Psychosocial impact of recurrent urogenital infections: a review

Abstract

Recurrent urogenital infections such as bacterial vaginosis, vulvovaginal candidiasis, and urinary tract infections have a high prevalence and pronounced psychosocial impact. However, no review has compared the psychosocial impacts across infection types. This narrative review discusses the impact of common recurrent urogenital infections on psychosocial aspects, including quality of life, stress, mental health, sexual health, work productivity, race and ethnicity, and satisfaction of medical care. Validated questionnaires show that women with recurrent vulvovaginal candidiasis and urinary tract infections have decreased scores on all aspects of quality of life. Those with recurrent vulvovaginal candidiasis and urinary tract infections show lower mental health scores compared to the general population, with increased risk of anxiety and depression. Recurrent urogenital infections affect sexual relationships and intimacy, including avoidance due to symptoms or as a method of prevention. Recurrent infections also increase medical cost and negatively affect work productivity, leading to a combined estimated cost of over US$13 billion per year. There are clear effects of racial inequality involving minority populations that affect diagnosis, treatment, prevalence, and reporting of recurrent urogenital infections. Satisfactory medical treatment improves quality of life and mental health in those suffering from these conditions. Research evaluating psychosocial aspects of recurrent urogenital infections is variable and is not comparable across vulvovaginal conditions. Even so, psychosocial factors are important in understanding contribution and consequence of urogenital infections. Education, awareness, normalization, community support, and access to care can help to alleviate the negative implications of recurrent urogenital infections.

Plain language summary

A narrative review discussing the psychosocial impact of common recurrent urogenital infections and highlights areas where further research is needed to improve clinical care.

Introduction

Recurrent urogenital infections, such as bacterial vaginosis (BV), vulvovaginal candidiasis (VVC), and urinary tract infections (UTIs) are the most commonly diagnosed infections among women. These infections are highly prevalent and have a much larger impact on society than is currently recognized.

Along with the discomfort, irritation, and pain associated with these conditions, there is a large social stigma associated with urogenital infections. For many women, discussing urogenital issues is often not culturally acceptable, leading to feelings of shame and embarrassment. ¹ In addition, the healthcare system does not routinely recognize the impact of urogenital infections on mental health. These mental health impacts range from stress to depression and anxiety. This is more pronounced in women suffering from recurrent episodes.^2,3 This review discusses the impact of common recurrent urogenital infections, focusing on BV, VVC, and UTIs, on psychosocial aspects, including quality of life, stress, mental health, sexual health, work productivity, race and ethnicity, and satisfaction of medical care.

Background on urogenital disorders

BV

BV is the most common vaginal condition worldwide in reproductive aged women (age = 15–44 years). ⁴ Approximately 30% of women are diagnosed with BV each year, with increased prevalence in non-white women (51% African American, 32% Mexican). ⁵ BV has been associated with increased risk of sexually transmitted infection (STI) infection, pregnancy complications (preterm birth ⁵ and miscarriage), ⁶ fertility issues, ⁷ and gynecological cancers.^8,9 According to a recent review and meta-analysis, the estimated global economic burden of BV is US$4.8 billion annually. This figure is nearly tripled when considering BV’s association with preterm birth and human immunodeficiency virus (HIV). ¹⁰

While the exact cause of BV is unknown, it is characterized by a decrease in vaginal Lactobacillus, an increase in microbial diversity and an overgrowth of disruptive bacteria. ⁴ It should be noted that many people with diverse vaginal microbiota are asymptomatic;^11,12 therefore, it is unclear if these women have “asymptomatic BV” or a “healthy” diverse vaginal microbiome. ¹¹

The most common symptoms of BV are increased white or gray vaginal discharge along with a strong, unpleasant, or fishy vaginal odor.^4,5 Because the etiology of BV is unknown, diagnosis often relies on symptom assessment and qualitative methods. Clinical diagnosis of BV follows the Amsel criteria. The Amsel criteria require that a patient has three of the following diagnostic criteria: white discharge, a pH greater than 4.5, clue cells, and a fishy odor.^13,14 However, these criteria are not consistent in those with suspected BV, and thus, the Amsel criteria is considered unreliable. ¹⁴

A second method for diagnosing BV is a microscopic evaluation called Nugent score and it is primarily used for research purposes. A vaginally collected sample is given a score from 1 to 10 based on the presence of three bacterial morphotypes: Lactobacillus, Gardnerella, and curved gram rods. ¹⁵ A score of 0–3 indicates “normal” lactobacilli, 4–6 intermediate, and 7–10 indicates high diversity and a positive BV diagnosis. ¹⁵ Although the Nugent criteria are considered the gold standard by the World Health Organization (WHO), it only measures the morphological diversity of bacteria within a sample ⁴ and does not provide indication of function or pathogenicity of those bacteria. Many women (particularly black and Hispanic women) have a diverse vaginal microbiome and are asymptomatic. Thus, using the Nugent score for diagnosis may incorrectly categorize a substantial population of patients.

