Preventing and Treating UTIs

Understanding UTIs

Urinary tract infections (UTIs) occur when bacteria, and sometimes fungi, enter the urinary tract from the urethra. From there, the bacteria can often travel up into the bladder or kidneys, causing additional issues and symptoms. UTIs are most common in women, but men can also get UTIs, especially as they get older.

Primary Symptoms of UTIs

Most women are likely familiar with the symptoms of a UTI: a strong urge to urinate, a burning feeling when urinating, frequently urinating in small amounts, cloudy urine, or pelvic pain.

Depending on what part of the urinary tract is affected, the symptoms can be different. For a UTI that affects the kidneys, symptoms may include upper back and side pain, a fever, shaking, chills, nausea, or vomiting. A UTI that affects the bladder may be associated with pelvic pressure, lower abdomen discomfort, frequent urination, pain when urinating, or blood in the urine. A UTI that affects the urethra may be characterized by a change in vaginal discharge or a burning sensation with urination (Mayo Clinic, n.d.).

How UTIs Are Diagnosed

You may be alerted to a UTI by the obvious symptoms, such as pain when urinating or a frequent need to urinate in small amounts. These symptoms are often sufficient for doctors to make an accurate diagnosis. However, these symptoms may not always be present, and your doctor may request a urine sample to confirm diagnosis. A urine test will often screen for the presence of nitrites, which are usually symptomatic of an infection. If diagnosis is not clear from the urine analysis, a urine culture may be carried out to see whether live bacteria are present. It can also determine which bacteria are causing the infection. Your doctor may perform a swab or a blood test to determine if there is an alternative diagnosis, such as a sexually transmitted infection (K. Gupta et al., 2017).

If you have frequent UTIs, your doctor may use a scope (cystoscopy) to look inside of your urethra and bladder to make sure everything is healthy.

UTIs can encompass various medical conditions such as bacteriuria (bacteria in the urine), acute cystitis (inflammation of the bladder), and catheter-associated UTIs (UTIs caused by catheter use in hospital settings). Acute cystitis can be caused by an infection or by irritating products or medications.

Risk Factors and Related Health Concerns

Women are at higher risk for UTIs than men are. People with impaired immune systems have an increased risk for UTIs because their bodies don’t protect them against infection as effectively. Other risk factors for UTIs include sexual activity, a new sexual partner, multiple sexual partners, kidney stones, an enlarged prostate, urinary catheter use, urinary tract abnormalities, or a recent urinary tract procedure (Arnold et al., 2016; Dason et al., 2011; Foxman et al., 2000; K. Gupta et al., 2017).

UTIs and Pregnancy

UTIs are the most common bacterial infection during pregnancy. The hormonal and anatomical changes during pregnancy may increase a woman’s risk of contracting a UTI. And UTIs pose a risk for the both the mother and the baby, increasing risk of preeclampsia (high blood pressure during pregnancy), preterm birth, intrauterine growth restriction, and low birth weight (Kalinderi et al., 2018). Thus, it’s important for health practitioners to screen pregnant women for UTIs and for pregnant women to be aware of the symptoms to prevent further complications.

Enlarged Prostate

An enlarged prostate is common among men, especially men over age fifty. Symptoms may appear similar to those of a UTI—for example, blocked urinary flow and increased need to urinate. An enlarged prostate can also prevent a man from completely emptying his bladder, and over time, an inability to fully empty the bladder may also cause a UTI (Mayo Clinic, 2019). Talk to your doctor if you are having urinary trouble.

Interstitial Cystitis

Interstitial cystitis, also known as bladder pain syndrome, is a condition characterized by chronic bladder pain and pressure, and its symptoms may mimic a UTI. Stress, sex, menstruation, and certain physical activities are some of the numerous things that can cause symptom flares. Treatment often involves lifestyle changes to reduce flares as well as bladder training or medications (NIH, 2017).

Sepsis

Sepsis occurs when bacteria or fungi infect the bloodstream, leading to an inflammatory response which can cause dysfunction and, in rare cases, death. In infants, especially premature infants in the neonatal intensive care unit, UTIs are a common cause of sepsis (Mohseny et al., 2018). Sepsis is more common among older adults, pregnant women, and people with weakened immune systems. Sepsis is treated by antibiotics and requires urgent medical attention. Symptoms of sepsis include high heart rate, confusion, pain, changes in mental function, and chills.

How UTIs Are Treated

The quickest and most effective way to treat a UTI is with oral antibiotics that kill the bacteria that caused the infection. However, some mild infections can spontaneously resolve on their own and may not require antibiotics. Overuse of antibiotics can result in antibiotic resistance, which may make future infections harder to treat. The decision on whether to treat with antibiotics depends on the severity of the infection and should be discussed with your health care practitioner (Falagas et al., 2009).

