Recurrent UTI: causes, treatment and prevention

A urinary tract infection (UTI) is an infection of part of the urinary system. The NHS says UTIs include cystitis (bladder infection), urethritis (infection of the urethra) and kidney infection, and that they are usually caused by bacteria from poo entering the urinary tract through the urethra. Most are short-lived and settle with treatment.

NICE defines recurrent UTI in adults as 2 or more UTIs in the last 6 months or 3 or more in the last 12 months, and the NHS gives the same figures as the point at which you should see a GP. NICE adds that recurrent UTI may be a relapse, caused by the same strain of bacteria, or a reinfection with a different strain or species, which matters when urine culture results are reviewed.

The practical points are straightforward. NICE sets out a stepwise approach that combines self-care with preventive treatment, and a persistent pattern deserves a proper review rather than another short course of antibiotics each time.

For an individual attack, the NHS says a GP may do a urine test (though this is not always needed), offer self-care advice and a painkiller, prescribe a short course of antibiotics, or ask you to wait 48 hours in case symptoms go away on their own. The NHS advises taking paracetamol up to 4 times a day for pain and a high temperature, resting, drinking enough fluids to pass pale urine regularly, and avoiding drinks that may irritate the bladder, such as fruit juices, coffee and alcohol. Finish any prescribed antibiotic even if you feel better.

The NHS says that if your UTI comes back after treatment, or you have 2 UTIs in 6 months or 3 in 12 months, you need to see a GP. They may prescribe a different antibiotic, or a low-dose antibiotic to take for up to 6 months, or vaginal oestrogen (cream, gel, tablet, pessary or ring) if you are in perimenopause or have gone through the menopause. They may also prescribe tablets that treat the infection and stop it coming back, or refer you to a specialist for further tests and treatments.

NICE guideline NG112 sets out a stepwise approach. The first step is behavioural and personal hygiene advice. After that the options depend on the person and the pattern, as the table shows.

The NHS lists things that increase the risk of bacteria entering the bladder: pregnancy, wiping from back to front, conditions that block the urinary tract such as kidney stones, conditions that make it difficult to empty the bladder fully such as an enlarged prostate or constipation, urinary catheters, a weakened immune system, having been through the menopause, using spermicide with contraception and not drinking enough fluids.

NICE Clinical Knowledge Summaries add detail on risk factors for recurrent UTI. In younger, pre-menopausal women these include sexual intercourse, spermicides, a new sexual partner, a history of childhood UTI and a maternal family history of UTI. In post-menopausal and older women they include a history of UTI before the menopause, urinary incontinence, urogenital atrophy, cystocele, increased post-void urine volume, catheterisation and reduced functional status in long-term care. Pre-existing urological conditions such as vesicoureteral reflux, kidney stones, other obstruction and poorly controlled diabetes are listed as risk factors for complicated UTI.

The NHS lists pregnancy as a risk factor for bacteria getting into the bladder, and says anyone who is pregnant and thinks they have a UTI should ask for an urgent GP appointment or get help from NHS 111. Pregnant women are also outside the group that can see a pharmacist for a suspected UTI, which the NHS limits to non-pregnant women and girls aged 16 to 64.

NICE Clinical Knowledge Summaries say a pregnant woman with a suspected UTI should have a mid-stream urine sample sent for culture before antibiotics are started, and that urgent hospital admission is needed if there are severe symptoms suggesting a serious complication such as pyelonephritis or sepsis. A recurrent UTI diagnosed during pregnancy should be referred to an obstetrician for investigation and follow-up. The same guidance advises against recommending over-the-counter cranberry products or urine-alkalinising agents in pregnancy, and the NHS says to speak to your doctor before taking D-mannose or cranberry products while pregnant.

Antibiotic choice in pregnancy is based on urine culture results and what is safe at that stage. NICE CKS say nitrofurantoin is avoided in the third trimester, so the choice may change as pregnancy progresses. NICE NG112 says that during pregnancy, once any current UTI has been treated, a trial of daily antibiotic prophylaxis can be considered if hygiene measures alone are not effective or not appropriate, with specialist advice, and that specialist advice should be sought before using methenamine hippurate in pregnancy.

