Hello urologists, gynaecologists, primary care doctors and all of you who have to deal with urinary tract infections. Urinary tract infection management and prevention is one of the activities on a routine basis for all caregivers. This Newsletter intends to review the last recommendation for managing and preventing urinary infections. Our focus is reducing the number of infections, avoiding antibiotic use when not indicated to prevent resistance and reviewing the evidence about non-antibiotic measures to prevent infections. Scientific support of the evidence and practice guidelines recommendations will be the key to all the information in the Newsletter.

This first article addresses the impact of recurrent urinary tract infections (rUTIs) on sexual health in both premenopausal and postmenopausal women.

The second article reviews the management of rUTIs through non-antibiotic approaches, with a particular focus on the role of herbal medicines.

The third article discusses strategies for the prevention of UTIs in pregnant patients, including an evaluation of the efficacy of ascorbic acid, which also contributes to urinary acidification.

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The primary risk factors for urinary tract infections (UTIs) include sexual intercourse and hormonal changes associated with menopause. Sexual activity has been implicated in approximately 4% of all UTIs and up to 60% of rUTIs. Recurrent UTIs (rUTIs) have a considerable impact on patients’ quality of life and are frequently associated with alterations in sexual function. Furthermore, sexual health outcomes may vary according to age and hormonal status, with notable differences between women of reproductive age and those who are postmenopausal. The aim of this study was to evaluate the symptoms associated with rUTIs and their impact on both quality of life and sexual function in premenopausal and postmenopausal women.

A case–control study was conducted, including 383 women with rUTIs and 161 healthy controls, stratified into premenopausal and postmenopausal subgroups. Collected data included age, hormonal status, bowel habits, number of sexual partners within the past year, and education level. UTI-related symptoms were assessed using the Acute Cystitis Symptom Score (ACSS), while sexual function was evaluated with the Female Sexual Function Index (FSFI), which measures six domains: desire, arousal, lubrication, orgasm, satisfaction, and pain. Questionnaires were completed anonymously via an online platform.

Regarding risk factor for rUTIs, constipation was more prevalent in women with rUTIs compared to controls (37.6% vs. 31.7%). Quality of life was substantially impaired, with 55.5% of participants reporting moderate-to-severe interference with occupational activities, and 59% reporting interference with social life. Sexual health assessment demonstrated that all FSFI domains were significantly impaired in patients with rUTIs. The proportion of women reporting no sexual activity was 8–10% among controls and 12–21% among rUTI patients. Subgroup analysis revealed that absence of sexual activity was reported by 8–12% of fertile women and 19–39% of postmenopausal women with rUTIs. Sexual desire was rated as low or very low in 61.9% of rUTI patients compared with 48.1% of controls. Low or very low confidence in achieving arousal was reported by 35.3% of rUTI patients versus 7.5% of controls. Difficulty achieving orgasm was noted in 29.6% of patients compared to 20.7% of controls. Pain or discomfort after vaginal penetration was reported more than half the time by 43.9% of rUTI patients versus 19.6% of controls. Dissatisfaction with sexual intercourse was significantly higher in women with rUTIs (53.6%) than in controls (15.8%).

Hormonal status also influenced outcomes. Moderate dissatisfaction with orgasm was reported by 28.5% of fertile women with rUTIs, 14.7% of postmenopausal controls, and 22.8% of postmenopausal women with rUTIs. Pain following intercourse was reported at least half the time by 17.6% of fertile controls, 50.6% of fertile women with rUTIs, 26.5% of postmenopausal controls, and 35.5% of postmenopausal women with rUTIs. Moderate or severe dissatisfaction with sexual life was observed in 14% of fertile controls, 50.6% of fertile women with rUTIs, 20% of postmenopausal controls, and 60.3% of postmenopausal women with rUTIs.

Authors concluded that rUTIs significantly impair both quality of life and sexual health in women, irrespective of hormonal status. Sexual dysfunction—including diminished desire, impaired arousal, orgasmic difficulties, dyspareunia, and dissatisfaction with intercourse—was consistently more prevalent in patients with rUTIs than in controls. These results highlight the importance of incorporating sexual health assessment into the clinical management of rUTIs. Treatment strategies should not only aim to reduce infection recurrence but also address the associated negative impact on sexual function and overall well-being.

