Recurrent UTI symptoms can send women through repeated rounds of antibiotics. These rounds do not address the actual cause. In fact, a recent study of 253 women with persistent urinary symptoms found that many had signs of conditions involving the vulvar tissue and pelvic floor. Importantly, these were not just problems confined to the urinary tract.
The findings are drawing attention to a broader issue in women’s urological care. For example, symptoms such as burning during urination, urinary urgency, frequent urination and lower abdominal discomfort do not always mean that bacteria are causing an infection.
Maria Uloko, a urologist in Los Angeles and co-author of the study, said she frequently sees patients who have been diagnosed with recurrent urinary tract infections after experiencing at least two episodes within six months. Alternatively, the diagnosis is made after three within a year. However, many have taken repeated courses of antibiotics but continue to experience the same symptoms.
“Most of them don’t actually have UTIs, even though that’s been their diagnosis time and time again,” Uloko said.
The research, published in The Journal of Sexual Medicine, examined medical records from 253 women evaluated for recurrent urinary symptoms. Researchers found that 85% had findings consistent with hormonally mediated vestibulodynia, while 75% had pelvic floor hypertonicity. Only 15% showed findings attributable to conditions limited to the urinary tract.
The study does not mean that recurrent bacterial UTIs are uncommon or that antibiotics are unnecessary. Instead, its findings point to the difficulty of distinguishing a bacterial infection from several other conditions. These other conditions can produce remarkably similar symptoms.
The research also adds to a growing recognition that the bladder, urethra, vulvar tissues and pelvic floor cannot always be evaluated separately when urinary symptoms persist. Moreover, the Journal of Sexual Medicine study describes persistent lower urinary tract symptoms as a potentially multifactorial problem. This is especially the case in women whose symptoms continue despite negative urine cultures.
Why recurrent UTI symptoms can be difficult to diagnose
One problem begins with the first test commonly used when a woman presents with symptoms that resemble a UTI.
A urinalysis can detect signs of inflammation in the urine, but it does not by itself establish that bacteria are causing an infection. Instead, a urine culture is used to identify bacterial growth and can help determine whether an antibiotic is appropriate.
Obtaining a useful culture also depends on collecting the sample correctly. A clean-catch specimen generally requires cleaning around the urinary opening and collecting urine from the middle of the stream. If the sample is contaminated, interpreting the results can become more difficult.
In practice, however, patients usually seek treatment because they are uncomfortable. When symptoms are significant and a urinalysis suggests inflammation, clinicians may start an antibiotic before the culture results are available. Treatment can then be adjusted if the culture identifies a bacterial infection.
That approach can make sense when a genuine infection is suspected. The difficulty arises when symptoms repeatedly return, cultures remain negative or treatment produces only temporary improvement.
“Clinicians often start them on a broad-spectrum antibiotic right away if that urinalysis comes back positive and adjust the medication if needed once the culture comes back,” Uloko said.
The distinction matters because antibiotics treat bacterial infections. They do not correct hormonal changes affecting vulvar tissue or release chronically tightened pelvic floor muscles.
The American Urological Association’s current guidance on recurrent urinary tract infections emphasizes documenting recurrent infections and limiting inappropriate antimicrobial treatment. This reflects concerns about antibiotic resistance and adverse effects associated with repeated therapy. Its guidance also distinguishes recurrent bacterial cystitis from other conditions that can produce urinary symptoms.
For women whose symptoms persist, the diagnostic process may therefore need to expand beyond the bladder.
Lindsey Burnett, a urogynecologist and assistant professor at the University of California, San Diego, and a co-author of the study, said lower urinary tract symptoms can have causes outside the urinary tract.
One example is hormonally mediated vestibulodynia, in which changes in hormones can affect vulvar tissue and produce inflammation and discomfort. Such changes can occur during menopause or breastfeeding and may also be associated with medications that alter hormonal signaling.
The source material identifies several medications and treatments as potential contributors, including hormonal contraceptives, some medications used for acne or hair loss, certain cancer treatments and hormone therapies used for conditions such as endometriosis or fibroids.
Another condition is genitourinary syndrome of menopause, or GSM. The decline in estrogen and other sex hormones during menopause can affect tissues involving the vagina, vulva, bladder and urethra. The resulting symptoms can include discomfort and urinary problems that resemble infection.
Hormonal changes may also affect the microbial environment of the vagina and urinary tract. That creates another layer of complexity. For example, a woman can have a genuine bacterial infection at one point and a noninfectious condition producing similar symptoms at another.
In other words, a history of recurrent UTI symptoms does not automatically establish that every episode has the same cause.
What women with recurrent UTI symptoms can ask about
For women experiencing repeated symptoms, one of the most useful questions is whether a urine culture actually confirmed a bacterial infection.
A positive urinalysis alone does not answer that question. A clinician can review previous cultures and determine whether documented infections corresponded with the symptoms being treated.
Women can also ask whether hormonal changes could be affecting the vulva or urinary system. This may be particularly relevant during the menopause transition, breastfeeding or when taking medications that influence hormone levels.
A third question concerns the physical examination.
Uloko and Burnett argue that evaluation of persistent urinary symptoms should include consideration of the vulvar tissue and pelvic floor, not only the bladder and urinary tract. In addition, pelvic floor muscles can become excessively tight and produce symptoms involving urination. Vulvar inflammation can also cause burning and discomfort that resemble a UTI.
A pelvic examination does not necessarily mean a Pap smear or speculum examination. Kaufman, a professor and chief of reconstructive urology and pelvic health at Vanderbilt University Medical Center who was not involved in the study, said a basic examination can identify changes around the vulva and the openings of the vagina and urethra.
For patients who need more specialized evaluation, urogynecology and pelvic-health services can assess urinary symptoms alongside pelvic floor conditions. For example, UC San Diego Health’s urogynecology program describes evaluation that can include urine analysis, urine culture, pelvic examination and assessment of pelvic floor conditions.
Treatment depends on the underlying diagnosis. That is why repeatedly changing antibiotics without reconsidering the diagnosis may fail to resolve persistent symptoms.
For women experiencing symptoms related to menopause, clinicians may also discuss therapies aimed at genitourinary hormone deficiency. The American Urological Association’s 2025 guideline on genitourinary syndrome of menopause addresses evaluation, diagnosis and treatment of GSM. In addition, The Menopause Society has endorsed that guideline.
Low-dose vaginal estrogen and vaginal DHEA are among the therapies discussed in the source material. Whether either treatment is appropriate depends on an individual’s medical history and diagnosis. This decision should be determined with a qualified clinician.
The Menopause Society’s professional resources provide access to information on clinical issues affecting women during midlife and beyond, including genitourinary syndrome of menopause.
The broader issue is that persistent urinary symptoms can involve several interconnected systems. For example, a woman may have a bladder condition, a pelvic floor disorder, hormonal changes affecting vulvar tissue, a bacterial infection or more than one of these problems at the same time.
For that reason, women who continue experiencing recurrent UTI symptoms despite treatment can ask whether their urine cultures have confirmed infection. They can also ask whether their vulvar tissue and pelvic floor have been evaluated and whether hormonal changes could be contributing.
The goal is not to assume that a UTI diagnosis is wrong. Instead, it is to make sure that persistent symptoms are being investigated rather than repeatedly treated without identifying why they keep returning.
The American Urological Association’s recurrent UTI guidance and its separate guidance on genitourinary syndrome of menopause reflect that broader approach to evaluation and treatment.
