Recurrent urinary tract infection management and prevention techniques among a population-based cohort of women

Abstract

Introduction:

Recurrent urinary tract infection (rUTI), defined as three or more UTIs in 12 months, has psychological, physical, and financial burden. Many women with rUTI are not satisfied with care and report only starting preventative measures after several infections. The goal of this study is to elucidate current UTI management trends and the implementation of UTI prevention strategies.

Methods:

A web-based study was sent to a national sample of adult women enrolled in ResearchMatch.org. Women were recruited to participate if they had a self-reported UTI in the past 12 months.

Results:

Of the 755 subjects, nearly 30% reported rUTI. Among women with rUTI, more than 50% reported being peri- or postmenopausal, and two-thirds reported vaginal symptoms. 15.8% of women with rUTI reported dissatisfaction with care versus 7.9% of women without rUTI. Most women see their primary care physician for UTI management and only 26% of women with rUTI follow with a urologist. More than 65% of women increase their fluid intake, wipe from front to back, and urinate after sexual activity to prevent UTIs. Significantly more women with rUTI use transvaginal estrogen, cranberry extract, and low-dose prophylactic antibiotics. These interventions appear to be driven by urologists.

Conclusion:

Most women who have had a UTI in the last 12 months implement lifestyle changes to prevent future infections. Most women see their PCP for UTI management and women with rUTI are twice as likely to report dissatisfaction with care. Despite urologists optimizing medical rUTI prevention, they appear to be underutilized.

1 |. INTRODUCTION

Nearly half of adult women will have at least one urinary tract infection (UTI) in their life and 20%–50% of those will experience at least three UTIs in 12 months, defined as recurrent UTIs (rUTIs).^1–3 Women with rUTI often experience significant financial, psychological, and physical burdens.^2,4–6 Many feel neglected by providers, as the negative impact of UTI symptoms on quality of life is frequently dismissed, and that antibiotics are frequently overprescribed with limited emphasis on prevention.⁵ A recent twitter survey captured similar themes regarding UTIs in women, including the profound impact on physical and mental health, inadequate treatment and diagnosis, feelings of limited knowledge about pathophysiology, and gaps in research.⁷ Due to these experiences and feelings of dissatisfaction, women often seek medical management and insights from alternative sources to medical providers, such as online forums, herbalists, and acupuncturists.⁵ Approximately two-thirds of women with rUTI wait until they have experienced four UTIs before beginning prophylactic measures.⁶ When they do seek care, the type of provider managing their rUTI also varies, including family physicians and generalists, urologists, and gynecologists.⁶

Preventive strategies for rUTI are publicly available for both patients and providers. US Federal agencies, such as the National Institute of Health and Centers for Disease Control, provide electronic patient and provider-level recommendations.^8,9 Several professional medical societies have more comprehensive guidelines, including the American Urologic Association (AUA) and American Urogynecologic Society.^3,10 Despite the availability of these resources, implementation remains unclear and care patterns are poorly understood. Current practices among women with rUTI in the general population, whether under the direction of a provider or self-care, remains largely unknown.

Therefore, the goal of this study was to better understand how US women manage rUTI in the general population regarding care patterns and prevention. We hypothesized that women with rUTI underutilize preventative measures and do not follow with specialists. The objectives were to assess UTI prevention strategies among women with rUTI as well as provider choice among a population-based cohort of adult women.

2 |. METHODS

2.1 |. Recruitment

After Institutional Review Board approval (#221171), adult women enrolled in ResearchMatch, a national registry of research volunteers, were contacted with a one-time email advertisement inviting them to participate in an anonymous, web-based questionnaire study. Subjects were invited to share their current management, prevention, and knowledge of UTIs, in addition to preferences regarding obtaining health information about UTIs. The recruitment email clearly stated the target audience of women 18 years of age or older, who have had at least one UTI in the last 12 months. Consent was obtained before starting the survey. Targeted invitations were emailed to individuals between 18 and 110 years old, who identified as female (n = 48 657); we also sent invitations to women aged 18–110 years, who self-identified UTI/UTI as a health condition (n = 246). Participants were incentivized with the chance to win one of ten $100 Amazon.com gift cards. Responses were captured anonymously with REDCap Survey. Invitations were sent to 48 657 women in September 2022; N = 827 subjects (1.7%) consented and elected to participate in the study.

