As a urologist, I often see patients in the office concerned about the number of urinary tract infections (UTIs) that they are experiencing. If you’ve experienced repeated UTIs, you know the toll they can take on your life. However, you may take some comfort in knowing they may not result from anything you have done.

What is a urinary tract infection?

For a variety of reasons, bacteria from the gut can get into the urinary tract and can cause bothersome urinary symptoms. Patients typically feel a strong urge to urinate or feel that they have to urinate frequently, often without much urine output. You may also notice your urine is cloudy, blood-tinged or has a strong smell. As many as 4 in 10 women who get a UTI will get at least one more within six months.

What are the symptoms of a urinary tract infection?

Since many conditions mimic a urinary tract infection, it is important to know their symptoms. Common symptoms associated with urinary tract infections include, but are not limited to:

• Pain, burning or discomfort with urination
• Urgent need to urinate
• Frequent trips to the restroom to empty the bladder
• Cloudy or foul smelling urine
• Presence of blood in the urine
• Pain low down in your abdomen under the belly button or lower back
• Feeling unusually tired with or without a fever (a fever is considered at 101° F)

What causes urinary tract infections?

Women often get infections more than men because the anus is closer to their urethra ( urinary drainage tube), and their urethra is much shorter, so bacteria may get into the bladder more easily. Risk factors for UTIs can vary with age.

• In patients less than 40 years of age, the most common risk factor is sexual intercourse. Sexual activity can spread bacteria from the anus/perineum towards to vagina/urethra. Douching is not advised as it can disrupt natural bacteria, known as lactobacilli, which help guard against urinary tract infections.
• Post-menopausal women or women on birth control may notice an increased risk of urinary tract infections related to the low estrogen state. The numbers of lactobacilli in the vagina naturally decline during menopause due to the lack of estrogen.
• People who are constipated tend to experience more urinary infections.

• People who drink little water may experience more urinary infections. Water helps flush bacteria out of the urethra, and bacteria can build up if you are not drinking enough water.
• Certain strains of E. coli may be found in the type of meat that we consume, which can influence the types of urinary tract infections we are exposed to.

How are urinary tract infections treated?

If you think you have a urinary tract infection, you should schedule an appointment with your doctor, who may run different tests. Submitting urine for a urine culture is the gold standard for diagnosing a urinary tract infection. Patients should be aware of the differences between a urine dip test, which provides instant information regarding a suspected urinary infection, versus a urine culture, which takes two to three days to finalize results.

Armed with the urine culture results, the doctor can identify the organism causing the infection (for example, E. coli) and confirm the correct antibiotic to clear the infection based on sensitivities. Without a urine culture, it is not clear if the antibiotic prescribed will be effective, leading to prolonged symptoms if the bacteria are resistant.

Ureaplasma and mycoplasma are atypical bacteria that live on the skin of many patients; while they do not pose a threat to some patients, other patients may experience urinary irritation. This type of infection is cleared with an antibiotic that is not commonly prescribed to treat urinary tract infections. Without a special urine culture to confirm the presence of this uncommon bacteria, many patients find their symptoms persist even after receiving several rounds of antibiotics.

Do over-the-counter medications work to treat urinary tract infections?

Over-the-counter medications can help relieve pain and UTI symptoms, but they won't treat or cure the UTI. A UTI needs to be treated with antibiotics to prevent serious health complications.

Over-the-counter medications can be useful in managing symptoms.

• Phenazopyridine – Can help relieve the pain you feel when urinating. It can cause your urine to turn reddish orange.
• Ibuprofen – Reduces any inflammation in your urinary tract and will help you experience less discomfort and reduce your urge to pee frequently.

Avoiding bladder irritants help ease the symptoms of a urinary infection. Bladder irritants include coffee, tea, juice, carbonated beverages, alcohol, artificial sweeteners, artificial dyes, spicy foods, to name a few.

Why did my urinary tract infection symptoms return after completing a course of antibiotics?

This is often a common concern of patients who is referred to a urologist for history of urinary tract infections. The answers lie within the fact that many other conditions mimic the symptoms of a urinary infection but are not actual infections, including:

• Overactive bladder – Pelvic floor dysfunction or consumption of bladder irritants can lead to bladder contractions which a person can feel as an increased urge to urinate despite recently visiting the bathroom. An overactive bladder is often uncontrollable and sometimes associated with leakage of urine.
• Genitourinary syndrome of menopause – After menopause, about half of all women experience genital, sexual and urinary symptoms associated with decreased estrogen, called genitourinary syndrome of menopause. This condition impacts greater than 50% of post-menopausal women.
• Interstitial cystitis – Pain experienced when the bladder fills up, leading to bladder pressure and increased pelvic pain.
• Vaginitis – Pain or burning of the vulva or vagina.
• Passing kidney stones – As kidney stones migrate they can sometimes be associated with the an urgency to urinate. Kidney stones may also be associated with back pain, blood in urine, nausea and or vomiting.
• Bladder cancer – A history of smoking increases the risk of developing bladder cancer, which can present as blood in the urine without a urinary tract infection.

Is there any risk of taking antibiotics for urinary tract infections?

Taking antibiotics when we need them is necessary to combat infection, however, when multiple rounds of antibiotics are received, it can increase the risk of yeast infections, a serious diarrhea infection (also known as C. diff infection), and it can cause multi-drug resistant organisms, making future infections less susceptible to antibiotics by mouth and require the use of a special IV to administer antibiotics. While it is reasonable to consider a low-dose antibiotic to prevent urinary tract infections, it is not often the first line to preventing urinary tract infections, as there are more effective options to consider first with fewer side effects associated.

How can I prevent urinary tract infections?

Recurrent urinary tract infection is defined as two in the last six months or at least three over the previous 12 months.

While there are many supplements on the market with varying success rates, there is much scientific evidence supporting topical (not by mouth) estrogen cream. Estrogens increase blood flow and restore lubrication and elasticity to the vagina and urethra. Estrogen cream supports the restoration of good bacteria (lactobacilli) to the vaginal flora (the vaginal microbiome is the microorganisms in the vagina), which can guard against infection. The benefits of topical estrogen cream replacement include the following:

• Decreased urinary tract infections
• Decreased dryness and soreness in the vagina by restoring lubrication making sexual intercourse more enjoyable
• Reduced urinary urgency

Is estrogen cream safe?

The concentration of estrogen cream prescribed is less than 0.01%. It works locally, and studies have shown there is no high risk of cancer, and studies show that patients with a personal history of uterine, ovarian or breast cancer can safely use estrogen cream. I always encourage my patients with cancer history to reach out to their oncologist before starting estrogen cream therapy if there is any concern.

In conclusion, obtaining a urine culture is important to ensure patients are diagnosed and treated correctly. If the urine culture is negative, other causes should be investigated to prevent a delay in diagnosing the underlying problem.