Typically, a broad-spectrum antibiotic is prescribed, and the type of bacteria is not examined. However, doctors may examine the type of bacteria for people with recurrent or hard-to-treat infections. The most common types of bacteria responsible for UTIs are E. coli followed by Staphylococcus, Klebsiella, Enterobacter, Proteus, and Enterococcus (McLellan & Hunstad, 2016). UTIs can also, on rare occasions, be caused by fungal infections, which can be treated by an antifungal agent. For more severe infections that have spread to the kidneys, intravenous antibiotics may be required.

Symptoms should clear up within a few days of antibiotic use, but you should always take the full course of antibiotics. Completing the full course of your antibiotics is crucial for preventing antibiotic resistance.

Recurrent UTIs

Recurrent UTIs are very common—approximately one in four women will experience a recurrence within a year of their original infection (Forde et al., 2019). Postmenopausal women are at high risk for recurrent UTIs due to hormonal changes, changes in the vaginal microbiota, and decreased immune function. Recurrent UTIs are usually treated by another course of antibiotics. For people who experience more than one recurrence, health care practitioners may also prescribe preventative measures such as continuous antibiotic prophylaxis (long-term prescribed antibiotics) or postcoital antibiotic prophylaxis (taking an antibiotic within two hours of sexual intercourse) (Dason et al., 2011).

Estrogen Therapy for Postmenopausal Women

For postmenopausal women who suffer from recurring UTIs, vaginal estrogen therapy has been shown to be effective. Estrogen therapy may be given intravaginally with creams or an estrogen ring. Side effects of estrogen therapy include breast tenderness, vaginal spotting, and vaginal irritation (Dason et al., 2011). A 2005 study found that estrogen therapy was effective for young women with recurrent UTIs, so it may be beneficial for others, too, not just for postmenopausal women (Pinggera et al., 2005). If you have recurrent UTIs, talk to your doctor about whether estrogen therapy may be helpful for you.

Cystoscopy with Fulguration of Trigonitis (CFT)

CFT is a treatment for antibiotic-resistant recurrent UTIs in which areas of the bladder that are presumed to harbor bacteria are destroyed with an electrode. CFT is done using cystoscopy, a hollow tube with a lens that is inserted into the urethra and fed up to the bladder, while the patient is under anesthesia. One study found that the success rate of CFT for antibiotic-resistant recurrent UTIs was between 65 and 75 percent (Hussain et al., 2015). CFT has minimal side effects and therefore may be a more attractive option than estrogen therapy for women with antibiotic-resistant infections.

Nutrients and Supplements for UTIs

Cranberry juice and cranberry products may help prevent UTIs along with probiotics, specifically Lactobacillus strains. There is some evidence that vitamin C and a sugar called D-mannose may each be beneficial at preventing UTIs.

Cranberry

Cranberry use is widespread for the prevention of UTIs. The benefits of cranberry juice are believed to come from their acidity as well as the various plant compounds they contain such as proanthocyanidins, which give the fruit its red color and may have antibacterial properties.

The results of clinical studies on cranberry have been mixed¬: Some studies have shown that cranberry products are almost as beneficial as low-dose antibiotics at preventing UTIs, while other studies have found no benefit of cranberry products in UTI prevention (Chih-Hung Wang et al., 2012; Jepsen et al., 2012). This is likely due to inconsistencies in the dose depending on whether the cranberry product comes in the form of a juice, tablet, syrup, or powder. And the amount of proanthocyanidins found in products may vary, too. The strongest evidence for cranberry’s ability to prevent UTIs is among women with recurrent UTIs and among children (Sihra et al., 2018).

Since there are minimal side effects associated with cranberry products and they are fairly low-cost, it may be worthwhile to start taking a cranberry supplement or drinking cranberry juice, especially if you are prone to UTIs.

Probiotics

A disrupted microbiome could potentially be associated with higher frequency of UTIs and other infections. Researchers have suggested that optimizing the microbiome with beneficial probiotics (live microorganisms) may help prevent UTIs (Aragón et al., 2018). However, the evidence has been mixed regarding the benefits of probiotics.

A 2018 meta-analysis found that Lactobacillus probiotics, the dominant strain in the vagina, significantly protected women from a recurrent UTI compared to placebo (Ng et al., 2018). Previous meta-analyses have shown conflicting results, which may be due to the fact that probiotics contain many different strains and may be administered both orally or vaginally for women (Grin et al., 2013; Schwenger et al., 2015).

