Recurrent UTI in women - a "pee-rsistently" difficult problem to treat?

Recurrent urinary tract infections (UTIs) in women are a common and a significant medical concern that can impact quality of life.

Women with recurrent urinary tract infections (UTI) are defined as having experience two or more UTIs within six months, or three or more UTIs within a year.

Recurrent UTIs often stem from harmful bacteria invading the urinary tract. Contributing factors include women having a short urethra, experiencing hormonal changes from menopause, engaging in sexual activity, and having underlying health conditions like diabetes.

Common symptoms include: 

• Burning pain while passing urine (dysuria), 

• Urinary frequency and 

• Urgency 

Red flags requiring more in-depth workup include:

• Visible blood in the urine, 

• Unexplained weight loss, etc

Managing recurrent UTIs involves a multifaceted approach. This includes:

• Practising proper hygiene, 

• Staying hydrated, 

• Urinating after sex, and 

• Avoiding irritants like douches or strong soaps

For some, a long course of prophylactic low dose antibiotics, or a single dose of antibiotic after intercourse may be prescribed.  

Postmenopausal women may also benefit from topical estrogens to the vagina. 

Taking supplements such as cranberry tablets, probiotics and/or D mannose (non diabetic) can also offer preventive benefits.

If you have been troubled by recurrent UTI, don't put up with it any more! Get proper advice by sending your question to our specialist in this limited-time forum. Ask now! 

About Dr Neo Shu Hui

Dr Neo Shu Hui is a consultant at the Department of Urology of Sengkang General Hospital (SKH). She has a continued interest in post graduate medical education as well as a special interest in the subspecialty of female, functional and reconstructive urology.

Questions and answers on recurrent urinary tract infections

1. Question by Rina

Hi doctor,

I am 71 years old.

The problem that has worried me for many years is my urinary frequency especially in night time, almost every 1-1/2 to 2 hours, I have to wake up to pass the urine.

I have gone to a hospital for consultation 2 years ago and got medicine for treatment, but no improvement at all. Then they said have to refer me to 内科医生, but I didn't go anymore.

Sorry my English is not good, hope you can understand and advise what I should do next. Thank you.

Answer by Dr Neo Shu Hui

Dear Rina, 

Thank you for your question. I perfectly understood your English. 

Urinary frequency at night is called nocturia. 

There may or may not be accompanying similar symptoms of urinary frequency and urgency in the daytime. Nocturia alone without pain during urination and without any daytime urinary symptoms does not indicate a urinary tract infection. 

Nocturia has many causes – including excessive fluid intake in the evening before bedtime, diuretic beverages in the evening (e.g., Coffee, tea, alcohol), certain medications (e.g. Furosemide), obstructive sleep apnoea, and any condition that causes leg swelling (e.g. Varicose veins, heart failure, poor liver function etc.).  Sometimes nocturia may be idiopathic as well. 

The treatment for your nocturia will depend on the underlying cause.  However, what you can do is to limit your fluid intake 3 hours before bedtime and during the night. Diuretic beverages like coffee, tea and alcohol should be avoided at least 6 hours before bedtime. You can also try to empty your bladder before sleeping.

2. Question by Xiuqi

Hi Dr Neo

My questions are as follows:

• Is it necessary for young girls to wipe the virginal area after peeing to prevent UTI?

• The over-the-counter medication to treat UTI is safe to consume and effective?

Thank you for your advice.

Answer by Dr Neo Shu Hui

Dear Xiuqi, thank you for your question. 

It is good to maintain hygiene in the vaginal area and wipe from front to back after urination and passing motion. Children with fever and UTI should undergo thorough medical evaluation for underlying medical conditions. 

Over the counter medication such as cranberry and probiotic supplements (for recurrent UTI) are usually safe to consume and can reduce UTIs. However, some people may experience certain side effects such as gastritis, diarrhoea etc. These effects are usually mild. 

Sexually active women may experience UTIs after sexual intercourse (not sexually transmitted diseases like herpes etc). Prevent UTIs by urinating after sex and avoiding spermicides. Cranberry and probiotics can also help. Some ladies may require a single dose of antibiotics after sex.

3. Question by Vicky

Hi Dr

I often got UTI v frequently. I am 65. One factor I notice is lack of water I think. I take calcium tablets twice a day, vit D, cholesterol med n anxiety med lapraxo 1/2 tablet on Mon , Wed and Fri. Wonder do these med cause heatiness? I often constipate hv to eat lots of fruits.

