Article Quick Links
- Chronic bladder infection – how a UTI can escalate quickly. >>>>
- Short courses of antibiotics could be making things worse. >>>>
- The pros and cons of prophylactic or preventative antibiotics for recurrent UTIs. >>>>
- Can I get better recurrent UTI treatment? >>>>
- Chronic urinary tract infection treatment specialists. >>>>
- Where do UTI home remedies fit in? >>>>
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 if it was your first UTI.
A common scenario, described by many females who experience recurrent UTI, and supported by various guidelines, looks like this:
A UTI will be diagnosed according to your symptoms and/or a dipstick strip test
You will be prescribed a UTI antibiotic
Possible Step Three
You may be asked to provide a urine sample for lab testing
Possible Step 4
Based on lab test results, you may be prescribed a different antibiotic after 2-3 days
|“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.
Short courses of antibiotics are not designed for recurrent UTI treatment. Particularly not those recurrent UTIs that are caused by an underlying, chronic bladder infection that has been around for months or even years.
Let’s take a quick look at why recurrent UTIs caused by a chronic bladder infection can be so hard to treat. We’ve also covered this in more detail here.
Chronic Bladder Infection: An Elusive Enemy
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.”|
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.
|“Most UTI guidelines are aimed at management of simple uncomplicated UTI. It can be very difficult to successfully manage complex or recurrent UTI in primary care. If symptoms persist, or where there is diagnostic uncertainty GP’s will need to make a referral for specialist assessment."|
You may be one of the many females who have had their urine tested numerous times, only to receive negative results, despite ongoing symptoms.
Laboratories that test urine samples use a set of guidelines that focuses on culturing and testing free-floating bacteria. When one or more types of bacteria are identified, a susceptibility test is conducted to find the most effective antibiotic for those specific bacteria.
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. On top of that, they can be 1000 times more resistant to antibiotics than free-floating bacteria.
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. And it’s nowhere near safe to apply 1000 times the dose of antibiotics.
As much 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.
Let’s get to the bottom of your options for recurrent UTI treatment.
Short Course Antibiotics For UTI Treatment
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 reasons…
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 bacteria causing YOUR UTI.
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, which on one hand is a global issue, and on the other, could be much more personal – it could be strengthening the antibiotic resistance of the bacteria behind your UTI, making it even harder to treat.
Prophylactic Antibiotics For Recurrent UTI Treatment
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 decrease their 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.
There are two main approaches to prophylactic antibiotics for recurrent UTI treatment:
- Postcoital prophylaxis – in sexually active females, a single dose of antibiotic post-sex
- 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.”|
Let’s jump straight into the pros and cons of prophylactic antibiotics for recurrent 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.
Can I Get Better Recurrent UTI Treatment?
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.
Chronic Bladder Infection Caused By Biofilms: What Can You Do?
There are two parts to this problem: Diagnosis and treatment. And they can be equally tricky.
We’ve mentioned in our UTI testing sections that standard UTI testing methods are not up to scratch. That’s putting it lightly. Standard urine culture test methods are inaccurate in up to 50% of cases. And, they are not designed to detect the presence of biofilms.
Because of the way biofilms work, with bacteria contained within a slimy matrix, it is highly possible there will be very few free-floating bacteria in your urine when you collect a sample.
The concentration of bacteria may be so low, that it is not registered as significant during a standard urine culture test. For this reason, some practitioners who specialize in chronic urinary tract conditions, recommend a urine broth culture test, microscopy of a fresh urine sample or testing that uses DNA sequencing.
These alternative urine testing options have provided higher levels of success in identifying a pathogen in cases of chronic bladder infection.
Want more information on better testing options? We have a whole section dedicated to that.
So, say you manage to get accurate testing and your results state that a particular pathogen or pathogens have been found in your urine. What then?
Due to the high levels of antibiotic resistance exhibited by biofilms, researchers are still speculating about the best approach to treatment.
It has been shown that a young biofilm formation can be much more easily treated than a matured structure.
So early and aggressive treatment is preferable, but early diagnosis of a biofilm infection is currently very difficult and those diagnosed with recurrent UTI or Interstitial Cystitis have often had the symptoms for months or years, so the infection is deeply entrenched.
The aim of any UTI treatment for a chronic bladder infection is to eradicate free-floating bacteria as well as eradicating the biofilm.
Several studies recommend combination therapy as the best approach to achieve this, which means treating the infection with more than one type of antibiotic, each with a different killing mechanism. Other practitioners have found more success with a single antibiotic administered at high doses.