Inclusion criteria included women (18 years or older) who had at least one UTI in the preceding 12 months. Subjects were excluded if they were currently pregnant, did not answer the survey question regarding number of UTIs in past 12 months (N = 66), or had a prior cystectomy (N = 6). After applying exclusions, the study sample included N = 755 subjects (Figure 1) or 91% of those who responded.

FIGURE 1.

Recruitment schematic with inclusion and exclusion criteria. Flowchart produced with Biorender software (https://biorender.com/).

2.2 |. Data collection

2.2.1 |. UTI management and prevention

UTI frequency was self-reported by subjects as the total number of UTIs in the past year. Women were asked “Over the past 12 months, how many UTIs did you have?” Subjects were dichotomized to rUTI if they reported three or more UTIs in the past year versus no rUTI (less than three UTIs), consistent with current definitions.³ Women also reported their age at first UTI. Subjects were asked “What symptoms(s) do you have when you have a UTI? Select all that apply” with answer choices of: Burning with peeing, Blood in urine, Urinary frequency, Bladder pain, Fever, Bladder spasms, Malodorous urine, Cloudy urine, Other, and None of the above. They were asked “Over the past year, which provider(s) have you seen regarding urinary tract infections (UTIs)? Select all that apply,” with options of primary care physician (PCP), urologist, gynecologist, nephrologist, other provider, or do not see a provider. Subjects were asked “Do you have a gender preference for providers who manage your UTIs?” and “Do you have a race preference for providers who manage your UTIs?” Subjects were then asked “Does your provider test your urine for infection (i.e., send for culture)?” with answer choices of Yes, No, or Don’t know. They were then asked “Which test does your provider use to check your urine for infection? Select all that apply” with answer choices of Urine dipstick, Urinalysis, Urine culture, No testing performed, Don’t know. Lastly, women were asked “Do you take antibiotics when you have a UTI?” with answer choices of Yes, No, and Don’t know.

To assess prevention and self-management strategies, subjects were asked “Which of the following do you use to prevent UTIs? Select all that apply” and given the option to free text “other” measures. These strategies were obtained from various resources, but also based on commonly described measures by patients.^3,8,9 Strategies included: increased fluid intake, vaginal estrogen (i.e., cream/tablet/suppository/ring), d-mannose tablets, cranberry extract tablets, cranberry juice, methenamine tablets (Hipprex), Lactobacillus (probiotics), peeing/emptying your bladder after sexual activity, showering instead of bathing, avoiding genital cleansing (i.e., douche), wiping from front to back, preventative low-dose daily antibiotics (taking for >1 month), self-start antibiotics after sexual activity, and avoid delaying a trip to the restroom.

2.2.2 |. UTI management satisfaction

Women also reported their overall satisfaction and ease of UTI care access. Subjects were asked “Please rate your satisfaction with the care you receive for UTIs” and “Please rate how easy it is to get care for your UTIs” and provided 6-point Likert scales (1 = very satisfied to 6 = very dissatisfied and 1 = very easy to 6 = very challenging, respectively). Satisfaction and ease of care were dichotomized to scores 1–3 representing “Satisfied with care” or “Easy to get UTI care,” and 4–6 representing “Dissatisfied with care” and “Challenging to get UTI care”, respectively.

