromise the immune system 
• Bowel problems, like diarrhea or fecal incontinence (Escherichia coli, or E. coli, is the bacterial culprit in 90% of all UTIs)

Some causes of UTIs can be easily identified and resolved. Remembering to empty your bladder in a timely manner, drinking enough fluids to flush out your urinary tract, and managing bowel movements are simple ways to avoid some of the common causes of UTIs, explains Julie Stewart, MD, a urologist at Houston Methodist Hospital.  

Men versus women 

Though both men and women get UTIs, women are disproportionately affected. Why? Because of basic female anatomy as it relates to the urethra, the tube that transports urine from the bladder out of the body.  

“The urethra in a woman is relatively short, typically about four centimeters,” says Dr. Cadish.  “Because men’s urethras have to traverse through the prostate and the length of the penis, their urethras are much longer and bacteria have a harder time getting up into the bladder than in women.”

 There’s another normal part of female anatomy that can increase the risk of UTIs, too: the vagina. According to Dr. Cadish, women have bacteria that normally live inside the vagina, but that bacteria sometimes travels to the urinary tract or bladder and causes a UTI. Hormonal changes may also make a woman more vulnerable to UTIs; the infections are more common after menopause and, often, before menstruation (thanks to the drop in estrogen).

But before you think men get off easy when it comes to UTIs, that’s not necessarily the case. “While women are at much higher risk of UTIs, the longer urethras in men put them at higher risk of not being able to empty their bladder well, often the result of a prostate problem,” says Dr. Cadish. Insufficient emptying due to an enlarged prostate can cause frequent UTIs.

 Though UTIs are not typically a sign of cancer, they are linked to both prostate and bladder cancer in other ways. A 2017 study published in PLoS One found that men who visited a doctor more than five times per year for lower urinary tract infections were more likely to develop prostate cancer than men who didn’t suffer from recurrent infections. 

Elsewhere, bladder cancer is often linked to frequent UTIs because one of the first signs is blood in the urine, a symptom easily dismissed in women as the result of bladder infection or hormonal changes. In other words, women are often diagnosed later with bladder cancer than men, having had many of their early cancer signs mislabeled as UTIs.

How is a recurrent UTI diagnosed?

According to Dr. Stewart, the criteria for diagnosing recurrent UTIs was recently re-evaluated by the American Urological Association (AUA). “Recurrent UTIs are defined as two UTIs in six months or three UTIs within one year,” she says, “but they need to be cases of culture-proven, bacterial cystitis with symptoms.”

In other words, you’ll need to have confirmed cases of bacteria from a urine sample and noticeable UTI symptoms to qualify. Dr. Stewart explains that some people regularly test positive for bacteria without symptoms and others have symptoms without a positive culture (possibly due to bladder irritation rather than bacterial infections). Those scenarios should be treated differently than a patient who presents with both.

“A urine culture includes a check of sensitivities, meaning that we can tell which antibiotics will kill that infection and which will not,” explains Dr. Cadish, adding that a diagnosis of UTI really means that the specific bacteria causing the infection has been identified in a culture. From there, a healthcare provider can prescribe an appropriate course of antibiotics for that particular infection.

It’s important not to neglect symptoms of UTIs; if left untreated, your UTI can become a kidney infection, a serious and potentially life-threatening problem known as pyelonephritis.

How is a recurrent UTI treated?

If you meet the criteria for recurrent UTIs, your primary care provider will likely refer you to a urologist who can begin to do some detective work.

“It’s our job as surgeons to understand if there are risk factors like anatomical or autoimmune issues,” says Dr. Stewart. “We look for causes and intervene on them if we can—like treating a kidney stone if there is one—but the majority of patients do not have a clear cause or ‘smoking gun.’”

This is known as an uncomplicated urinary tract infection, and while it can be frustrating to not find a clear cause or explanation, urologists can still work with you to develop a treatment plan. Typically, the treatment for recurrent UTIs includes antibiotic therapy as-needed with a medication like:

• Bactrim (sulfamethoxazole-trimethoprim)
• Macrobid (nitrofurantoin)
• Keflex (cephalexin)

The antibiotic used depends on the strain of bacteria shown in the urine culture.

“There are several antibiotics we’ve agreed have the least ‘collateral damage,’” says Dr. Stewart, “and we try to treat the infection with the most appropriate antibiotic for the shortest duration that will be effective.” 

