Remember when you were younger and urinary tract infections (UTIs) were often associated with sex?
You may have been told to always go to the toilet after intercourse to help prevent an infection. Perhaps you experienced that familiar burning sensation when urinating, the constant urge to go to the toilet, or the frustration of another course of antibiotics. For many women, UTIs become less frequent as they get older. But then, around perimenopause and menopause, they can start appearing again, sometimes without any obvious trigger.
So what's changed? The answer has a lot to do with oestrogen and its role in maintaining the health of our urinary and genital tissues.
Why Are Women More Susceptible to UTIs?
Women have a much shorter urethra than men. The urethra is the tube that carries urine from the bladder to the outside of the body. In women, the opening of the urethra sits just above the vaginal opening, relatively close to the anus.
Most UTIs are caused by bacteria, particularly Escherichia coli (E. coli), which normally live harmlessly in our intestines. Problems arise when these bacteria move from the bowel area towards the urethra and travel up into the bladder, where they can multiply and cause infection.
Sexual activity can increase the likelihood of this happening because friction and movement can transfer bacteria towards the urethral opening.
This explains the familiar advice to urinate after sex. The idea is that passing urine may help flush away bacteria before they have an opportunity to establish an infection. While scientific evidence that this prevents UTIs is limited, it's a simple habit that may be worth maintaining.
But as we move through menopause, there's another important factor at play.
The Oestrogen Connection: It's Not Just About the Vagina
When we think about oestrogen, we tend to associate it with periods, fertility, hot flushes and vaginal dryness. But oestrogen has a much broader role.
There are oestrogen receptors throughout the vulva, vagina, urethra and bladder. These tissues all respond to oestrogen, which helps maintain their structure, thickness, elasticity and function. As oestrogen levels fluctuate during perimenopause and decline after menopause, several changes occur.
1. The Tissues Become Thinner and More Fragile
Oestrogen helps maintain healthy, well-hydrated tissue in the vagina and lower urinary tract. With declining oestrogen, these tissues can become thinner, drier and more easily irritated. Changes to the protective lining and surrounding tissues can make the urinary tract more vulnerable to infection.
2. The Vaginal Microbiome Changes
Oestrogen also helps maintain a healthy vaginal environment. During our reproductive years, oestrogen promotes the accumulation of glycogen in vaginal cells. As these cells naturally shed, glycogen becomes available to support beneficial bacteria, particularly Lactobacillus species. These bacteria produce lactic acid, helping maintain the naturally acidic vaginal environment that discourages the growth of potentially harmful bacteria.
When oestrogen declines, glycogen availability reduces, Lactobacillus populations may decrease, and vaginal pH generally rises. This creates an environment in which bacteria associated with urinary infections may be better able to thrive.
3. Bladder and Urinary Function Can Change
Oestrogen also influences the health and function of the urethra and bladder. Some women experience increased urinary urgency, frequency, discomfort or recurrent infections. Other age-related changes, including pelvic floor weakness or incomplete bladder emptying, may contribute to these symptoms.
Together, these changes form part of what is known as Genitourinary Syndrome of Menopause (GSM). GSM can include vaginal dryness, discomfort during sex, irritation, urinary urgency and recurrent UTIs.
Unlike hot flushes, which often improve over time, genitourinary symptoms can persist or become more troublesome without appropriate treatment.
How Can We Reduce the Risk of UTIs?
While we can't prevent every UTI, there are several ways to reduce the risk, particularly during and after menopause.
1. Pay Attention to How You Wipe
Most of us were taught from an early age to wipe from front to back after going to the toilet. There's a good anatomical reason for this: The anus is home to bacteria that normally live in our digestive tract, including E. coli. Wiping from back to front can transfer these bacteria towards the vaginal and urethral openings.
Wiping from front to back helps minimise this transfer.
Although research hasn't conclusively established how much wiping direction affects UTI risk, it remains sensible hygiene advice, particularly after a bowel movement.
2. Consider Vaginal Oestrogen
One of the most effective, evidence-based options for reducing recurrent UTIs in postmenopausal women is low-dose vaginal oestrogen.
Unlike systemic menopausal hormone therapy (MHT), which circulates throughout the body, vaginal oestrogen acts primarily on the tissues of the vagina and surrounding urinary structures.
It can help:
Improve the thickness and health of vaginal tissues.
Restore a more acidic vaginal environment.
Support beneficial Lactobacillus bacteria.
Reduce vaginal dryness and irritation.
Lower the likelihood of recurrent UTIs.
In Australia, vaginal oestrogen is available as creams, pessaries and vaginal tablets. These deliver low doses of oestrogen directly to the vaginal tissues, with minimal absorption into the bloodstream.
Because absorption into the bloodstream is generally minimal, it has a different risk profile from systemic hormone therapy.
Importantly, women already using systemic MHT may still benefit from vaginal oestrogen, as systemic treatment doesn't always adequately relieve these local symptoms.
It's worth discussing this option with your GP, particularly if you're experiencing repeated infections (or have other GSM symptoms). Your doctor can advise on the most appropriate preparation and whether it's suitable for your medical history.
3. Keep Well Hydrated
Adequate fluid intake helps maintain regular urine production and bladder emptying. When we're not drinking enough, we tend to urinate less frequently, potentially allowing bacteria more opportunity to multiply in the bladder.
Aim to drink regularly throughout the day, adjusting your intake for your activity level, climate and individual health needs.
4. Don't Regularly Hold On
Empty your bladder when you need to, rather than habitually delaying going to the toilet.
