Urinary Tract Infections (UTIs)

Most cis and trans women know what UTIs are because they are so common and can be extremely uncomfortable and irritating in both how they feel and how they interfere with a woman’s life. UTIs are so common for girls and women throughout their lives that women can find themselves simultaneously making decisions about the best ways to identify and handle UTIs for themselves, for their children or grandchildren, and as caregivers for older loved ones.

 

How common are UTIs?

Nearly 1 in 3 women have a clinically significant UTI by the age of 24.[1] [2]

Almost half of women will experience a UTI in their lifetimes.[3] [4] [5]

Recurrent UTIs (rUTIs) = having more than 2 infections in a 6 month period, or 3 infections over 12 months with complete resolution for at least 2 weeks.[6] Almost half of women who get one UTI experience a recurrence within 6-12 months.[7]

In the USA, UTIs account for more than 8-10 million office visits, 1-3 million emergency department visits, and 100,000 hospitalizations each year. [8] [9]

Definitions

Bacteriuria: presence of bacteria in urine. Bacteriuria without symptoms (asymptomatic bacteriuria) is no longer considered appropriate to diagnose a UTI

Urinary Tract Infection (UTI): an infection in the urinary system (kidneys, ureters, bladder, and the urethra)

The most common UTIs:

  • Cystitis: an infection of the bladder (the organ that collects and stores urine)
  • Urethritis: an infection of the urethra (the tube that carries urine from the bladder out of the body/to the urinary opening)
  • Nephritis: an inflammation of the kidneys, usually due to bacterial infection (also called pyelonephritis)

Causes of UTIs 

Everything from bicycling to wearing sexy underwear (thongs) gets blamed for UTIs![10]  Most UTIs are caused by organisms that are fine elsewhere (such as in the vagina or the rectum) wrongly getting into the urethra and bladder. Although viruses and fungi can cause UTIs, the most common cause is that bacteria (E.coli) found in the stools in the rectum get into the urinary tract.[11]  Up to 95% of UTIs are cause by E. coli bacteria.[12]  [13]   

Why are they more common in women than in men*?

Girls’ and women’s anatomy is the key explanation for why UTIs are much more common in girls and women than in boys and men. In girls and women, the openings to the urethra, the vagina, and the rectum are very close together so it is easy for an organism to accidentally get moved from the anus or vaginal opening to the urinary opening. In contrast, try imagining the more difficult maneuvering it takes for bacteria from a man’s anus to reach the tip of his penis to enter his urinary tract. Proof that the short distance between women’s anal and urinary openings is key to explaining UTIs is demonstrated by the fact that the differences in distance between those openings in different women are useful for explaining the differences in UTI susceptibility in women: the distance from the female urethra to anus is significantly inversely proportional to the risk of developing a UTI. A woman with only 4.8 cm between her urinary and anal openings is more likely to develop a UTI than a woman with 5 cm between openings![14]

The fact that women’s urethras are ~ 5 times shorter than men’s urethras may also play some role in whether infectious agents can quickly ascend up the shorter urethra without getting flushed out, thereby being able to reach the bladder and quickly multiply.

*Most UTI’s in men are the result of problems that restrict normal urine flow, such as enlarged prostate.

Some symptoms of UTIs

  • Pain or burning while urinating (dysuria)
  • Urgent need to urinate frequently (urinary urgency)
  • Feeling the need to urinate even though the bladder is empty
  • Cloudy, bloody, or strange smelling urine
  • Pelvic pain

More serious symptoms (which might indicate infection has moved to the kidneys) 

 

  • Severe back pain
  • Nausea, vomiting
  • Shaking and chills
  • Fever

Prevention of UTIs/Prevention of Recurring UTIs

The above female anatomy information explains why minimizing ways organisms can get from the anus or vagina to the urinary opening, flushing out the system (i.e. drinking water and urinating) regularly, and making sure the bladder is completely emptied (leaving no infectious organisms around to multiply) are key to minimizing UTIs.

Prevent organisms from getting from the anus or vagina to the urinary opening.  Pat dry front to back instead of wiping in the “wrong” direction or use separate toilet paper to cleanse the anus; Change menstrual pads or urinary incontinence pads often; Discover whether internal (tampons) or external (pads) best suit your body.

Drink plenty of water & other liquids to keep the urinary tract flushed out regularly.  Avoid liquids that irritate the bladder such as coffee or alcohol; Avoid sugary drinks; Many women find that products believed to contain compounds that prevent bacteria from adhering to the walls of the urinary tract (e.g., cranberry products) or increase the acidity of the urine (e.g., Vitamin C) are useful.

