Recurrent UTI Treatment: Which Approach Is Right For You?

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• Short course antibiotics for UTI treatment. >>>>
• Prophylactic antibiotics for recurrent UTI. >>>>
• Long term antibiotics for UTI. >>>>
• Estrogen for recurrent UTI treatment. >>>>
• UTI home remedies. >>>>
• Recurrent UTI treatment specialists. >>>>

The truth is, there are very few conclusive guidelines for recurrent UTI treatment. If you show up at a clinic with yet another UTI, you will most likely receive a short course of antibiotics – the same treatment you would receive if it was your first UTI.

“My doctor just gives me a prescription for Nitrofurantoin each time. I’ve been using the same antibiotic for years. She used to test my urine with one of those strips, but now she trusts that I know I have a UTI. Sometimes she just calls in my script so I don’t need an appointment.”

This would be all well and good if it cleared up your recurrent UTIs and you didn’t end up back at the doctor or pharmacy for yet another course of antibiotics every few months.

If you take antibiotics each time you get a UTI, but you continue to get UTIs, you should question whether the antibiotic is working at all.

We all know a little something about bacteria. We commonly group bacteria with other pathogens, like viruses, into one big group called germs. And we’re all aware of the role germs play in illness and infections.

You may not know that bacteria can be found as free-floating cells, or clustered together in communities called biofilms. In an uncomplicated urinary tract infection, free-floating bacteria can be detected in the urine with appropriate testing, then treated with the right antibiotic.

Without fast and effective treatment, bacteria in the bladder may attach to the bladder wall and begin to form a biofilm community. Once attached, the bacterial community generates a slimy protective coating that creates a safe environment and shields it from outside influences.

When a biofilm reaches this stage, it is extremely resistant to antibiotics, as well as the body’s natural defence mechanisms. This is where a chronic infection begins. You might refer to it as recurrent UTI or chronic cystitis – the kind of urinary tract infection that just keeps coming back.

“I would have episodes of excruciating pain, blood in my urine and that smell that just tells you that you have a UTI. Then sometimes I would feel practically normal. All the other days in between, I had these niggling symptoms, constantly threatening to blow up at any given moment.”

Can UTI Treatment Succeed If Biofilms Are Involved?

Biofilms that cause chronic urinary tract infections can be difficult to detect and very hard to treat efficiently. Currently, no guidelines exist to help clinicians and microbiologists detect and treat biofilm infections of the urinary bladder.

Free-floating bacteria behave very differently to bacteria within a biofilm. Bacteria growing as biofilms are also much more difficult to identify in a urine sample.

No three or five day course of antibiotics designed to treat free-floating bacteria is even going to make a dent on your average biofilm.

As much as we do know about biofilms, the mechanisms behind this phenomenon are still poorly understood. To add another layer of doom, biofilms can be formed by one or multiple species, in complex structures.

If the right treatment is found for one of the species in a biofilm, as its prominence decreases, a second species may rise to take its place.

This doesn’t necessarily mean treatment is impossible, but it can take a few rounds of different targeted antibiotics to get to the bottom of a multiple-bacteria biofilm. Learn more about chronic UTI here.

As far as recurrent UTI treatment options, it pays to understand the pros and cons. There are a few to delve into:

1. Short course antibiotics
2. Prophylactic antibiotics
3. Long term antibiotics
4. Estrogen therapy
5. UTI home remedies

Let’s take a look at each in more detail.

When prescribed an antibiotic for uncomplicated UTI treatment, the course duration will usually be 3, 5 or 7 days (or longer if a kidney infection is suspected), depending on the antibiotic prescribed. Single dose antibiotics, such as Fosfomycin (Monurol), are also prescribed in some cases.

Common short course antibiotics are listed in our UTI antibiotics section, with their potential side effects. We won’t go into detail here for the following reason…

Short courses of antibiotics are not designed for recurrent UTI treatment. Particularly not those recurrent UTIs that are caused by an underlying bladder infection that has been around for months or even years.

What Is The Best Antibiotic For UTI?

We see hundreds of questions in forums, along the lines of, “Can I use (insert random antibiotic here) for a UTI?”