Lactobacillus rhamnosus GR-1 and Lactobacillus reuteri RC-14 are the most studied strains (Ng et al., 2018). Probiotics may be most beneficial for women with a history of recurrent UTIs or those who have used antibiotics numerous times, increasing their risk for antibiotic-resistant strains of bacteria.

Fermented foods may be another opportunity to consume potentially beneficial probiotics. A 2003 study from Finland found that frequent consumption of fermented-milk products containing probiotics was associated with a significantly lower risk of a recurrent UTI (Kontiokari et al., 2003). Try incorporating more fermented foods into your diet or taking a daily probiotic containing several strains of Lactobacillus.

Vitamin C

Some researchers have hypothesized that increasing the acidity of urine may help reduce infections by killing off bacteria. A 2001 study showed that acidifying human urine samples with vitamin C reduced the growth of bacteria such as E. coli in the sample. The authors found that vitamin C increased the amount of reactive nitrogen oxides, which led to the antibacterial effect observed (Carlsson et al., 2001). A 2010 clinical study found that pregnant women who took one hundred milligrams of vitamin C daily for three months along with ferrous sulphate and folic acid had fewer UTIs than women who were given just the ferrous sulphate and folic acid with no vitamin C (Ochoa‐Brust et al., 2007). There is a need for further research on vitamin C to determine whether it is generally beneficial at preventing UTIs.

There is a clinical trial recruiting subjects at the American University of Beirut Medical Center to take either one gram of vitamin C for two weeks or a placebo to see if vitamin C will help prevent catheter-associated UTIs.

D-Mannose

D-mannose is a sugar that plays a role in metabolism and also may prevent bacteria from adhering to the tissue lining the bladder. Due to its anti-adhesive properties, D-mannose products in the form of powders are sold for UTI prevention. A 2014 study tested whether two grams of D-mannose powder for six months was effective for women with recurrent UTIs compared to fifty milligrams of the antibiotic nitrofurantoin or a placebo. Subjects who took either D-mannose or the antibiotic had a significantly lower risk of a recurrent UTI during the study than those who took a placebo. Subjects who took D-mannose had fewer side effects than those who took antibiotics. These results suggest that D-mannose powder is an effective and safe preventative measure against UTIs (Kranjčec et al., 2014). This is the only published clinical trial that has studied D-mannose for UTI prevention, so further research is needed to confirm its benefits.

There is a clinical trial led by researchers at Washington University School of Medicine currently recruiting postmenopausal women with recurrent UTIs to take two grams of D-mannose daily for three months. We are eager to see the results upon publication.

Dietary Changes

Besides cranberry juice, which is discussed in the supplements section, there aren’t many dietary changes that have been adequately studied for UTIs. There is some mounting evidence that garlic may have antibacterial properties and help prevent UTIs. Other things that have been studied include a Mediterranean diet, fruit juice, and fermented foods (mentioned in the probiotics section, above).

Garlic

Garlic has been traditionally used as an antibacterial and antiviral food that is believed to protect the body from infectious pathogens. And scientists have begun to validate its traditional use, finding that allicin, one of the active substances in crushed garlic, has antimicrobial activity against various bacteria, including E. coli, as well as fungi, such as Candida albicans (Ankri & Mirelman, 1999).

Some preclinical studies have shown that garlic may be protective against UTIs. A 2015 study took urine samples infected with antibiotic-resistant bacteria and treated them with garlic extract, finding that it could block the growth of most of the antibiotic-resistant bacteria in the urine samples (S. Gupta et al., 2015). But research on urine samples does not address whether eating garlic will have benefits for the bladder. That question was addressed by a 2010 study in mice that looked at a type of bacteria called Pseudomonas aeruginosa, which is responsible for many cases of catheter-associated UTIs. The researchers fed the mice garlic and found that this lowered the amount of the bacteria in the mice’s kidneys and protected their kidneys from damage (Harjai et al., 2010).

The best evidence for the antibacterial effectiveness of garlic was from a 2017 clinical study of patients in intensive care units who were given 400 milligrams of garlic by tablet for six days while hospitalized. Researchers then took catheter samples from these patients and a group of control patients who had been given a placebo to test for the presence of bacterial or fungal infection. The thirty-seven patients who received garlic did not develop any infections, while five of the forty-one control patients developed an infection (Madineh et al., 2017).

So there is mounting evidence for the effectiveness of garlic for the prevention of UTIs, although further clinical research is still needed. If you experience recurrent UTIs, you may find it beneficial to start eating more garlic. Crush before cooking to make sure that allicin is formed.