2.2.3 |. Clinical and demographic variables

Participants self-reported age, body mass index (calculated from height and weight), race/ethnicity (including White, Black, and Other [“Other” consisted of Asian, Native Hawaiian or Other Pacific Islander, Hispanic, Prefer not to answer, or Other]), education (including “did not complete high school,” high school graduate/GED, Associate’s or Bachelor’s degree, and Graduate or professional degree), employment status (i.e., work for pay full time, work for pay part time, unemployed, retired, on disability, or other), insurance status (i.e., private, Medicare, Medicaid, military-based, other, or no insurance), and household income (including ≤$19 999, $20 000–$84 999, $85 000–$199 000, $200 000+, and Prefer not to answer). Comorbid medical conditions were also assessed, including diabetes, hypertension, stroke, irritable bowel syndrome, inflammatory bowel syndrome, kidney stones, and radiation to the abdomen/pelvis. Subjects were asked about prior genitourinary procedures, including “Did you deliver at least one baby vaginally (birth canal)?,” “Have you had a hysterectomy or removal of your uterus?,” “Have you ever had surgery for repair of pelvic organ prolapse (e.g., cystocele, rectocele, uterine prolapse, or ‘bladder tack?’,” “Have you ever had surgery for urinary incontinence (i.e., sling procedure)?,” and “Have you ever had any other type of urinary system surgery (i.e., fistula, diverticula, mesh excision, injections)?” with answer responses of Yes, No, and Don’t know. Participants were also asked “Have you ever been told that you have a problem with your bladder emptying as a result of nerves or muscles that supply the bladder not working well?,” “Do you currently use a catheter to empty your bladder?” with answer responses of Yes, No, and Don’t know. Women were also asked about vaginal symptoms (“In the past 30 days, have you had any of the following symptoms? Select all that apply.”), including vaginal itching, vaginal dryness, vaginal burning, pain with sexual intercourse, vaginal bulge, other vaginal symptoms, and no vaginal symptoms. Subjects were also asked “Which of the following best characterizes your current menstrual status?” with answer choices of Premenopausal, Perimenopausal, Postmenopausal, and Don’t know.

2.2.4 |. Statistical analysis

The primary exposure measure was the group designation of rUTI (yes or no). The independent variables were compared between groups, using χ² and Fisher’s exact testing for categorical variables and Student’s t test for continuous variables. Stratification of prevention strategies by provider type (PCP, gynecology, urology, and other) was also performed. SPSS version 26 software was used for analyses; P-value was < 0.05.

3 |. RESULTS

Of the 755 women included in the analysis, 27.8% (N = 210) reported three or more UTIs in the past 12 months and comprised the case group (women with rUTI). The numbers of UTIs are shown in Supporting Information: Figure 1. Comparisons between demographic and clinical variables among women with rUTI versus no rUTI are shown in Table 1. The average number of UTIs over 12 months was 1.3 (SD: 0.48) among women without UTI and 4.3 (SD: 2.1) in women with rUTI (p < 0.001). Women with rUTI were generally older (45.4 vs. 40.9 years, p < 0.001), less educated (high school graduate or GED 25.2% vs. 16.7% without rUTI, p = 0.006), more likely to be on disability (10.5% vs. 4.6% without rUTI, p = 0.01), and more likely to make $19 999 or less (12.9% vs. 6.5% without rUTI, p = 0.01). There were no differences between medical conditions, including diabetes, hypertension, stroke, irritable bowel syndrome, inflammatory bowel disease, kidney stones, and prior radiation to abdomen/pelvis. Women with rUTI were more likely to have prior vaginal delivery (63.8% vs. 52.6%, p = 0.008) and hysterectomy (18.1% vs. 11.2%, p = 0.01); no significant differences in pelvic organ prolapse, incontinence, or other urinary system surgeries were noted between groups (Table 1). Significantly more women with rUTI use a catheter to empty their bladder (3.8% vs. 1.1%, p = 0.03); no differences in bladder emptying were detected (Table 1).

TABLE 1.

Comparison of demographic and clinical variables between women with and without rUTI.