BV is treated with 5–7 days of metronidazole or clindamycin; ¹⁶ however, recurrence is common with over 50% recurring in 6–12 months following treatment. ¹⁷ Recurrent BV is usually defined as three or more episodes per year. ¹⁸ Subsequent symptomatic episodes may or may not be clinically validated prior to treatment. In addition, post-antibiotic yeast infections occur in 10%–30% of women. ¹⁹

VVC

VVC, or yeast infections, is caused by an overgrowth of the yeast Candida, with Candida albicans accounting for 85%–90% of cases. ²⁰ VVC is the second most common vaginitis after BV, ²¹ with 75% of women experiencing one or more episodes of VVC in their lifetime. ²² VVC has a high recurrence rate (4+ episodes per year), with an estimated 28% of people having a second episode within 12 months. ²³

Diagnosis of VVC relies on detection of Candida using either microscopy or yeast culture in the absence of other infections. ²⁴ Over-the-counter topical or intravaginal treatments for VVC are widely available and formulations include either Clotrimazole, Miconazole, or Tioconazole. ¹⁶ Recommended prescription treatments include intravaginal Butoconazole or Terconazole or oral Fluconazole. ¹⁶

The symptoms of VVC often overlap with other forms of vaginitis, such as vulvar itching, irritation, swelling, and burning. ²¹ VVC is often accompanied by abnormally thick cheese-curd textured white, green, or yellow discharge. ²¹ Studies have shown that 77% of clinical diagnoses ²⁵ and 69%–74% of self-diagnosis are inaccurate.^26,27 Inaccurate diagnosis leads to overuse and misuse of over-the-counter antifungals, resulting in a presumption of recurrence ²⁸ and feeling “incurable.” VVC is likely the most commonly known and culturally accepted form of vaginitis leading to many people with vaginitis presuming and seeking treatment for presumed yeast infection. ²⁸ In addition, access and prevalence of over-the-counter treatment options allow for women to treat symptoms without confirming their diagnosis.

UTIs

UTIs are considered one of the most common bacterial infections, affecting 150 million people worldwide each year ²⁹ and primarily affect women. Nearly 1 in 3 women will have experienced at least one UTI before age 24 years, ³⁰ and almost 50%–60% of adult women will experience at least one UTI in their lifetime with incidence increasing with age. ³ Recurrent UTIs (3+ in 1 year) are quite common, with 27% of women experiencing a second UTI 6 months following their first. ²⁹

Symptoms of UTI include urinary frequency, urgency, and dysuria, sometimes accompanied by hematuria. Uropathogenic Escherichia coli (UPEC) is considered the primary cause of both complicated and uncomplicated UTIs, and it is estimated to be responsible for 80% of all UTIs. ³ However, UTIs can be caused by both Gram-positive and Gram-negative bacteria, as well as certain yeast species.

UTIs are most commonly diagnosed with a urine dipstick (test strip) or standard urine culture, both of which are only 50%–80% accurate.^31,32 As with BV, reliable diagnostics do not exist for UTIs. Twenty percent of women who experience UTI symptoms have a negative standard culture. ³³ This is because the standard urine culture was optimized to grow E. coli and thus misses 50% of non-E. coli uropathogens. ³²

The most common treatment for symptomatic UTIs is antibiotics, with type and dose dependent upon the causative organism. However, treatment with long-term prophylactic antibiotics can lead to alterations of the vaginal and gastrointestinal microbiome and contributes to antimicrobial resistance. ²⁹

Psychosocial factors associated with recurrent genitourinary infections

Quality of life

VVC, BV, and UTIs each have different causes and unique symptoms, but they also share a number of commonalities. First, each infection disproportionately affects women.^4,22,30 Due to the historic lack of resources allocated to diseases affecting women,^34,35 these infections are severely understudied. Second, there is a social stigma surrounding these infections, and therefore, many women express feelings of embarrassment, shame, and distress.^1,36–39

The social stigma results in a wide range of emotional and behavioral responses. For example, women with recurrent bacterial vaginosis (rBV) report avoiding social situations, avoiding personal contacts at work, and engage in costly and often time-consuming personal hygiene rituals to mask the vaginal odor that accompanies BV.^1,40 In addition, women with rBV often express a desire for isolation or social withdrawal during episodes.^1,40 Women with recurrent urinary tract infection (rUTI) report a decreased ability to interact in social situations. ⁴¹ Post-menopausal women with rUTIs report feeling like a burden to their family and may fear leaving the house, both of which result in increased isolation. ³⁸

Across multiple studies, all three infections show a consistent and detrimental effect on quality of life. Women with recurrent vulvovaginal candidiasis (rVVC) consistently report decreased overall quality of life compared to controls. ⁴² These effects are observed across social, psychological, and financial indicators. ⁴² Over a decade ago, Birmingham and Ashe ⁴³ reviewed the literature on the impact of UTIs on quality of life and found that across 12 studies UTIs had a detrimental effect across all aspects of life. Since then, additional studies have shown a decreased overall quality of life in women who suffer from UTIs, including an impact on mental health,^38,44 sexual activity, ⁴⁵ everyday activities,^38,44,46 and severity based on UTI incidence.^38,44,47