Mediterranean Diet

In one interesting study, adhering to a Mediterranean diet reduced the odds of contracting a UTI among 874 pregnant women during their first trimester. The women ate a diet high in vegetables, fruits, nuts, and extra virgin olive oil and low in juice (Assaf-Balut et al., 2019). However, this is the only such study that has looked at the Mediterranean diet and UTIs, so there isn’t enough evidence yet to say that a Mediterranean diet is helpful across the board for preventing UTIs in either pregnant or nonpregnant women.

Fruit Juice

A 2003 study from Finland found that frequent consumption of fruit juices (specifically raspberry, lingonberry, strawberry, raspberry, currant, and cloudberry juices) was associated with a lower risk of UTI recurrence. The authors suggested that this may be due to compounds called flavonols, which are found in high amounts in berries and may have antibacterial properties (Kontiokari et al., 2003). Much of the research on fruit juice has focused on cranberry and its potential to prevent UTIs. See the supplements section for information on cranberry.

Lifestyle Changes for UTIs

Certain types of birth control, such as diaphragms and spermicide-treated condoms, may increase your risk of UTIs. To prevent UTIs, you’ll want to maintain proper hygiene.

Birth Control

Certain forms of birth control, such as diaphragms, which push against the urethra and make it hard to empty the bladder, as well as spermicide-treated condoms, have been associated with an increased risk of UTIs (Fihn et al., 1996; Foxman et al., 2000).

Hygiene

Anatomically, women have a shorter urethra than men do and also have a shorter distance between their anus and urethra, which increases women’s risk of getting UTIs. Thus, proper hygiene is important to prevent infection. Wipe carefully from front to back after using the toilet to avoid contaminating your urethra with bacteria. Avoid feminine products or cleanses that contain irritants that may inflame the urethra or change the vaginal environment (CDC, 2019; Crann et al., 2018).

Hydration

Theoretically, drinking more liquids could help flush bacteria out of the urinary tract before it spreads and causes infection. However, studies have shown conflicting results about fluid intake, and overhydration may actually worsen some urinary symptoms (Bergamin & Kiosoglous, 2017). If you have a UTI, you may find that certain drinks such as alcohol, caffeine, or citrus juices irritate your bladder and increase your need to urinate.

Sexual Activity

Having frequent sexual intercourse is the strongest risk factor for developing a UTI. If you are suffering from recurrent, troubling UTIs, you may want to consider avoiding sexual activity until you have spoken to your health care practitioner and fully recovered from the recurring UTIs. You may have heard the common advice to pee after sex, but studies have failed to show that this is helpful at preventing UTIs in any significant way (Bergamin & Kiosoglous, 2017). Despite the lack of evidence for urinating after sex, many health care practitioners still recommend doing so because there’s no harm in it. What you can also try: Avoid spermicide-treated condoms (see birth control section above) and avoid feminine products such as lotions and soaps that contain chemical irritants that may cause vaginal discomfort.

Maintaining a Healthy Weight

Several studies have shown that adult women and men as well as children with higher body mass index (BMI) are significantly more likely to suffer from a UTI, although it’s not clear why (Hsu & Chen, 2018; Nseir et al., 2015; Semins et al., 2012).

New and Promising Research on UTIs

Researchers are studying novel treatments for UTIs that can clear the bacterial infection without the use of antibiotics in order to avoid antibiotic resistance. New studies have also uncovered why some women may suffer from recurring UTIs.

Diet and Antibiotic Resistance

The food you eat can change the bacterial makeup of your gut, but whether or not the food you eat can also confer antibiotic resistance is not yet understood. This could be important for people with recurrent UTIs who frequently take antibiotics or don’t respond to certain antibiotics over time due to antibiotic resistance. Researchers from the Netherlands studied a group of 612 people and took samples of their urine, then tested the samples to see how resistant they were to several common antibiotics. The researchers found that 40 percent of the people had amoxicillin-resistant urine cultures, while 27 percent had trimethoprim-resistant cultures. Less than 5 percent of the cultures were resistant to the antibiotics nitrofurantoin and cefotaxime.

Next, the researchers wanted to determine how diet impacted this antibiotic resistance, so they had these same people detail their historical consumption of various foods. Those who reported eating more chicken had higher odds of being cefotaxime-resistant, while those who ate more pork were more norfloxacin-resistant. On the other hand, those who ate more cheese showed less resistance to amoxicillin and amoxicillin-clavulanic acid (Mulder et al., 2019).

The study suggests that certain foods may affect antibiotic resistance, likely due to the antibiotics used in raising the animals. More research in this vein may have implications for the types of diets that are recommended to people with recurrent UTIs.