Demographic variables	No rUTI, N (%)	rUTI, N (%)	p
N (%)	545 (72.2)	210 (27.8)
Age (mean ± SD)	40.9 (16.2)	45.4 (16.4)	<0.001
Age of first UTI (mean ± SD)	23.5 (10.1)	23.9 (11.2)	0.58
Average number of UTI over 12 months (mean ± SD)	1.3 (0.48)	4.3 (2.1)	<0.001
Race			0.66
White	395 (72.6)	159 (75.7)
Black	53 (9.7)	17 (8.1)
Other	96 (17.6)	34 (16.2)
BMI	27.5 (7.4)	26.8 (6.9)	0.25
Education			0.006
Associate’s degree or bachelor’s degree	264 (48.4)	104 (49.5)
Graduate or professional degree	190 (34.9)	53 (25.2)
High school graduate (includes GED)	91 (16.7)	53 (25.2)
Employment			0.011
Work for pay, full time	300 (55.0)	100 (47.6)
Work for pay, part time	75 (13.8)	35 (16.7)
Retired	67 (12.3)	33 (15.7)
Unemployed	36 (6.6)	9 (4.3)
On disability	25 (4.6)	22 (10.5)
Other	42 (7.7)	11 (5.2)
Household income			0.03
$0–19 999	35 (6.4)	27 (12.9)
$20 000–84 999	279 (51.2)	100 (47.6)
$85 000–199 999	170 (31.2)	55 (26.2)
$200 000+	31 (5.7)	11 (5.2)
Prefer not to answer	30 (5.5)	17 (8.1)
Insurance			0.096
Private insurance	331 (60.7)	111 (52.9)
Medicare	88 (16.1)	53 (25.2)
Medicaid	66 (12.1)	27 (12.9)
Military-based	13 (2.4)	5 (2.4)
Other	23 (4.2)	8 (3.8)
No insurance	24 (4.4)	6 (2.9)
Clinical variables	No rUTI, N (%)	rUTI, N (%)
Diabetes mellitus	40 (7.3)	19 (9.0)	0.57
Hypertension	111 (20.4)	53 (25.2)	0.20
Stroke	13 (2.4)	2 (1)	0.30
Irritable bowel syndrome	80 (14.7)	44 (21)	0.11
Inflammatory bowel disease	22 (4)	12 (5.7)	0.54
Kidney stones	49 (9)	30 (14.3)	0.06
Radiation to abdomen/pelvis	11 (2)	11 (5.2)	0.08
Prior genitourinary surgeries
Vaginal delivery	263 (52.6)	120 (63.8)	0.008
Hysterectomy	61 (11.2)	38 (18.1)	0.01
Repair of pelvic organ prolapse	21 (3.9)	14 (6.7)	0.17
Urinary incontinence	19 (3.5)	10 (4.8)	0.43
Other urinary system surgery	20 (3.7)	11 (5.2)	0.44
Catheter use
Incomplete bladder emptying	39 (7.2)	26 (12.4)	0.07
Currently using a catheter to empty bladder	6 (1.1)	8 (3.8)	0.03

Abbreviations: BMI, body mass index; rUTI, recurrent urinary tract infection; UTI, urinary tract infection.

For UTI symptoms, more than 80% of subjects reported urinary frequency and burning with peeing (Supporting Information: Table 1). Women with rUTI more commonly experience blood in urine (36.7% vs. 27.2%, p = 0.01), bladder pain (66.7% vs. 51%, p < 0.001), bladder spasms (30.5% vs. 18.2%, p < 0.001), and cloudy urine (72.9% vs. 59.3%, p < 0.001) (Supporting Information: Table 1). Regarding vaginal symptoms in the past 30 days, women with rUTI were more likely to report vaginal dryness (32.9% vs. 25.1% without rUTI, p-0.03), vaginal burning (21.9% vs. 12.3% without rUTI, p < 0.001), and pain with sexual intercourse (26.7% vs. 19.4% without rUTI, p = 0.03) (Table 2). Only 35.7% of women with rUTI reported no vaginal symptoms (vs. 47.5% women without rUTI, p = 0.003). When asked about menstrual status, women with rUTI were significantly more likely to be postmenopausal (37.1% vs. 24.8% without rUTI, p = 0.003).

TABLE 2.

Comparison between self-reported vaginal symptoms in the past 30 days and menstrual status between women with rUTI and no rUTI.

Symptoms	No rTI, N (%)	rUTI, N (%)	p
Vaginal itching	173 (31.7)	74 (35.2)	0.36
Vaginal dryness	137 (25.1)	69 (32.9)	0.03
Vaginal burning	67 (12.3)	46 (21.9)	<0.001
Pain with sexual intercourse	106 (19.4)	56 (26.7)	0.03
Vaginal bulge	16 (2.9)	9 (4.3)	0.37
Other vaginal symptoms	34 (6.2)	17 (8.1)	0.36
No vaginal symptoms	259 (47.5)	75 (35.7)	0.003
Current menstrual status			0.003
Premenopausal	230 (42.4)	61 (29)
Perimenopausal	79 (14.5)	30 (14.3)
Postmenopausal	135 (24.8)	78 (37.1)
Don’t know	56 (10.3)	19 (9)

Abbreviations: rUTI, recurrent urinary tract infection; UTI, urinary tract infection.

