Nonantibiotic prophylaxis for recurrent uncomplicated urinary tract infections (UTIs) begins with confirming true infection, since many symptomatic patients may actually have noninfectious bacteriuria. Nonantibiotic strategies for confirmed UTIs include addressing residual urine, having adequate hydration, using vaginal estrogen in postmenopausal women, drinking cranberry juice, and/or using mannose or methenamine hippurate, each of which has varying levels of data supporting their use.

What we need to do first for patients with suspected recurrent uncomplicated UTIs is establish a diagnosis because many of the patients who are referred to us have asymptomatic bacteriuria. In many cases, these patients do not need antibiotics; they just need counseling as to why antibiotics may not be necessary for this condition.

Once symptomatic events have been documented by a urine culture, it is important to look at the pattern of recurrence to determine whether the patient is experiencing reinfection or relapse. Reinfection (ie, bacteria reentering the urinary tract) will demonstrate different strains and/or sensitivity patterns of the same strain over repeat infections, which tend to occur at long intervals. Bacterial persistence (ie, bacteria remaining within the urinary tract) will demonstrate a rapid recurrence with the same strain and sensitivity pattern on recurrent infections. Suppressive antibiotic therapy may be necessary and can be titrated to prevent recurrent uncomplicated infections.

For patients with a pattern of reinfections, our next step should be to ask the following questions: Why are these patients getting these recurrent infections? What is the root cause? We will often perform a postvoid residual test with ultrasound in women with documented recurring UTIs because they may carry higher volumes of residual urine. And, as we know, one defense for the prevention of UTIs is voiding. For patients with significant residual urine, we may put them on tamsulosin or something similar to help them empty their bladders better.

Hydration is also important. Many patients fail to hydrate properly, and studies have shown that high-volume drinking and voiding can be beneficial in reducing the risk of UTIs. This is something that everyone can do.

In some women, particularly those who are postmenopausal, the vaginal epithelium is atrophic. For these patients, topical vaginal estrogen can help reduce the migration of bacteria to the bladder. It has been established that estrogen replacement therapy restores the defensive ability of the vaginal epithelium.

Many patients do ask me about cranberry juice and mannose replacement therapy for UTI prevention. Cranberry juice is nonantibiotic, so it does not generate resistant bacteria. I tell patients that there are some data, but they are not robust; however, if they want to try it, I am okay with it. Regarding mannose replacement therapy, initial studies suggested that mannose may reduce bacterial colonization and infection, while subsequent studies in humans have been conflicting. In my opinion, the bottom line is that the data are soft.

Our next most common approach instead of using antibiotic prophylaxis for patients with recurrent uncomplicated UTIs is using methenamine hippurate, which is converted into ammonia and formaldehyde when it is in a bladder with an acidic environment. Methenamine hippurate is not as effective as antibiotic prophylaxis, but it has the distinct advantage of not exposing individuals to antibiotic therapy, which may lead to the development of resistant organisms over time. Many patients do opt for the methenamine hippurate approach.

I think that these are the main issues and steps that should inform the nonantibiotic treatment and prevention of recurrent uncomplicated UTIs: establish the diagnosis, address residual urine, use vaginal estrogen when appropriate, ensure adequate hydration, consider using cranberry juice or mannose with the understanding that the data are soft, and consider using methenamine hippurate as a nonantibiotic prophylactic option.

I want to emphasize that it may be appropriate in some cases to treat patients based on symptoms if they are having isolated events. However, if this is recurring, you do not want to make the mistake of prescribing antibiotics repeatedly. I do not advocate repeatedly treating even symptomatic women without getting cultures. If you see repeated negative cultures but a patient has symptoms of burning, dysuria, and blood, among other symptoms, that is a red flag. You should consider sending them to urology for additional workup.