Urinary tract infections (UTIs) are among women's most frequent clinical bacterial infections. Up to 60% of women will develop at least one UTI in their lifetimes, and one in three will have at least one symptomatic UTI by age 24. UTI reinfection rates are as high as 80%. While the initial treatment of acute, uncomplicated UTI is antibiotic therapy, complementary and integrative modalities are available to prevent recurrent UTI and reduce exposure to antibiotics. (1, 9)

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What is a UTI?

A urinary tract infection (UTI) is an infection in any part of the urinary system, including the kidneys, ureters, bladder, and urethra. Most UTIs involve the lower urinary tract, the bladder (cystitis) and the urethra (urethritis). Kidney infections (pyelonephritis) are less common than lower UTIs but are more serious. (2)

What Causes UTIs?

Microorganisms in the vaginal, genital, and anal areas may enter the urethra, travel upwards into the urinary tract, and cause UTIs. These microorganisms are usually bacteria; more than 90% of bladder infections are caused by Escherichia coli (E. coli) translocated from the gastrointestinal tract. Other etiological bacteria of importance include Klebsiella, Proteus, Enterobacter, and Enterococcus. (3, 7)

Candida albicans, a species of yeast that lives commensally in the gut, mouth, throat, vagina, and skin as part of the normal human microbiome, is often overlooked as a cause of recurrent UTIs. 6.8% of UTIs have been calculated to be caused by Candida albicans.

UTI Symptoms

The classic symptoms of a UTI are pain with urination (dysuria), urinary frequency/urgency, and blood in the urine (hematuria). Other symptoms related to UTI may include foul-smelling or cloudy urine, urinary urge incontinence, penile pain, and fatigue. (3, 4)

Each type of UTI may result in more specific symptoms, depending on which part of the urinary tract is affected (5):

• Urethritis: burning with urination, urethral discharge
• Cystisits: pelvic pressure, lower abdominal discomfort
• Pyelonephritis: back or flank pain, fever, chills, nausea, vomiting

Most lower UTIs are classified as uncomplicated if treated promptly. However, if left untreated, a lower UTI can lead to (5):

• Repeat UTIs
• Kidney damage from pyelonephritis
• Delivering a low birth weight or premature infant when UTI occurs and is left untreated during pregnancy
• Urethral narrowing
• Sepsis

Why Are UTIs More Common in Women than Men?

Women are at higher risk for UTIs because their urethras are shorter than men's, and their urethral opening is closer to the anus. This makes it easier for bacteria or other infectious pathogens to travel to the urethra and ascend to the bladder. Women get UTIs up to 30 times more often than men, and up to 40% of women who get a UTI will get at least one more within six months. (6)

Why Do Some People Get Recurrent UTIs?

Recurrent UTIs are defined as two infections in six months or three in one year. Many factors can increase the risk of recurrent UTI, but frequent sexual intercourse is the greatest risk factor because sexual activity can move germs from other areas to the urethra. (6)

Vaginal and gastrointestinal dysbiosis can increase the risk of recurrent UTIs. Using spermicides can kill beneficial vaginal bacteria that prevent the growth of pathogenic bacteria and yeast that cause UTIs. Opportunistic and pathogenic bacteria that overgrow in the gut can be easily transported to the urethra. (2, 5)

Hormonal fluctuations can also influence the development of UTIs. During pregnancy, hormones can alter the composition of bacteria in the urinary tract. It can also be more challenging to void completely during pregnancy because the uterus sits on top of the bladder; leftover urine with bacteria can cause a UTI. After menopause, physical changes attributed to estrogen depletion increase the risk of UTI in postmenopausal women. Low estrogen contributes to reductions in healthy vaginal Lactobacilli, thinning of drying of vaginal tissues, and weaker bladder contractions, making it more difficult to empty the bladder completely. These changes make it easier for harmful organisms to overgrow and cause UTIs. (6, 8)

Any medical condition that suppresses the immune system, like diabetes, is a risk factor for UTI because it lowers the body's innate ability to fight off infection. Diabetes can also cause nerve damage, making it difficult to empty the bladder completely (6).