The study of these three infections differs often using different questionnaires and including different populations (Tables 1 and 2). For example, UTI and VVC studies use the Short Form (SF)-36 questionnaire which is a validated quality of life survey that measures physical, social, and psychological aspects through 36 questions, ⁴⁸ while BV studies do not (Table 2). Using this questionnaire, studies have shown that women with VVC had significantly lower scores across all domains of the questionnaire compared to the general population. ⁴⁹ A strength of this questionnaire is that its use allows for comparison across multiple diseases. One group found that rVVC was as disruptive to a patient’s mental health as living with diabetes (64.87 vs 64.9) and more disruptive to their physical score than patients with type 2 diabetes (63.05 vs 67.4). ² Another group found that suffering from rVVC has a similar impact on a patient’s quality of life as asthma or chronic obstructive pulmonary disease (COPD). ⁴⁹ Research has found that compared to asymptomatic women, women with acute UTIs have significantly lower perception of general health, worse pain, lower social function, and worse emotional wellbeing. ⁵⁰

Table 1.

Summary of studies organized by infection type.

Citation	Patient population	Age (years)	N	Administered questionnaire	Diagnostic	Recurrence	Race/ethnicity
A. Vulvovaginal candidiasis (VVC)
Ehrström et al. 51	Reproductive aged women	27.5	Study = 35 Controls = 35	Docco questionnaire	Fungal culture	4+ in 1 year	NR
Ehrström et al. 52	Reproductive aged women	27	Study = 33 Controls = 28	Docco questionnaire	Fungal culture	4+ in 1 year	NR
Irving et al. 53	Reproductive aged women	29	Study = 28 Controls = 16	Hospital Anxiety and Depression Scale (HADS) Satisfaction with Life Scale (SWLS) Rosenberg Self-Esteem Scale (RSE) Perceived Stress Scale (PSS)	Fungal culture	2+ in past 6 months	White
Aballea et al. 49	Research panel respondents	30	620 across 6 countries	EQ-5D SF-36	Self-reported	4+ in 1 year	NR
Nyirjesy et al. 54	New clinic patients	33.1	Study = 38	Center for Epidemiologic Studies Depression scale The Cohen PSS John Henry scale	Symptoms and positive fungal culture	Unclear	Majority white (61%–92%)
Zhu et al. 2	New clinic patients	30.9	Study = 102 Control = 100	SF-36	Symptoms and positive fungal culture	4+ in 1 year	Chinese
Akimoto-Gunther et al. 55	Sexually active patients	18–50	VVC = 22 rVVC = 26 Controls = 206	Specific to study	Symptoms and positive fungal culture	Unclear	NR
Moshfeghy et al. 56	Reproductive aged women	NR	rVVC = 50 Controls = 50	Female Sexual Function Index (FSFI) Depression Anxiety Stress Scales (DASS)	Fungal culture	4+ in 1 year	NR
Giraldo et al. 57	New clinic patients	Age 18–50	rVVC = 11 Controls = 29	FSFI	Symptoms and positive fungal culture	4+ in 1 year	Majority white (72%–83%)
Fukazawa et al. 42	Reproductive aged women	30.9	Study = 100 Controls = 101	World Health Organization Quality of Life Abbreviated Assessment (WHOQOL-Bref)	Fungal culture	4+ in 1 year	Majority white (82%–88%)
Chappel et al. 91	Women purchasing VVC medication	18–74	Study = 209	Semi-structured interviews	NA	NA	NR
B. Bacterial vaginosis (BV)
Culhane et al. 58	First trimester pregnant	24.1	Study = 224 Controls = 166	PSS	Nugent score	NA	Majority African American (62%)
Culhane et al. 59	First trimester pregnant	24	Study = 1371	PSS Objective stressors: housing, interpersonal conflict, material hardship, neighborhood danger/safety	Nugent score	NA	Majority black (67%)
Nansel et al. 60	Non–pregnant Tracked quarterly for 1 year	15–44	Study = 3614	PSS	Nugent score	NA	Majority black (percentage not given)
Harville et al. 61	Pregnant women (before 20 weeks)	Reproductive aged	Study = 897	Phone interviews PSS Spielberger State-trait Anxiety Inventory Sarason Life Experiences Survey Medical Outcome Study Social Support Scale	Nugent score Intermediate scores were included in the BV negative group	NA	22% African American 68% white
Payne et al. 40	African American women with history of BV	36.5	Study = 23	Semi-structured in person recorded interviews with nurse practitioners	NA	NA	African American
Bilardi et al.1,36,37	Women with history of BV	18–45	Study = 35	Semi-structured interviews	Not reported	NA	NR
Bilardi et al. 62	Women with history of BV	20–49	Study = 103	Semi-structured interviews	NA	NA	NR
Wigan et al. 63	Men with a female partner with BV	28	Study = 9	Semi-structured interviews	NA	NA	NR
Borgogna et al. 64	Northwestern Plains American Indian women	30	Study = 70	American Indian Service Utilization, Psychiatric Epidemiology, Risk and Protective Factors Project (AI-SUPERPFP) survey Rosenberg Self-Esteem Scale (MAQ) Instrument Scale Center for Epidemiological Studies Depression Scale Historical Loss Scale (HLS)	16S—molecular-BV defined as CSTIV/highly diverse	NA	American Indian
C. Urinary tract infections (UTIs)
Ellis and Verma et al. 50	Time of UTI diagnosis	18–64	Study = 47 Controls = 71	SF-36	Physician diagnosed	NA	NR
Ciani et al. 45	Clinic patients with history of UTI	44	Study = 309	Medical records Study-specific questionnaire including a visual analogue scales (VAS) for QoL measurements	NA	3+ in 1 year	NR
Renard et al. 47	rUTI on prophylactic antibiotics	46.3	Study = 575	Hospital Anxiety and Depression (HAD) Leicester scale—measures impact on QoL from urinary symptoms	NA	3+ in 1 year	Multi-country recruitment. But race was not reported
Eriksson et al. 38	History of rUTI	67–96	Study = 20	Semi-structured interviews	NA	2+ in 1 year	NR
Flower et al. 46	NA—posts on an rUTI forum	13–65	Study = 7,870	The Cystitis and Overactive Bladder Foundation (COBF) online questionnaire	NA	NA	NR
Ennis et al. 41	Post-menopausal women	67–96	Study = 85 Control = pop references	SF-36	Symptoms plus positive SUC	2+ in 1 year	Singaporean: 59% Chinese, 7% Malay, 9% Indian, and 25% others
Ghouri et al. 65	Analysis of posts on a pregnancy forum	30–40	675 users in 202 threads	Categorize online posts about UTIs	NA	NA	NR
Wittman et al. 66	History of UTI	50–64	Study = 162	Online questionnaire	NA	3+ in 1 year	NR
Gonzalez et al. 39	Online posts from women with UTIs	NA	53,460 users 83,589 posts 859 websites	Digital Ethnography to categorize online posts about UTIs	NA	NA	NR