When asked about provider type seen during UTI episodes, PCP was the most common choice followed by gynecology overall (Table 3). Among women with rUTI, 26.2% saw a urologist versus only 8.6% of women without rUTI (p < 0.001). Additionally, 5.2% of women with rUTI saw nephrology versus only 1.3% of women without rUTI (p = 0.003). Regarding urine testing, 91.9% of women with rUTI endorse testing versus 85.1% of women without rUTI (p = 0.04) (Supporting Information: Table 2). When asked about the tests ordered by providers, significantly more women with rUTI self-reported urine dipstick (44.3% vs. 27.2%, p < 0.001), Urinalysis (56.2% vs. 42.4%, p < 0.001), Urine culture (59% vs. 41.3%, p < 0.001) (Supporting Information: Table 2). More women without rUTI were unsure of the testing (24.2% vs. 12.9%, p < 0.001). Lastly, 93.8% of women with rUTI take antibiotics during a UTI versus 87.5% of women without rUTI (p = 0.04) (Supporting Information: Table 2).

TABLE 3.

Comparison of provider type seen for UTI management between women with history of rUTI versus no rUTI.

Provider seen for UTIs	No rUTI, N (%)	rUTI, N (%)	p
PCP	335 (61.5)	165 (78.6)	<0.001
Urologist	47 (8.6)	55 (26.2)	<0.001
Gynecology	118 (21.7)	51 (24.3)	0.44
Nephrology	7 (1.3)	11 (5.2)	0.003
Other	92 (16.9)	41 (19.5)	0.39
None	68 (12.5)	16 (7.6)	0.06

Abbreviations: PCP, primary care physician; rUTI, recurrent urinary tract infection; UTI, urinary tract infection.

Individual UTI prevention measures reported by the sample and compared between women with and without rUTI are shown in Figure 2. On average, women with rUTI implement more prevention strategies (4.4 ± 1.8) than those without rUTI (3.8 ± 1.8, p < 0.001). Significantly more women with rUTI than without rUTI reported using: transvaginal estrogen cream (14.3% vs. 7.2%, p = 0.002); d-mannose (11.4% vs. 6.1%, p = 0.01); cranberry extract (39.5% vs. 22.2%, p < 0.001); preventative low-dose daily antibiotics (10.5% vs. 5.5%, p = 0.02), and postcoital self-start antibiotics (7.1% vs. 2.8% without rUTI, p = 0.006). Table 4 displays “Other” forms of UTI prevention implemented by women recorded with free text responses.

FIGURE 2.

Comparison of urinary tract infection (UTI) prevention techniques between women with history of recurrent UTI (rUTI) versus no rUTI.

TABLE 4.

Other forms of UTI prevention techniques described by study participants.

Abstinence

Antibiotics

Boric acid vaginal suppositories every day

Change underwear frequently

Change underwear more than once per day

Bidet (reported by two participants)

Eat Greek yogurt

Avoid hot tubs or chlorine pools

Homeopathy

Honey or yogurt in the vagina after sex

Sleep without underwear

Myrbetriq

Probiotic

Pyridium

Salt cure and baking soda cure

Second pee empty bladder when urinate

Tart cherry juice

Urinate every 4 h

Use wipes and peribottle after bowel movement

Cotton (underwear) or no underwear

Cut out sugar, most fruit, and juice or soda

Use green and herbal tea

Pelvic floor exercises

Elevate feet when using toilet

Special nonirritating soap

Uva ursi extract

Vitamin c

Washing in a specific way after urinating

Wipes

Vaginal soap

No bath products

Abbreviation: UTI, urinary tract infection.

When stratifying by provider type, no significant differences in UTI prevention strategies were seen among women with rUTI managed by their PCP or gynecologist (Table 5). However, there were significant differences seen among women with rUTI who visited a urologist. Compared with those who did not see a urologist, significantly more women with rUTI used vaginal estrogen (32.7% vs. 7.7%, p < 0.001), d-mannose (21.8% vs. 7.7%, p = 0.005), and a low-dose daily antibiotic (21.8% vs. 6.5%, p = 0.001). Among those who saw “other” providers, no significant difference in prevention strategies existed (p > 0.05 for transvaginal estrogen, cranberry extract, d-mannose, low-dose daily antibiotic and postcoital self-start antibiotics; data not pictured).

TABLE 5.

Among women with rUTI, comparison of UTI prevention techniques based on provider seen for management.

