What Should You Do If You Think You Have a UTI?
See a healthcare provider for urine testing and appropriate antibiotic treatment. Drink plenty of water to flush bacteria. Take the full course of prescribed antibiotics even if symptoms improve quickly. Over-the-counter phenazopyridine (AZO) can relieve urinary pain while antibiotics take effect but does not treat the infection.
Diagnosis of uncomplicated UTI is based on clinical symptoms confirmed by urinalysis and urine culture. A clean-catch midstream urine sample is tested for leukocyte esterase, nitrites (suggesting bacterial presence), and white blood cells. Culture and sensitivity testing identifies the specific bacteria and guides antibiotic selection, particularly important in the era of increasing antibiotic resistance. The IDSA (Infectious Diseases Society of America) guidelines recommend treating uncomplicated cystitis with nitrofurantoin 100 mg twice daily for 5 days, trimethoprim-sulfamethoxazole (TMP-SMX) 160/800 mg twice daily for 3 days, or fosfomycin 3g single dose.
Fluoroquinolones (ciprofloxacin, levofloxacin) should NOT be used for uncomplicated UTIs due to their broad-spectrum activity promoting resistance, risk of serious side effects (tendinopathy, neuropathy, aortic dissection), and FDA black box warning. They should be reserved for complicated UTIs and pyelonephritis. For patients with penicillin allergy or resistance to first-line agents, amoxicillin-clavulanate and cephalosporins are alternatives. Symptoms typically improve within 1-2 days of starting antibiotics.
The IDSA guidelines recommend treating uncomplicated cystitis with nitrofurantoin, TMP-SMX, or fosfomycin as first-line agents
What Causes Urinary Tract Infections?
Escherichia coli (E. coli) from the gastrointestinal tract causes 80-90% of uncomplicated UTIs. Bacteria enter through the urethra and ascend to the bladder. Women are particularly susceptible due to shorter urethra length (4 cm vs 20 cm in men), proximity of the urethral opening to the anus, and hormonal effects on the vaginal microbiome.
Uropathogenic E. coli (UPEC) strains possess specific virulence factors including type 1 fimbriae and P fimbriae that allow them to adhere to uroepithelial cells, resist urinary flow, and invade the bladder lining. After adhering, bacteria can form intracellular bacterial communities (biofilms) within the bladder wall that are protected from antibiotics and immune clearance, contributing to recurrent infections. Other common uropathogens include Staphylococcus saprophyticus (5-15% of UTIs in young women), Klebsiella pneumoniae, Proteus mirabilis, and Enterococcus species.
Antibiotic resistance is an increasing concern. E. coli resistance to TMP-SMX exceeds 20% in many regions, which is the threshold at which IDSA recommends against empiric use. Extended-spectrum beta-lactamase (ESBL)-producing E. coli is an emerging challenge, particularly in recurrent UTIs and healthcare-associated infections. Local resistance patterns (antibiograms) should guide empiric antibiotic selection. Fosfomycin and nitrofurantoin maintain relatively low resistance rates and are preferred first-line agents.
E. coli resistance to TMP-SMX exceeds 20% in many regions
How Can You Prevent Recurrent UTIs?
Evidence-based prevention strategies include adequate hydration (at least 1.5 liters of water daily), post-intercourse urination, cranberry products containing 36 mg proanthocyanidins daily, vaginal estrogen for postmenopausal women, and D-mannose supplements. For frequent recurrences, prophylactic antibiotics or self-start therapy may be prescribed.
A randomized trial published in JAMA Internal Medicine found that increasing water intake by 1.5 liters per day reduced UTI episodes by 48% in premenopausal women with recurrent UTIs. Cranberry products prevent UTIs by blocking E. coli adhesion to bladder cells. A 2023 Cochrane review of 50 trials confirmed cranberry products reduce UTI risk by approximately 26%, with standardized supplements (36 mg PACs) more effective than juice. D-mannose, a natural sugar, prevents E. coli adhesion and showed efficacy similar to nitrofurantoin prophylaxis in a pilot randomized trial.
For postmenopausal women, vaginal estrogen (cream, ring, or tablet) is one of the most effective prevention strategies, restoring the vaginal microbiome and reducing UTI recurrence by 36-75% in clinical trials. For women with 3 or more UTIs per year, options include continuous low-dose prophylaxis (nitrofurantoin 50-100 mg nightly), post-coital prophylaxis (single dose after intercourse), or patient-initiated self-start therapy (patient-held antibiotics to begin at first symptom onset). Methenamine hippurate is a non-antibiotic prophylactic option with growing evidence.
A randomized trial found increasing water intake by 1.5L per day reduced UTI episodes by 48%