NR: not reported; VVC: vulvovaginal candidiasis; rVVC: recurrent VVC; NA: not applicable; QoL: quality of life; SUC: standard urine culture; CSTIV: community state type IV; SF-36: Short Form-36.

Table 2.

Summary of currently published literature by disorder.

	VVC	BV	UTI
Total number of studies	11	9	9
Average N of study group	116	638	1218
Type of questionnaire used:
SF-36	18% (2/11)	0	22% (2/9)
Semi-structured interviews	9% (1/11)	44% (4/9)	11% (1/9)
Perceived Stress Scale (PSS)	18% (2/11)	44% (4/9)	0
Depression/anxiety scales a	36% (4/11)	11% (1/9)	11% (1/9)
Race/ethnicity reported:
Did not report	55% (6/11)	27% (3/11)	88% (8/9)
Did not report or reported majority white	90% (10/11)	27% (3/11)	88% (8/9)

VVC: vulvovaginal candidiasis; BV: bacterial vaginosis; UTI: urinary tract infections; DASS: Depression Anxiety Stress Scales; HAD: Hospital Anxiety and Depression Scale; SF-36: Short Form-36.

^aIncludes EQ-5D, DASS, Center for Epidemiologic Studies Depression Scale, and HAD.

Pain

Unlike VVCs and UTIs, BV is not normally associated with pain. From an online survey using a validated questionnaire, Aballéa et al. ⁴⁹ reported that women with rVVC had significantly higher levels of pain and discomfort (p < 0.0001) when compared to the population norm. Ennis et al. ⁴¹ used the SF-36 questionnaire to compare the results from patients with rUTI to those from the general population adjusted for age, gender, and ethnicity. They found that pain had the highest impact on overall quality of life ⁴¹ In fact, Ciani et al. ⁴⁵ found that women with UTIs are in significantly more pain than healthy individuals, and Maxwell et al. ⁴⁴ found that pain, rate of recurrence, and symptom burden had the greatest effect on an rUTI women’s overall quality of life.

Stress

Life stressors, from dramatic life changes to physical danger, all activate the hypothalamic–pituitary–adrenal (HPA) axis resulting in increased levels of cortisol. Levels of perceived stress have been associated with changes in a range of physiologic functions including the immune response ⁶⁷ and dysbiosis in both the gut ⁶⁸ and vaginal ⁶⁹ microbiomes. Cortisol has been shown to dampen certain immune processes while heightening others ⁶⁹ resulting in an ineffective immune activation and poor pathogen clearance. In addition to these immune changes, cortisol also influences the vaginal wall. Research suggests that cortisol decreases the glycogen deposition in the vaginal epithelium ⁶⁹ which results in a decrease in levels of protective lactobacilli. This could be an explanation for how periods of stress can trigger vaginal and urinary infections.