Think about how sexual activity might relate to UTIs.  Genitals should be washed before and after sexual activity; Urinating after sexual activity will help clear the urinary tract; Remember that anything that touches or goes in your anus – finger, penis, sex toy, gloves, condoms, dental dams – needs to be thoroughly washed or replaced before touching genitals; Think about which positions and activities put pressure on the urethral area or the bladder.

Think about how contraceptive choice might relate to UTIs.  Women taking oral contraceptives have a higher rate of UTIs than women who don’t take them; Diaphragm rims could press against the urethra so a different size or a different rim could be tried;  Some women are sensitive to spermicidal products including nonoxynol-9 or flavored condoms and lubricants.

Discover hygiene practices that suit your body.  Daily washing of genitals and the anal area is important; Avoid douching, which upsets the vaginal flora; Some women find showers are better than baths; Choose milder soaps and unscented feminine hygiene products instead of perfumed and scented ones.

Think about clothing choices. Cotton underwear “breathes” more than synthetic underwear that can trap moisture; Loose fitting bottoms allow air to circulate whereas tight clothes may prevent this and actually push on the urethra or transfer organisms into the urinary opening.

Treatment

UTIs have often been treated by antibiotics but, in this era of promoting a more responsible and cautious approach to antibiotic use, many women will be encouraged to find other ways of reducing UTI symptoms and to wait to see if the UTI resolves itself before resorting to antibiotic treatment. See “Urinary Tract Infections: Changing the Culture” in Rx for Change. (But please note: pregnant women and anyone with UTI symptoms accompanied by chills, fever, vomiting, and/or pain in the kidneys [near middle of the back] should not wait to contact their health provider.)

Because UTIs are very common, there is much money to be made from marketing UTI treatment products. The internet, including many web-sites specializing in medical information, is full of ads for such products. Even though many products will be helpful and safe, it is important to remember that good scientific trials proving effectiveness and safety have not been done for many of these products, the Food and Drug Administration may not regulate these products, and if something is powerful enough to be effective it is worth trying to figure out how it is working and how to safely use it and stop using it.

Many of the suggestions for preventing UTIs will also work to treat a UTI, especially good hydration and flushing out the system (with particular attention to completely emptying the bladder). Some women and some studies say cranberry and Vitamin C products are worth trying and over the counter drugs like Advil or Tylenol may help relieve pain. Warning: The drug phenazopyridine (manufactured under brand names such as Azo and Uristat), specifically designed to treat UTI pain is listed as a DO NOT USE drug by Worst Pills, Best Pills[15].

Probiotics, such as kombucha, can be useful in preventing UTIs.

Probiotics seem a particularly promising way to maintain or restore a balanced community of microorganisms (microbiome).[16] [17]  Many people are already aware of this and choose to consume live-culture yogurt. Probiotics contain live microorganisms, most of which are similar to beneficial bacteria that occur naturally in the human gastrointestinal tract. Studies have found mixed results in effectiveness of various probiotics in treatment and prevention of recurring infections of the gastrointestinal tract and the genitourinary tract.[18] [19] [20]   While some results are encouraging in terms of UTIs, more research is needed to determine the best composition and use of probiotics. In some cases, vaginal application may work better than oral use.[21]  Because there are not presently Federal standards for probiotics, tests have shown that products often do not contain the bacteria and the amounts claimed on the label. Even testing of many samples of the same product finds inconsistent composition.[22] Studies have shown few if any negative side-effects, which combined with a long history of safe use, means probiotics are generally considered safe.[23]  [24]  (It is recommended to consult your physician before starting on a regimen of probiotics.)

Additional Issues

Specific subgroups of women are at increased risks for UTIs. These include women with spinal cord injuries, diabetes, multiple sclerosis, acquired immunodeficiency diseases, underlying urologic abnormalities, and women who use catheters.[25]

Trans women

In addition to issues related to adjusting to changing anatomy for someone transitioning, there are societal attitudes, such as hostility to transgender people using public bathrooms, which may add to the complexities of preventing UTIs.  Results from a 2015 survey of transgender people in the U.S. found that in the previous year 59% had avoided public restrooms due to fear of confrontation and 31% had avoided eating or drinking so that they would not need to use a public restroom.[26] These behaviors are obviously not healthy, particularly in preventing or treating UTIs.  As some laws bar transgender people from using their bathroom of choice and many have faced verbal or physical violence in bathrooms, public attitudes and policies need to change in order to make bathrooms accessible and safe.