Patients with structural urinary tract variations may also be more prone to infection risk. Blockages in the urinary tract, such as kidney stones or an enlarged prostate, can trap urine in the bladder. Patients requiring urinary procedures that involve medical instruments or catheterization also are at increased risk for recurrent UTIs because these devices serve as an initiation site of infection by introducing opportunistic organisms into the urinary tract. (2)

Functional Medicine Labs to Test for Root Cause of Recurrent UTIs

Running a urinalysis with urine culture is imperative for patients reporting UTI symptoms to confirm infection and determine appropriate and effective treatment, especially if planning to treat with antibiotics. Urinalysis has a sensitivity of 80-90% and a specificity of 50% to detect UTI (9). Nitrites and leukocyte esterase measured by urinalysis are the most accurate indicators of acute UTI in symptomatic patients; a colony count of at least 10³ colony-forming units per mL of a uropathogenic on culture is diagnostic of cystitis. (10)

While these tests are important for diagnosing and treating acute infection, they don't explain underlying factors predisposing a patient to recurrent UTIs. Therefore, functional medicine providers often order other tests screening for dysbiosis, hormonal patterns, and immune function.  

Complete Blood Count (CBC)

A CBC with differential is a set of tests that provide information about the white blood cells, red blood cells, and platelets in a person's blood. During acute, active infection, it is common to see elevations in total white blood cells and neutrophils. A CBC with low white blood cells can indicate chronic infection and immunosuppression in patients with recurrent UTIs, suggesting additional evaluation is needed.

Comprehensive Stool Test

A comprehensive evaluation of the gut microbiome, using a test like GI MAP, will identify gastrointestinal dysbiotic patterns and overgrowth of pathogenic or opportunistic bacterial and fungal species that may be the source of recurring infection. Comprehensive stool tests can assist treatment decision-making, as they perform antibiotic and herbal sensitivity testing on any infections identified so that the doctor can ensure effective treatment is administered and prevent antibiotic resistance.

Vaginal Microbiome Testing

Similar to the comprehensive stool test, assessing the vaginal microbiome with a test like Vaginal BiomeFx identifies the abundance of beneficial and pathogenic microorganisms in the vaginal microbiome. This test is especially indicated for women with recurrent vaginal infections, like vulvovaginal candidiasis and bacterial vaginosis, which can be the source of urinary infection and mimic symptoms of UTI.

Female Hormone Panel

A comprehensive female hormone panel, performed through serum, saliva, or urine, can identify hormonal imbalances in estrogen, progesterone, and testosterone that may disrupt the healthy vaginal anatomy and microbiome, contributing to an increased risk of UTI.

Diabetes Panel

A diabetes panel is a comprehensive assessment of glucose metabolism and blood sugar. Abnormal results can be diagnostic for prediabetes or diabetes, which increases the risk of UTIs.

Additional Labs to Check  

Imaging may be recommended for patients with recurrent UTIs or who don't respond to treatment to examine the urinary tract for urogenital anomalies, disease, and injury. Ultrasound, computed tomography (CT), and cystoscopy are typical imaging procedures ordered for a more extensive evaluation of the urinary tract. (2)

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Conventional Treatment for UTIs

Antibiotic therapy is the core treatment for UTIs, with the primary objective being eradicating bacterial growth in the urinary tract. A three-day course of trimethoprim-sulfamethoxazole or a five-day course of nitrofurantoin is recommended as first-line therapy for managing uncomplicated UTIs. Low-dose daily prophylactic antibiotic treatment may be recommended for patients prone to UTI. (9)

Integrative Medicine Treatment for Recurrent UTIs

Using lab results to guide treatment plans, diet and lifestyle modifications, and dietary supplements can be important in treating recurrent UTIs by addressing the root cause of recurring infections.

Nutrition for Recurrent UTIs

In general, ingesting large amounts of refined sugar and allergenic foods may impair immune function and cause local urinary tract inflammation. Although there are no controlled trials to support dietary restriction, it would be reasonable to advise patients with recurrent UTIs to perform a short-term therapeutic elimination diet of refined sugars and common allergenic foods (milk, eggs, fish, Crustacean shellfish, tree nuts, peanuts, wheat, and soybeans) to observe if urinary symptoms improve.

Research suggests that a vegetarian diet can help prevent UTIs because it reduces exposure to E. coli, often found in poultry and pork products, and is rich in phytochemicals that exhibit antibacterial and anti-inflammatory effects.