It is important to understand that there is no such thing as “the best antibiotic for a UTI.”

There IS such a thing as the best antibiotic for the specific type of bacterium (or multiple bacteria) causing YOUR UTI. Antibiotic susceptibility testing can help identify possible treatment options.

And although some types of bacteria are more common than others when it comes to causing UTIs, it’s really important you realize, the cause of YOUR UTI is unlikely to be the same as the cause of a random online stranger’s UTI.

Just because their UTI treatment was successful, it does not mean the same UTI treatment will work for you.

More importantly, there is increasing doubt over whether short course antibiotics provide any benefit at all in cases of recurrent UTI caused by a persistent, embedded bladder infection.

“I always took antibiotics as soon as I felt UTI symptoms. It would pretty much clear up by the next day. Then I got a UTI when I didn’t have my antibiotics with me. I freaked out, but by the next day it had cleared up anyway. Now I have no idea whether the antibiotics even help.”

Temporary flare ups of UTI symptoms caused by a chronic infection may or may not be relieved faster than when non-antibiotic treatments are used. This means, the antibiotics you rely on for UTI treatment every time you get symptoms may not be making any difference whatsoever.

And if the infection is not cleared, a recurrence is almost certain.

Ineffective antibiotic treatment may also contribute to bacterial resistance, making the UTI even harder to treat.

Prophylactic antibiotics for recurrent UTI treatment sounds complicated, but in reality, it just means preventative antibiotic use. That is, you use antibiotics before you feel any UTI symptoms, in the hope of preventing one from happening at all.

We want to state straight up that there is evidence that long-term prophylactic antibiotics for recurrent UTI treatment do not alter the long-term risk of recurrence.

This basically means that patients with recurrent UTIs who take prophylactic antibiotics may experience a decrease in frequency of symptoms during prophylaxis (that is, while they are taking the antibiotics).

But when they stop prophylaxis, their acute episodes return at the same rate as before their UTI treatment started.

Ultimately, long-term prophylactic antibiotics do not appear to alter a patient’s basic susceptibility to infection in most cases.

How Prophylactic Antibiotics Are Taken

There are two main approaches to prophylactic antibiotics for recurrent UTI treatment:

1. Postcoital prophylaxis – in sexually active females, a single dose of antibiotic post-sex
2. Continuous prophylaxis – a long-term low dose of antibiotic, usually a single dose daily

Postcoital prophylaxis appears to have similar effectiveness but fewer side effects than continuous prophylaxis for preventing recurrent UTI. This is mainly because females on postcoital prophylaxis generally take fewer doses of the antibiotic.

A third type of UTI treatment often grouped with prophylactic options is acute self-treatment. This is a “self-start” approach where a patient is provided prescriptions for antibiotics, and can initiate their own standard 3-day course when they feel UTI symptoms coming on.

Acute self-treatment is recommended for ≤2 episodes of UTIs per year or for females who are not suitable candidates for longer term prophylaxis. Continuous or postcoital antibiotic prophylaxis are generally considered suitable for ≥3 episodes of UTIs each year.

Interestingly, studies into prophylactic antibiotics for recurrent UTI treatment have demonstrated that patients are highly accurate in diagnosing their own UTIs. So keep this in mind the next time you receive negative UTI test results – if you think you have a UTI, it’s quite likely you do. The test is probably wrong, not your intuition.

“I had had so many UTIs over the course of 2 years, my doctor decided it was a fairly safe option to prescribe postcoital antibiotics. I took them for a few months, but then I stopped, and the UTIs just came back.”

The Pros And Cons Of Prophylactic Antibiotics For UTI Treatment

PROS	• Studies show, that for the duration of prophylactic antibiotics for UTI treatment, females experience up to a 95% reduction in UTI recurrences. • Our interviewees that rely on prophylactic antibiotics find the anxiety related to a potential recurrence is reduced with the knowledge that it is less likely.
CONS	• Studies show that once prophylactic treatment is ended, females are likely to return to the same rate of UTI recurrence they experienced before they commenced the treatment. • Any type of antibiotic use comes with potential side effects, which include destroying good bacteria in the gut and increasing the risk of yeast infection. • Research has found that prophylactic antibiotics for UTI treatment promote the development of antibiotic-resistant forms of UTI-causing E.coli (uropathogenic E.coli, or UPEC).

