The impact of recurrent urinary and vaginal infections on women

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Reference: July 2025 | Issue 7 | Vol 11 | Page 33

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Recurrent urinary tract infections (rUTIs) and vaginal infections pose a significant burden on women’s health, adversely affecting quality of life and psychological wellbeing. UTIs are among the most prevalent bacterial infections in women, with recurrence defined as two or more infections within six months, or three or more within a year.¹

Vaginal infections, particularly bacterial vaginosis and candidiasis, frequently co-exist with UTIs and may increase susceptibility to urinary infections or result from them, contributing to a cycle of recurrent urogenital disease. These conditions not only place a considerable strain on healthcare systems, but are also major drivers of antimicrobial resistance (AMR) and a source of ongoing morbidity for affected individuals.^2,3

Up to 60 per cent of women will experience a UTI at least once in their lifetime, with approximately 20-30 per cent of these developing recurrent episodes.^{2, 4} A large-scale study identified several key risk factors for recurrence in women, including menopause, oestrogen deficiency, a history of UTIs, sexual activity, diabetes, stress, poor personal hygiene, and the use of spermicides or diaphragms as contraceptive methods.⁵

Vulvovaginal atrophy (VVA), particularly common in postmenopausal women, is increasingly recognised as a key factor in recurrent UTIs. A 2025 study showed that women with VVA have a significantly elevated risk of UTIs, and that using vaginal prasterone pessaries effectively decreased the rate of infection recurrences.⁶

Pathophysiology

The underlying mechanisms behind recurrent urogenital infections are complex, involving an interplay between microbial behaviour, host factors, and environmental influences. A key factor in the recurrence of UTIs is the ability of certain bacteria, particularly uropathogens, to form biofilms. These biofilms are organised communities of bacteria that produce a protective outer layer, allowing them to attach firmly to the bladder lining.

Within this biofilm structure, the bacteria are shielded from the immune system and are far less susceptible to antibiotics. This protective environment enables the bacteria to survive in a dormant or slow-growing state, making them difficult to eliminate with standard treatments. As a result, infections may return even after appropriate antibiotic therapy, contributing to the chronic or recurrent nature of these conditions.⁷

UroPathogenic Escherichia coli (E coli) is the most common cause of UTIs, especially in women who experience recurrent episodes. UPEC has specific virulence factors that allow it to survive in the urinary tract and cause repeat infections. One key mechanism is its ability to invade the superficial cells lining the bladder and form intracellular bacterial communities. Inside these cells, the bacteria are protected from both the body’s immune response and from antibiotics, which often cannot reach them effectively.

These hidden bacteria can remain inactive for a period and then become reactivated, particularly when the bladder lining sheds naturally or in response to stress or irritation. Once reactivated, they can spread to nearby tissues or re-enter the bladder, causing another infection. This process creates a persistent cycle of infection, which is particularly challenging to break in women who have structural or functional urinary tract abnormalities that make them more vulnerable.⁷

Changes in the vaginal microbiome known as vaginal dysbiosis also play a key role in recurrent infections of the urogenital tract. In a healthy state, the vaginal environment is dominated by Lactobacillus species, which help protect against infection by producing lactic acid and hydrogen peroxide. These substances keep the vaginal pH low, creating conditions that inhibit the growth of harmful bacteria.

However, when Lactobacillus populations are reduced, due to factors such as antibiotic use, hormonal changes, menopause, or sexual activity, the vaginal environment becomes less acidic and more vulnerable to colonisation by uropathogens and anaerobic bacteria. This shift increases the risk of both UTIs and conditions like bacterial vaginosis, creating a cycle of recurring infection and microbial imbalance.⁸

When the natural balance of the vaginal microbiome is disrupted, the risk of not only vaginal infections, but also UTIs, increases. The urogenital microbiome, which includes the vaginal and periurethral bacterial communities, serves as both a protective barrier and a potential reservoir for uropathogens. Disruption of this ecosystem can allow harmful bacteria to ascend from the vaginal or periurethral area into the urinary tract.

For example, Gardnerella (G.) vaginalis, a key organism involved in bacterial vaginosis, is often found alongside UPEC in recurrent infections. Emerging evidence suggests that G. vaginalis may even promote the reactivation of dormant E. coli within bladder cells, strengthening the link between vaginal dysbiosis and recurrent UTIs.⁸

The pathophysiology of recurrent urinary and vaginal infections involves a dynamic interplay between microbial virulence, biofilm, and intracellular persistence, host immune response, and microbial ecology. Understanding these mechanisms is important to developing more effective prevention and treatment strategies that extend beyond symptomatic relief to target the underlying microbial and immunological contributors to chronic urogenital infection.

Psychosocial and quality of life impact

Recurrent urogenital infections significantly affect the psychosocial well-being of women. Many women report feelings of anxiety and embarrassment related to their condition, which often leads to fear or avoidance of intimacy, negatively impacting relationships and increasing emotional distress.¹ The recurrent nature of these infections also disrupts important aspects of daily life such as sleep quality, work performance, and social engagement.

