Recurrent UTIs: which non-antibiotic approaches actually work?

Today, we’re speaking to Professor Miriam Santer, a GP in Dorset and Professor of Primary Care Research based at the University of Southampton. Title of paper: Non-antibiotic interventions to prevent recurrent urinary tract infections in women: overview of systematic reviews of randomised controlled trials DOI: https://doi.org/10.3399/BJGP.2026.0055 Recurrent urinary tract infection (UTI) is very common and defined as two or more UTIs in the last six months or three or more UTIs in the last 12 months. Long-term antibiotic prophylaxis is widely used but other preventative strategies have been suggested. This overview of systematic reviews found good evidence for some treatments but identified unresolved questions such as treatment adherence for vaginal oestrogen, questions about long-term use for methenamine hippurate and optimal dosage for cranberry. Increased fluid intake has been shown to be of benefit for women drinking less than 1.5 litres at baseline but is without robust evidence in other groups. The evidence base is still developing for other treatments, such as vaccines. Transcript This transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions. Speaker A 00:00:00.560 - 00:00:55.830 Hi and welcome today to BJJP interviews. I'm Nada Khan and I'm the Senior Research editor for the bjgp. In today's episode, we're talking to Professor Miriam Santer, a GP in Dorset and Professor of Primary care research based at the University of Southampton. We're here to discuss the recent paper she's published here in the BJJP titled Non Antibiotic Interventions to Prevent Recurrent Urinary Tract Infections in Women. An Overview of Systematic Reviews of Randomized Controlled Trials. So, hi Miriam, it's nice to see you again. And I suppose to start with, it's worth acknowledging that recurrent UTIs are something that we see incredibly often as GPs, but they can also have a really big impact on women's lives and I guess I just wanted to go through what prompted you to take this angle in this review and think about non antibiotic options for preventing them? Speaker B 00:00:56.520 - 00:02:38.580 Well, it was exactly that, that I had a colleague, a non clinical colleague who had recurrent UTI and I guess I hadn't really appreciated the massive impact that they had in terms of, you know, keeping, being ill, keeping missing work, everything else. And it did make me think again about my own practice, whether I really manage recurrent UTI or whether I just manage it as a series of one off events. So it made me think about my own practice. And then also the reason we looked at non antibiotic options was because the Primary Care Research Centre in Southampton where I work, we do a lot of work on infections and on antimicrobial stewardship and we were aware that prophylactic antibiotics tend to be quite well used and also series of one off antibiotic episodes are quite well used but that the non antibiotic interventions, we felt they were less well used and just wanted to know the evidence behind it. Apart from doing infections research, we also do a lot of research on how to support people self manage long term conditions and we thought we could make a brilliant resource or online intervention to help people prevent urinary tract infection. And as part of that we just wanted to know a bit more about the evidence based and in some ways we were a little disappointed that there wasn't much evidence for some of the very commonly advised things, but also surprised that for some things like methenamine and vaginal estrogen, actually the evidence base is, is pretty well established now. So it was interesting. Speaker A 00:02:38.900 - 00:03:04.080 Yeah. And as you said, there's a huge number of things that women are told might help prevent recurrent UTIs and this was an umbrella review that brought together evidence from 27 systematic reviews. But let's just talk through what. So you mentioned about vaginal oestrogen, because this seems to be one of the clearest messages from the review. Talk us through what you found and how strong is the evidence here? Speaker B 00:03:04.480 - 00:04:07.360 So there were seven systematic reviews covering vaginal estrogen and they were pretty positive and especially the most recent one. To be fair, most of the evidence is in post menopausal women, but the NICE guideline changed in 2024 to say perimenopausal and postmenopausal, because there's awareness in the rest of the menopause literature that actually genital urinary symptoms in menopause are often do present before menopause. So it's a slightly confusing message. The evidence base for prevention of UTIs is postmenopausal, but the guidelines are perimenopausal and postmenopausal. But the evidence is pretty strong. It's been amassing over a number of years. Seven systematic reviews have been positive about it. Unlike systemic oestrogen, where systematic reviews have been pretty conclusive that systemic estrogen doesn't make a difference in preventing recurrence. But of course, women can take both at the same time if they need to. Speaker A 00:04:07.520 - 00:04:21.750 And one thing I found really interesting was that there was particularly low uptake of vaginal estrogen in more deprived areas. Do you think that there's something driving that and what can we do to try to prevent that sort of inequity in access? Speaker B 00:04:21.990 - 00:05:59.500 And it's tempting to say more research needed. And that was something we found in the literature, that there's a suggestion that vagina strings are less used in the UK than