In addition, living with a chronic or recurring infection causes stress. Research has shown that women with rVVC report higher levels of stress ⁵⁶ and perceive their lives as more stressful ⁵³ than healthy controls. Secondarily, women with rBV report acute stress during episodes of BV. ⁴⁰

Other research has shown a correlation between cortisol levels and recurrent symptoms. Under normal conditions cortisol levels are elevated in the morning to promote awakening, and then decrease throughout the day. ⁷⁰ A common measurement of chronic stress is a reduction in the early morning cortisol level. ⁷⁰ Multiple studies have shown a connection between rVVC and blunted morning cortisol levels compared to controls.^51,55 These measurements of chronic stress were also correlated with higher rates of burnout and reports of feeling less meaning in life ⁵² as well as physiological changes such as decreased antioxidant capacity. ⁵⁵

There is also a link between perceived stress and BV.^58,59,71 In pregnant women, higher Nugent scores are associated with higher levels of perceived stress, even after adjusting for socioeconomic and behavioral variables.^58,59 Nansel et al. ⁶⁰ tracked women over time and found that not only was perceived stress associated with developing BV (odds ratio (OR) = 1.29; 95% confidence interval (CI)), but women had 1.28 greater odds of getting BV with a 1-point increase in their perceived stress score. In addition, a diverse vaginal microbiome has been correlated with high rates of trauma and stress in American Indian women. ⁶⁴

Depression and anxiety

There is a strong link between urogenital infections and mental health, particularly in women who suffer from recurrent infections. While the sample size of many studies is small, there is a high correlation between depression and anxiety with rVVC occurrence.^49,56,53 In a study comparing the frequency of different vaginitis conditions, it was reported that 42% of women diagnosed with rVVC also have depression or anxiety. ⁵⁴ In a separate study, women with rVVC had significantly lower mental health scores on the SF-36 questionnaire compared to controls. ² Based on analysis of data for the 2012 National Ambulatory Medical Care Survey, women with VVC are twice as likely to receive prescriptions for antidepressants as women being seen for contraception use. ²³

Very few studies have quantitatively measured depression and anxiety in women with BV. One study looking at perceived stress in pregnant women with BV found that BV was not associated with “trait anxiety” (how a person generally feels) but was associated with “state anxiety” (current feelings of anxiety) (OR = 2.0, 95% = CI 1.2–3.3). ⁶¹ However, the authors found that this correlation disappeared when the model was adjusted for race, age, and income (OR = 1.3, 95% CI = 0.7–2.4). ⁶¹

For UTIs, Ennis et al. ⁴¹ found that all mental health scores in their UTI cohort were significantly lower than the adjusted general population scores. In addition, rUTIs are associated with anxiety and depression, particularly with the sudden, painful, yet unexpected onset of an episode. ³

Sexual health and satisfaction

Recurring urogenital symptoms and infections take a toll on romantic and sexual relationships. Fifty seven percent of women with rVVC reported that yeast infections strained their relationships and 78.6% reported that it affected their sexual activity. ⁵³ Studies using the validated Female Sexual Function Index (FSFI) questionnaire report that women suffering from rVVC have fewer orgasms and decreased sexual satisfaction compared to controls, but no difference in desire, arousal, lubrication, or pain.^56,57

The relationship between BV and sex has been controversial. BV is not classified as an STI, and men do not show symptoms of BV, ⁶³ even though they carry BV-related bacteria on their penis. ⁷² However, women consistently report sex as a primary trigger for BV.^37,62 It was only recently that the Centers for Disease Control and Prevention (CDC) published an opinion stating that there was enough evidence to support that BV can be sexually transmitted, ⁷³ but it is still not widely accepted as an STI. This lack of clear communication has led to complicated emotions and behaviors regarding sex and BV with public health communication implications.

Consistently, women report that BV has an immense impact on their sexual intimacy.^1,40,66 Women with BV report feeling self-conscious and shameful about vaginal odor resulting in strains to their sexual relationships, a desire to remain abstinent, ⁴⁰ or to refrain from certain sexual practices or positions. ¹ Due to the stigma around vaginal odor, some partners respond poorly when the subject of BV comes up, ¹ further reinforcing the misconception that vaginal odor is due to poor hygiene practices or an indication of infidelity.^1,63 When women were asked about lifestyle changes, they implemented to prevent BV from recurring, changes in sexual practices were most commonly stated. ³⁶

Sexual activity is consistently associated with BV recurrence; therefore, partner involvement in treatment may provide an avenue to prevent continued re-infection. Because there is no diagnostic, and men do not typically show symptoms, it can be hard for partners to accept treatment for BV. Most men reported that they primarily participated in treatment to support their partner,^1,63 aligning with the common misconception that BV is a “female issue.” Male participants reported that if they were in a causal relationship, they would be unlikely to participate in any BV prevention. ⁶³ However, if BV were classified as an STI, it could lead to greater stigmatization. For example, many men reported that if BV was an STI, then sudden onset of BV symptoms would lead to suspicions of infidelity. ⁶³ Public health messaging should consider how an STI designation would impact probability of partner treatment, as well as public perception of an already stigmatized and misunderstood condition.

