Recognising and preventing urinary tract infections 

Common symptoms of a UTI include needing to pee suddenly or more often than usual; pain or a burning sensation when peeing; smelly or cloudy pee; blood in your pee; pain in your lower tummy; feeling tired and unwell, and, in older people, changes in behaviour such as severe confusion or agitation

Menopause coach and author Catherine O’Keeffe

Back in 2015, during her Live at the Apollo stand-up special, a then 33-year-old Amy Schumer revealed she was experiencing her first ever urinary tract infection (UTI).

“Nobody tells you how embarrassing it’s going to be,” she told the audience. “Like ‘How’d you get it?’ You know how I got it! I had sex and then I was too lazy to pee right after.”

Schumer’s schtick was funny, but it was also true.

According to consultant obstetrician gynaecologist Breffini Anglim O’Regan, peeing immediately after sex is a crucial prevention strategy — “significantly” reducing the risk of a UTI in women of all ages, particularly those in new relationships who tend to be having lots of sex.

“A lot of people will get UTIs after intercourse,” explains the Coombe-based doctor.

“So it’s really important when you’re having intercourse — particularly when you’re post-menopausal, because if you’re not using vaginal oestrogen your vaginal tissues are a lot thinner — that you pee straight away [afterwards].

“Technically, it’s a time when bacteria can be introduced into the vagina or in around the urethra, and that’s how you can get infections.”

Guidance from the HSE states that UTIs are usually caused by [e.coli] bacteria from poo entering the urinary tract. A recurrent UTI (in adults) is defined as “two or more UTIs in the last 6 months or three or more UTIs in the last 12 months”.

UTI is an umbrella term; different parts of the urinary tract can be affected. When the infection is in the bladder, it is called cystitis (this is the most common type of UTI); in the urethra, it is called urethritis; and in the kidneys, it is known as pyelonephritis.

Common symptoms of a UTI include needing to pee suddenly or more often than usual; pain or a burning sensation when peeing; smelly or cloudy pee; blood in your pee; pain in your lower tummy; feeling tired and unwell, and changes in behaviour such as severe confusion or agitation in older people.

For women who are in perimenopause, menopause, or post-menopause, the situation becomes more complex.

Dr Breffini Anglim O'Regan, consultant obstetrician gynaecologist at the Coombe hospital

“When your oestrogen levels drop, the vaginal microbiome changes,” says Dr Anglim O’Regan.

“The vagina is right beside the rectum, and it’s right beside the bladder. Also, the bladder microbiome changes. Because of that, you’re more prone to getting recurrent UTIs because of the change in the bacterial make up or microbiome.”

When the vagina is treated with local oestrogen, it restores the vagina’s microbiome. That oestrogen also absorbs into the bladder, she explains.

Vaginal oestrogen is, she says, “the first-line treatment for prevention of recurrent UTIs in menopause”.

Local (or vaginal) oestrogen is a very safe, localised form of hormone replacement therapy (HRT). It is available on prescription and is covered by the Government’s free HRT scheme.

It comes in cream, gel, and tablet form (the pessary was discontinued in August). It is also available as a vaginal ring, which lasts up to three months after insertion, but this is only available on private prescription.

“As we get older, the loss of oestrogen when we go through perimenopause and menopause affects our tissue in our vagina, in our vulva, and in our urethra and our bladder,” says Catriona Keye, an advanced nurse practitioner in general practice and in menopause care at Scholarstown family practice in Dublin.

“Oestrogen keeps the tissue plump, moist, it promotes collagen and elastin, so it makes the area resistant to infection. It keeps the area moist so intercourse is comfortable. It keeps the flora at a normal level, so it reduces your risk of thrush and bacterial vaginosis.”

“What also happens is vulvo-vaginal atrophy (VVA),” she adds.

VVA is when the labia and surrounding tissues shrink, and is also known as genitourinary syndrome of menopause (GSM).

(While prevalence estimates vary by source, it is believed that between 36-84% of women going through perimenopause and menopause experience GSM.)

“And that [shrinkage] means the tissue at the opening of our urethra is more exposed [resulting in] an increased risk of urinary tract infection. Because it’s not covered, it’s not protected.”

Keye prescribes vaginal oestrogen for women of all ages (while it is normally used from perimenopause on, it can be helpful for vaginal dryness in breastfeeding women postpartum when oestrogen levels are low): “If somebody’s coming to me with recurrent urinary tract infections, I’m going to talk to them about vaginal oestrogen. There’s no age limit on it.I start women in their 80s who are coming to me with recurrent UTIs. If that cohort can avoid a UTI, they’re going to avoid delirium. I would start a lot of older women on it because the awareness wasn’t there before.”

At Feelgood’s recent September Reset event, an audience member spoke movingly about her mother and aunt, both older women, who were experiencing recurrent UTIs, and asked what was being done to support women of advanced years for whom this issue can be distressing and even life-threatening.

Older people, particularly those with dementia, are prone to getting delirium from a UTI infection, explains Dr Anglim O’Regan: “An infection can trigger delirium. So you have to be really careful.”

Delirium can further impair cognitive function in those with dementia. Older women also take longer to recover and, if they get it once, they are at higher risk of its recurrence.

Wellness Warrior Catherine O’Keeffe’s late mother, who had dementia, experienced “constant UTIs” in her final years. “She had gone through a stage where she wasn’t very verbal,” says O’Keeffe, who is a workplace menopause consultant.

“We only knew [she had a UTI] as her confusion would become more marked. You might see her wincing when she was going to the bathroom.”