elsewhere. They're less used in areas of greater socioeconomic deprivation. And also it's not very well understood whether it's a prescribing issue or whether it's an uptake and adherence or acceptability issue. There's. So for prescribers, there's some things that are off putting. So I don't really understand why vagina are not licensed for prevention of uti, given the evidence base for women. It's a number of other things. Sometimes, you know, not having had a sufficiently informed discussion about all the different types, you know, gel cream, pessaries, and sometimes it's also that the patient information leaflet that comes with the packet describes it as hrt, where it's really very little of it is systemically absorbed. So it, it is, it's safer than hrt. I mean, of course HRT is Pretty safe. Vaginal estrogen is even safer. But that message doesn't always get across. And then also maybe it's because the information leaflet and all the other information tends to focus on genital urine symptoms of the menopause that people don't necessarily link it in their minds. And I'm talking about prescribers as well as women with preventing UTI and maybe just don't keep using it long enough. So more research needed. But I think there's a number of barriers to uptake regarding vaginal estrogen and. Speaker A 00:05:59.500 - 00:06:22.180 I can think of a lot of conversations I've had with women with recurrent UTIs and suggesting vaginal estrogen and often they're quite surprised but quite happy that I'm suggesting something that could work. So I think there is a bit of a information asymmetry there between what some prescribers are doing, maybe people who are really used to prescribing these things and patients as well. Speaker B 00:06:22.340 - 00:06:41.460 And I've also certainly met a few women who said, oh, was I meant to keep using that? They don't necessarily see it as a, as something they need to take in the long term to keep preventing it, you know, which is. And for something which you're only doing twice a week, that is a slightly challenging behavior to keep remembering to use it. Speaker A 00:06:41.790 - 00:06:52.350 And I guess one other thing that you also found really good evidence for was methanomine. Talk us through how we should be thinking about methanamine in relation to long term prophylaxis as well. Speaker B 00:06:52.670 - 00:07:29.200 So methenamine has also made it into the nice guideline on preventing recurrent uti. And I think I might have forgotten to say so that's anyone who's had two UTIs in six months or three UTIs in 12 months. And the evidence is pretty good for methenamine as well as vaginase drinks. As someone who hasn't responded to basic lifestyle advice, we might come on to that. The evidence is a little bit poor, but it's still suggested that you discuss lifestyle advice first. Should, if they're perimenopausal or menopausal, consider vaginal estrogen, but at all ages consider methenamine. Speaker A 00:07:29.760 - 00:07:39.680 Interesting. And do you think that I don't know if there's any evidence in these reviews about how they're used or whether they're underused or do you think gps are confident in prescribing these? Speaker B 00:07:40.310 - 00:08:15.880 Anecdotally I've heard that. Well, and going on social media would suggest that some women are still finding it hard to obtain from their gp. Having said that, if you look at UK data like open prescribing, you can see there's a pretty steep rise in prescribing for methadone. So I think the rates are going up and I suspect that means more GPs are prescribing it because it can't all be coming from urologists. So we didn't find evidence in this review, but. But my understanding from having looked at the data is that actually it is being increasingly used. Speaker A 00:08:16.360 - 00:08:40.820 Yeah. And that's on the back of some pretty good clinical trials evidence as well, I think the Ultra trial, I think, in that area. Great. And I think cranberry is really interesting because it's something that people often ask about and I think when people think about UTIs, they often think about, oh, I should be drinking some cranberry juice. What does the evidence actually tell us? Does. Is there anything about cranberry or type or dose of cranberry that people use? Speaker B 00:08:41.540 - 00:09:18.420 Well, we found six different systematic reviews on cranberry and the evidence on dose is not particularly strong, so it's quite reasonable. The nice guideline concludes that it's worth discussing it, but it can't be prescribed. It's probably safe to say that juice is not particularly effective. Cranberry tablets. More of the evidence is around cranberry tablets where there's going to be a more consistent dose than from just drinking juice. But, no, the optimal dose is not yet known, but it probably does help. Speaker A 00:09:18.660 - 00:09:31.300 And I guess we've talked, we touched on just sort of lifestyle advice and what about something as simple as drinking more water? Is that the kind of lifestyle advice that we should routinely be giving women with recurrent UTIs, or do you think it's a bit more nuanced than that? Speaker B 00:09:31.840 - 00:10:41.740 So there's two systematic reviews that included fluid intake, but both of them only really found one substantial trial. And it's quite interesting. They only included women who drank 1.5 liters or less per day, which actually is below average. And the intervention there was, they were giving people bottled water to drink with every meal. So people who have low fluid intake should definitely be drinking more. But when you read advice, that's