Intestinal Bacteria and Recurrent UTIs

Most UTIs are caused by E. coli bacteria. There are various strains of E. coli that have become resistant to the commonly prescribed antibiotics, including the ST131-H30R and ST1193 strains. To better understand these strains and where they live in the body, researchers from the University of Washington School of Medicine surveyed 1,031 women who had been UTI-free for the past year and asked them to provide stool samples. Almost 90 percent of these samples contained E. coli and of those, 10 percent contained antibiotic-resistant strains. The dominant antibiotic-resistant strains were the aforementioned ST131-H30R and ST1193 strains (Tchesnokova et al., 2019). This study shows that the guts of healthy women may carry superbug strains of antibiotic-resistant E. coli that are responsible for resistant and recurrent UTIs.

Recurrent UTIs in Postmenopausal Women

Postmenopausal women are at a high risk for recurrent UTIs and are often overtreated with antibiotics, to which they may become resistant over time. To better understand recurrent UTIs, researchers at the University of Texas Southwestern Medical Center took biopsies from women’s bladders while they were undergoing CFT treatment for antibiotic-resistant recurrent UTIs.

Fifty-seven percent of the bladder samples contained E. coli, while other samples contained bacteria such as E. faecalis and K. pneumoniae. These bacteria were found both on the surface of the bladder tissues as well as deep inside the tissue samples, showing that the bacteria is able to permeate the bladder wall (De Nisco et al., 2019).

This study sheds light on important factors that affect postmenopausal women’s risk of UTIs. Further research is needed to determine how to remove these bacteria. See the CFT section for one such treatment that is currently being used.

Vaginal Bacteria and UTIs

Frequent sexual activity is the biggest risk factor for developing a UTI. It’s previously been believed that this is likely due to the spread of bacteria during sex. A new study from researchers at Washington University School of Medicine exposes another possible reason: Gardnerella vaginalis, a type of bacteria that lives in the vagina. The study used a mouse model to show that exposing mice’s bladders to G. vaginalis damages cells on the bladder’s surface and reactivates latent E. coli bacteria, making the mice more susceptible to infection (Gilbert et al., 2017). Thus, UTIs may be driven by a complex interplay between multiple bacteria, especially during sex, when bacteria is more likely to move from the vagina to the bladder.

Copper

Copper is known for its antibacterial properties. However, a recent study from Washington University School of Medicine found that copper may also, paradoxically, play a nutritional role in supporting the growth and spread of E. coli bacteria. The researchers found that E. coli contains a molecule called yersiniabactin that takes copper ions into the cell and uses them to help the cells grow. This process is called nutritional passivation, which refers to how the molecule is able to make copper work for it by fostering growth, instead of against it as an antibacterial (Koh et al., 2017). By taking copper inside the bacterium, yersiniabactin stops copper from reaching high quantities outside, which could be deadly to the bacteria. Future research into drugs that could block yersiniabactin’s activity and increase copper in its environment may be an interesting solution to the overuse of antibiotics for UTIs.

UTIs and Mental Illness

People with dementia can exhibit unique symptoms when they have a UTI—instead of the classic urinary pain, it may appear more like delirium. And studies have linked various other neuropsychiatric conditions such as schizophrenia and depression to UTIs as well. A 2015 review article found that UTIs may either trigger or worsen these neuropsychiatric disorders by various mechanisms such as inflammation or widespread infection (Chae & Miller, 2015). Further research is needed to understand this apparent mind-body connection and determine whether treating UTIs can potentially relieve symptoms of these other psychiatric conditions.

Novel Vaccine

A 2016 study from the University of Michigan Health System presented a novel vaccine for the prevention of UTIs called the siderophore vaccine. Siderophores are iron-chelating molecules found in bacteria such as E. coli that secure iron, which is essential for bacterial growth. This study showed that a vaccine containing a siderophore antigen resulted in mice producing antibodies to siderophores. The hypothesis was that these antibodies would prevent bacterial siderophores from obtaining iron. The vaccine was effective in mice, significantly reducing the bacteria in their kidneys and urine (Sassone-Corsi et al., 2016). Further research on this vaccine is needed in humans to determine its effectiveness and safety.

Clinical Trials for UTIs

Clinical trials are research studies intended to evaluate a medical, surgical, or behavioral intervention. They are done so that researchers can study a particular treatment that may not have a lot of data on its safety or effectiveness yet. If you’re considering signing up for a clinical trial, it’s important to note that if you’re placed in the placebo group, you won’t have access to the treatment being studied. It’s also good to understand the phase of the clinical trial: Phase 1 is the first time most drugs will be used in humans, so it’s about finding a safe dose. If the drug makes it through the initial trial, it can be used in a larger phase 2 trial to see whether it works well. Then it may be compared to a known effective treatment in a phase 3 trial. If the drug is approved by the FDA, it will go on to a phase 4 trial. Phase 3 and phase 4 trials are the most likely to involve the most effective and safest up-and-coming treatments. In general, clinical trials may yield valuable information; they may provide benefits for some subjects but have undesirable outcomes for others. Speak with your doctor about any clinical trial you are considering.

