Why do I keep getting UTIs?

If you’ve ever had a UTI, you probably don’t need us to describe the feeling.

The burning. The constant need to pee. The trip to the bathroom only to produce approximately three drops. The sudden, intense awareness of a body part you’d really rather not be thinking about all day.

And then, just when you think it’s gone… hello again.

Urinary tract infections (UTIs) are incredibly common, particularly in women. For some people they’re an occasional nuisance. For others, bladder symptoms seem to turn up with frustrating regularity.

But here’s the important bit:

Sometimes what feels exactly like a UTI isn’t actually a UTI.

And if you keep experiencing “UTIs” but your urine cultures or midstream urine tests (MSUs) keep coming back negative, it may be time to ask a slightly different question:

What else could be making my bladder and urethra unhappy?

First up: what actually is a UTI?

A UTI happens when bacteria enter the urinary tract and multiply. Most commonly, the infection affects the bladder, known as cystitis, although infection can also involve the urethra or travel upwards towards the kidneys. This is important as it can lead to hospital admissions for more severe infections.

Women are particularly prone to UTIs for one very simple anatomical reason: our urethra is short and lives in a busy neighbourhood.

The vulval anatomy makes it relatively easy for bacteria, particularly bacteria originating from the bowel, to find their way into the urinary tract.

When someone has typical symptoms, a urine sample can help establish whether bacteria are actually present and, importantly, which antibiotics they are sensitive to.

This becomes particularly useful when the symptoms keep coming back.

When it feels like a UTI… but the MSU is negative

This is where things get interesting.

Burning, frequency, urgency, pelvic pressure and feeling as though you constantly need to pee are symptoms. They aren’t, by themselves, proof that you have an infection.

Sometimes an MSU (mid-stream urine test) confirms a bacterial UTI.

Sometimes it doesn’t.

A negative culture doesn’t completely exclude infection, particularly if antibiotics have already been started. But if you repeatedly have these symptoms and your urine cultures are negative, simply taking another course of antibiotics may not be the answer.

Instead, it is worth considering other causes of bladder and urethral symptoms.

These can include hormone changes associated with menopause, pelvic floor muscle problems and conditions such as bladder pain syndrome (also known as interstitial cystitis).

Your pelvic floor may be part of the problem

The pelvic floor isn’t just a hammock patiently holding everything up.

It is a complex group of muscles surrounding the vagina, urethra and rectum.

Sometimes these muscles become hypertonic, meaning that rather than relaxing normally, they remain excessively tense or guarded.

This can happen for many reasons. Painful sex, previous infections, pelvic pain, endometriosis, stress, surgery or simply repeatedly bracing against pain can all contribute.

A tight pelvic floor can reproduce bladder-like symptoms, including urgency, frequency, difficulty starting or completely emptying the bladder, urethral burning and pelvic pressure. Even in the absence of an infection.

And then a frustrating cycle can develop.

Your bladder hurts, so your pelvic floor tightens to protect you. The tight muscles create more pain and urinary symptoms. Your nervous system becomes increasingly alert to sensations from the area. More pain leads to more guarding… and around you go.

This is one reason pelvic floor physiotherapy can be so valuable. And importantly, treatment isn’t necessarily about doing more pelvic floor squeezes. If your muscles are already overactive, the aim may be exactly the opposite: learning how to relax and lengthen them.

When the volume knob gets turned up

Another piece of the puzzle is something called visceral hyperalgesia.

This describes increased sensitivity to sensations coming from our internal organs.

Normally, your bladder quietly fills in the background before eventually sending your brain a polite message that you might want to find a toilet.

But in some people with persistent pelvic or bladder pain, the nervous system becomes sensitised. Normal sensations — bladder filling, pressure, sex or muscle tension — can start to be interpreted as uncomfortable, urgent or painful.

Think of it as the volume knob on the bladder’s alarm system being turned up.

This doesn’t mean the symptoms aren’t real. They are very real. But the problem may lie partly in how the bladder, pelvic floor and nervous system are communicating rather than in bacteria that need to be killed.

Why not just take another antibiotic?

Antibiotics are incredibly useful when you actually have a bacterial infection.

But they don’t treat tight pelvic floor muscles, menopausal tissue changes, vulval skin conditions or a sensitised bladder.