This last point is extremely important. Without even knowing it, by taking ineffective antibiotics you could be encouraging a difficult-to-treat embedded infection to form in your urinary tract.

For this reason alone, specialists in the area of chronic urinary tract infections do not recommend the use of low dose antibiotic regimens for UTI treatment.

So while you may find prophylactic antibiotic treatment helpful, there is a good chance your UTIs will return if you cease the treatment, and you may actually be making your condition worse.

Treatment of biofilms or embedded infection within the bladder may take a longer term approach.

We’ve discussed elsewhere on our site the difficulty of treating an infection encased in a biofilm, or within the bladder wall.

Bacteria can live for 6 months or more protected within their biofilm or within the bladder wall. The long-term duration of treatment is in part considered necessary because of this lifecycle.

Periodically, bacteria may escape from a biofilm and either be flushed from the body, or attach to the bladder wall to form new biofilm communities.

The idea behind a constant regimen of high dose antibiotics over six months or more, is that any bacteria that do escape into the urine will hopefully be eradicated before reattaching to the bladder wall.

And eventually, the lifecycle of the already embedded bacteria will also have come to an end.

The best case scenario with long term high dose treatment is that the bacterial community within any biofilm is destroyed.

The main difference between this type of UTI treatment, and the continuous prophylactic antibiotic treatment mentioned above, is the dosage.

Prophylactic doses are low, and are intended to prevent acute episodes. Biofilm treatment doses are high, and are intended to eradicate the infection completely over time.

“For the cases I see, on average it takes a year of antibiotic treatment to resolve their symptoms, but there’s a wide variance. There are some people with infections we can’t get rid of, and we have to control the symptoms.” Professor Malone-Lee, Whittington Hospital, UK

This type of treatment shouldn’t be attempted alone. It’s essential to work with a clinician that can oversee treatment and assess the use of antibiotics. As we all know, antibiotics can come with side effects, and these can be serious.

One protocol for long term antibiotic treatment for chronic UTI has been demonstrated in the UK.

Can estrogen help for recurrent UTI?

We’ve covered this in detail in our content on UTI and Menopause, but for a quick overview…

Post-menopausal females that experience recurrent UTI may be prescribed hormone replacement therapy (HRT). This could be estrogen in a systemic form (a pill taken orally) or topical form (a cream that is applied inside the vagina).

So why estrogen? And why in the vagina?

Science has shown that the vaginal and urinary microbiomes are interconnected, and it would appear that a healthy vaginal environment with a good amount of lactic acid can provide some protection from UTIs.

To maintain this healthy vaginal environment, it’s important that Lactobacilli are abundant. These Lactobacilli multiply when the right source of food is readily available. In this case, that source of food is glycogen that is found on the surface of the vaginal epithelial cells (vaginal lining).

The more glycogen that is available, the more the Lactobacilli eat, and the more they multiply. It is thought that estrogen increases the stores of glycogen.

When females go through menopause, the levels of estrogen are reduced, resulting in diminished glycogen stores, and therefore the Lactobacillus population is also reduced.

Studies have shown that estrogen therapy may help reverse this process and result in a reduced risk of UTI.

Learn more about estrogen treatment for UTI.

While there are many studies aimed at measuring the effectiveness of different antibiotics for UTI treatment, there is very little solid research around non-antibiotic treatment of UTIs. We’ve covered the most searched for UTI home remedies in detail in a separate article.

A number of researchers have questioned whether antibiotics should be the go-to for first-time uncomplicated urinary tract infections, suggesting they may be unnecessary in many cases.

Because diagnosis and treatment guidelines are based on evidence, and because natural remedies are rarely studied, they are not found within therapeutic guidelines, and your doctor is very unlikely to recommend them.

Should You Try UTI Home Remedies?

The only person that can make this decision is you. And before deciding, you should learn what you can about any UTI remedy you’re considering.