Or is UTI due to poor hygiene which I don’t think so or outside toilet? Appreciate your reply.

Answer by Dr Neo Shu Hui

Dear Vicky,

Many thanks for your question. Indeed, lack of fluid intake is a risk factor for getting recurrent UTIs. We generally advise at least 1.5L water intake to reduce the likelihood of getting UTIs, if there is no other medical contraindication (like heart failure etc). Getting adequate fluid intake will also help with your constipation.

UTI in your age group can be from many factors, including from preexisting medical issues like diabetes, an inability to empty the bladder well during urination etc. Maintaining good hygiene at the vaginal area will also help.  However, do not use harsh soaps or douch your vagina.

4. Question by Vince

Hi Dr,

From my 4 years getting UTI and being hospitalised a number of times, due to SpinalAVM Bladder & Bowels issue, I have settled using alcohol swaps, 10’ Catheter, Aqua Gel and Wipes. To date this has helped me greatly and also very affordable in the long run.

Just wondering why SingHealth only taught us to use pink alcohol, lignocaine, cotton balls, catheters and swipes which is so costly and at 59 I had to struggle for more than a year post discharge from the conveyor belt since 2/2023?

It would have helped SpinalAVM survivors like us who have to deal with so many crippling factors?

We don’t even have a support group in Singapore for SpinalAVM so I had to cultivate my own to survive. Thank you!

Answer by Dr Neo Shu Hui

Dear Vince, 

Thank you for sharing your experience. An AVM is an arterio-venous malformation, which is an abnormal formation of blood vessels. With a spinal AVM, the nerve supply to the bladder can be affected, leading to poor bladder function. The bladder may not be able to empty well on its own and hence you will need to drain the urine yourself with a tube or catheter. Urinary tract infections are more common because of poorer drainage by the bladder.

Drainage of urine with a catheter must be done in an aseptic manner. Chlorhexidine wash is gentle on the skin and less stinging than alcohol (especially if the alcohol has not evaporated fully). The catheter also should be well lubricated for comfort during insertion of the tube.

There are many products in the market that can help you achieve clean and comfortable urinary catheterisation. These include shorter catheters (for females), lignocaine gel for lubrication (has numbing qualities), and once-use disposable, pre-lubricated urinary catheters (more convenient but more costly).

Also, I want to thank you for taking the initiative to start an AVM support group to help those facing the same challenges and struggles.

5. Question by Serena

Dear Dr Neo

Thanks for taking time to read and answer my question.

I experienced UTI a few times in the past and definitely do not wish to experience it again.

I've started taking cranberry supplements and I was recommended cranberry with d-mannose which I've been taking for the past year. It seems to work to prevent UTI.

I would like to know:

a) Can I continue to take cranberry with d-mannose supplement daily indefinitely? Or should I switch to cranberry supplements? Or are there other types I should take?

b) what's the best dosage to take?

I'm 55 years old. It's confusing as the articles I read all recommend different dosages. Thank you for your advice.

Answer by Dr Neo Shu Hui

Dear Serena, thank you for your question.

Cranberry with d-mannose is a 2 in 1 supplement.  D-mannose supplements are not suitable for diabetic patients as D-mannose is a sugar. Cranberry contains proanthrocyanidins that prevent bacteria from sticking to the lining of the urinary tract.

There are no absolute guidelines on the best dosage of cranberry. The American Association of Family physicians recommends a dose of at least 300-400mg cranberry twice/day.

6. Question by Helena

Dear Dr,

I am 80 years old and on diapers.  Am prone to UTI.  Any advice on how to prevent? Thank you.

Answer by Dr Neo Shu Hui

Dear Helena, 

I am sorry to hear that you have frequent UTIs. General advice to prevent UTIs include:

1. Frequent changes of diapers to keep the area dry and clean

2. Clean the genital area thoroughly but gently when changing diapers.  Wipe from front to back. Use mild unscented soaps and water and ensure the area is dry before putting on a new diaper. Avoid scented products or harsh chemicals.  Avoid douching.

3. Stay well hydrated (if not limited by any health condition) and avoid holding urine for extending periods of time >3-4H. 

4. Cranberry tablets and probiotics can be useful.   

5. Maintain good diabetic control if you have diabetes.

6. Discuss with your doctor if topical estrogen therapy or a long course of continuous low dose antibiotics may be beneficial for you.