Over time, this can lead to a sense of helplessness and frustration, exacerbating issues like stress and low mood. This highlights the importance of a comprehensive biopsychosocial approach to treatment, emphasising not only effective infection management, but also patient education and psychological support to improve overall quality of life.¹

Management and prevention

rUTIs present a significant clinical challenge due to their multifactorial aetiology and the tendency for infections to persist or reoccur despite treatment. Management strategies must be comprehensive, tailored to the individual patient, and aimed not only at acute infection resolution but also at long-term prevention.

The traditional reliance on antibiotics as the primary treatment modality has come under increasing scrutiny due to rising AMR and the negative impact of repeated antibiotic courses on the patient’s microbiome. Modern approaches to rUTI management emphasise a combination of antimicrobial stewardship, lifestyle modification, hormonal therapy when appropriate, and emerging non-antibiotic prophylactic interventions.^3,8,9

Antibiotic use and AMR

Antibiotics remain the first-line therapy for acute UTIs and have been used in prolonged or prophylactic regimens to prevent recurrences. However, prolonged antibiotic use is associated with increased risk of AMR, both at the individual patient level and from a public health perspective.^8,9 The selective pressure exerted by repeated courses can lead to resistant uropathogens, complicating subsequent treatment and reducing therapeutic options.

Antibiotics disrupt the gut and vaginal microbiota, potentially increasing susceptibility to further infections through dysbiosis.^8,9 This risk highlights the need for judicious antibiotic prescribing and consideration of alternative or adjunctive therapies in the management of rUTIs.

Stepwise management approach

The HSE provides comprehensive guidance on the management of rUTIs in adult non-pregnant females. Treatment and prevention should follow a structured, evidence-based, and individualised approach. The first step in managing rUTIs is ensuring that antibiotic prescribing is appropriate and based on recent urine culture and sensitivity results. Only antibiotics that are proven effective for the specific pathogen involved should be considered, as empirical treatment without microbiological confirmation can contribute to poor outcomes and rising AMR.¹⁰

Non-antibiotic preventive strategies are strongly recommended as first-line measures. These include increasing daily fluid intake to encourage regular and complete bladder emptying, which helps flush bacteria from the urinary tract. Women are also advised to urinate soon after sexual intercourse, as this has been shown to reduce the likelihood of bacteria entering the urethra and ascending into the bladder. The use of spermicides, diaphragms, and perfumed feminine hygiene products should be avoided, as these can disrupt the natural protective vaginal flora and increase susceptibility to infection.¹⁰

Antibiotic prophylaxis may be considered for patients experiencing frequent or particularly troublesome infections that significantly impact their quality of life. However, this strategy should be reserved for those who do not respond to non-antibiotic measures and should always follow a clearly defined plan. Prophylactic antibiotics can be administered either as a post-coital single dose or as continuous nightly therapy, and only after ruling out complicating factors such as structural or functional urinary tract abnormalities.

Commonly used agents include nitrofurantoin and trimethoprim, although renal function must be considered, particularly when prescribing nitrofurantoin, which should be avoided in patients with an estimated glomerular filtration rate of less than 45mL/min/1.73 m². Alternative antibiotics such as amoxicillin or cefalexin may be considered in specific cases, particularly when allergies or resistance patterns are present.¹⁰

The HSE advises that any patient receiving antibiotic prophylaxis should be regularly reviewed at three and six months to determine whether the prophylaxis can be safely tapered or discontinued. Evidence suggests that up to 50 per cent of women may remain symptom-free after stopping prophylaxis, supporting a cautious and time-limited use of long-term antibiotics.

Clinicians must remain vigilant for potential side effects of prolonged antibiotic use, including nitrofurantoin-induced pulmonary toxicity, hepatic injury, and peripheral neuropathy, as well as general risks such as vaginal candidiasis, gastrointestinal disturbances, and Clostridioides difficile infection.¹⁰

By prioritising non-pharmacological interventions, reserving antibiotics for appropriate cases, and regularly reviewing the need for ongoing treatment, healthcare providers can help reduce the burden of rUTIs while mitigating the risks of resistance and adverse drug effects.

Hormonal therapy in postmenopausal women

In women undergoing menopause, decreased oestrogen levels lead to atrophic changes in the urogenital epithelium, thinning of the vaginal mucosa, and reduced colonisation by protective Lactobacillus species. This hormonal decline significantly increases vulnerability to recurrent infections.

Vaginal oestrogen therapy has demonstrated robust efficacy in restoring the integrity of the urogenital mucosa and re-establishing a healthy microbiome dominated by Lactobacilli which produce lactic acid and hydrogen peroxide to maintain an acidic environment hostile to pathogens. These effects translate clinically into a reduced frequency of UTIs and symptomatic improvement in VVA.⁵

More recently, vaginal prasterone, a form of dehydroepiandrosterone, has been shown to improve epithelial health and may offer additional or alternative benefits in preventing infections by similarly enhancing mucosal defence mechanisms.⁵ Both treatments are recommended in European and Irish clinical guidelines, reflecting local epidemiological data that highlight the high prevalence of rUTIs among postmenopausal women.