Take your time and allow your bladder to empty comfortably. If you frequently feel that your bladder hasn't emptied properly, this is worth discussing with your healthcare professional.
5. Look After Your Bowel Health
Constipation can contribute to urinary problems, particularly when it affects bladder emptying. A diet rich in fibre from colourful vegetables, fruit, legumes, nuts, seeds and wholegrains, together with adequate fluids and regular movement, can help maintain healthy bowel function.
6. Avoid Irritating Products
Perfumed soaps, vaginal washes, deodorants and douching can irritate delicate vulval tissues and disrupt the local environment. Gentle external cleansing is generally all that's required. The vagina cleans itself and doesn't need internal washing.
Why UTIs Shouldn't Be Ignored
While most UTIs are relatively straightforward to treat, they shouldn't be dismissed as simply an uncomfortable inconvenience. A UTI usually begins in the lower urinary tract, most commonly the bladder. If the infection spreads, bacteria can travel up the ureters (the tubes connecting the bladder to the kidneys) and cause a kidney infection, known as pyelonephritis.
Kidney infections are more serious and can potentially cause kidney damage, particularly if infections are severe or treatment is delayed.
In older women, particularly those who are frail, a UTI can also contribute to delirium, a sudden change in brain function that may cause confusion, disorientation or unusual drowsiness. However, sudden confusion isn't always caused by a UTI and should always be promptly assessed by a healthcare professional.
In more severe cases, a urinary infection can also lead to sepsis, a potentially life-threatening condition in which the body's response to infection causes damage to its own tissues and organs.
Signs That an Infection May Be Spreading
While burning, urgency and frequent urination are typical symptoms of a bladder infection, symptoms that may indicate a kidney infection include:
Fever or chills
Pain in the back or side, particularly around the kidney area
Nausea or vomiting
Feeling generally very unwell
These symptoms require urgent medical assessment.
The good news is that most UTIs can be treated effectively, particularly when identified early. However, recurrent infections should be investigated rather than simply managed with repeated courses of antibiotics.
Reducing the Need for Antibiotics
Another important reason to focus on preventing UTIs is to reduce the need for repeated courses of antibiotics. While antibiotics are essential for treating bacterial infections, they don't just affect the bacteria causing the UTI. They also disrupt the beneficial bacteria living in our gut and vagina, potentially affecting the delicate balance of these microbial communities. This disruption can contribute to digestive disturbances, altered immune responses and reduced protection against harmful bacteria.
Repeated antibiotic use can also contribute to antibiotic resistance, making future infections more difficult to treat.
This is why prevention is so valuable, particularly for women experiencing recurrent UTIs. Supporting the health of the vaginal and urinary tissues, including through vaginal oestrogen where appropriate, can help reduce infections and the need for antibiotics.
Of course, when antibiotics are medically indicated, treating the infection promptly remains important.
UTIs in Older Women: When Something as Simple as Wiping Becomes Difficult
There's another aspect of UTI prevention that I think deserves much more attention, particularly for older women.
As we age, everyday movements that we've taken for granted can become increasingly difficult. Arthritis, reduced shoulder mobility, wrist stiffness, muscle weakness and reduced flexibility can all affect our ability to manage personal hygiene. And something as simple as wiping from front to back may no longer be physically possible.
I became particularly aware of this while caring for my own elderly mum. As her mobility and dexterity declined, she struggled to manoeuvre her wrist and arm into the position needed to wipe from front to back. Instead, she had to wipe from back to front. She experienced recurrent UTIs, and it made me realise how easily this very practical issue can be overlooked.
What surprised me was that, despite repeated visits to the GP and hospital for UTIs, no one seemed to ask how she was wiping herself, let alone whether she was physically able to wipe from front to back. There was plenty of focus on treating the infections, but little discussion about what might be contributing to them.
Maintaining Strength and Mobility Is Part of Prevention
This is another reminder of why maintaining muscle strength, joint mobility and flexibility becomes increasingly important as we age.
We often talk about strength training for bone health, maintaining muscle mass and preventing falls. But staying strong and mobile also helps us maintain the ability to perform everyday activities, including personal hygiene.
Regular resistance exercise, gentle stretching and mobility work can help preserve shoulder movement, arm strength, wrist function and the flexibility needed for daily tasks.
For older women, particularly those already experiencing mobility difficulties, other practical strategies may include:
Toilet aids with extended handles that make cleaning easier.
Bidet attachments or gentle water-based cleansing.
Assistance with personal hygiene when required.
Occupational therapy assessment to identify suitable equipment and strategies.
Managing constipation and incontinence to reduce prolonged contact with faecal material.
While these measures haven't all been shown to directly prevent UTIs, they can help maintain good hygiene, independence and dignity.
The Bigger Picture: Urinary Health Is Part of Women's Health
We talk a lot about hot flushes, weight gain, sleep disturbances and mood changes during menopause. But the impact of declining oestrogen on the vagina, urethra and bladder receives far less attention.
Recurrent UTIs aren't necessarily something women simply have to accept as part of getting older.
Understanding how oestrogen protects these tissues, recognising the changes that occur during menopause and knowing that effective treatments are available can make a real difference.
And as women move into their later years, we need to consider the practical challenges that come with reduced strength, mobility and independence. Sometimes prevention isn't just about knowing what to do. It's about being physically able to do it.
Whether you're navigating menopause yourself or caring for an ageing parent, urinary health deserves to be part of the conversation.
If you're experiencing recurrent UTIs, vaginal discomfort or changes in bladder function, speak with your GP about appropriate assessment and treatment, including whether vaginal oestrogen may be beneficial.