Uromune Vaccine

J. Curtis Nickel, MD, FRCS, a professor of urology at Queen’s University in Canada, is recruiting women with recurrent UTIs for a clinical trial of the bacterial vaccine Uromune. Uromune contains inactive forms of the four most common UTI-causing pathogens: E. coli, Klebsiella pneumoniae, Proteus vulgaris, and Enterococcus faecalis. The vaccine will be given to subjects orally as a spray every day for three months to see whether it reduces the incidence of UTIs over the following year of the study.

Heparin

Gynecologist Jameca R. Price, MD, at the University of Oklahoma is studying a blood thinner called heparin to see whether it is effective for women with recurrent UTIs. Heparin will be administered weekly for six weeks by bladder instillation, via a catheter inserted into the bladder. Previous studies have suggested that heparin may defend the body against invading bacteria, in addition to its purpose as an anticoagulant, so this study hopes to determine whether it’s effective against UTI-causing bacteria.

Acupuncture

Gynecologist Gerda Trutnovsky, MD, at the Medical University of Graz is recruiting women with recurrent UTIs for a study to determine the efficacy of acupuncture for UTI prevention. Subjects will be randomized to either twelve acupuncture treatments and recommended use of cranberry products or only recommended use of cranberry products. Acupuncture points will include both the body and the ear.

Probiotics

Urologist Melissa M. Montgomery, MD, is recruiting women with recurrent multidrug-resistant UTIs for a clinical study to determine whether six months of probiotic therapy in addition to the standard of care—antibiotics—will help. The probiotic is a novel strain containing Bifidobacterium infantis.

Additional Resources

1. • The Centers for Disease Control and Prevention (CDC) provides basic information on UTI symptoms and treatment.

2. • The National Institutes of Health (NIH) has extensive information on UTI diagnosis and treatment as well as information on how the urinary tract functions.

3. • goop Q&A with ob-gyn Rebecca Nelken on pelvic pain, urinary incontinence, and pelvic disorders.

References

Ankri, S., & Mirelman, D. (1999). Antimicrobial properties of allicin from garlic. Microbes and Infection, 1(2), 125–129.

Aragón, I. M., Herrera-Imbroda, B., Queipo-Ortuño, M. I., Castillo, E., Del Moral, J. S.-G., Gómez-Millán, J., Yucel, G., & Lara, M. F. (2018). The Urinary Tract Microbiome in Health and Disease. European Urology Focus, 4(1), 128–138.

Arnold, J. J., Hehn, L. E., & Klein, D. A. (2016). Common Questions About Recurrent Urinary Tract Infections in Women. American Family Physician, 93(7), 560–569.

Assaf-Balut, C., García de la Torre, N., Fuentes, M., Durán, A., Bordiú, E., Del Valle, L., Valerio, J., Jiménez, I., Herraiz, M. A., Izquierdo, N., Torrejón, M. J., De Miguel, M. P., Barabash, A., Cuesta, M., Rubio, M. A., & Calle-Pascual, A. L. (2019). A High Adherence to Six Food Targets of the Mediterranean Diet in the Late First Trimester is Associated with a Reduction in the Risk of Materno-Foetal Outcomes: The St. Carlos Gestational Diabetes Mellitus Prevention Study. Nutrients, 11(1), 66.

Bergamin, P. A., & Kiosoglous, A. J. (2017). Non-surgical management of recurrent urinary tract infections in women. Translational Andrology and Urology, 6(2), S142-S152–S152.

Carlsson, S., Wiklund, N. P., Engstrand, L., Weitzberg, E., & Lundberg, J. O. N. (2001). Effects of pH, Nitrite, and Ascorbic Acid on Nonenzymatic Nitric Oxide Generation and Bacterial Growth in Urine. Nitric Oxide, 5(6), 580–586.

CDC. (2019). Urinary Tract Infection | Community | Antibiotic Use | CDC.

Chae, J. H. J., & Miller, B. J. (2015). Beyond Urinary Tract Infections (UTIs) and Delirium: A Systematic Review of UTIs and Neuropsychiatric Disorders. Journal of Psychiatric Practice, 21(6), 402–411.

Chih-Hung Wang, Fang, C.-C., Chen, N.-C., Liu, S. S.-H., Yu, P.-H., Wu, T.-Y., Chen, W.-T., Lee, C.-C., & Chen, S.-C. (2012). Cranberry-Containing Products for Prevention of Urinary Tract Infections in Susceptible Populations: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Archives of Internal Medicine, 172(13), 988–996.