UTI prevention technique among women with rUTI	No PCP provider, N (%)	PCP provider, N (%)	p	No gynecology provider, N (%)	Gynecology provider, N (%)	p	No urology provider, N (%)	Urology provider, N (%)	p
N (%)	45	165		160	50		155	55
Vaginal estrogen (i.e., cream/tablet/suppository/ring)	8 (17.8)	22 (13.3)	0.45	23 (14.4)	7 (14)	0.95	12 (7.7)	18 (32.7)	<0.001
d-mannose tablets	6 (13.3)	18 (10.9)	0.65	19 (12)	5 (10)	0.72	12 (7.7)	12 (21.8)	0.005
Cranberry extract tablets	18 (40)	65 (39.4)	0.94	61 (38.1)	22 (44)	0.46	61 (39.4)	22 (40)	0.93
Preventative low-dose daily antibiotics (taking for >1 month)	6 (13.3)	16 (97)	0.48	16 (10)	6 (12)	0.69	10 (6.5)	12 (21.8)	0.001
Self-start antibiotics after sexual activity	3 (6.7)	12 (7.3)	0.89	11 (7)	4 (8)	0.79	8 (5.2)	7 (12.7)	0.06

Abbreviations: PCP, primary care physician; rUTI, recurrent urinary tract infection; UTI, urinary tract infection.

Finally, when it comes to perceptions and preferences of UTI care, significantly more women with rUTI reported dissatisfaction with the UTI care that they receive (15.8% vs. 7.9% among women without UTI, p = 0.002). No significant differences were seen regarding ease of UTI care (UTI considered challenging in 22.2% of women with rUTI vs. 16.8% of women without rUTI, p = 0.09), for gender preference of provider (35.2% of women with rUTI vs. 38.5% of women without rUTI, p = 0.43), or race preference of provider (4.3% of women with rUTI vs. 3.7% of women without rUTI, p = 0.96).

4 |. DISCUSSION

In this sample of women, nearly one-third of participants qualified as having rUTI, or 3 or more UTIs in the prior 12 months. Although most women see their PCP for UTI management regardless of rUTI status, of those with rUTI, only 26% reported seeing a urologist. This study suggests that urologists are more likely to implement additional UTI preventative strategies, including transvaginal estrogen, d-mannose, and low-dose prophylactic antibiotics. Regardless of rUTI status, women are implementing three to four prevention strategies to prevent UTIs. Interestingly, more than two-thirds of all participants regularly drink more fluids, wipe from front to back and void after sexual activity to minimize UTI risk; nearly half take showers instead of baths, avoid urinary holding, and drink cranberry juice. Studies have shown that many of these hygienic tactics do not play a role in UTI prevention.³ Overall, women with rUTI were twice as likely to be dissatisfied with their care.

UTIs, regardless of frequency, have a profound impact on daily living among adult women. Studies have shown that there is psychological burden for the sudden onset of UTI.¹¹ Women also experience guilt and depression/anxiety due to the functional and social impairment with UTIs.^1,11 For these reasons, treatment alone does not improve UTI burden.¹ Renard et al.¹¹ showed that initiating a preventative strategy among women with rUTI not only decreased the number of UTI by nearly half, but showed a significant improvement in baseline anxiety. This emphasizes the importance of optimizing prevention among adult women afflicted with UTIs. In February 2023, Newlands et al.¹² published a validated Recurrent UTI Impact Questionnaire, to quantify these negative themes and capture progress with provider interactions and interventions. As prevention is optimized, providers can measure overall improvement among their patients.

Overall, most women see their PCP regardless of rUTI status. This offers a unique opportunity for PCPs to educate about UTI prevention strategies in the ambulatory setting or place a referral to a specialist if patients meet the criteria for rUTI. Again, this study showed that 75% of women with rUTI were not seen by or referred to urologists. Studies have shown that, among PCPs, UTI treatment choice is based on resources such as UpToDate.com, which contains concise and accurate evidence-based information. Although UptoDate.com does discuss preventative strategies, this may be considered out of scope for some providers. Visits for UTI represent only 0.8% of all primary care ambulatory encounters.¹³ Future studies should assess barriers among PCPs for escalating UTI prevention measures, and/or placing referrals to specialists, as women suffer from rUTI for too long before being referred to a specialist or started on prophylactic measures.⁶