An it’s important to understand this:

The absence of evidence around non-antibiotic UTI treatments does not mean they do not work, but it does mean we don’t know if they work.

Just because a number of people agree in a UTI forum that a particular remedy works for them, it does not mean it will work for you, or that it even works at all.

Think about it… If you rely on a specific home remedy every time symptoms of a UTI flare up, yet you continue to get UTIs, you can almost guarantee that remedy is not addressing the underlying problem.

Obviously, this does little to curb the enthusiasm for natural UTI remedies online. There is always plenty of discussion on how to treat your next UTI, but very little around resolving the issue so it never happens again.

It’s essential to separate the myths from fact – there are natural UTI remedies that are looking very promising as future UTI treatment options, but there are other very well publicized natural UTI remedies that have been proven ineffective.

It can be difficult to figure out who to believe. So in our UTI home remedies article we’ve taken a look at how home remedies stack up, including D-mannose and vitamin C.

Finding the proper specialist to treat your UTIs is an important step, as discussed by UK reality TV star Marnie Simpson who has also dealt with a chronic UTI. There are very few practitioners who specialize in the treatment of recurrent urinary tract infections, but we maintain a list by region of those we have come across in our research.

If you would like more information on specialists in your area, it’s best to get in touch with us directly. We can’t guarantee we can help, but feel free to reach out.

And please get in touch if you would like to recommend a practitioner who has helped you!

Below we’ve highlighted just a few specialists that have spent years gaining insight into recurrent UTI in order to help their patients.

Ruth Kriz, Nurse Practitioner, Washington DC, USA

A former IC patient, Ruth Kriz runs a private clinic in Washington, DC, that specializes in the treatment of chronic urinary tract infections (among other conditions).

Ruth Kriz embraces an integrative approach to the problem, taking into account other factors that may be contributing to your body’s inability to clear the chronic infection in your urinary tract. These can include mycotoxins, heavy metals, co-infection, and adrenal and thyroid problems, among others.

“In addition, nutritional status, immune function, allergies, adrenal and thyroid function, and gastrointestinal issues are evaluated as needed so that healing can be optimized." Ruth Kriz, APRN

In our recurrent UTI testing section we highlighted a few alternative urine testing options that may provide more accurate results. Kriz utilizes a number of these, and has an additional global network of specialist testing providers, that enable her to quickly identify potential issues.

“As the body of knowledge expands concerning the connection between chronic infection and biofilms, as well as the availability of advanced testing techniques, it is essential that we, as practitioners, utilize these methods to provide accurate diagnosis and new treatment approaches for patients." Ruth Kriz, APRN

Ruth Kriz has years of experience in successfully treating Interstitial Cystitis and other chronic urinary tract infections with antibiotics and herbal supplements. When it comes to UTI prevention, she looks beyond the urinary tract to potential vaginal infections, and testing sexual partners.

We’ve put together a detailed outline of Ruth Kriz and her approach, to help you decide whether it may be right for you.

As Ruth Kriz is nearing retirement, she is no longer accepting new patients. It may be possible to organize a phone consultation between Ruth and your own doctor.

Michael Hsieh, MD, PhD, is the Director of Transitional Urology at Children’s National Health System and the George Washington University.

Hsieh has extensive experience in laparoscopic and robotic surgery for urologic conditions, but also runs an NIH-funded bladder biology research group.

Throughout his research, Hsieh has studied the naturally occurring microbiome, and how the presence of non-pathogenic bacteria may prevent urinary tract infections. He also headed a research group focussed on bladder inflammation, UTI and bladder cancer.

Most patients that see Hsieh for urinary tract infections have suffered from multiple episodes and are desperate for something that works. His investigative approach has enabled him to assist patients with previously unidentified urinary pathogens.

“I am very careful about labelling patients with IC, I think a lot have occult UTI with difficult to culture organisms. By utilizing more accurate testing methods we are able to identify pathogens in many cases, and develop appropriate treatment.” Michael Hsieh, MD, PhD

Hsieh takes a multi-pronged approach to diagnosing, treating, and preventing UTIs. In order to reach a diagnosis, he supplements conventional urine testing with microbiome-based techniques that are highly sensitive and can detect UTI-causing bacteria that don’t always grow out using conventional urine culture methods.

