When UTIs Keep Coming Back—What You Need to Know

This episode was inspired by a recent coaching group I joined with Janice Mitchell, a pelvic floor physical therapist with incredible insight and compassion. The women in that group had thoughtful, important questions about recurrent urinary tract infections, which I often hear in my practice.

So today, we're diving into that discussion and sharing it with you.

If you've ever dealt with bladder infections that come and go (and come back again), this episode will help you better understand what's going on and what you can do about it.

Together with Janice, we cover:

• What truly defines a UTI and why urine cultures matter
• How low estrogen levels and tight pelvic floor muscles can mimic UTI symptoms
• The role of vaginal estrogen and other medical options in treatment and prevention
• What to expect from your provider—and how to advocate for better care

You're in the right place if you're tired of the cycle and want answers that make sense. 

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Timeline:

00:30 Introduction and Overview

01:19 Understanding UTIs: Causes and Symptoms

05:01 Diagnosing UTIs: Tests and Procedures

09:03 Treatment Options for UTIs

09:43 Vaginal Estrogen: Benefits and Usage

15:17 Preventing UTIs: Tips and Recommendations

18:04 Addressing Bleeding During or After Sex

Transcript

Hi there. A few weeks ago I spent some time with Denise Mitchell from my PFM, that's my pelvic floor muscles. Denise is a physical therapist who practices clinically, but also spends a lot of time educating and coaching women with prolapse and helping them understand their options.

I answered some questions from her coaching group and there were a lot of great questions that came from this. I thought you would benefit from this discussion as well. So today's podcast is gonna center on recurrent urinary tract infections or bladder infections that keep coming back, listen and learn.

So we're gonna jump into, we have questions surrounding a variety of topics, prolapse bladder. Pelvic floor, they're all related to those things. So we're gonna start by talking about UTIs or urinary tract infections. And we know that that can feel really bad, right? Like you feel burning, you feel pain when you're urinating.

It would be uncomfortable to insert anything, like your whole world is just kind of, uh, messed up and you might be leaking. So now that we started on that wonderful topic. Um, what are your thoughts on UTIs in terms of what's causing UTIs, um, and how do we determine what is the cause? Is it pelvic floor?

Is it actually an infection? How do we know and what do we need to do? Yeah, so urinary tract infections are really common in women and they. Become more common when women first become sexually active, and they also become more common around the time of menopause, right? So as your estrogen declines, you're a little bit more, um, predisposed to having UTIs.

But the thing that I would tell you is when I look at my schedule and I see someone coming to see me because they're having recurrent UTIs. I always interpret that in my head as they are having some pain in their pelvis, right? So when you have a bacterial infection, right, that's what a UTI I is. You have too many bacteria in your bladder.

It, it causes irritation. But there are other things that can do it to, and I would tell you, I mean the, the most common things that we see, sometimes it's a vaginal infection. So you, you just, you know, wanna check for that. But the two things that I see a lot of that I, I don't think these things are on most people's radar.

One is low estrogen. So when you have low estrogen levels, because you're perimenopausal, you can have low estrogen, um, levels because of birth control pills because you're breastfeeding. When that happens, those tissues become a lot more delicate. And so you can get the, those irritative symptoms too. We see it most commonly perimenopause.

Um, and, you know, perimenopause can start in your early forties and, and nobody, I mean, again, not really on anyone's radar. Um, so that's an important thing to look at, kind of that hormonal status. And the other thing that can do it is a tight pelvic floor, right? So when patients have a really tight pelvic floor, sometimes they'll come in with these irritative symptoms and it, it all, you know, whether it's your pelvic floor, whether it's low estrogen, whether it's really a bladder infection.

It feels the same to a lot of people. I mean, and it, it's hard to tell if. It's the muscles. If it's the vagina that hurts. If it's the bladder that hurts, I, I have never had a patient come in and say, Hey, my pelvic floor is tight. Right? Without having been told that in the past, right? We just don't, we don't think about those things.