Genital surgery itself may cause problems with urination, possibly increasing UTIs. [27] Tucking, which is a method used by some trans women (and also some cis men) to hide the crotch bulge of the penis and testes,  if used regularly or for long periods of time, can cause a build-up of bacteria that can cause UTIs.[28]  Many transgender people have difficulty finding a healthcare provider with whom they are comfortable enough to come out and discuss their concerns in an open way.  Many providers do not have enough good training in working with transgender people, so the providers themselves may be very uncomfortable, too.

Children

Babies and young children, especially girls, are commonly affected by UTIs but a fever is often the only symptom in young children, so good communication with a health provider is especially important. The use of antibiotics for UTI treatment in children is receiving particular attention both because antibiotics have a questionable benefit to children and because recent studies show that childhood exposure to antibiotics may have particular negative effects.[29]  Of course, childhood is the crucial time for helping little girls learn about their anatomy for UTI prevention and lots of more interesting things.

Pregnant Women

Pregnant people are especially susceptible to UTIs.

Pregnant women are especially susceptible to UTIs because the weight of the growing fetus in the uterus can prevent the complete emptying of the bladder. As UTIs increase the risk for kidney infection, preeclampsia, premature delivery, and fetal mortality, screening for and treating UTIs is especially important in pregnant women.[30] [31] 

Post-menopausal women 

Post-menopausal women may experience UTIs for the first time in their lives or have more recurrent UTIs because of their lowered estrogen levels and the accompanied changes in the vagina, urethra, and bladder. Post-menopausal women can try prevention suggestions above, paying particular attention to the importance of hydration and completely emptying the bladder regularly. Some sources suggest the use of estrogen creams, tablets, or rings.[32] While the NWHN has warned women about the effects of long-term estrogen as menopause hormone therapy (MHT) the NWHN says that low dose vaginal estrogen does not increase the risk of many problems associated with MHT. (See “I’ve Got a Question.”)[33]

Very promising are new understandings about how the lowered estrogen in post-menopausal women relates to the changes in vaginal flora so that “good” (lactobacillus) bacteria which control acidity are reduced making women more susceptible to infections. Better understanding of how to promote and restore a healthy balance of organisms (see probiotics above) will be of particular benefit in reducing post-menopausal UTIs.[34] [35]

Older and elderly women

All UTI issues and controversies are intensified in relation to older women because older women are the most susceptible to UTIs and rUTIs, because UTIs in older women are often connected to other issues (including urinary incontinence, difficulty or pain in urination, increasing aging and disability issues, changing ability to have control over their bodies and their lives), and because this is the population (especially in community living and institutional settings) where the misuse and overuse of antibiotics, the dangerous levels of bacterial resistance and resulting life-threatening diseases, receive the most attention.

Asymptomatic bacteriuria is common in older and elderly women (incidence increasing from 3.5% in the general population to 16-18% in women older than 70 years, with some longitudinal studies reporting it affects 50% of older women)[36] so medical journals are full of articles emphasizing that asymptomatic bacteriuria in older women should not be treated with antibiotics.[37] [38] [39] [40]

Because so many factors come together and come together differently for different older women, it is difficult to know or prove which quality of life issues are sufficiently related to possible UTIs to be tested for and treated. A Journal of the American Medical Association (JAMA) article described that “there was a significant association between laboratory confirmed UTI and acute dysuria (difficulty or pain in urination), change in character of the urine, and change in mental status” but went on to recommend that “symptoms such as dizziness and confusion alone should not be attributed to UTI.” [41]

Organizations specializing in quality care for older people and individual caregivers taking care of elder loved ones who have witnessed how UTIs can impact older people have urgent work to do in ensuring that the new emphasis on minimizing antibiotic use does not reduce the vigilance in identifying and managing UTIs. A Place for Mom says, “A sudden change in behavior is, in fact, one of the best indicators of a urinary tract infection in older adults… Falls, confusion, new onset of incontinence in someone who had been getting to the bathroom, decrease in appetite, any of these can be a sign of a urinary tract infection. It really requires a detective-like index of suspicion from the caregiver.” [42] Supporting older women staying hydrated when they are trying to manage incontinence and ensuring that good hygiene is manageable are as important as teaching little girls about their anatomy.