His UTI prevention recommendations include scientific data-based probiotics, certain cranberry products, antibiotics, and hormonal treatments.

“I believe in personalized medicine for UTI, in the sense that each patient's UTIs are different and each patient is at a different place. Diagnosis, treatment, and prevention should be tailored accordingly, and take into account patient preferences and the pros and cons of various approaches.” Michael Hsieh, MD, PhD

Hsieh currently sees chronic UTI patients at both the Children’s National Health System, and George Washington University locations. Information on how to make an appointment is provided via the above links.

To prepare for an appointment, it’s a good idea to gather any previous test results. This includes urinalysis and urine cultures as well as any microbiome-based test results. If you have had any type of imaging of your urinary tract, it’s best to bring the images as well as the accompanying report.

Learn more about Dr Hsieh’s approach to recurrent UTI treatment.

Professor Malone-Lee, Whittington Hospital, London UK

Professor Malone-Lee is well known in the UK for his work in the treatment of the “UTIs from hell” at the LUTS Clinic at Whittington Hospital, London. Malone-Lee utilizes a testing technique revived from the 1920s – microscopy of a fresh urine sample – to identify pathogens in chronic urinary tract infections.

"We do one test; immediate microscopy of a fresh specimen of urine; counting the white and red blood cells, bladder lining cells, bacteria and fungi. The symptoms and the microscopic data are interpreted...they force consideration of all the data particularly the patient's narrative." Professor Malone-Lee, Whittington Hospital, UK

He has pointed out on a number of occasions that there is no set of guidelines for doctors to follow when patients with urinary tract infections do not respond to standard UTI treatment. Patients at the LUTS Clinic generally describe symptoms, despite consistently negative results from standard urine testing.

“Our biological studies reveal mixed microbial infections hiding inside the cells of the bladder. Located there, the microbes seem quiescent but cause low-grade inflammation that may cause various bladder symptoms...Cloistered, inside cells bacteria escape antibiotic and immune attack.” Professor Malone-Lee, Whittington Hospital, UK

By developing new approaches to treatment, the LUTS Clinic has successfully treated thousands of patients from all over the world. Patients of the clinic are typically kept on antibiotic treatment for 6-12 months before their symptoms are resolved.

Malone-Lee’s regime consists of bespoke long-term, first generation, narrow-spectrum antibiotics and is successful in the majority of cases.

This treatment protocol works on the basis that maintaining a constant level of antibiotics in the bladder kills-off infections in bladder lining cells as they shed naturally into the urine, and prevents new bladder lining cells from being invaded by bacteria.

Malone-Lee has identified cases that have thus far been impossible to treat. In these cases treatment is focussed on controlling the symptoms and providing the patient with a significantly enhanced quality of life.

The LUTS Clinic currently accepts private patients only, including international patients.

The Steps To Overcoming Recurrent UTI

For those of us who experience persistent UTI, the treatment options can seem pretty grim.

We’ve covered short course antibiotics, which are unlikely to resolve recurrent UTIs caused by a chronic bladder infection and may not even help with symptoms.

Then there’s prophylactic antibiotics for UTI treatment, which can reduce episodes of recurrence while you’re on it, but once you stop, you could be right back where you started, or in an even worse position.

Not to mention the havoc frequent or long-term antibiotics can wreak throughout your body.

So what are the options here? We’d love to say we can point you in the right direction for a guaranteed cure, but, as we’re sure you’ve guessed, it’s not that simple.

UTI Treatment: Steps To Success

There are multiple parts to this problem. First, learn everything you can about recurrent and chronic UTI.

Then, the success of your journey will depend on four things:

1. Collecting a high quality urine sample
2. Pursuing more accurate UTI testing
3. Working with a specialist that understands recurrent UTI and can help with 1 and 2
4. Having the perseverance to find another doctor if step 3 doesn’t work out

Share your questions and comments below, or get in touch with our team.