The NHS lists the symptoms of a UTI. They are the same in a first infection and a recurrence.

• Pain or a burning sensation when peeing.

• Needing to pee more often than usual, including at night.

• Needing to pee suddenly or more urgently.

• Pee that looks cloudy, or blood in your pee.

• Lower tummy pain, or pain in your back just under the ribs.

• A high temperature, feeling hot, cold or shivery, or a very low temperature below 36C.

• Feeling tired or weak.

The NHS says women and girls aged 16 to 64 who are not pregnant or breastfeeding can see a pharmacist for a suspected UTI. It says to ask for an urgent GP appointment or get help from NHS 111 if you keep getting UTIs (2 within 6 months or 3 within 12 months), if you are a man, are pregnant, use a catheter, have diabetes, have a weakened immune system, are aged 65 or older, have blood in your pee or pain in the lower tummy or back, or if symptoms get worse quickly or do not improve within 48 hours.

It also says to call 999 or go to A&E if you or your child are confused, drowsy or have difficulty speaking, because a UTI that spreads to the kidneys can be serious and may cause sepsis.

NICE CKS advise that assessment should include onset, severity and pattern of symptoms, sexual history, risk factors for recurrent or complicated UTI, family history, the possibility of pregnancy and lifestyle factors. A urine dipstick and/or urine culture with susceptibility testing may be arranged, which matters in recurrent infection because previous culture results and antibiotic use guide the choice of treatment.

The NHS notes that chronic, or long-term, UTIs can be difficult to diagnose because urine tests do not always pick up the infection and symptoms can be similar to other conditions. If you have been treated but still have symptoms, it advises speaking to your GP and asking to be referred to a specialist.

NICE says to refer or seek specialist advice for men aged 16 and over, people with recurrent upper UTI, people with recurrent lower UTI when the underlying cause is unknown, pregnant women, children and young people under 16, people with suspected cancer and anyone who has had surgery that altered the urethra. NICE CKS also advise specialist referral for recurrent or persistent unexplained UTI.

The NHS lists a range of things you can try: wipe from front to back, keep the genital area clean and dry, drink plenty of fluids so you pee regularly and do not feel thirsty, wash the skin around the vagina with water before and after sex, pee as soon as possible after sex, wear cotton underwear and promptly change soiled nappies or pads. Things to avoid include scented soap around the genital area, holding pee in, rushing when peeing and spermicidal lubricants, condoms, diaphragms or caps.

On supplements, the NHS says there is some evidence it may be helpful to take D-mannose or cranberry products every day if you keep getting a bladder infection, but they can contain a lot of sugar, should be discussed with a doctor in pregnancy and cranberry should be avoided with warfarin. NICE describes the evidence for cranberry as uncertain, notes that D-mannose is a sugar, not a medicine, and says evidence is inconclusive on whether probiotics reduce the risk.

For many people, a combination of self-care and one preventive treatment brings the frequency down markedly, and some find that infections cluster around specific triggers such as sex or dehydration. NICE notes that some people can identify triggers that often bring on a UTI, and that these differ from person to person, so a diary of what preceded each episode can help the review.

The NHS says chronic UTIs can have a big impact on quality of life. It is reasonable to say so to your GP, ask what has been ruled out and ask when a specialist review would be appropriate. NICE advises that people on preventive antibiotics be reviewed regularly and that they know to seek medical help for symptoms of an acute UTI.

On the NHS the route normally starts with a pharmacist or GP, urine testing and preventive measures, then referral to urology or urogynaecology if the cause is unclear or infections continue. Some people choose a private urologist or gynaecologist for quicker access to cystoscopy or imaging. The tests and treatments are broadly the same; what differs is waiting time, the choice of clinician and who coordinates follow-up. Whichever route you use, keep a copy of your urine culture results, as they guide antibiotic choice later.