They say knowledge is power and I’m here to level you up.
Join me below as we delve briefly into the mysteries of the female urinary tract, find out who or what has it in for you, where they come from and why, discover what you can do about it right now, this minute (or in 10 minutes once you’re done reading, no rush), when to seek offline help, and how to bulletproof your bladder.
5 Ws and an H (the journalism majors got it): the who, what, why, when, where and how of UTIs.
What is a UTI exactly?
UTIs happen very commonly in women. In the US, women are treated for 6 million UTIs every year (1). 40-50% of women will have a UTI at least once in their lives, and many of them will get multiple (2).
A small percentage of women also develop chronic or recurrent UTIs which are more difficult to diagnose and treat. Men on the other hand rarely get UTIs, mostly because of their signature feature – the extra long urethra.
How do you get a UTI and why do women get UTIs so frequently compared to men? The main reason is that the connection to the outside of the body (the urethra) is so short in women, so bacteria that get onto your skin can easily take the short driveway up into your bladder (3).
The bacteria that causes 90% of UTIs is E. Coli, which is normally found in the gut where it is actually helpful (4). This is why you may have heard that you should always wipe from the front to the back when using the bathroom. This is so any microscopic particles of E. Coli don’t get pushed towards the urethra in front.
- Pain: burning or stinging during or after urination, and sometimes constantly
- Frequency – having to go more than normal, or feeling like you have to go all the time, even though there’s nothing left.
- Personal care Urgency – feeling like you have to run to the bathroom or you’ll lose control of your urine.
- Mild Pain in the pelvis or lower stomach.
- Hematuria – a fancy medical word for blood in the urine.
- Mild pain in the lower back
- Mild tiredness
- Severe pelvic or lower stomach pain
- Pain in the kidney area: this is on both sides of the spine, in the soft part of the back which is below your bottom ribs and above your hip bones. This could mean the UTI has spread up into your kidneys.
- Fever more than 99.9°F – another warning sign of possible kidney infection.
- Severe tiredness
- Nausea or vomiting
- Vaginal discharge
- Vaginal irritation
- Vaginal odor
The easiest way for a doctor to diagnose a UTI is being told (or texted) by a woman, “I’ve got a UTI”. It’s one of the easiest things in medicine to get right.
It may sound like a joke, but it’s actually common practice and is even recommended by prominent standard setting bodies such as the American Board of Obstetricians and Gynecologists and is based on published research (5, 6, 7).
The reason is that the accuracy of self-reporting is very high. More than 90% of women who have both painful urination and frequent urination, without vaginal discharge or irritation, will test positive for a UTI and more than 50% of women who report any of the common symptoms of a UTI will also test positive (6).
For comparison the 90% level of accuracy, based on the most common symptoms of UTI, is right up there with the accuracy of the rapid flu test (8) and rapid strep test (9).
But sometimes you don’t have the typical symptoms, so in a doctor’s office the two lab tests used to confirm the diagnosis of UTI are:
- Urine culture
- have red flag symptoms of a more severe infection,
- don’t have the common symptoms of a UTI,
- have very frequent UTIs, or
- have never had a UTI before.
- white blood cells (WBCs or leukocytes),
- red blood cells (RBCs or erythrocytes) and,
A urine culture can be done before treatment with an antibiotic and then repeated afterwards to make sure that the bacteria are gone. If there is any doubt that your symptoms are caused by an infection, you have red flag signs, or you get UTIs really frequently, it’s probably best to see a doctor in person and get a urine culture done to ensure the right treatment.
Common UTI treatments
- Prescription Antibiotics
- Analgesics (Painkillers)
Cheap and Safe
Macrobid is another really common and safe medication, especially for women who can’t become pregnant. It is slightly more expensive than Keflex, probably because it is more convenient: dosing is 100mg twice a day for 7 days.
Cheap and easy, but think twice
Bactrim and Cipro are the cheapest of the usual suspects and the most convenient with 3 day dosing, but, full disclosure:
Bactrim was outlawed in England after an investigative reporter uncovered evidence of many severe side effects and even death. The reporting didn’t make a big splash on this side of the Atlantic and the FDA wasn’t convinced, so it is still used very commonly in the US.
Cipro has been used heavily for UTIs in the past, but because of that a lot of resistance to this antibiotic has developed. There is also a black box warning on Cipro in the US stating that it has been associated with serious and even disabling side effects, that in some cases were permanent.
These side effects include inflamed or even ruptured tendons (the tissues that connect your muscles to your bones, famously the achilles tendon) and phantom sensations in the limbs called peripheral neuropathy. These types of symptoms have been reported in more than 10% of patients taking Cipro.
Because of the high levels of bacterial resistance and the dangerous side effects, Cipro is now only recommended for patients who have no other choice. That’s usually either because they are allergic to the other options, or because, based on a urine culture, they are found to have a rare strain of bacteria that is resistant to all the other options and is only sensitive to Cipro.