She adds that sometimes longer, daily low-dose antibiotics are needed to manage a more chronic infection due to other health problems. For example, a 2018 study in The Lancet Infectious Diseases found that continuous antibiotic treatment was effective in preventing UTIs in patients who use catheters. Some women may also be told to take a single dose of an antibiotic after sexual activity to prevent bacterial growth.

If you have an active infection being treated with antibiotics, you may also need to use an OTC pain reliever, like acetaminophen or ibuprofen, until the antibiotic starts working. You can also take an OTC medication designed to help with several symptoms of UTIs, like Azo Urinary Pain Relief.

How to prevent urinary tract infections

Depending on why your provider suspects you’re experiencing recurrent UTIs, there are a number of ways you can potentially prevent reinfection and avoid antibiotic treatment at least some of the time. 

Medications and supplements

1. D-mannose is a sugar commonly found in fruit, which is known to adhere itself to the E. coli bacteria in your bladder and prevent bacterial overgrowth in the lining of the bladder. Dr. Cadish recommends taking this OTC supplement at a dose of two grams daily. A 2016 study in the European Review for Medical and Pharmacological Sciences found D-mannose to be an effective treatment and prevention strategy for UTIs (and it doesn’t carry many side effects).
2. Methenamine, available by prescription, may be useful in preventing future infections (though it doesn’t work to treat existing ones). It’s an older antibiotic that may have a cleansing effect on the urinary tract and is considered an antiseptic or antibacterial treatment, rather than one that can cure an active infection.
3. Vaginal estrogen therapy, especially for postmenopausal women, is another option for prevention. Dr. Stewart says that because menopause changes the pH of vaginal tissues, it makes bacterial growth more likely. Replacing the estrogen in small amounts, she explains, can improve the pH of vaginal tissues and prevent overgrowth of “bad” bacteria while promoting the growth of “good” bacteria. 

Lifestyle changes

1. Drinking plenty of fluids every day will help you flush normal bacteria out of your urinary tract, preventing overgrowth.
2. Go to the bathroom frequently. Don’t hold your urine for extended periods of time or rush through the process without fully emptying your bladder. Doing so can lead to an overgrowth of bacteria in your bladder.
3. Address any ongoing GI issues, like constipation or diarrhea. Since most of the UTI-causing bacteria comes from the rectal area, having frequent bowel movements exposes you more often to contamination; meanwhile, being constipated can put pressure on the bladder and affect its overall function (this is especially common in children). 
4. Avoid frequent consumption of foods known to irritate the bladder, like caffeine, alcohol, and spicy foods.

Hygiene tips 

1. Wipe from front to back after bowel movements, for women, to avoid spreading bacteria from the rectal area to the urethra. Men should also keep their genitals clean, especially after sex.
2. Urinate soon after sexual intercourse to flush out any bacteria transferred to the urethra.
3. Keep the genital area dry and unrestricted. Wear cotton underwear, avoid hot tubs and ill-fitting undergarments, and don’t use any feminine cleansing products like douches or deodorant.
4. Use alternative forms of contraception. According to a 2013 review of studies in Reviews in Urology, using spermicide and barrier methods of contraception (like diaphragms and condoms) may increase the potential for bacterial growth after intercourse.

Natural remedies

1. Incorporate a daily source of cranberry. Anyone with recurring UTIs has probably been told to drink cranberry juice or take a cranberry supplement because the fruit may have a protective effect on the bladder. But the research—and the medical recommendations—are split. Dr. Cadish says cranberry juice and supplements won’t hurt you, but won’t help you much either. On the other hand, Dr. Stewart says there may be some truth to the connection between cranberries and bladder health: “There is something called PAC, a molecule that coats the bladder lining and might prevent E. coli from accumulating in the bladder [and causing infections].” However, most OTC supplements don’t have enough PAC to make a difference, warns Dr. Stewart; the current research suggests that a dosage of at least 37 milligrams may be needed to have an effect (and most supplements have only two milligrams).
2. Take a daily probiotic. It may ward off UTIs. These good bacteria live primarily in your gut, but also in the vagina—especially the probiotic lactobacillus, which can reduce UTIs in women who have a healthy vaginal flora.
3. Add more vitamin C to your diet. The hard evidence to support this strategy is lacking, but researchers think that vitamin C may inhibit bacterial growth by making your urine more acidic. One older study from 2007 found that a group of pregnant women taking a combination of supplements including vitamin C were less likely to develop UTIs than the group of women whose supplements did not include vitamin C.

 It can be discouraging when UTIs keep coming back. Talk to your healthcare provider. With advice, you can find the right combination of treatments that will work for you.