What Too Many of Us Don’t Know About UTIs
If you’ve ever had a urinary tract infection (UTI), you probably don’t need a reminder of how miserable it can be: the burning feeling when urinating; an urge to pee that doesn’t go away; the unsatisfyingly tiny amount of (possibly cloudy, bloody, or strange-smelling) pee you’re able to pass despite feeling like you could “go” all the time; the fear that once the infection clears, it’ll return.
UTIs are something nearly half of all women will experience at least once in their lifetime, and nearly half of those infections will recur. What’s more, UTIs are becoming more common (they’ve increased by about 70 percent from 1990 to 2021!) and more difficult to treat. Yet despite how widespread UTIs are, confusion about why they happen and the best ways to prevent and treat them persists.
Here, Maria Uloko, MD, a leading urologist, researcher, and comprehensive sexual medicine specialist, shares the facts she wishes more of us knew about why UTIs happen and why they’re on the rise, plus the prevention and treatment options that should be on our radar.
Consider this your new guide filled with the crucial facts that can help you protect your health and advocate for better care.
Fact No. 1: UTIs are on the rise in women of all ages.
If it feels like you’re hearing more about UTIs, with more women in your life complaining about these uncomfortable infections, it’s not a coincidence. UTI cases around the world have increased by about 70 percent from 1990 to 2021, and projections suggest this number will keep going up through 2050, with an expected growth rate of 17 percent. In addition to more infections, UTIs are also becoming more complicated and harder to treat.
So yes, there are a lot of UTIs happening right now. Why? There multiple factors, says Dr. Uloko, including:
- Antibiotic resistance: Studies show more than 92 percent of UTI-causing bacteria are resistant to at least one common antibiotic, and almost 80 percent are resistant to at least two.
- Aging populations: Our risk of UTIs increases dramatically with age, particularly for people over 60. It’s also important to know that UTIs become especially pronounced in those 75 and older. (More on why—and the surprising symptom to look out for—below.)
- Diabetes: UTIs in women with diabetes are harder to treat, with higher resistance to commonly used antibiotics in these patients.
- Contaminated meat: Research estimates that 8 percent of E. coli UTIs—approximately 480,000 to 640,000 cases annually in the U.S.—may be attributable to meat-associated bacterial strains. What’s more, the widespread use of antibiotics to prevent disease in farm animals has been shown to contribute to antibiotic resistance in humans, which may help explain why more people are developing resistance to the antibiotics commonly used to treat UTIs.
Fact No. 2: UTIs can manifest as delirium or confusion in older adults.
That’s right: If an elderly parent or loved one starts experiencing symptoms of cognitive decline, you (and even many doctors) may immediately assume dementia. Yet it’s important to know that in nearly 29 percent of older adults, UTIs show up as delirium or confusion.
“Many older women are misdiagnosed with dementia progression when they actually have a treatable UTI,” says Dr. Uloko.
When you know this, you can help an aging parent or loved one by asking the right questions and advocating for testing. While a UTI can cause confusion, it’s not likely to be the only symptom. Other classic signs of UTIs include pain or burning while peeing; an increased urge to pee; blood in the urine; new urinary incontinence (aka leakage); tenderness or pain in the low belly or mid-back (where your kidneys are); and/or a fever. If any of these symptoms are present and there’s confusion or delirium, it’s important to ask for testing for a UTI as part of a thorough medical evaluation.
Fact No. 3: Women become more susceptible to UTIs as we age—and at points in our life when our hormones shift.
Here’s a fact about female physiology too few of us know: The vulvar vestibule, urethra, and bladder are rich in both estrogen and androgen receptors. When these receptors don’t get the hormones they need, it can create an environment that’s more prone to infection.
But it’s not just menopause that creates hormonal changes that put us at increased risk for UTIs. “Any time we have a change in hormones, we can disrupt the balance of hormones in our vulvovaginal tissue and become more susceptible to UTIs,” says Dr. Uloko. That means big hormonal transitions like pregnancy and breastfeeding can impact UTI risk. So can taking exogenous hormones, such as those in birth control, acne medications, and hair loss medications.
What happens when we lose androgens and estrogens during these hormonal upheavals?
- The vulvar skin pH changes, which changes our vaginal microbiome and can make UTIs more likely.
- The skin can also become inflamed, which makes it more susceptible to infections.
Here’s the catch: These skin changes and inflammation can mimic symptoms of a urinary tract infection, which means many women can get stuck in a cycle of wondering if they have a real infection, or just persistent symptoms, says Dr. Uloko. “This is tricky because our best screening tools can’t catch the difference, so women just get antibiotics,” adds Dr. Uloko. In fact, Dr. Uloko is the author of a study that’ll be published in the Journal of Sexual Medicine later this year that found 85 percent of the selected patient population that came in with recurrent symptoms actually had a hormonal issue because of a loss of androgens and estrogens (and predominantly androgens).
