SUFU 2021: Recurrent Urinary Tract Infection: Fact or Fiction

( Dr. Duane Hickling presented the evidence behind many common urinary tract infections (UTI) treatments: water, methenamine salts, D-Mannose, and lactobacillus. He noted that UTIs are common as 20% of college-aged women had at least one culture-confirmed UTI recurrence within 6 months. UTI recurrence is underestimated as it is often underreported. Antibiotic resistance is now a major threat to public health as we are seeing decreased susceptibility rates with no new antibiotics on the horizon. Patients are demanding alternatives to antibiotics. He reviewed the following interventions to prevent UTIs:

  • Increased water intake (1.5 L/day) does improve UTI recurrence risk (Hooten, 2018) so should recommend it clinically.
  • Methenamine salts are recommended to prevent UTIs. Methenamine is hydrolyzed to ammonia and formaldehyde which is felt to be bacteriostatic. Hydrolysis is increased in acidic urine which is why it is combined with Vitamin C. Broad-spectrum microbial activity and lack of resistance makes this an attractive preventative solution. The side effect profile is limited, but evidence as to its effectiveness is lacking. A 2012 Cochrane review noted that methenamine hippurate appears to be effective for a short duration in those individuals without renal tract abnormalities but may be ineffective if used long term. But current multiple center trial on the use of methenamine is being conducted (Forbes, 2018).
  • D-MANNOSE is an inert monosaccharide that is rapidly metabolized and excreted in the urine. Inhibits urothelial binding of bacteria. Studies are small with an inconsistent diagnosis of UTI. It may be a preventative effect but larger studies needed as to dosing and duration of use.
  • Probiotics: Living microorganisms that confer health benefits to their host when consumed and administered in adequate quantities. Lactobacillus most common vaginal microbiota and its colonization is inversely correlated with E.coli colonization in women with recurrent UTIs. Few studies on oral lactobacillus. Cochrane review noted poor evidence for use of vaginal lactobacillus but small studies available. Not sure what to recommend as to its use. Potential therapy.
Presented by: Duane Hickling, MD, urologist at The Ottawa Hospital and Assistant Professor in the Division of Urology, Department of Surgery, Faculty of Medicine at the University of Ottawa.

Written by: Diane K. Newman, DNP, ANP-BC, FAAN is an Adjunct Professor of Urology in Surgery, Perelman School of Medicine, University of Pennsylvania and Co-Director of the Penn Center for Continence and Pelvic Health


  1. Forbes, R et al. Alternatives To prophylactic Antibiotics for the treatment of Recurrent urinary tract infection in women (ALTAR): study protocol for a multicentre, pragmatic, patient-randomised, non-inferiority trial. Trials. 2018 Nov 9;19(1):616. doi: 10.1186/s13063-018-2998-4.
  2. Foxman B, Barlow R, D'Arcy H, Gillespie B, Sobel JD. Urinary tract infection: self-reported incidence and associated costs. Ann Epidemiol. 2000 Nov;10(8):509-15. doi: 10.1016/s1047-2797(00)00072-
  3. Hooton TM, Vecchio M, Iroz A, Tack I, Dornic Q, Seksek I, Lotan Y. Effect of Increased Daily Water Intake in Premenopausal Women With Recurrent Urinary Tract Infections: A Randomized Clinical Trial.  JAMA Intern Med. 2018 Nov 1;178(11):1509-1515. doi: 10.1001/jamainternmed.2018.4204

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