The anti-Candida diet should be recommended to patients with UTI of Candida etiology. This anti-inflammatory diet aims to limit the consumption of sugars that can enable Candida overgrowth and assist in restoring a healthy microbiome to prevent UTI recurrence.

Supplements and Herbs for Recurrent UTIs

Many herbs are indicated in eradicating bacteria and palliation of urinary symptoms that can be used instead of or in conjunction with prescription antibiotics. Advantages of therapeutic botanicals include fewer side effects, more patient approval, less cost, and reduced risk of multi-drug resistance compared to their conventional counterparts.

Diuretic herbs: like goldenrod, lovage, parsley, and stinging nettle, increase urine volume, helping to flush out urinary pathogens.

Antiseptic and antiadhesive herbs: including uva ursi, juniper, Oregon grape, goldenseal, and cranberry, excrete antimicrobial compounds that kill bacterial and fungal pathogens and interfere with their adhesion to the cells lining the urinary tract.

Berberine-containing herbs: can broadly address dysbiosis within the gastrointestinal and genitourinary systems. (11)

D-mannose: is a monosaccharide that can inhibit bacterial adhesion to the lining of the urinary tract. Several clinical studies have shown the efficacy of D-mannose in preventing recurrent UTIs and treating acute uncomplicated UTIs in women. Three days of D-mannose monotherapy is 85.7% effective, suggesting that it may be as effective and a promising alternative to antibiotic therapy. (12)

Probiotics: may help prevent UTI development by competitively excluding pathogenic organisms in the vagina, urinary tract, and gastrointestinal tract, producing compounds that inhibit the growth of these pathogens, and maintaining a proper bladder pH. Supplementation of Lactobacillus spp. has been shown to help prevent recurrent UTIs long-term. (11)

Evidence shows that hormone replacement therapy using topical vaginal estrogen normalizes vaginal flora, reduces the risk of vaginal atrophy, and prevents recurrent UTIs.

Stress Reduction for Recurrent UTIs

Recurrent UTIs can significantly interfere with daily activities of living, relationships, and sleep, contributing to emotional distress and feelings of frustration, worry, and anger. Understanding this, a holistic treatment plan should incorporate mind-body therapies to alleviate stress and the emotional burden of recurrent UTIs.

Acupuncture is a form of mind-body medicine with evidence to support that it may prevent recurrent UTIs in adult women. Studies have demonstrated that the rate of UTI among cystitis-prone women treated with acupuncture was one-third the rate of that among untreated women and half the rate among women treated by sham acupuncture (9).

Hygiene Practices for Recurrent UTIs

Using good genital hygiene practices is one of the best ways to prevent UTIs. People with vaginas should always wipe from front to back to avoid moving bacteria from the rectum into the urethra. Regularly changing period products, like pads and tampons, and thoroughly cleaning sex toys can prevent bacterial spread to the urinary tract. Avoid douching and using deodorants on the vagina. (3, 13)

Stay hydrated. Drinking plenty of water daily ensures that you urinate frequently, which empties the bladder and helps to flush out bacteria from the urinary tract. Avoid holding your bladder and urinate when you feel the urge. Urinating before and after sex is also important to flush out bacteria introduced to the urethra during sexual activities. (3, 13)

People who use diaphragms and spermicide as birth control have an increased risk of developing UTIs. Other forms of birth control are available for those prone to recurrent UTIs. (3, 13)

Tight-fitting clothing can create a moist environment, promoting bacterial and fungal growth. Wear loose-fitting clothing and cotton underwear to prevent moisture accumulation around the urethra. (3)

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Summary

Urinary tract infections are common, especially in the female population, given the anatomy of the urinary tract in relation to the vagina and anus. Recurrent UTIs are diagnosed when a person experiences two in six months or three in one year. The conventional approach to recurrent UTIs emphasizes repeat courses or daily low doses of antibiotics, which can be associated with high costs, adverse effects, and drug resistance. Additionally, this approach doesn't address the root of the problem.

An integrative approach to recurrent UTIs involves identifying and correcting the sources of infection. UTI prevention is possible by using complementary and integrative modalities to correct dysbiosis, optimize structural tissues, and prevent contamination of the urinary tract.