So it's really important to kind of assess the whole thing. So if you're someone who's getting recurrent urinary tract infections, you wanna make sure that you're getting cultures. Because sometimes the dipsticks will look positive. Cultures tell us if it's really an infection or if it's something else that's going on.

And you know, the most common reason, and I, I'm sure everyone is gonna think this is gross, but the most common reason that we get infections is just because the anus is so close to the urethra in women. And you just, you know, there's a little cross contamination no matter how careful you are about things.

It's not a hygiene issue, it's just. You know, those two areas being really close together. And so, you know, most urinary tract infections are e coli. 'cause that's what we see in the gut. Can you walk me through, so let's say somebody's having a ur urinary type symptoms burning discomfort when they're, when they're peeing.

They go into urgent care. So they're gonna do a dipstick test on their urine, which is They dip. Yeah. So they dip it in and the dipstick test is, you know, it, it tells you if it's not an infection, right? It doesn't always tell you if it is an infection. A lot of urgent cares will do a culture, and then you just have to go back in and, and look.

Frequently when you go to an urgent care, they're just treating that one episode, right? They're not kind of looking at everything. Sometimes if you go to an urgent care three or four times and you're seeing the same person, they'll say, look, this, you gotta, you gotta go figure this out, right? This isn't, there's something else going on.

But yeah, you want, you wanna get a culture to make sure that it's an infection. So I'll, I'll frequently have people come into the office and they'll say, you know, I'm getting urinary tract infections, because that's what it feels like. And most people have had one before, so it's familiar. And then when I go back and look at the cultures, the cultures are, are negative, right?

So it's, it's not that they're not irritated, it's just that it's not a bacteria causing that problem. And so would someone ask for that? So let's say I'm patient and I'm at the urgent care, and they say the, the urine test said that it was negative for UTI. Uh, then am I, do I ask negative? What's a good way to be proactive as a patient?

Yeah. If it's negative, you don't have to check a culture. If it's positive, it's totally reasonable to check a culture. So the culture will tell you. What bacteria it is, right? Which is good to know. And then a culture will also tell you what antibiotics will kill that bacteria, right? Mm-hmm. So that helps us make sure that you're on the right antibiotic.

Okay. Do most clinics then have that equipment that they can test it on site and that they would know like when I leave, what type of antibiotic I should be on? Or are they sending it off to a lab? They send it off to the lab. So you send it off to the lab and they actually grow the bacteria. So it takes about 48 hours to get that diagnosis to know exactly what bacteria it is.

Especially if you're getting recurrent urinary tract infections, you wanna see if you're getting the same bug all the time. If it's something else, you know, sometimes the problem is we just didn't treat you long enough and you need a, a longer treatment. So those things help us figure that out. But a person that is, that shows negative on the dipstick shouldn't be treated with antibiotics at that point.

They should not. That is correct. But that's far more common than it should be, that you get treated when things are negative. I mean, I, I think sometimes, you know, common things are common, right? And so sometimes people assume, oh, this sounds like a urinary tract infection. It must be urinary tract infection, right?

Right. Mm-hmm. I mean, providers do that too. But no, if the urinalysis is negative, it's, it is not, it's not an infection. There's something else going on, and it, it takes a lot of time sometimes to convince somebody because it's, it's not uncommon to talk to someone and say, you know, this is an infection.

They'll say, but I've had infections. This feels like an infection. Say, well, yes, that's true. Yeah. But it's not an infection. And they want the pill. They want the pill. Gimme the pill to make it better. Gimme the pill. Yeah. And, and sometimes it'll make it better. Sometimes it, it doesn't make it better. Right.

So it, it takes a lot of talking to people and working through it with them. Right. It's.

If someone was watching this and there's someone that's had recurrent UR urinary tract infection type symptoms and they've gone into primary care or urgent care repeatedly, like upwards of two or three times in the last year. Yeah. Um, what would you tell them should be their next step? What would you recommend?