[1] Foxman B, “Epidemiology of urinary tract infections: incidence, morbidity, and economic costs,”  Am J Med  2002 July 8; 113 Suppl 1A: 5S-13S.

[2] Bergamin PA, Kiosoglous AJ, “Non-surgical management of recurrent urinary tract infections in women,” Transl Androl Urol 2017 Jul; 6 (Suppl 2): S142 – S152.

[3] Foxman B, “Epidemiology of urinary tract infections: incidence, morbidity, and economic costs,”  Am J Med  2002 July 8; 113 Suppl 1A: 5S-13S.

[4] Bergamin PA, Kiosoglous AJ, “Non-surgical management of recurrent urinary tract infections in women,” Transl Androl Urol 2017 Jul; 6 (Suppl 2): S142 – S152.

[5] Jung C, Brubaker L, “The etiology and management of recurrent urinary tract infections in postmenopausal women,” Climacteric 2019 Jan 9: 1-8.

[6] Bergamin PA, Kiosoglous AJ, “Non-surgical management of recurrent urinary tract infections in women,” Transl Androl Urol 2017 Jul; 6 (Suppl 2): S142 – S152.

[7] Jung C, Brubaker L, “The etiology and management of recurrent urinary tract infections in postmenopausal women,” Climacteric 2019 January 9: 1-8.

[8] Mody L, Juthani-Mehta M, “Urinary Tract Infections in Older Women: A Clinical Review,”  JAMA 2014 Feb 26; 311(8): 844-854.

[9] Public Citizen Health Research Group,  “A Guide to Drugs for Uncomplicated Urinary Tract Infections,” Worst Pills, Best Pills Newsletter May 2016. Retrieved on January 22. 2019 from: https://www.worstpills.org/member/newsletter.cfm?n_id=1030

[10] Colino, S, “7 Surprising Risk Factors for Urinary Tract Infections,” Retrieved on January 19, 2019 from: https://www.everydayhealth.com/urinary-tract-infection/7-surpri

Referring to “Mind Over Bladder,” a book by Jill Maura Rabin.

[11] Public Citizen Health Research Group,  “A Guide to Drugs for Uncomplicated Urinary Tract Infections,” Worst Pills, Best Pills Newsletter May 2016. Retrieved on January 22. 2019 from: https://www.worstpills.org/member/newsletter.cfm?n_id=1030

[12] Farid H, “More water, fewer UTIs?” Harvard Health Publishing. Retrieved on January 19, 2019 from:

https://www.health.harvard.edu/blog/more-water-fewer-utis-20

[13]Bergamin PA, Kiosoglous AJ, “Non-surgical management of recurrent urinary tract infections in women,” Transl Androl Urol 2017 Jul; 6 (Suppl 2): S142 – S152.

[14] Bergamin PA, Kiosoglous AJ, “Non-surgical management of recurrent urinary tract infections in women,” Transl Androl Urol 2017 Jul; 6 (Suppl 2): S142 – S152.

[15] Public Citizen Research Group, Worst Pills, Best Pills “Drug Profile,” Retrieved on January 31, 2019 from: https://www.worstpills.org/member/drugprofile.cfm?m_id=113

[16] Hill, D, Sugrue I, Tobin C, Hill C, Stanton C, Ross RP, “The Lactobacillus casei Group: History and Health Related Applications,” Front Microbiol 2018 September 10; 9: 2,107.

[17] Bolen B, “How to Choose the Best Probiotic for You,” Updated October 10, 2018. Retrieved on January 19, 2019 from: https://www.verywellhealth.com/how-to-choose-the-best-probio

[18] Wilkins T, Sequoia J, “Probiotics for Gastrointestinal Conditions: A Summary of the Evidence,” Am Fam Physician 2017, August 1; 96 (3): 170-178.

[19] Hanson L, VandeVusse L, Jerme M, Abad CL, Safdar N, “Probiotics for Treatment and Prevention of Urogenital Infections in Women: A Systematic Review” J Midwifery Women’s Health 2016 May; 61 (3): 339-355.

[20] Bergamin PA, Kiosoglous AJ, “Non-surgical management of recurrent urinary tract infections in women,” Transl Androl Urol 2017 Jul; 6 (Suppl 2): S142 – S152.

[21]Bergamin PA, Kiosoglous AJ, “Non-surgical management of recurrent urinary tract infections in women,” Transl Androl Urol 2017 Jul; 6 (Suppl 2): S142 – S152.