A third option that is being trialled is direct irrigation of the bladder with a high concentration of antibiotics. This involves using a syringe to inject antibiotics directly into the bladder, rather than taking the medication by mouth.
Whether single or multiple antibiotics are used, treatment of biofilms within the bladder typically means long-term, higher than normal doses of antibiotics. The long-term duration of the treatment is in part necessary because of the life cycle of bacteria.
Bacteria can live for 6 months or more, protected within their biofilm. Periodically, bacteria may escape from the biofilm and either be flushed from the body, or attach to the bladder wall to form new biofilm communities.
By continuing a regimen of high dose antibiotics over six months or more, there is the possibility that any escaping bacteria will be eradicated before attaching to the bladder wall. And eventually, the life cycle of the already embedded bacteria will also have come to an end.
The best case scenario? A permanent resolution – biofilm 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.”|
It’s essential to have a specialist in chronic urinary tract infections oversee this type of treatment. As we’ve mentioned in our UTI Antibiotics guide, antibiotics can come with serious side effects. Progress needs to be monitored, and follow up testing must be done to gauge the appropriateness of the antibiotic, and the dosage.
It seems now would be a good time to share how various specialists approach UTI treatment for chronic bladder infections.
Chronic Urinary Tract Infection Treatment Specialists
There are very few practitioners who specialize in treatment of chronic urinary tract infections, but those we have come across in our research, we have included below.
We will add further information about other practitioners as we confirm it. Please get in touch if you would like to recommend a practitioner who has helped you!
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).
In our 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.
Kriz may recommend a series of tests to provide a more complete picture of your body’s immune system health and its inflammatory response to infection.
|“In addition, nutritional status, immune function, allergies, adrenal and thyroid function, and gastrointestinal issues are evaluated as needed so that healing can be optimized" |
Kriz has years of experience in successfully treating Interstitial Cystitis and other chronic urinary tract infections with antibiotics and herbal supplements.
If Washington is beyond your reach, it may be possible to organize a phone consultation, or to request Ruth Kriz work directly with your own doctor.
It’s important to bear in mind that most doctors are not trained or experienced in treating chronic UTI, so you should not necessarily expect your own doctor to be able to interpret or act on test results.
It can take several months for the symptoms to resolve and the bladder to heal, so you want to make sure you’re always on the right track. Finding the right practitioner to support you throughout the process is crucial.
Michael Hsieh, MD – Urology, Washington DC, USA
Hsieh has extensive experience in laparoscopic and robotic surgery for urologic conditions, but is also the Stirewalt Scientific Director of the Biomedical Research Institute, where he runs a bladder biology research group and is developing a broader microbiology research program across multiple laboratories.
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.” |
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.” |
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.
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."|
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.”|
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.
Alternative Treatment For Chronic Urinary Tract Infection
While long-term antibiotics is currently the only solution for chronic UTIs, innovative solutions are being developed. We’ll cover these in the near future.
We will also continue to add information about practitioners with a history of successfully treating recurrent UTI, chronic bladder infection and Interstitial Cystitis. If you’d like to recommend a practitioner, please get in touch.
Where Do Natural UTI Remedies Fit In?
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.
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.
Clinical trials for non-antibiotic UTI treatments frequently conclude that urgent attention is needed in this area.
Fortunately, we are starting to see more trials targeting urinary tract conditions, and the hope is that these will change testing, diagnosis and treatment for the better.
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.
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.
It’s important to understand this. 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.
We’ll say the same thing here that we said about antibiotics… The cause of your UTI is unlikely to be the same as the cause of a random online stranger’s UTI.
Don’t cherry pick remedies just because someone online seems to have a similar story to you…
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 Natural UTI Remedies section we’ll take a look at how home remedies stack up against other UTI treatment options.
One vastly overlooked but crucial application of natural UTI remedies is in healing the urinary tract. In conjunction with treatment of an underlying infection, it is so important to support your urinary tract in ways that help it heal after what may have been years of inflammation due to infection.
Until your urinary tract has healed and the inflammation has subsided, it is quite possible to continue to experience symptoms, even after an infection has been cleared. In fact, it can take a year or more for your urinary tract to heal.
The damaged mucosal lining of your bladder must be repaired, or it will continue to be a great environment for bacteria to return and thrive. If your primary UTI treatment is long term antibiotic use, it’s also critical to do what you can to prevent yeast overgrowth.
So next, we’ll take a look at how natural UTI remedies can help put you on the path to a full recovery, during and post-treatment.
Share your questions and comments below, or get in touch with our team.