like two or three liters a day, we really don't know that. And it can feel a little bit blamey, a lot of the quality. We didn't do a qualitative study, but if you read the qualitative evidence around uti, because women have quite often been given this message for a current UTI on a number of occasions, it can Add to the feeling of it being a little bit stigmatizing, a bit dismissive and a bit as though it was. It was your fault that you didn't do this. Whereas actually, we don't really know how much difference it makes for people who are drinking more than 1.5 liters a day initially. Speaker A 00:10:42.059 - 00:11:04.760 And we were talking just before we started about Tory Ford's work on recurrent thrush and about how she's conceptualizing it not just as single episodes of thrush, but as recurrent thrush as a specific condition. And I suppose maybe the qualitative of evidence, although you didn't look at that specifically here, but we were reflecting on some of the parallels, weren't we, just before we started. Speaker B 00:11:05.320 - 00:11:45.530 Yeah, yeah. And the qualitative evidence is so strikingly similar. This feeling that it's a mundane, trivial thing, feeling dismissed and the cumulative experience of a number of consultations and feeling a bit hopeless about it after a while, a bit hopeless, not just about the recurrent uti, but about the feeling that it's not really being managed or looked after is. Is. Is. I was so struck at the similarities, really. And, yeah, again, you do wonder a little bit, is that because it's a women's health care issue and it's seen as a bit, dare I say it, trivial. Speaker A 00:11:45.930 - 00:12:05.910 And there are some interventions that are really popular with. With women, so particularly D Mannose and probiotics, and people can buy those just from the pharmacy review suggests that the evidence isn't really strong enough to recommend them. Do you have any thoughts about that evidence and maybe what we should be advising people who are asking about it? Speaker B 00:12:06.390 - 00:13:22.790 It's really tricky. And so the reviews mostly concluded for D. Mannose probiotics, vaccines, that more evidence was needed. The interesting thing about doing a review of reviews or an umbrella review, as we did, is, is that recent trials haven't yet been. If they've not yet been included in a systematic review, they're not yet included in the overview of systematic reviews. And the most recent trial on D. Mannose suggested that it probably isn't effective, but some people with UTI really feel it is effective. So it's a really hard one. There were some adherence issues in that trial. It may be that it works for some people and not others. A few studies have suggested that things like cranberry may work better in younger women. And it's possible that D. Mannose, which is essentially a type of sugar, works in a similar way. And obviously we can't prescribe it like cranberry. D Mannose is something that women will be buying themselves. So if someone wanted to try it, I certainly wouldn't put them off. But it definitely doesn't have the same strength of evidence as methenamine or vaginal estrogen, for instance. Speaker A 00:13:23.100 - 00:13:49.340 And you've touched upon this and I guess one thing that struck me from your paper was how little we know about whether women actually want to use these treatments and whether they can stick with them. And we've talked a bit about sort of fluid intake and also the different over the counter treatments as well. Have you got any thoughts about what we need to know about the adherence and acceptability in this area and I guess why it's kind of limiting our understanding of whether these treatments work? Speaker B 00:13:49.710 - 00:15:24.930 I think there's, there's questions about how long people need to stay on methenamine for. You mentioned the very good trials. They weren't terribly long trials. I think we need to know a lot more about the acceptability and adherence to different vaginal estrogens. I'd love to see more evidence on cranberry and what dose and what formulation we should be saying. I would be interested also to know more about evidence for other things, like, you know, all the things that other people are told like washing before and after sex, going to do a pee before and after sex. Very hard to do in rct, but at the moment it's in the guidelines, but it's not in all the guidelines. If you look internationally, some international guidelines don't include them because there's no evidence for them and because it's potentially stigmatizing. So I think a bit slightly more nuanced conversations when people may have had that message repeatedly. Wiping to front to back is a common one as well that people might be told repeatedly. And certainly in some of the qualitative studies I've read, people just say this just feels so patronizing to be told that again and again. I think how we communicate those sorts of messages also needs more thought, more sensitivity, more, you know, how can we do that? Well, to make sure that people are fully informed but they don't feel like they're just being told the same slightly stigmatizing advice again and again and often. Speaker A 00:15:24.930 - 00:15:32.010 I suppose that women who are having recurrent UTIs will be the expert in their condition and how they feel and how they treat it as well. Speaker B 00:15:32.170 - 00:15:38.480 Yeah, absolutely. They will heard these messages before. They may well have tried quite a lot of them before. Speaker A 00:15:38.800 - 00:15:41.520 Any other key findings you want to pull out from this review?