So it depends, right? It depends on their age and kind of what else is going on. So when you have a lack of estrogen, so perimenopause, menopause, you can get irritative symptoms that feel like an infection, but you are also more likely to get infections too. So, um, you know, if it's someone who's perimenopause or menopausal, we'll almost always start with vaginal estrogen because vaginal estrogen is one of the best UTI preventatives that we have, right?

And we like vaginal estrogen 'cause it stays in the pelvis, it stays in, um, the vagina and the bladder. It helps these sys symptoms. It doesn't get into the rest of your system. So it's really, really safe. Sometimes people hate it 'cause you know, the cream's a little bit mucky and you know, there are, there are those types of things that we have to work through.

But vaginal estrogen, which you would use twice a week, is an excellent preventative and, and that's usually what we start with. Great, great man. We need to do maybe a whole one just on vaginal estrogen. Um, I mean, sometimes vaginal estrogen feels like a magic cream, right? Because it can help with so many different things.

And I, I think, you know, when you're menopausal, I think women start thinking about low estrogen. But you know, if you're 40 and you're having some irritative symptoms, that's not really on your radar. Right? And those are the people that it, it. I mean, those may be the first kind of symptoms you get of low estrogen.

Right. And you're, you're just not thinking about it. 'cause it's not something that we talk about. And, and you know, I mean, that cream can totally make it all go away, but yes, it, it is, um, you know, probably one of my top five favorite things in the world. Aw, I love it. It's true. So would an urgent, would an urgent care be able or willing or likely to prescribe that or would they need to go to a urologist or a urogynecologist or a GYN or their family care like?

I think it depends on, on where you are. I mean, an urgent care could do it, but they're not, you know, they're just taking care of that urgent need. Right. They're not thinking about prevention for you. But any physician or provider can, um, can prescribe vaginal estrogen. Right. So I see a lot of primary cares doing it.

Um, a lot of GYNs will do it. A lot of urologists will do it. Yeah. So urogyn, you know, I mean, it's probably the first or second thing that we do. But, but yeah, you could ask your, your primary care. Okay. And with vaginal estrogens, it's not a pill that you're taking, it's not systemic. Right. Are there any cancer concerns with that?

No, there are not. So I, and, and that's because, you know, there've been all these studies that have been done, and when we, if you're menopausal and we give you vaginal estrogen, and you take the amount that is prescribed, right. If you take more, this isn't true. You take the amount that is prescribed and we check your blood levels, your estrogen stays in the menopausal level, so it does not increase at all.

So there, there's, um, no increase in breast cancer, so, or other cancers. But the caveat to that is some women who have an estrogen responsive cancer just, it just feels crazy to them to take estrogen, right? And, and so they won't do it. And if I have a patient who has had a cancer, especially in estrogen responsive cancer, I'll contact their urologist or their oncologist.

Right. Their cancer doctor. Mm-hmm. Um, and it used to be that sometimes they would say no, I haven't had anyone say no in the last, you know, probably five to 10 years. But I think it's courtesy just to say, Hey, we're, we're, we're, you know, this is what we're doing. Right. And I would tell you. I mean, this is probably too much information.

Right. But I, no, nothing is cancer last year. Right. And I am on vaginal estrogen and I have no concerns about my cancer. So tell me. I love that. Thank you for sharing. I mean, I don't love it. Of course. I don't love it. You, it's okay.

Um, tell me about the twice a week. So what if you did it five times a week or like, why, why limit? If this is a good thing, why limit it to twice a week? And so how do you know? Don't need more than twice a week? I mean, usually, you know, the idea is to use the smallest amount that gets rid of the symptoms.

Every now and then, I have someone who will use it three times a week. But getting into the higher doses, if you are using it more frequently, then your, um, systemic level can increase. So how often would someone need to have their estrogen checked if they're using local estrogen, or what would we recommendation on that?

