Urinary tract infections are among the most common infections among women, and yet in many cases their treatment has for years remained the same fixed and automatic approach: Symptoms appear – antibiotics are prescribed. However, the clinical reality of recent years shows that this approach is no longer appropriate.
The burden on the system, the rise in bacterial resistance, and the renewed understanding of the types of infections and treatment methods require a change in approach. One prominent example is the story of a 20-year-old female soldier who suffered over the past year from eight different episodes of urinary tract infections. In each episode she described lower abdominal pain, difficulty urinating, burning, and waking at night due to a feeling of not fully emptying the bladder. She repeatedly turned to the unit clinic and was initially treated with one antibiotic, which led only to partial improvement. Within a short time the symptoms returned, the medication was replaced with another antibiotic – and it also did not solve the problem. After about another month, a third antibiotic was given, which also did not improve the symptoms. Only then was it decided to refer her to a urologist, in order to understand what lay behind the recurrences and what caused the antibiotic treatment to fail to provide a solution.
Her case illustrates a much broader phenomenon: Overuse of antibiotics and uncontrolled use of medications intended to deal with an acute infection, without stopping to examine the situation, the type of infection, the medical history, and the risk of resistance.
Half of women will experience a urinary tract infection
Official data show that about half of women will experience at least one urinary tract infection during their lifetime, and about 30% will suffer from recurrent infections. Alongside these numbers, troubling data have been published in recent years about increasing bacterial resistance, among other things as a result of overuse of certain medications. For example, antibiotics of the ciprodex type have been presented in recent years as a prominent example: Due to extensive and uncontrolled use, the resistance rate to them in Israel reaches about 25%, according to data from laboratories and medical associations. This result is not just an individual problem; it changes the rules of the game in the treatment of urinary tract infections, especially in recurrent situations.
Against the background of these findings, the latest position papers of the European Association of Urology present a clear distinction between a mild infection and a complicated infection, and sharpen the understanding that a large proportion of cases – even when it is a recurrent infection – do not require immediate antibiotic treatment. A mild infection is one in which the symptoms are local only: Burning, frequency, urgency, and mild pain. Even if it is a recurrence, as long as there is no fever, chills, lower back pain, or a general feeling of illness, it is sometimes possible to manage the episode with conservative measures: Increased fluid intake, rest, behavioral changes, herbal supplements, and controlled urination.
In contrast, when fever, back pain, chills, or a feeling of illness appear – this is a complicated infection that requires immediate antibiotic treatment and sometimes also broader investigation.
What causes urinary tract infections?
The prevalence of infections throughout the female life cycle is influenced by physiological, hormonal, and behavioral factors. At the end of the teenage years and in the early twenties, a peak in infection prevalence is observed, mainly due to the onset of sexual activity and changes in hygiene and voiding habits. Women after childbirth may deal with incomplete emptying of the bladder or with changes in the vaginal and urethral mucosa that increase the risk of infection. During menopause, another peak occurs: The decline in estrogen levels causes thinning of the mucosa, which makes it easier for bacteria to penetrate the bladder. Therefore, in these situations there is room to consider local hormonal treatment that strengthens the mucosa and reduces recurrences.
Alongside these physiological factors, many women arrive for treatment equipped with a series of myths that are unfounded and can be misleading. For example, tight clothing or jeans do not cause urinary tract infections; at most they may create a feeling of moisture or discomfort, but the source of most infections is bacteria originating in the digestive system. Public toilets almost never constitute a source of infection, and the chance of contracting an infection from them is negligible, and the same applies to swimming pools.
On the other hand, frequent use of intimate washes actually increases risk, because it harms the bacteria that protect the area. The assumption that any pain or burning indicates a bacterial infection is also wrong – many times it is dryness, irritation from a cleansing product, or even a fungal infection. Cranberries do not treat an active infection, but may help slightly with prevention only. Most importantly to remember, not every infection requires antibiotic treatment; the body can sometimes heal on its own, and white blood cells, which are part of the defense mechanism, may cause symptoms that persist even after the infection has passed.
Basic behavioral changes can significantly reduce the risk of recurrences: Adequate fluid intake, avoiding prolonged holding, ensuring complete emptying, avoiding unnecessary intimate washes, and preserving the natural flora. When dealing with recurrent cases, it is recommended to carry out a comprehensive evaluation that includes a urine culture, antibiotic sensitivity testing, assessment of voiding habits, and, if necessary, imaging tests. Only after a full understanding of the causes of the infection can an accurate prevention plan be built.
In some cases, herbal preparations can be combined as part of preventive treatment. Preparations that include components such as hibiscus and propolis can affect the biological environment of the urinary system, change acidity, reduce the ability of bacteria to adhere to the bladder wall, and inhibit microbial proliferation. They are not a substitute for antibiotics in complicated situations, but can be a supportive tool and provide relief in mild or recurrent situations.
Harms quality of life
Recurrent infections harm the quality of life of many women: They make daily functioning difficult, harm work, disrupt sleep, prevent physical activity, and damage relationships and sexual activity. For some women, the recurrences create constant fear and lead to avoidance of activity. Any preventive treatment or behavioral change that can reduce the number of episodes dramatically affects their quality of life.
In conclusion, it is important to recognize the warning signs that cannot be ignored: The appearance of fever, chills, flank pain, lower back pain, fatigue or significant weakness, and vomiting. Worsening that does not improve within two days or the appearance of visible blood in the urine – all of these require turning to a doctor and performing tests and a urine culture in order to identify the type of infection and tailor the correct treatment.
Dr. Boris Friedman is a senior urologist at Carmel Hospital and head of the Department of Urology at the Lin Medical Center in Haifa