Analgesics (pain killers)
- Pyridium (Phenazopyridine)
- Tylenol and NSAIDs.
Pyridium or phenazopyridine is commonly available over the counter as AZO UTI pain reliever (not the AZO cranberry capsules) and famously turns your urine orange, while helping numb the urethra so that you don’t have pain when urinating. It won’t cure a UTI and is just meant to give you pain relief until you can get rid of the infection.
Tylenol (paracetamol) and NSAID’s can help with any source of pain including a UTI. NSAID stands for Non-Steroidal Anti-Inflammatory Drug and includes over the counter products like Aspirin (salicylic acid), Motrin (ibuprofen) and Aleve (naproxen). There are also prescription strength Tylenol and NSAID’s available, but the same strength can be had without a prescription by just taking higher doses of the over the counter versions, though you might not want to (dun dun dun – read on).
The maximum dose of Tylenol is 1000mg every 6 hours. The maximum dose of Motrin (ibuprofen) is 800 mg every 8 hours. However, the higher the dose, the greater the risk of side effects. Also one size doesn’t fit all in Macy’s or in medicine. A small woman will be able to tolerate less than a larger one. Even though both Tylenol and Ibuprofen are available over the counter, and you would expect that to mean they are safe to use, they can both cause serious, even lethal side effects.
“Warning Wilhelmina Robinson”: Possible Serious Side Effects of Over the Counter Painkillers (yup, this is what I was foreshadowing up there)
We don’t have a lot of data on side effects for Pyridium, but up to 10% of patients do report headaches and stomach upset and rare side effects include kidney failure and liver damage (estimated at less than 1 in a 100 patients) .
We do have a lot of data for both Tylenol and NSAIDs. One thing that’s not mentioned much is that just like antibiotics they can both cause alterations in healthy gut bacteria, but unlike antibiotics, some people (you know who you are) tend to pop them like candy at the slightest twinge of any pain, so the cumulative effect may be greater than from occasional antibiotic use. The changes to healthy bacteria can persist for months after stopping what caused them, are resistant to probiotics, can suppress immune function, create vitamin deficiencies and cause chronic bowel problems.
Ok, I know what you’re thinking, so far not that bad, right? Unfortunately it gets a lot worse: Tylenol is associated with increased rates of death, heart attack, stomach bleeding, and kidney failure. It is known to cause liver failure in overdose, but it also causes liver failure in people just taking standard doses for pain control, but usually in those who take a small amount more than recommended, which can easily happen when combining multiple Tylenol containing products. The risk of liver failure leading to transplant and death are highlighted in an FDA black box warning.
Less serious, but maybe equally disturbing is data suggesting Tylenol can rewire the brain and change our personalities in subtle ways making us less likely to empathize with others (10, 11, 12, 13).
As for NSAID’s like Aspirin, Motrin (ibuprofen) and Aleve (naproxen): they can increase heart attack and stroke risk, double the risk of hospitalization with heart failure (in patients that already have heart failure), raise blood pressure and very commonly cause stomach ulcers, even after relatively short treatment lengths.
But perhaps the most important risk for women with a UTI taking the above medications is covering up symptoms without addressing the root cause with a curative antibiotic. This can lead to a false sense of security as the infection rages on in the background and digs in deeper into the bladder wall or up into the kidneys, from where it can even get into the blood stream.
So the main takeaways would be if you are going to use a painkiller to help with mild symptoms be sure you don’t use it for more than a couple days without also treating the underlying infection with an antibiotic, and stick to the lowest doses for the least amount of time. Pyridium is generally considered the safest option of the three and is likely the most effective for UTIs.
Bulletproof your bladder AKA Preventing UTIs
There are some easy ways to drastically reduce your chances of getting a UTI. Drinking more fluids and urinating regularly instead of holding your urine will definitely help. The other proven approach to prevention are some specific hygiene tweaks (don’t shoot the messenger):
- Wiping front to back,
- Cleaning the privates before and after sex, and
- Urinating afterwards too (16).
The most important of these by far is urinating after sex: if you don’t, you are about 8 times more likely to develop a UTI. For the other two the increased risk is about double (16).
Finally having sex less than 3 times a week will decrease your risk of getting a UTI by about 5 times (16), but is also pretty likely to decrease your overall wellbeing, not to mention that according to one study it could decrease your salary by up to 5% and increase your risks of diabetes, heart disease and arthritis (17). Some things just aren’t worth it and we have the studies to prove it.
- really common and mostly due to E Coli,
- most commonly cause burning and frequency without vaginal discharge or odor,
- super easy to diagnose without any tests and
- a cinch to cure online with cheap generic antibiotics
Prevention is mostly about:
- drinking more,
- not holding it,
- cleaning before and after sex and
- not forgetting to pee afterwards.