Beyond Antibiotics: Preventing Recurrent UTIs

Nicola, 53, is at the end of her tether. She’s been plagued by multiple UTIs over the past year.

‘I’m so fed up, and all these antibiotics can’t be good for me’, she says. ‘My friend swears by probiotics. Do you think I should try them?’

Recurrent UTI (defined as two or more UTIs in the last 6 months, or three or more in the last 12 months) is a frequent presentation to primary care, with significant impact on quality of life. Repeated antibiotic use can be a source of concern for patients and clinicians alike, 

The European Association of Urology guideline (EAU guideline) was updated in 2025 including a helpful overview of non-antibiotic strategies.

It advocates a stepwise approach, with discussion of risk avoidance and behavioural measures as a starting point (e.g. avoiding delaying urination generally and post coitally, wiping front to back, ensuring adequate hydration, and avoiding occlusive underwear), then consideration of non-antibiotic options, followed by antimicrobial prophylaxis if insufficient response. 

What is adequate hydration?! They key piece of evidence here comes from a RCT on pre-menopausal women with baseline low fluid intake of under 1.5L, which found that an additional 1.5L water per day was associated with a reduction in episodes of UTI (JAMA Intern Med 2018). It remains uncertain what the optimal level of intake is, and how applicable this is to older patients. However, we can advise that boosting water consumption may be beneficial, particularly for those with low baseline levels. 

Of non-antibiotic treatments, vaginal oestrogen for post-menopausal women and methenamine hippurate were the most strongly recommended.

The evidence considered for vaginal oestrogen was largely based on postmenopausal women (barring a very small study looking at use in younger women on oral contraception), and showed benefit relative to placebo, but inferiority to antibiotic prophylaxis. Notably, NICE guideline on recurrent UTI (NG112) supports broader use of vaginal oestrogen based on expert consensus, also recommending considering use for those experiencing perimenopause. Importantly, oral oestrogen did not show benefit for cystitis prevention, underscoring the importance of considering vaginal oestrogen even if women are already on systemic HRT for other symptoms. 

Excitingly, methenamine hippurate showed non-inferiority to prophylactic antibiotic use (HealthTechnolAssess.2022). Further, a recent RCT found that 6 months of methenamine hippurate reduced the frequency of UTIs by 25% compared with placebo in women aged ≥70 years (Clin Microbiol Infect. 2025). However, surprisingly the study found that rates of UTI requiring antibiotics in the 6 months following treatment cessation were significantly higher in the methenamine hippurate group than the placebo group, with an IRR 1.7. Food for thought when considering treatment duration and counselling patients! 

Now to Nicola’s key question regarding probiotics. The EAU guideline considered evidence for Lactobacillus spp.. Meta-analyses combining all known strains did not demonstrate significant benefit. However, sensitivity analysis excluding studies with ineffective strains did show positive effect. The most promising results were for probiotics containing L. rhamnosus GR-1, L. reuteri B-54 and RC-14, L. casei shirota and L. crispatus CTV-05. Conclusions were limited by significant heterogeneity between studies, including both oral and vaginal routes of administration. The guideline suggests a ‘weak’ recommendation to discuss these options, but the data was considered insufficient to make recommendations on optimal route, dose or treatment duration. 

For those interested in herbal remedies, there is some evidence that combinations of xyloglucan, hibiscus and propolis, or Centaurii herba, Levistici radix and Rosmarini folium may reduce recurrence of cystitis. 

There was contradictory evidence regarding the efficacy of cranberry products and D-mannose. Like NG112, the EAU guideline supports discussing these as options patient may wish to explore, whilst being clear about uncertainty. 

So back to Nicola! Having already optimised risk prevention measures and reporting good levels of hydration, she decides to try vaginal oestrogen. She remains interested in probiotics and might explore these further in the future!

Interested in learning more? Join us on Tuesday 6th October for our FREE online Recurrent UTI clinic, where we'll explore the latest evidence on recurrent UTI through practical, case-based discussions, with plenty of tips to take straight back to your consultations.