[22]Public Citizen Health Research Group, “Benefits of Probiotics Remain Unproven,” Worst Pills, Best Pills Newsletter June 2017. Retrieved on January 27, 2019 from: http://www.worstpills.org/member/newsletter.cfm?n_id=1130

[23] Doron S, Snydman DR, “Risk and Safety of Probiotics,” Clinical Infect Dis 2015 May 15; 60 Suppl 2: S129-134.

[24] Wilkins T, Sequoia J, “Probiotics for Gastrointestinal Conditions: A Summary of the Evidence,” Am Fam Physician 2017, August 1; 96 (3): 170-178.

[25] Foxman B, “Epidemiology of urinary tract infections: incidence, morbidity, and economic costs,” Am J Med  2002 July 8; 113 Suppl 1A: 5S-13S.

[26] Lopez G, “The largest survey of transgender people yet shows the dangers of bathroom hysteria” retrieved on January 23, 2019 from: https://www.vox.com/2016/7/12/12161210/transgender-bathro

[27] Melloni C, Melloni G, Rossi M, Rolle L, Carmisciano M, Timpano M, Falcone M, Frea E, Cordoba A, “Lower Urinary Tract Symptoms in Male-to-Female Transsexuals: Short Term Results and Proposal of a New Questionnaire,” Plast Reconstr Surg Glob Open 2016 Mar;4(3):e655

[28] Williams, K, “UTIs while transgender,” 2018, August 2. Retrieved on January 23, 2019 from: https://uqora.com/blogs/news/utis-while-transgender

[29] Kutasy, B, Coyle D, Fossum M, “Urinary Tract Infection in Children: Management in the Era of Antibiotic Resistance – A Pediatric Urologist’s View,” Eur Urolo Focus 2017 Apr; 3(2-3): 207-211

[30] Yan L, Jin Y, Hang H, Yan B, “The association between urinary tract infection during pregnancy and preeclampsia: A meta-analysis,” Medicine (Baltimore) 2018 Sep; 97(36): e12192

[31] Foxman B, “Epidemiology of urinary tract infections: incidence, morbidity, and economic costs,” Am J Med  2002 July 8; 113 Suppl 1A: 5S-13S.

[32] Ricciotti H, “’Not Again!’– When UTIs won’t quit at midlife,” Harvard Health Publishing. Retrieved on January 19, 2019 from: https://www.health.harvard.edu/blog/not-again-when-utis-wont-

[33] NWHN, “I’ve Got a Question About Estrogen Creams,” January 15, 2019. Retrieved on January 30, 2019 from:

https://www.nwhn.org/ive-got-a-question-about-estrogen-crea

[34] Bergamin PA, Kiosoglous AJ, “Non-surgical management of recurrent urinary tract infections in women,” Transl Androl Urol 2017 Jul; 6 (Suppl 2): S142 – S152.

[35] Jung C, Brubaker L, “The etiology and management of recurrent urinary tract infections in postmenopausal women,” Climacteric 2019 January 9: 1-8.

[36] Mody L, Juthani-Mehta M, “Urinary Tract Infections in Older Women: A Clinical Review,”  JAMA 2014 Feb 26; 311(8): 844-854.

[37] Mody L, Juthani-Mehta M, “Urinary Tract Infections in Older Women: A Clinical Review,”  JAMA 2014 Feb 26; 311(8): 844-854.

[38] Dasgupta M, Brymer C, Elsayed S, “Treatment of asymptomatic UTI in older delirious medical in-patients: A prospective cohort study,” Arch Gerontol Geriiatr 2017 Sep; 72: 127-134.

[39] Phillips CD, Adepoju O, Stone N, Moudouni DK, Nwaiwo O, Zhao H, Frentzel E, Mehr D, Garfinkel S, “Asymptomatic bacteriuria, antibiotic use, and suspected urinary tract infections in four nursing homes,” BMC Geriatr 2012 Nov 23; 12: 73.

[40] Nace DA, Drinka PJ, Crnich CJ, “Clinical uncertainties in the approach to long term care residents with possible urinary tract infection,” J Am Med Dir Assoc 2014 Feb; 15 (2): 133-139.

[41] Mody L, Juthani-Mehta M, “Urinary Tract Infections in Older Women: A Clinical Review,”  JAMA 2014 Feb 26; 311(8): 844-854.

[42] A Place for Mom, “Elderly Urinary Tract Infections – A Place for Mom,” Retrieved on January 31, 2019 from:

https;//www.aplaceformom.com/planning-and-advice/articles/el…