The connection between sex and UTIs is long standing. Sexual intercourse and sex with a new partner are known risk factors for UTIs. ⁷⁴ It is commonly recommended that women urinate after sex to rinse the urethra of contaminating organisms;^39,66 however, the effectiveness of this practice has never been scientifically validated. ⁷⁴ A recent large-scale analysis of over 80,000 social media posts from women suffering from UTIs found that women with UTIs often abstain from sex in order to prevent recurrence. ³⁹ One study showed that 78% of women with UTIs indicated impaired sexual activity due to the UTI episodes, ⁴⁵ and women with rUTIs were significantly less sexually active than those with a single acute UTI. ⁴⁵ During a UTI episode, many post-menopausal women report an understandable lack of interest in sex. ³⁸ Women with a history of UTIs reported that this history caused them to refrain from or avoid sex, ⁶⁶ further explaining that refraining from sex was a method to prevent infection.^39,66

Cost and impact on work productivity

BV and VVC are the two most common types of vaginitis, ²¹ and UTIs are one of the most common bacterial infections across all age groups. ⁷⁵ VVC is estimated to cost US$2.84 billion a year, ²³ BV estimated at US$4.8 billion a year, and UTIs estimated at US$6 billion per year in the United States (a 2001 estimate). ⁷⁶ These numbers increase when considering the secondary impact on preterm birth and STI acquisition. ⁷⁷ However, the economic costs extend past the medical industry and include missed work and lost wages.

Women with rVVC miss an average of 6 h of work per VVC episode. ⁴⁹ Statistics for the impact of BV on work are lacking, but many women report missing work due to vaginal odor. ⁴⁰ In addition, embarrassment around vaginal odor leads to reluctance to work in close quarters, use public restrooms, and requires frequent perineal care during the day,^1,40 contributing to decreased focus and productivity.

The economic costs of UTIs have recently been estimated to be US$3.5 billion per year in combined medical costs and time missed from work. ²⁹ In an analysis of the costs per episode of UTIs, it was estimated that the first episode costs more than any subsequent episode because women see more doctors, do more diagnostic testing, and take more antibiotics. ⁴⁵ However, women who failed clinical treatment missed more work hours overall than those that respond to treatment. ⁷⁸ These data unsurprisingly suggest that even though the costs per episode decreases over time, the overall economic burden is much greater for rUTIs than acute UTIs.

Race and ethnicity

The effect of race and ethnicity on quality-of-life measurements to rVVC is poorly studied and therefore poorly understood. With the exception of a study conducted in China, ² all of the current data includes a predominantly white female population (Table 1). Many studies failed to even report race or ethnicity (Tables 1 and 2). Only one study compared white and black population suffering from rVVC and found that black women had significantly lower perceived quality of life (p = 0.02); however, only 1%–4% of subjects in this study self-identified as black. ⁴²

It has been widely reported that black and Hispanic women have a higher rate of BV ⁷⁹ and more commonly have diverse vaginal microbiomes compared to white and Asian women. ¹² In addition, black women have higher rates of preterm birth. ⁸⁰ This has often been explained as a result of differences in socioeconomic status or lifestyle factors, such as sexual behavior and hygiene practices (i.e. douching).^79,81,82 However, what is not commonly discussed are the effects of inequality and racism on vaginal health of minority populations.

In the early 2000s, Culhane et al.^58,59 conducted a series of studies looking at the rates of BV in first trimester pregnant women at clinics in Philadelphia. Both studies were done with a majority of black participants (62% and 67%, respectively, Table 1). They found that perceived stress was linearly correlated (almost in a dose-dependent manner) with higher vaginal diversity (as measured by Nugent scores), even after adjusting for sociodemographic and behavioral risk factors (OR = 2.2, 95% CI = 1.1–4.2). ⁵⁸ In a second study, Culhane et al. ⁵⁹ found racial differences in objectively stressful exposures, such as housing instability, overcrowding, food insecurity, lack of access to medical care, harassment, street violence, and risk of assault. Across the board, black women had higher rates of these stressors, with Hispanic women often following. The authors then included these stressors into a prediction model for BV, which reduced the racial disparity in rates of BV. ⁵⁹ In fact, when community level stressors were taken into account, such as neighborhood violence and housing insecurity, it decreased the odds ratio between black-to-white BV incidence by 21%. ⁸³

A recent study by Borgogna et al. ⁶⁴ looked at the vaginal microbiome and rates of molecular BV in 70 Northwestern Plains American Indian women. American Indians have the highest rates of stress and high rates of STIs in the United States. ⁶⁴ They found that 66% of women had a diverse microbiome, identified as community state type IV (CSTIV), the highest reported in any population. ⁶⁴ The authors went on to also find a strong correlation between levels of lifetime trauma and vaginal diversity (OR = 2.5; 95% CI = 1.1–5.3). ⁶⁴

All these data suggest that the difference in vaginal microbiome composition between white, Asian, black, Hispanic, and American Indian women might not be due to genetics, individual activity, or cultural behaviors, but rather a physiological result of the stress generated by instability, poverty, or racial inequality.