We don't check it because if you're taking it as recommended, we know your blood levels are fine. So the only exception to that is if someone came in and they were having bleeding and they still had a uterus right then that's something that we would evaluate and, and kind of look for. But otherwise, we don't do any testing.

We just treat you based on symptoms. And if your symptoms are better and you're taking the estrogen twice a week, you don't have an increase in your systemic level. All right. So thoughts on how to prevent UTIs. So one of them I would imagine would be vaginal estrogen if you're in that age bracket. Yep.

Vaginal estrogen is kind of the big one. Um, there have been a couple of studies that have come out recently about DNOs, so we used to think DNOs was a very excellent preventative and it, there have been a couple studies that have come out that have shown that it is not as helpful as we thought it.

There are a lot of people that on it, that are on it and swear by it, so I never take anybody off of it. Um, there's a medication called methenamine, and Methenamine is also a good preventative. Um, it basically makes your urine like formaldehyde and bacteria don't like that. You know, cranberry is pretty neutral.

Um, I would tell you, you know, one year there's a study that says it works. The next year there's a study that says it doesn't work. So. That is pretty neutral. So the big things are the vaginal estrogen, the methenamine, and then um, you can consider dano. Mm-hmm. If nothing else works, then sometimes I will put a patient on a very low dose of antibiotic to prevent the infections.

That's something we try not to do very frequently, just to reserve antibiotics for when you really need it. Right. 'cause you're creating more resistance there. But, but for some people that can make a, a huge difference. The other thing that I would tell you about UTIs, there's actually, I mean this may be a little controversial.

There's a vaccine in Europe that's for UTIs that has inactive bacteria, and I think it's the, I think it's against four bacteria, the four most common bacteria. And that has been shown to be, um, very effective for preventing UTIs, but it's not available in the. Do you know if they're working on FDA approval?

They're, I have to look into it. I'm not sure what is happening. So a about a year and a half ago you could ask the FDA and, and you could, um, get a special dose of it for a patient, but you had to request it from the FDA and you can't do that right now. So I'm not a hundred percent sure where that is in the process right now.

Mm-hmm.

Game changing Uhhuh and anybody watching this that may be in Europe, something that they can talk to their provider about? Totally, yeah. Or I mean, you could, you know, go to Ireland and try to sneak a vaccine. I don't know how easy that would be to do, but I don't know either. Okay. Let's see. I think we covered, well, let's talk about the bleeding.

Because you just mentioned that, 'cause there was a question in here, if a woman in her forties is bleeding a little bit during or after sex, what? What would you say is the problem? Yeah, yeah. What would you say is the problem or what would you suggest she do in terms of Yeah, so I, I think the important thing is it's not normal, right?

And it needs to be evaluated. And the thing that we worry about is there's something inside your uterus that's bleeding. And, and that could be something benign, right? It doesn't have to be something horrible, right? It could be like a little polyp that's getting irritated, um, you know, during that activity.

But, but that's something that you just wanna look at. And frequently, you know, it, it means that you're, you're gonna get a biopsy, right? To see if there's anything there where they would go in vaginally and take a little piece. Yep. Yeah. We, um. So if we do an endometrial biopsy and, and somebody might start with an ultrasound, right?

And, and look in the uterus to see if there's anything there. But if we're gonna biopsy in the office, usually we have this little plunger that sucks cells out. So you put it in the cervix and uterus, and then you use that to, um, to suck out the cells. It's a small procedure. It probably takes five minutes.

It, it's uncomfortable. It's crampy. It's not fun, but it's quick. So, okay. And there isn't any cutting involved. You're tissue. There's no cutting. Mm-hmm. There's no cutting. I mean, it's really, it's this very skinny straw that has like a suction device on it. So, no, no. Cutting. Okay. And that is called an endometrial biopsy.

It's an endometrial biopsy. So the endometrium is the lining on the inside of the uterus.