A recent study found that many women treated for recurrent UTIs didn't have UTIs at all. Instead, their symptoms were caused by hormonally driven inflammation and pelvic floor dysfunction.
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Maria Uloko sees the same scenario in her urology practice in Los Angeles every day: A woman has been diagnosed with recurrent urinary tract infections (which means she's had at least two in six months or three in a year), taken repeated rounds of antibiotics, and feels confused as to why the infections keep coming back.
Then, Uloko tells these patients something that often feels both revelatory and frustrating. "Most of them don't actually have UTIs, even though that's been their diagnosis time and time again," she says. "In fact, millions of women are being treated for UTIs they may not actually have."
Uloko is the co-author of a recent study published in The Journal of Sexual Medicine that backs this up. She and her fellow researchers reviewed the medical records of 253 women with recurrent UTIs and found that just 15% showed evidence of problems that were limited to the bladder or urinary tract. The remaining 85% had signs of hormonally driven inflammation of the vulvar region and 75% had pelvic floor dysfunction.
These conditions produce identical symptoms as UTIs — burning with urination, urgency, frequency, and/or lower abdominal pain — but require different treatment.
"What we found is that in women with recurrent UTIs, the majority didn't have a bladder problem at all; they had a vulvar problem," says Uloko.
Uloko's study provides insights that could help patients with urinary tract symptoms, says Melissa Kaufman, professor and chief of the division of reconstructive urology and pelvic health at Vanderbilt University Medical Center who was not involved in the research. "These findings will accelerate our discipline's investigations into a comprehensive unifying hypothesis to more precisely optimize care," she said via email.
One reason is the current diagnostic process for UTIs. When a patient comes in with classic UTI symptoms, the first thing most clinicians order is a screening test called a urinalysis, which detects the presence of inflammation — not bacteria. To determine whether there's a bacterial infection, that urine must be cultured.
What's more, that urine sample must be a "clean catch," which requires thoroughly cleaning the urinary tract opening and surrounding areas and collecting only the midstream of urine, something not all patients are instructed on how to do, says Kaufman.
"But because patients are suffering in real time, clinicians often start them on a broad-spectrum antibiotic right away if that urinalysis comes back positive and adjust the medication if needed once the culture comes back," says Uloko.
There's also a lack of training among medical professionals, says Uloko, adding that doctors are taught that when a patient presents with classic UTI symptoms, it should be considered a UTI until proven otherwise. "We do the urinalysis, send the culture, start the antibiotic, and for the patients who get better, amazing," she says. For the patients who don't get better, the cycle continues "because the doctor, who hasn't been taught how the vulva relates to urinary, colon, and sexual health, doesn't know what else to do."
The truth is that lower urinary tract symptoms that may look and feel like a UTI can be caused by things other than bacteria, says Lindsey Burnett, a urogynecologist, assistant professor at the University of California, San Diego, and co-author with Uloko on the study.
For example, a loss of hormones to the vulvar tissue can cause inflammation, a condition called hormonally mediated vestibulodynia. This can happen due to natural physiological changes to hormones that happen during breastfeeding and menopause. It can also happen if you're taking medications that impact hormones.
For example, oral birth control is one of the most commonly prescribed anti-androgen medications that can disrupt the hormonal balance in the vulvar tissue and cause inflammation that prompts UTI-like symptoms. Other commonly prescribed medications that can cause vulvar inflammation include medications for acne (such as isotretinoin, sold as Accutane) and hair loss (such as minoxidil, sold as Rogaine); oncologic treatments for breast, ovarian, and/or uterine cancer (such as aromatase inhibitors and selective estrogen receptor modulators); and hormone therapies for endometriosis or fibroids.
The genitourinary syndrome of menopause, or GSM, a collection of symptoms caused by the decline in estrogen and other sex hormones during menopause, can also affect the tissues of the vagina, vulva, bladder, and urethra and cause UTI-like symptoms. Chronic inflammation due to GSM can also prompt the pelvic floor muscles to go into a state of reactive guarding, says Uloko, which can make them hypertonic (too tight) and can further disrupt bladder function.