Crann, S. E., Cunningham, S., Albert, A., Money, D. M., & O’Doherty, K. C. (2018). Vaginal health and hygiene practices and product use in Canada: A national cross-sectional survey. BMC Women’s Health, 18(1).

Dason, S., Dason, J. T., & Kapoor, A. (2011). Guidelines for the diagnosis and management of recurrent urinary tract infection in women. Canadian Urological Association Journal, 5(5), 316–322.

De Nisco, N. J., Neugent, M., Mull, J., Chen, L., Kuprasertkul, A., de Souza Santos, M., Palmer, K. L., Zimmern, P., & Orth, K. (2019). Direct Detection of Tissue-Resident Bacteria and Chronic Inflammation in the Bladder Wall of Postmenopausal Women with Recurrent Urinary Tract Infection. Journal of Molecular Biology, 431(21), 4368–4379.

Falagas, M. E., Kotsantis, I. K., Vouloumanou, E. K., & Rafailidis, P. I. (2009). Antibiotics versus placebo in the treatment of women with uncomplicated cystitis: A meta-analysis of randomized controlled trials. Journal of Infection, 58(2), 91–102.

Fihn, S. D., Boyko, E. J., Normand, E. H., Chen, C.-L., Grafton, J. R., Hunt, M., Yarbro, P., Scholes, D., & Stergachis, A. (1996). Association between Use of Spermicide-coated Condoms and Escherichia coli Urinary Tract infection in Young Women. American Journal of Epidemiology, 144(5), 512–520.

Forde, B. M., Roberts, L. W., Phan, M.-D., Peters, K. M., Fleming, B. A., Russell, C. W., Lenherr, S. M., Myers, J. B., Barker, A. P., Fisher, M. A., Chong, T.-M., Yin, W.-F., Chan, K.-G., Schembri, M. A., Mulvey, M. A., & Beatson, S. A. (2019). Population dynamics of an Escherichia coli ST131 lineage during recurrent urinary tract infection. Nature Communications, 10(1), 1–10.

Foxman, B., Gillespie, B., Koopman, J., Zhang, L., Palin, K., Tallman, P., Marsh, J. V., Spear, S., Sobel, J. D., Marty, M. J., & Marrs, C. F. (2000). Risk Factors for Second Urinary Tract Infection among College Women. American Journal of Epidemiology, 151(12), 1194–1205.

Gilbert, N. M., O’Brien, V. P., & Lewis, A. L. (2017). Transient microbiota exposures activate dormant Escherichia coli infection in the bladder and drive severe outcomes of recurrent disease. PLOS Pathogens, 13(3), e1006238.

Grin, P. M., Kowalewska, P. M., Alhazzani, W., & Fox-Robichaud, A. E. (2013). Lactobacillus for preventing recurrent urinary tract infections in women: Meta-analysis. The Canadian Journal of Urology, 8.

Gupta, K., Grigoryan, L., & Trautner, B. (2017). Urinary Tract Infection. Annals of Internal Medicine, 167(7), ITC49.

Gupta, S., Kapur, S., Dv, P., & Verma, A. (2015). Garlic: An Effective Functional Food to Combat the Growing Antimicrobial Resistance. 8.

Harjai, K., Kumar, R., & Singh, S. (2010). Garlic blocks quorum sensing and attenuates the virulence of Pseudomonas aeruginosa. FEMS Immunology & Medical Microbiology, 58(2), 161–168.

Hsu, P.-C., & Chen, S.-J. (2018). Obesity and risk of urinary tract infection in young children presenting with fever. Medicine, 97(49), e13006.

Hussain, S. A., Alhalabi, F., & Zimmern, P. E. (2015). Long-term efficacy of fulguration of trigonitis for recurrent urinary tract infections in women. Urological Science, 26(3), 197–201.

Jepsen, R., Williams, G., & Craig, J. (2012). Cranberries for preventing urinary tract infections. Cochrane Database of Systematic Reviews, 10, 82.

Kalinderi, K., Delkos, D., Kalinderis, M., Athanasiadis, A., & Kalogiannidis, I. (2018). Urinary tract infection during pregnancy: Current concepts on a common multifaceted problem. Journal of Obstetrics and Gynaecology, 38(4), 448–453.

Koh, E.-I., Robinson, A. E., Bandara, N., Rogers, B. E., & Henderson, J. P. (2017). Copper import in Escherichia coli by the yersiniabactin metallophore system. Nature Chemical Biology, 13(9), 1016–1021.

Kontiokari, T., Laitinen, J., Järvi, L., Pokka, T., Sundqvist, K., & Uhari, M. (2003). Dietary factors protecting women from urinary tract infection. The American Journal of Clinical Nutrition, 77(3), 600–604.