According to Dr. Uloko, this is good news, because it points to UTIs being preventable and reversible, as long as doctors know what they’re treating and prescribe vaginal DHEA (a precursor to testosterone) and/or vaginal estrogen, to help give those androgen and estrogen receptors in the vulvovaginal tissue the hormones they need.
Dr. Uloko is on a mission to help women understand that our vulvovaginal health is related to our bladder health. While most of us have been taught to believe that the vulva is a sexual organ, it goes far beyond that. And understanding how hormones—specifically androgens and estrogens—impact our vulvovaginal health can in turn help us understand how best to prevent UTIs.
Unfortunately, most doctors aren’t formally trained in vulvar physiology and anatomy and don’t understand how the bladder, vulva, and vaginal health are all tied together. Because of that, Dr. Uloko says it’s crucial that we educate ourselves about our vulvovaginal health and become our own best healthcare advocates.
Fact No. 4: The old advice to pee immediately after having sex and wipe front-to-back takes our attention away from other, less talked about causes of UTIs.
Yes, these tips fall into the category of sound advice when it comes to UTI prevention. But our hyper focus on these commonsense tactics distracts us from the other advice that may move the needle more, says Dr. Uloko. For example, pelvic floor dysfunction—especially hypertonicity, or when muscles are too tight—can be a factor related to UTIs. Addressing constipation is another important move, and one too many women consider unrelated to UTIs.
When the rectum is full of stool, it bulges into the space where the bladder needs to fully expand, explains Dr. Uloko. This presses on the bladder and prevents it from emptying completely during urination, and the urine left behind becomes a breeding ground for bacteria. What’s more, hardened stool and straining to poop can introduce bacteria (usually E. coli from the digestive tract) to the urethral area, making it easier for the bacteria to travel up to the bladder. This combination can put you at a higher risk for a UTI.
Fact No. 5: You may have to bring up a known treatment proven to prevent and treat UTIs, which is vaginal DHEA and estrogen.
For far too long, the standard urologic workup included evaluating urinary system anatomy or function to identify infection risk, says Dr. Uloko. “What we have failed to recognize is that the bladder is a part of the vulva, which means the vulva is a part of the urinary system,” she says. “The vulvar vestibule, urethra, and bladder share a common origin and function as a hormone-responsive unit.” In other words, when we change hormonal health, we change vulvar health, which directly impacts bladder health.
When Dr. Uloko explains this to her patients, she uses the analogy of a garden: estrogens and androgens are the water and sunlight that keep our tissues healthy. When we lose these hormones, our tissues become inflamed and more susceptible to infection.
Current guidelines recommend vaginal estrogen as the gold standard treatment and prevention for peri- and postmenopausal women with recurrent UTIs. However, Dr. Uloko believes vaginal DHEA is significantly underutilized. “Vaginal DHEA is a precursor to estrogen and testosterone, and it’s broken down into estrogen and testosterone, delivering the right nutrients to the tissue,” she says.
In Dr. Uloko’s clinic, she rarely prescribes vaginal estrogen alone; it’s always combined with an androgen, because she understands the intricate nature of the vulva. However, it’s important to understand that more research is needed. For example, while one study of more than 22,000 women demonstrated substantial reductions in UTI prevalence with vaginal DHEA, there hasn’t been a direct comparison of estrogen versus DHEA. This lack of research isn’t just important when it comes to making sure more doctors feel confident prescribing these treatments, but it’s also crucial for insurance coverage. As of right now, vaginal DHEA is not covered by insurance and is only FDA approved for postmenopausal women with vulvar pain.
While we wait for this research to happen, talk to your doctor about vaginal estrogen and/or DHEA and whether it might be right for you. And remember, these treatments are local, low-dose hormones that are typically safe for women of all ages to use—even those where systemic hormone therapy isn’t recommended.
Fact No. 6: There are many things that cause UTIs, and it’s rarely hygiene. (In other words, it’s time to drop the shame so many of us experience when we get recurrent UTIs.)
For many women, dealing with UTIs brings up a lot of shame. This is often due to the fact that women are told to wipe front-to-back and pee after sex—and the implication is that we must not be following good hygiene practices like these if we do get UTIs. What’s more, many healthcare providers dismiss recurrent UTIs as inevitable, adds Dr. Uloko.
“The shame keeps women from advocating for themselves,” says Dr. Uloko. “They think, ‘I must not be cleaning myself properly,’ when the actual issue is hormonal deficiency.”
What Dr. Uloko wants every woman to know is this: UTIs aren’t a moral failing; they happen because of physiology, and often because of a change in the hormonal ecosystem. She also wants women to know that we have effective treatments beyond antibiotics.
When you know that hormonal changes can impact your vulvar and bladder health, you can address the root cause of UTIs, says Dr. Uloko.
“The shame will end when we start looking at the vulva and treating the hormonal deficiency.”
Answer
Your legs.
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