Satisfaction with medical care

Overall, women were satisfied with medical care after the first urogenital infection episode, but satisfaction decreased following each subsequent episode. Part of the problem is the lack of accurate diagnostics and high rates of misdiagnosis. Due to social stigma, knowledge around vaginal infections is lacking. Yeast infections are the most widely accepted cause of vaginal itch. As such, over-the-counter yeast, infection medication is often the first course of treatment. It is only when those treatments fail that many women seek medical care. ³⁶

Recent studies have found that both physicians and patients often misdiagnose vaginal complaints.^25,84 In a study of 220 physician diagnosed people with vaginal symptoms, 61% of BV and 77% of yeast infection diagnoses were incorrect. ²⁵ In a separate study looking at the ability of deployed military women to self-diagnose, they found that 56% accurately self-diagnose for BV and 69.2% for VVC. ²⁶ In yet another study, in which the use of over-the-counter antifungals was studied, it was found that only one-third of people correctly diagnosed VVC. ²⁸ Even given these studies, women continuously reported they would welcome more varied over-the-counter options so they could take care of their vaginal complaints in a more private manner. ³⁶

Women who seek medical care for BV are often frustrated by the lack of consistent messaging and understanding from physicians, as well as lack of treatment options. ³⁶ Many women with BV reported feeling dismissed and told, “it’s just something to deal with” or “it will resolve itself.” ³⁶ Many of these women have been through multiple rounds of antibiotic treatments that only provide short-term relief. This prompts them to turn to alternative home remedies and lifestyle changes. Home remedies range from over-the-counter (OTC) supplements and douches to homemade suppositories and treatment baths. ⁶² Lifestyle changes include wearing cotton underwear, showering frequently, and abstaining from sex. ⁶²

The quality of life for women with rUTIs is also improved by satisfactory medical treatment. Overall, quality of life, depression, and anxiety all improve in women with rUTI once on prophylactic treatment. ⁴⁷ This includes impact on activities such as making short trips outside the home, interest in hobbies, social and family interactions as well as impact on feelings such as embarrassment, depression, fear, guilt, and shame. ⁸⁵ The same has been reported for post-menopausal women with UTIs who have had adequate care and alleviation of symptoms. ³⁸

As stated previously, the cost of medical care per UTI episode goes down with subsequent episodes. The authors of this study called this phenomenon the “cost of resignation” because these women lose faith in the medical system and resign themselves to recurrent UTIs. ⁴⁵ Other women report frustration in the medical system because they do not feel that their symptoms fit the textbook definition of a UTI. ⁴⁶ In a study of 83,589 online posts around UTIs, 25.7% of posts were looking for community support suggesting that women are not receiving support from family or medical institutions. This study found that the majority of posts were regarding treatment options, from self-management strategies (13.3%), antibiotics (10%), alternative therapies (6.7%), and to access to care (6.7%). ³⁹ In countries without universal healthcare, medical insurance is required to access the numerous doctor visits and prescriptions associated with rUTI. Many women report feeling anxious about affording care or losing health insurance, ³⁹ thereby worsening perceived stress and anxiety.

Finally, there is hesitation around continued use of antibiotics for rUTIs. Many women express a desire for new or alternative treatments. ³⁹ There is concern that antibiotics have downstream effects on the microbiome of other body sites such as the gastrointestinal tract, ³⁹ developing antibiotic resistance,^39,46 or concerns over antibiotic use during pregnancy.^39,65,86 To improve satisfaction with care, more research should be aimed at identifying alternative non-antibiotic treatments for urogenital infections.

Discussion

Urogenital infections are commonly diagnosed in women of all ages. Yet these infections are understudied and often dismissed as transient and non-life-threatening health concerns. These infections, particularly when they recur, have a large impact on every aspect of a woman’s life. Here, we have reviewed the impact of urogenital infections on quality of life, stress, mental health, sexual health, economics, and work productivity. In addition, we discuss how a woman’s experience of urogenital infections varies based on race and ethnicity, and their satisfaction with the care they receive.

Recurrent infections are often associated with decreased quality of life, heightened stress, depression, and anxiety. Some studies go so far as to show that recurrent infections have a similar impact on mental and physical health compared to COPD, asthma, or type 2 diabetes.^2,49

There are a few caveats to comparing across studies of vaginal infections. First, the definition of recurrence differed by infection and study (Table 1). The definition of rUTI ranged from 2 or 3 episodes per year (Table 1), while the definition of rVVC is 4+ episodes a year (Table 1). Interestingly, there were no studies comparing the quality-of-life differences in recurrent BV to single episodes of BV (Table 1), perhaps due to insufficient diagnostics or less acute onset of symptoms. Currently, it is assumed that BV is a chronic condition, as opposed to occurring in acute episodes.^36,38,62

Second, the majority of studies have low sample sizes (between 20 and 100 per cohort, Tables 1 and 2). However, even given this caveat, the results are consistent across studies suggesting a strong correlation between urogenital infections and impacts on quality of life.