7. Question by Lourdes

Hello Dr. Neo Shu Hui,

I have recurrent UTIs from my kidney stones embedded in my kidneys; after taking antibiotics a month or so, the infection will come back because of the stones.

I do not have any symptoms of UTIs. I understand that there are two different schools of treatments; one to take antibiotics once discovered infection.

The problem is the antibiotics will not work after some time and there won’t be a lot of antibiotics I can take. The other school will not treat me with antibiotic even with infections until I have symptoms. 

What worries me is will infection in my body not treated affect my health? What bacteria counts that I reached that I have to take antibiotic even without symptoms? Thank you for your advice.

Answer by Dr Neo Shu Hui

Dear Lourdes,

Stones can form in infected urine, and they can also harbour bacteria and are associated with UTIs. Kidney stones also can predispose to infections of the kidneys (pyelonephritis) if they obstruct urine flow from the kidney to the bladder.

Presence of bacteria in the urine without symptoms (asymptomatic bacteriuria) is not routinely treated as this can give rise to antibiotic resistance. There is no universal threshold of bacterial counts that warrants treatment of asymptomatic bacteriuria. Only pregnant women require treatment of asymptomatic bacteriuria. 

Preventive strategies for recurrent UTI associated with stones will include:

1. Treat and remove the urinary tract stones as much as possible.

2. Maintaining good fluid intake and following a diet that minimizes formation of stones (e.g., Low purine, low oxalate, low salt diet)

3. Cranberry tablets/probiotics/topical estrogen (for postmenopausal group)

4. Discuss with your doctor if low dose prophylactic antibiotics may be suitable for you.

5. Ensure you are able to empty your bladder well

8. Question by Serene

Hi Doctor,

I would like to find out if UTIs can go away by itself or only antibiotics can get rid of it? For example, if I experience mild symptoms like having the urge to pee more frequently and slight discomfort, but no burning feeling yet, will the UTI go away gradually if I drink more water or take cranberry supplement? Thank you.

Answer by Dr Neo Shu Hui

Dear Serene,

Mild UTIs can sometimes resolve on their own with increased water intake, urine alkalinizers (e.g., Citravescent) and possibly cranberry supplements. However, there's a risk that untreated UTIs can worsen. If your symptoms worsen or persist, do seek medical advice.

9. Question by Sukhdip

Hi Dr,

I am 65 yrs of age and have the issue of recurring UTI. I am allergic to a number of antibiotics and also sulphur drugs.

In order to prevent UTI I have been taking Hiprex which I purchase from Australia and so far for the past 2 mths or so I have no incident of UTI.

Wanted to know any side effects and is it ok to be on this (Hiprex) for a long period of time. Thank you for your advice.

Answer by Dr Neo Shu Hui

Dear Sukhdip,

Hiprex is methenamine Hippurate. It works by being converted in the urine to formaldehyde, which has antibacterial properties.

Some side effects of Hiprex are gastrointestinal issues like nausea, vomiting, diarrhoea and stomach upset. Bladder irritation, painful urination and blood in the urine may occur. Allergic reactions, skin rashes may also occur. Rarer side effects include anterior uveitis and liver dysfunction.  If used in the long term, it is good to monitor your kidney and liver functions regularly.

10. Question by Mdm Eunice

Dear Dr Neo,

I am 80+ years old now. These recent 2 years, I used to get UTI two to three times within a year.

I had burning pain while passing urine. I was given antibiotic by the doctor. What is the main reason why I get this infection?

I take 2 small cups of coffee and 1000 ml of water a day. Thank you for your advice.

Answer by Dr Neo Shu Hui

Dear Eunice,

Thank you for your question.

Recurrent UTIs in older adults can be due to weakened immune function (e.g. Diabetes, steroid usage, chemotherapy etc), incomplete bladder emptying (e.g.  Neurogenic bladder, dysfunctional voiding, prolapse of the bladder etc), or menopause giving rise to lack of estrogen in the vagina. Some elderly also require urinary catheters, which also are a risk factor for UTIs. 

To prevent UTIs, stay hydrated, practice good hygiene, avoid holding urine, and ensure complete bladder emptying. Cranberry supplements may help, and regular check-ups with healthcare providers are essential for managing underlying conditions and monitoring for infections. Proper catheter use and maintenance are also crucial. Discuss your situation with your doctor for a personalised prevention plan.