Women with rUTI, who see a urologist, are more likely to be started on vaginal estrogen and d-mannose, as well as low-dose prophylactic antibiotics; self-start antibiotics also approached significance (p = 0.06). These medical modalities of prevention are supported by varying levels of evidence and are described in the rUTI AUA guidelines, which are commonly referenced by practicing urologists.³ Regarding low-dose prophylactic antibiotics, the primary goal of rUTI prevention is to minimize antibiotic use. Women with rUTI generally do not want to take antibiotics and feel that antibiotic prescriptions are dismissive and overused.⁵ Prophylactic antibiotics have been shown to be effective, but UTIs can recur after cessation.³ The goal is to minimize acute UTI frequency and create a therapy plan with the patient. Expectations should be managed appropriately and the general course of action (i.e., duration of low-dose antibiotic) should be openly discussed. Communication will hopefully strengthen the patient- provider relationship, and lead to higher rates of satisfaction among women with rUTI.

Although about half (51%) of women with rUTI in this study reported being peri- or postmenopausal, only 14% overall reported using transvaginal estrogen. Current AUA guidelines for rUTI recommend transvaginal estrogen for women that are peri- or postmenopausal.³ Systematic reviews have found a decreased frequency of infections among post-menopausal women suffering from genitourinary syndrome of menopause (GSM), who use transvaginal estrogen.¹⁴ GSM refers to a complex of genital symptoms secondary to estrogen hormone withdrawal, including vaginal dryness or irritation, discomfort or pain, urinary urgency or frequency, and rUTI.¹⁵ Our study highlights a significant discrepancy in care. The AUA recently assembled an expert panel regarding GSM to develop a set of guidelines given its impact on female urologic health.

This study has limitations, which should be considered when evaluating the findings. Selection bias for participation limits external validity and generalizability to the population. ResearchMatch is limited to women with email; those who do not have access to computers or limited technical capability would inherently be excluded. ResearchMatch volunteers also opt into the database to participate in research projects, which may bias data. Like all web-based surveys, we cannot control who takes this survey. Responses were self-reported and no attempt was made to verify answers. This is of particular importance given that self-reported UTIs were the primary study inclusion criteria and determined how subjects were categorized. Thus, misclassification bias may exist based on how participants interpreted and responded to the survey questions. Patients with additional conditions that may predispose to UTI, such as immunocompromise, were not excluded from recruitment which may bias the data. This study did not assess the efficacy or temporality of UTI prevention measures on current UTI status. Women may develop rUTI despite being optimized with prophylactic strategies, or they may have resolved rUTI secondary to measures. Lastly, we did not capture data about additional providers who manage rUTI, including infectious disease specialists and urogynecologists.

Despite the limitations, this study offers unique insights regarding current UTI management trends and prevention strategies used by women in the community. It also highlights differences in management strategies based on who a woman sees for care. Women with rUTI were more likely to be medically optimized (i.e., transvaginal estrogen cream, cranberry extract) if they reported seeing a urologist. Most women see their PCP for UTIs, yet specialists appear underutilized. This suggests that there may be opportunities for improvement in care and in earlier referral patterns to specialists. There were also discrepancies in the use of transvaginal estrogen in menopausal women with rUTI, even though this is a highly effective and recommended intervention. Future research should examine barriers to transvaginal estrogen prescriptions. Lastly, many women reported using low-dose daily antibiotics as well as self-start antibiotics, even though antibiotics are perceived negatively. Future research might explore the role of prophylactic antibiotics on increasing rates of antibiotic resistant bacteria.

5 |. CONCLUSION

Women who had a UTI in the past year implement behavioral changes to minimize risk of future infections. Most women see their PCP for UTI management, with only 26% of women with rUTI seeing urologists. Women with rUTI, who see urologists, are more likely to be using transvaginal estrogen, cranberry extract, and prophylactic antibiotics. Women with rUTI report higher rates of dissatisfaction with management, which highlights the significant opportunity to improve care for women suffering from rUTI.

Supplementary Material

Additional supporting information can be found online in the Supporting Information section at the end of this article.

DATA AVAILABILITY STATEMENT

Data was collected and stored anonymously in the REDCap database. The authors confirm that the data supporting the findings of this study are available within the article [and/or] its Supporting Information.