Non-antibiotic prophylaxis

Given concerns about antibiotic resistance, non-antibiotic prophylactic strategies have gained considerable attention. Immuno-active agents such as bacterial lysates or oral vaccines aim to boost the host’s innate and adaptive immune responses to uropathogens. While these agents have shown promise in reducing infection recurrence rates, they are not yet widely implemented pending further validation from large-scale clinical trials.¹¹

Natural compounds like cranberry extract, which contains proanthocyanidins that inhibit bacterial adhesion to the urothelium, have been popularised, although systematic reviews report mixed results regarding their effectiveness. D-mannose, a sugar that blocks fimbrial adhesion of E coli to bladder cells, has shown more consistent benefit in clinical studies and is increasingly recommended as a prophylactic option, especially in patients seeking to avoid antibiotics.^7,8 Intravesical vaccines, which involve direct administration of antigens into the bladder to elicit localised immune responses, are an emerging area of research that may provide targeted protection in the future.^8,9

Patient education

Patient education on behavioural and hygiene measures remains fundamental to prevention. Women are encouraged to practice good perineal hygiene by wiping front to back to reduce the risk of faecal bacteria ascending to the urethra. Avoidance of bubble baths, douches, and feminine sprays that may disrupt the vaginal flora is advised.

Counselling regarding sexual health, including the avoidance of spermicides and consideration of alternative contraceptive methods, helps reduce UTI risk associated with sexual activity. Promoting timely voiding and discouraging bladder holding can also reduce bacterial colonisation and infection risk.^8,10

Multidisciplinary care models

Given the complexity of recurrent urogenital infections involving anatomical, microbiological, hormonal, and behavioural factors, multidisciplinary care models have been shown to optimise patient outcomes. Collaboration among urologists, gynaecologists, infectious disease specialists, and primary care providers allows for comprehensive assessment, including imaging and functional studies to identify anatomical abnormalities or other predisposing conditions such as pelvic organ prolapse or incomplete bladder emptying. This integrated approach supports personalised treatment plans that incorporate medical, surgical, and lifestyle interventions as appropriate.^{3, 8}

European and Irish context

In both Ireland and across Europe, rUTIs pose a considerable health concern, particularly among older women undergoing hormonal changes such as menopause. Recognising this burden, national health authorities, including the HSE and the European Association of Urology (EAU), have updated clinical guidelines. These guidelines advocate a comprehensive, stepwise approach to rUTI management.

Central to this approach is antimicrobial stewardship, which prioritises prudent antibiotic use alongside preventive strategies. The HSE actively promotes patient education campaigns and supports primary care initiatives aimed at reducing unnecessary antibiotic prescribing, aligning with national and European-wide efforts to combat AMR. EAU guidelines encourage the use of vaginal oestrogen therapy for eligible, postmenopausal women and recommend considering non-antibiotic prophylactic measures, such as immune-active agents and behavioural interventions, to help limit AMR development. Ongoing research funded through European networks is enhancing our understanding of regional patterns in pathogen resistance and refining prevention protocols tailored to local epidemiology.^10,12,13

Future directions

A deeper understanding of the relationship between rUTIs and the urogenital microbiome is opening doors to innovative therapies beyond antibiotic use. Emerging microbiome-focused research highlights potential for personalised probiotic treatments designed to restore healthy microbial communities. In women with rUTIs, these may reduce pathogen colonisation and support bladder mucosal defences.⁸

Immunomodulatory therapies and vaccines targeting common urinary pathogens, such as oral E coli lysates, and emerging intravesical vaccines are in clinical evaluation. Early data suggest these interventions might enhance innate and adaptive immunity without relying on antibiotic exposure, offering a promising new direction for prophylaxis.⁸

Advances in diagnostic technology are also important. State-of-the-art assays capable of detecting biofilm structures and intracellular bacterial reservoirs within the bladder epithelium are under development. These tools may help clinicians distinguish between superficial recurrences and deeper-seated, persistent infections, enabling more precise, individualised treatment plans.⁷

The integration of microbiome modulation, host-directed immunotherapies, and biofilm-specific diagnostics represents a holistic approach that could significantly reduce antibiotic dependence, curb AMR, and improve long-term outcomes for women with chronic rUTIs.⁷

Conclusion

Recurrent urinary tract and vaginal infections present a complex and persistent challenge, significantly affecting women’s physical health, psychological wellbeing, and quality of life. These infections are often driven by microbial resistance, biofilm formation, hormonal changes, and disruption of the urogenital microbiome.

While antibiotics remain central to acute treatment, growing concerns around AMR have shifted focus toward holistic, personalised care strategies. These include non-antibiotic prophylaxis, hormonal therapies, microbiome restoration, and improved diagnostics. National and European guidelines increasingly support a multidisciplinary, stepwise approach that integrates medical, behavioural, and patient-centred interventions.

With continued research and innovation, the future holds promise for more effective, sustainable solutions that move beyond symptom control toward long-term prevention and improved patient outcomes.