About 50% of women and 14% of men will experience a urinary tract infection (UTI) at some point in their life.1

UTI’s are considered “recurrent” if someone has:

• At least TWO UTI’s within a 6 month period; OR
• At least THREE UTI’s within a 12 month period. 2

If a catheterised person has bacteria in their urine but is asymptomatic, that would NOT be considered a UTI and would only be treated in very specific circumstances.2

The people at highest risk of recurrent UTI’s are: (1, 3, 4)

• Women – particularly women over the age of 55 years;
• Pre-menopausal women who have sexual intercourse more than 9 times per month or who use spermicide, diaphragms or have a high number of sexual partners;
• Pregnant women;
• People who are catheterised;
• People who are incontinent;
• People with diabetes;
• People with spinal cord injuries (with and without a catheter);
• People with multiple sclerosis.

NICE recommends prophylactic antibiotics (e.g. trimethoprim or nitrofurantoin) to manage recurrent UTI’s, when behavioural and personal hygiene measures and vaginal oestrogen have not been effective.5  However, sometimes clients and GP’s want to try a different approach, if for example antibiotics are not sufficient to solve the problem and/or there is concern about antibiotic resistance or side effects.

What options do non-pregnant, adult clients have for the self-management of recurrent UTI’s?

All clients should speak to their GP, urologist or ob-gyn regarding medical and self-care options for managing recurrent UTI’s.   

1. Drink more fluid. (2, 6)

In spite of high fluid intake being widely promoted as a strategy to prevent UTI’s, there is very little research supporting this.  Of the research that is available, consuming over 1.5 litres of fluid per day is what is recommended.

2. Monitor and maintain healthy blood glucose levels. (7)

UTI’s are more common in people with diabetes, partly due to higher concentrations of glucose in the urine, but also due to these individuals often having a reduced immune system.  Sometimes people with diabetes also have neuropathy (nerve damage) and this can affect the bladder and cause issues with urine retention and dysfunctional voiding.  These problems further increase the risk of UTI’s.  Not everyone who has diabetes is aware that they have it and not everyone with diabetes maintains good control of their blood glucose levels.  For these reasons, clients with recurrent UTI’s should ALWAYS have their HbA1c checked (to rule this out as a contributing factor).  For people with known diabetes, the better they manage their blood glucose levels, the lower their risk of UTI’s.

It’s worth noting that while high blood glucose levels can increase the risk of UTIs, the reverse is also true and having a UTI can actually increase someone’s blood glucose levels.  Clients who are consuming high amounts of cranberry juice trying to prevent a UTI (see below), may also be inadvertently increasing their blood glucose levels.

3. Ask the GP about vaginal oestrogen for post-menopausal women (creams, tablets or rings). (5, 8)

Low oestrogen levels (due to menopause) cause the muscles of the urethra to weaken and makes it easier for bacteria to enter the urethra and move up into the bladder causing a UTI.  Low oestrogen levels can also reduce the level of “good” bacteria in the bladder and make the tissue in the urethra (and vagina) thinner, drier and more irritated.  All of these factors increase the risk of UTI’s.

Vaginal oestrogen has been found to reduce the risk of UTI’s by more than 75% after 6-12 weeks of treatment.

4. Consider cranberry products (2, 4, 5, 9, 10)

**People taking warfarin should NOT use cranberry products.** 

While there is evidence that cranberry products can help reduce UTI’s in certain populations, the optimal dose, duration and type of cranberry product to use (e.g. juice, capsules, tablets), has yet to be determined. According to the 2023 Cochrane review “Cranberries for preventing urinary tract infections,” proanthocyanidins (PAC) are the active ingredient that inhibits E. coli from adhering to the lining of the bladder.  However, given that there are varying levels of PAC in different cranberry products, the optimal dose of PAC to prevent recurrent UTI’s is still unclear.  In spite of this, both NICE Guidelines – Urinary Tract Infections (recurrent): antimicrobial prescribing and the 2023 European Association of Urology guidelines, still advise the use of cranberry products as a self-care strategy because the risk of harm is low.

The evidence is the most robust for using cranberry products in the following situations:

• Uncatheterised women with recurrent, symptomatic, culture-verified UTI’s

The 2023 Cochrane review found that cranberry products can reduce the risk of recurrent, symptomatic, culture-verified UTI’s in women by 26%.  Other studies have found that it helps these women in up to 32% of cases.

• People with indwelling catheters

A systematic review and meta-analysis found that the risk of UTI’s for those with indwelling catheters reduced by 51% when using cranberry products.

Note that there is little (to no) evidence that cranberry products will have any benefit for those with neuromuscular bladder dysfunction, incomplete bladder emptying, elderly institutionalised adults or pregnant women.

5.  Consider D-mannose. (2, 5, 11)

The 2022 Cochrane review on using D-mannose for preventing and treating UTI’s, felt evidence was inconclusive and they could not support or refute its use.

However, in spite of this, D-mannose is still recommended under the “self-care” section of NICE Guidelines and 2023 European Association of Urology guidelines.

6.  Consider vaginal probiotics (2, 4)

NICE Guidelines state the evidence for using vaginal probiotics is inconclusive.

However, the European Guidelines state that vaginal probiotics are effective, specifically if they contain the specific strains of Lactobacillus shown to have the highest efficacy.  These include:

• Lactobacillus rhamnosus GR-1;
• Lactobacillus reuteri B-54 and RC-14;
• Lactobacillus casei shirota; or
• Lactobacillus crispatus CTV-05.

Unfortunately, the optimal dose, route of administration and treatment duration have yet to be determined.

There is still much to be learned about the best ways to prevent recurrent UTI’s.  Self-care strategies often have a low risk of doing any harm however, their effectiveness is sometimes questionable (depending on the situation).  Clients therefore need to have realistic expectations when trying these strategies and liaise with their GP, urologist or ob-gyn regarding medical treatment options as well.

If you have a case management or litigation client with a brain injury, spinal cord injury or complex orthopaedic trauma in need of a comprehensive dietetic assessment and report, please contact Specialist Nutrition Rehab at info@specialistnutritionrehab.co.uk or 0121 384 7087.

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