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Antibiotic prescription is one of the main drivers of the rapid global increase in antimicrobial resistance. Antibiotics are frequently used not only for the treatment of urinary tract infections (UTIs) but also prophylactically to prevent recurrence. Consequently, treatment strategies that enhance host defense mechanisms and reduce antibiotic exposure should be considered. This systematic review and meta-analysis aimed to provide an overview of the effectiveness of herbal medicines in controlling UTI symptoms and reducing antibiotic use. A total of 23 publications were included: 5 meta-analyses, 3 systematic reviews, and 10 randomized controlled trials.

Several studies assessed the role of cranberry products in the prevention of recurrent UTIs (rUTIs). However, significant heterogeneity was noted regarding product formulation, composition, and dosage. Authors concluded that larger, well-designed studies with standardized dosing and clearly defined inclusion criteria are required to generate definitive recommendations. Cranberry products were generally well tolerated. Nonetheless, sweetened cranberry preparations should be used with caution in children with overweight or diabetes. Very high intake may cause diarrhea, while cranberry tablets may increase urinary excretion of oxalate and other lithogenic ions, requiring caution in individuals predisposed to nephrolithiasis.

Two studies compared herbal medicines with antibiotic treatment. The use of a herbal medicine containing 400 mg L-methionine, 100 mg Hibiscus sabdariffa, and 100 mg Boswellia serrata Roxb. administered twice daily to women with rUTIs was evaluated. One week of treatment resulted in clinical and quality-of-life improvements comparable to those observed in the antibiotic control group. During 90 days of follow-up, patients in the herbal treatment group reported greater improvements in quality of life. Furthermore, a higher proportion of patients transitioned from symptomatic UTI to asymptomatic bacteriuria in the herbal treatment group compared to the antibiotic group. Adverse effects related to herbal therapies were less frequent than those associated with antibiotics and were generally mild or absent.

Authors concluded that the current evidence suggests that herbal formulations, may provide symptomatic relief and reduce antibiotic use in women with rUTIs. While safety profiles appear favorable, further large-scale, high-quality randomized trials with standardized formulations are necessary to confirm efficacy and establish evidence-based recommendations.

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Urinary tract infections (UTIs) occur in an estimated 8–23% of pregnant women, of whom 20–40% may develop acute pyelonephritis. Asymptomatic bacteriuria is also common in pregnancy, and current guidelines recommend antibiotic therapy in such cases. The purpose of this study was to evaluate the effect of prophylactic administration of ascorbic acid (100 mg/day) on the frequency of UTIs in pregnant women.

A single-blind clinical trial was conducted in 110 pregnant women. Participants were randomized into two groups. 55 pregnant women in the treatment group received ferrous sulfate (200 mg/day), folic acid (5 mg/day), and ascorbic acid (100 mg/day) for three months. 55 pregnant women in the control group received ferrous sulfate (200 mg/day) and folic acid (5 mg/day) for three months. Urological symptoms were assessed, and urine cultures were obtained monthly over the three-month period.

Prophylactic administration of ascorbic acid significantly reduced the incidence of UTIs. The prevalence of UTIs was 12.7% in the treatment group compared to 29.1% in the control group. Three women in the ascorbic acid group reported experiencing pyrosis and nausea, which were alleviated either by food intake or with the administration of an aluminum–magnesium hydroxide preparation. The authors noted that it remained uncertain whether these symptoms were directly attributable to ascorbic acid supplementation or to other pregnancy-related factors, such as dietary gastric irritants, mechanical compression of the stomach by the gravid uterus, or delayed gastric emptying secondary to duodenal pressure.

The discussion review the effects of ascorbic acid. It has several physiological roles, including participation in cellular respiration, protection of folic acid reductase (thereby favoring erythropoiesis), and involvement in collagen synthesis, steroid hormone production, and lipid metabolism. Importantly, ascorbic acid may contribute to antimicrobial defense. Experimental evidence suggests that Escherichia coli and Pseudomonas aeruginosa are more susceptible to the combination of acidified urine (pH 5.0–5.5) and nitrites, resulting in increased production of nitric oxide and other reactive nitrogen intermediates. Thus, urinary acidification associated with ascorbic acid intake may provide protective effects against UTIs in pregnancy.