Third, there is very little information on how stage of life corresponds to impact on the quality of life during urogenital infections. The majority of these studies were conducted on reproductive aged women. While a few studies focused exclusively on pregnancy and BV^58,59,61 or pregnancy and UTIs,^65,86 the coverage is inconsistent. It is known that the incidence of UTIs increases following menopause; however, only one study looked at the post-menopausal UTI population. ⁴¹

It is well documented that chronic stress is associated with impaired immune function ⁶⁷ resulting in increased rates of infection. ⁸⁷ In addition, stress is often a trigger for depressive episodes. ⁸⁸ It is also acknowledged that recurrent urogenital infections also contribute to stress and impacts on mental health. Determining cause and effect between stress, depression, or anxiety and recurrent urogenital infections is difficult to decipher. For example, women with BV report that symptoms have a severe impact on their daily lives, ¹ and when symptoms recur, they report feelings of helplessness and lack of control. ¹ Paired with behaviors of social isolation^1,40 and ritualistic hygiene regiments, ⁴⁰ this creates an environment conducive to feelings of anxiety and depression. Despite the directionality, recurrent urogenital infections are clearly associated with mental health. Counseling and mental health resources should be considered when assessing a patient with recurrent infections.

The negative impact on mental health associated with vaginal infections decreased when patients were satisfied with their medical care. Women with recurrent UTIs show improvement in depression and anxiety once they receive prophylactic treatment. ⁴⁷ Frustration with messaging from doctors and lack of treatment options for recurrent infection result in women turning to outside sources for alternative untested therapies.^{36,39,46,65,86} More research is needed to develop better educational platforms to empower women to feel in control of their diagnosis, which can improve their quality of life and decrease impacts on mental health. In addition, future studies are needed to assess if increased social support, mental health support, and education decrease stress, improve quality-of-life, or even reduce rates of recurrence.

As we compiled this research, we found a discrepancy between the types of studies and the types of infections. Studies on VVC tended to be more quantitative in their assessment of quality of life and mental health. These studies relied on validated standardized questionnaires such as the SF-36 and a variety of depression and anxiety scales (Table 2). In contrast, the studies on BV tended to be more qualitative in nature, relying on semi-structured interviews by trained professionals (Table 2). The only exception being the use of the Perceived Stress Scale (PSS) which was used in both BV and VVC research but not in UTI research (Table 2). Studies on UTIs were a mix of validated questionnaires like SF-36 (Table 2) and either semi-structured interviews or analysis of online posts (Table 1). Because of this discrepancy, there are no metrics with which to compare the three infections.

In addition, in medical literature, BV is not typically associated with pelvic pain ¹⁸ but rather “vaginal discomfort.” ⁸⁹ Yet the distinction between pain and discomfort has never been defined, and the true levels of pain during BV have not been quantified. Here again using a validated questionnaire, like the SF-36, would provide valuable information for comparing BV symptoms to other urogenital disorders.

We also found a discrepancy in reporting race and ethnicity across infection types. Studies focused on UTIs and VVC either neglected to report race or consisted of predominantly white women, while BV studies consisted of predominantly black women (Table 2). While it is known that a greater percentage of black and Hispanic women have a more diverse microbiome ¹² (and thus, higher rates of BV), it has not been shown that white women have higher rates of UTIs or VVC. Yet race was either not reported or the black population was dramatically underrepresented from studies of these respective disorders (Table 2). Future research must take into account racial and ethnic representation in their study populations.

Finally, all the studies assessed individual urogenital diseases, but many of these diseases occur together either as mixed vaginitis or sequential infections.^19,20 An estimated 20%–30% of women with BV also have Candida present, ⁹⁰ and there is an estimated 10%–30% risk of developing post-antibiotic VVC. ¹⁹ Meaning that an individual may clear up one infection only to have to treat another. These statistics are not captured in measurements of recurrence yet would have the same impact on a woman’s quality of life as suffering back-to-back episodes of any single urogenital disease. More research is needed to understand the impact of managing multiple sequential infections and develop methods to support mental health throughout all stages of treatment.

This review was focused on providing an overview of the available literature on the psychosocial impact of urogenital infections, as such it has a few limitations. This review does not focus on clinical recommendations nor does it cover the evidence behind specific impact of behavioral factors on rates of recurrence or the impact of urogenital infection on reproductive health. This review does show that recurrent urogenital infections have a dramatic impact on the emotional, social, and mental wellbeing of patients, and it points out gaps in our current understanding.

Conclusion

Urogenital infections such as VVC, BV, and UTIs have an impact on a wide range of psychosocial factors, including quality of life, stress, mental health, sexual health, work productivity, race and ethnicity, and satisfaction of medical care. When infections are chronic, recurrent, misdiagnosed, or incompletely diagnosed, the impact is further magnified. Although the biological aspect of diagnosis and treatment is essential in urogenital infections, the psychosocial component of these conditions, that so deeply affect quality of life, cannot be discounted. Education, awareness, normalization, community support, and access to care can help to alleviate the negative implications of recurrent urogenital infections. Identification of psychosocial factors is the first step, but the next step will be to focus research and initiatives in this much needed direction.