11. Question by Marilyn

Dear Dr Neo,

I'm having this recurrent UTI rather frequently. 

Every time when I have this UTI, I'll take this URAL Effervescent Granules sachets and sometimes it can last for more than a week.

Please advise and I'm 60. Thank you.

Answer by Dr Neo Shu Hui

Dear Marilyn,

Recurrent UTIs can be frustrating and challenging to manage. Ural effervescent granules can help alleviate symptoms by making the urine less acidic, but they do not treat the underlying infection (if any).

You may want to visit a doctor to test your urine with a urine culture to see if this is a true urinary tract infection that needs to be treated with antibiotics.

12. Question by Piu Man

Dear Dr Neo Shu Hui,

I am already menopause for few years and have recurring UTI these 2 years.  I take probiotics and Cranberry. How may I consult a urology specialist? Thank you.

Answer by Dr Neo Shu Hui

Dear Piu Man,

Consulting a urology specialist can provide targeted care for your recurrent UTIs. Since you have undergone menopause, you may benefit from topical estrogens to the vagina/urethra to reduce recurrent UTIs (if you have no medical contraindication to estrogens).

You can start by consulting your primary care physician – he or she can evaluate your condition, perform initial tests and provide a referral to a urologist.  Alternatively, online directories or your insurance panel may also have a list of urologists in the private sector that you can contact directly.

It will be helpful to your urologist if you can keep a diary of your symptoms – including the symptoms, severity, frequency and any potential triggers. Take note of how long each UTI lasts and what treatments or over the counter supplements and medications you have tried. You should also bring along the results of previous urine tests (eg. urine cultures) and relevant investigations to the visit.

13. Question by Doris

Hi Dr Neo,

Is protein in urine a serious problem? What must I do to prevent this? Each time I go for my 6-monthly fasting test, I will get this problem, though about 3.9 to 4.6 mg/mmol. (I don’t understand). Will I end up with kidney failure later on or reverse if I’m able to keep it under control?

Please enlighten me on this. Thank you.

Answer by Dr Neo Shu Hui

Dear Doris,

Protein leakage in the urine can be a sign of kidney or other health problems.

Transient causes of protein leakage include fever, UTIs, strenuous exercise etc and generally improve subsequently.

On the other hand, persistent proteinuria can be secondary to chronic diseases like diabetes or high blood pressure leading to protein leaking from the kidneys into the urine.  

Persistent proteinuria can be an early sign of kidney damage. Over time, it can lead to chronic kidney disease. 

It is essential to work closely with your healthcare provider to identify the cause of proteinuria and develop an appropriate management plan. Early intervention and consistent care can significantly improve your prognosis and reduce the risk of kidney failure.

14. Question by Schmitt

Hi Dr,

Why do I get UTI yearly at least twice. Also, my last two occasion I have blood and small clots being passed out. Any reason for concern? Thank you.

Answer by Dr Neo Shu Hui

Dear Schmitt,

While severe UTIs can result in blood in the urine, it would be good for you to visit a urologist to ensure that you have no other serious underlying health concern that is causing blood in your urine. You will require further evaluation to rule out urinary tract stones and growths.

15. Question by Nanda

Hi Dr Neo, 

I have recurrent uti and had done all necessary check up for it. The check-up result is okay. Daily, I took Probiotic, d-mannose & cranberry to prevent it from coming back. But I will still get uti.

May I know what else I can do to prevent it from coming back? Thank you.

Answer by Dr Neo Shu Hui

Dear Nanda,

Managing recurrent UTIs can be challenging, especially when you are already taking preventive measures like probiotics, D-mannose, and cranberry supplements. Here are some additional strategies that might help prevent UTIs:

1. Keep well hydrated and pass urine regularly

2. Maintain good hygiene, wipe from front to back after passing urine

3. If your UTI occurs after sexual intercourse, avoid spermicides and pass urine after sex.  You might benefit from a single dose of antibiotics post sex to prevent UTI.

4. A long course (eg. 6 months – 1 year) of low dose antibiotics might also help to reduce UTIs.

5. If you are in the menopause age group, you may also benefit from topical estrogens to your vagina/urethra area.

6. Methenamine Hippurate (Hiprex) may also reduce rates of recurrent UTI.

7. Lastly, oral and sublingual UTI vaccines are available which can reduce the rates of UTI.  However, they are not HSA approved at this point in time of writing.

Ref: H24