Difficulty identifying a UTI in a person with dementia is common, but untreated, a UTI can lead to the life-threatening complication of urosepsis, and is a medical emergency.

Signs of confusion, agitation, and withdrawal in an older person with dementia may be indicative of a UTI and medical help should be sought.

O’Keeffe quotes a study cited in recent British Menopause Society literature that found a 52% reduction in recurrent UTIs from the use of vaginal oestrogen.

In her mum’s case, because of her dementia, vaginal oestrogen wasn’t an option as she was unable to self-treat, and having it administered by a medical professional had the potential to cause distress. “As a woman gets older, it’s very complex,” O’Keeffe says, highlighting the fact that similar barriers to access may arise for older women with intellectual disabilities.

“Vaginal oestrogen is amazing for recurrent UTIs. In women who are over 45, if they’re getting recurrent UTIs, vaginal oestrogen is the first thing we should be doing, not plaguing them with antibiotics,” agrees clinical specialist and pelvic health physiotherapist Aoife Harvey, the owner of Women’s Health Dublin physiotherapy practice in Donaghmede.

Antibiotics are necessary to treat an active UTI, while vaginal oestrogen is preventative, but vaginal oestrogen can be prescribed concurrently with antibiotics.

(In the case of recurrent UTIs, Dr Anglim O’Regan doesn’t favour low-dose antibiotics as a preventative measure as doing so can lead to antibiotic resistance “and then you’re back to square one”.)

Antibiotics are not the only treatment option for an active UTI, however, in Britain, UTIs are the second most common reason for antibiotic use, contributing to the rise in antimicrobial resistance, according to the Urology Foundation. 

There’s research to suggest the dietary supplement D-mannose, a type of sugar naturally found in fruits, can treat a UTI.

Charlotte O’Connor. Photograph Moya Nolan

Charlotte O’Connor, 54, first began to suffer from UTIs in her 20s and found they “came back with a vengeance” after she gave birth to her sons.

Before she turned 50, she found they were getting worse and, rather than continue with repeated courses of antibiotics, she decided to investigate alternatives, which included vaginal oestrogen: “And I haven’t had one now for three years or so.”

She credits the women’s health physio at the practice she attended with helping educate her on solutions and suggesting vaginal oestrogen. O’Connor has also found D-mannose helpful: “I don’t really need it anymore, but I have it in my back pocket just in case.”

“It’s effective,” says Dr Anglim O’Regan of D-mannose, explaining that UTI-causing bacteria can hide in the bladder, then emerge when conditions are right, and cause a kidney infection.

“What D-mannose does is it stops the bacteria from clinging to the bladder wall. It’s effective in preventing UTIs in about 30-40% of patients. So it’s good.

“I use it a lot in younger women because, with younger women who are getting recurrent UTIs, it’s not the low oestrogen and it’s less likely to be a prolapse [causing them].”

A bladder that has prolapsed into the vagina can cause a UTI as it prevents the bladder from being fully emptied, resulting in “stale urine sitting there, brewing an infection”, Dr Anglim O’Regan says. 

A bladder prolapse can be corrected with a pessary or surgery. Kidney stones can also cause UTIs, she says, as can bladder cancer — “but that would be rare”.

A year and a half ago, 67-year-old Cecilia Bradley was prescribed vaginal oestrogen to help treat urinary frequency.

She had also suffered from UTIs on an intermittent basis from her late 40s on, and says she was “probably perimenopausal when they started”.

Her doctor fully explained the benefits of local oestrogen to her, but comments by an acquaintance in relation to (now debunked) breast cancer risks associated with HRT spooked her. “So I never took it,” she says. “I just was a little bit scared.”

HRT and vaginal oestrogen are different. Regular HRT has a systemic effect, while vaginal oestrogen only acts locally and is not associated with any increased breast cancer risk.

Vaginal oestrogen is only contraindicated for those actively on treatment for breast cancer, Dr Anglim O’Regan says. “Vaginal oestrogen just acts in the vagina, so even if you have a history of breast cancer, it’s totally safe.”

“In the UK, vaginal oestrogen is over the counter. Any woman over the age of 50 can walk in and get it,” says Aoife Harvey, who is currently has a petition with almost 9,000 signatures to have the British product available over the counter in Ireland.

For the “really rare” cohort of women who are sensitive to vaginal oestrogen, Harvey highlights a DHEA-based alternative called Intrarosa. 

It converts to oestrogen and testosterone in the vagina, and she says it can really help with vaginal lubrication. Indeed, a 2025 study published in the official journal of the US Menopause Society showed that women with VVA (GSM) have a significantly elevated risk of UTIs, and that using vaginal prasterone (DHEA) pessaries effectively decreased the rate of infection.

It is not covered under the free HRT scheme.

The final word goes to Harvey who advises women to “just keep advocating for yourself.”

Reducing UTI risk

Vaginal oestrogen must be taken correctly to be effective.

Depending on the type, there is an initial priming dose used for a specific period, followed by a maintenance dose. 

See the package leaflet or ask your pharmacist;

• Hydration is important, urine should be a pale yellow colour if you’re drinking enough water;
• Reduce or avoid caffeine, fizzy drinks, and alcohol as they can contribute to bladder irritation and recurrent UTIs;
• If you have diabetes, speak to your GP or pharmacist before taking D-mannose, as it may affect blood sugar levels in some people;
• Do not hold your pee, delaying urination allows bacteria to multiply;
• After using the toilet, wipe front to back to reduce bacterial spread;
• Avoid perfumed products around the genital area and tight synthetic underwear.