Kranjčec, B., Papeš, D., & Altarac, S. (2014). d-mannose powder for prophylaxis of recurrent urinary tract infections in women: A randomized clinical trial. World Journal of Urology, 32(1), 79–84.

Madineh, H., Yadollahi, F., Yadollahi, F., Mofrad, E. P., & Kabiri, M. (2017). Impact of garlic tablets on nosocomial infections in hospitalized patients in intensive care units. Electronic Physician, 9(4), 4064–4071.

Mayo Clinic. (n.d.). Urinary tract infection (UTI)—Symptoms and causes—Mayo Clinic. Retrieved February 24, 2020, from Retrieved February 24, 2020, from https://www.mayoclinic.org/diseases-conditions/urinary-tract-infection/symptoms-causes/syc-20353447

Mayo Clinic. (2019). Benign prostatic hyperplasia (BPH)—Symptoms and causes. Mayo Clinic.

McLellan, L. K., & Hunstad, D. A. (2016). Urinary Tract Infection: Pathogenesis and Outlook. Trends in Molecular Medicine, 22(11), 946–957.

Mohseny, A. B., van Velze, V., Steggerda, S. J., Smits-Wintjens, V. E. H. J., Bekker, V., & Lopriore, E. (2018). Late-onset sepsis due to urinary tract infection in very preterm neonates is not uncommon. European Journal of Pediatrics, 177(1), 33–38.

Mulder, M., Kiefte-de Jong, J. C., Goessens, W. H. F., de Visser, H., Ikram, M. A., Verbon, A., & Stricker, B. H. (2019). Diet as a risk factor for antimicrobial resistance in community-acquired urinary tract infections in a middle-aged and elderly population: A case–control study. Clinical Microbiology and Infection, 25(5), 613–619.

Ng, Q. X., Peters, C., Venkatanarayanan, N., Goh, Y. Y., Ho, C. Y. X., & Yeo, W.-S. (2018). Use of Lactobacillus spp. To prevent recurrent urinary tract infections in females. Medical Hypotheses, 114, 49–54.

NIH. (2017). Treatment for Interstitial Cystitis | NIDDK. National Institute of Diabetes and Digestive and Kidney Diseases.

Nseir, W., Farah, R., Mahamid, M., Sayed-Ahmad, H., Mograbi, J., Taha, M., & Artul, S. (2015). Obesity and recurrent urinary tract infections in premenopausal women: A retrospective study. International Journal of Infectious Diseases, 41, 32–35.

Ochoa‐Brust, G. J., Fernández, A. R., Villanueva‐Ruiz, G. J., Velasco, R., Trujillo‐Hernández, B., & Vásquez, C. (2007). Daily intake of 100 mg ascorbic acid as urinary tract infection prophylactic agent during pregnancy. Acta Obstetricia et Gynecologica Scandinavica, 86(7), 783–787.

Pinggera, G.-M., Feuchtner, G., Frauscher, F., Rehder, P., Strasser, H., Bartsch, G., & Herwig, R. (2005). Effects of Local Estrogen Therapy on Recurrent Urinary Tract Infections in Young Females under Oral Contraceptives. European Urology, 47(2), 243–249.

Sassone-Corsi, M., Chairatana, P., Zheng, T., Perez-Lopez, A., Edwards, R. A., George, M. D., Nolan, E. M., & Raffatellu, M. (2016). Siderophore-based immunization strategy to inhibit growth of enteric pathogens. Proceedings of the National Academy of Sciences, 113(47), 13462–13467.

Schwenger, E. M., Tejani, A. M., & Loewen, P. S. (2015). Probiotics for preventing urinary tract infections in adults and children. Cochrane Database of Systematic Reviews.

Semins, M. J., Shore, A. D., Makary, M. A., Weiner, J., & Matlaga, B. R. (2012). The Impact of Obesity on Urinary Tract Infection Risk. Urology, 79(2), 266–269.

Sihra, N., Goodman, A., Zakri, R., Sahai, A., & Malde, S. (2018). Nonantibiotic prevention and management of recurrent urinary tract infection. Nature Reviews Urology, 15(12), 750–776.

Tchesnokova, V. L., Rechkina, E., Chan, D., Haile, H. G., Larson, L., Ferrier, K., Schroeder, D. W., Solyanik, T., Shibuya, S., Hansen, K., Ralston, J. D., Riddell, K., Scholes, D., & Sokurenko, E. V. (2019). Pandemic Uropathogenic Fluoroquinolone-resistant Escherichia coli Have Enhanced Ability to Persist in the Gut and Cause Bacteriuria in Healthy Women. Clinical Infectious Diseases.