Repeated or unnecessary antibiotics can cause side effects, disturb the gut and vaginal microbiomes and contribute to antibiotic resistance. They may also distract everyone from finding the real reason symptoms keep returning.

So if you are repeatedly reaching for antibiotics, particularly when your urine cultures are negative, it is worth reassessing the diagnosis.

Hormones have a lot to answer for

If UTIs — or symptoms that feel like UTIs — suddenly become a recurring feature during perimenopause or menopause, declining estrogen may be part of the picture.

Estrogen helps maintain healthy, resilient vaginal, vulval and urinary tissues and supports the normal vaginal microbiome.

As estrogen levels fall, these tissues can become thinner, drier and more vulnerable to irritation. The vaginal microbiome also changes, which can increase susceptibility to genuine bacterial UTIs.

These changes are part of what we call genitourinary syndrome of menopause (GSM).

And this is one area where we have good evidence for treatment.

Current American Urological Association (AUA) guidelines recommend low-dose vaginal estrogen for perimenopausal and postmenopausal women with recurrent UTIs to reduce the risk of future infections. In New Zealand, this may be prescribed as Ovestin (estriol) cream but there are also other preparations available.

Importantly, vaginal estrogen is different from whole body hormone treatment. Even if you’re already using estrogen as a patch or gel, you may still benefit from local vaginal estrogen if recurrent UTIs or other symptoms of GSM are a problem.

Talk to your GP or healthcare professional about whether it might be appropriate for you.

Don’t forget dryness and friction

Dry or irritated skin around your best bits can make urinary symptoms worse, particularly during and after sex. Using a suitable moisturiser or lubricant can reduce friction and help protect delicate tissue. (link to lube article)

Nu Balm can be used as a lubricant and vulval moisturiser, making it a useful addition when dryness or friction is contributing to discomfort.

And remember, your best bits aren’t dirty. Avoid fragranced intimate washes, douching and vigorous scrubbing. Gentle vulval care is generally best. Some women also chose to pass urine after sex, although the evidence that this alone prevents UTI is limited.

So who should I see?

Your GP is often the best place to start.

If symptoms are recurrent, keeping a record of your urine culture results can be surprisingly helpful. The pattern matters: are these repeated culture-proven infections, or repeated episodes of urinary symptoms without evidence of infection?

Depending on what is happening, you might also see:

A pelvic health physiotherapist, particularly if there is pelvic pain, painful sex, difficulty relaxing the pelvic floor or evidence of hypertonic pelvic floor muscles.

A gynaecologist, particularly if symptoms occur alongside vaginal dryness, vulval symptoms, painful sex, menopause, abnormal bleeding, endometriosis or other pelvic pain.

A urologist, particularly for recurrent proven infections, blood in the urine, problems emptying the bladder, unusual organisms or persistent bladder pain and urinary symptoms requiring further investigation.

Sometimes the most useful approach involves more than one of these people working together.

When should I seek help urgently?

Burning when you pee, frequency, urgency, lower abdominal discomfort or blood in your urine are all reasons to seek medical advice, particularly when symptoms are severe or keep recurring.

If you develop fever, chills, vomiting, feel significantly unwell or develop pain in your back or side, seek medical care promptly. These can be signs of an infection involving the kidneys.

And visible blood in the urine should not simply be assumed to be “another UTI”, particularly if it persists after an infection has been treated.

The bottom line?

If you genuinely keep getting bacterial UTIs, there are things we can do to reduce them.

But if you keep getting UTI symptoms and your urine cultures keep coming back negative, that’s a different conversation.

Your bladder doesn’t exist in isolation. It lives alongside the vagina, vulva, pelvic floor muscles and a remarkably sophisticated network of nerves.

Hormonal changes, muscle tension, tissue irritation and nervous-system sensitisation can all create symptoms that feel remarkably like an infection.

So rather than automatically reaching for another course of antibiotics, it may be time to look at the bigger picture.

Test when appropriate. Treat genuine infection appropriately. Look after the vaginal and vulval tissues with natural body friendly products like Nu Balm. Consider the pelvic floor. And if things still aren’t adding up, ask for further assessment.

Because spending your life planning your day around the nearest toilet?

No, thank you.