A review of 27 systematic reviews shows which non-antibiotic options can help prevent recurrent UTI

Recurrent UTI means two or more infections in six months, or three or more in a year. About 6% of adult women meet that definition. UTIs account for nearly a quarter of antibiotic prescriptions in England. And 1.7% of adult women take long-term antibiotics to prevent them.¹

Guidelines differ on the non-antibiotic options. Miriam Santer and colleagues have now pulled the evidence together. The BJGP published their overview on 19 October 2026. It covers systematic reviews of randomised trials in women aged 16 and over with recurrent UTI. All the options studied could be used in the community.¹

The team searched from 2014 to May 2025 and found 27 reviews. Seven were rated high or moderate quality. The rest were low or critically low. This was mainly because they lacked a public protocol or did not report their methods in full.¹

The options with the most support¹

• Vaginal oestrogen (postmenopausal women). A Cochrane review included two trials against placebo. Both found fewer UTIs with vaginal oestrogen (RR 0.25, 95% CI 0.13 to 0.50, and RR 0.64, 95% CI 0.47 to 0.86). The results varied a lot between trials. A later review rated the evidence moderate certainty. It found no link with side effects, but numbers were low. Most trials used fairly high doses, of 50 micrograms of oestradiol a day or more. The best dose and form are not known.
• Cranberry. The 2023 Cochrane review included 8 trials in women with recurrent UTI (1,555 women). Cranberry products probably cut the risk of UTI confirmed by culture (RR 0.74, 95% CI 0.55 to 0.99, moderate certainty). Tablets and powder seemed to work better than juice or syrup. The Cochrane authors suggest this may be down to adherence or a more even dose. The best dose is not known.
• Methenamine hippurate. The two most recent trials used 1 g twice a day for 12 months. Neither found a significant difference in UTI rates compared with antibiotic prophylaxis. In the larger trial, the methenamine group used more antibiotics in the six months after stopping. The best length of treatment is still unclear.
• Drinking more (women who drink little). This rests mainly on one trial of 140 premenopausal women. All drank less than 1.5 litres a day. Adding 1.5 litres of water a day meant 1.5 fewer UTIs over a year (95% CI 1.2 to 1.8). There is no robust evidence for women who already drink enough.

The options that need stronger evidence¹

• Probiotics: nine reviews broadly agree the evidence is not good enough.
• D-mannose: seven reviews. The Cochrane review rated the evidence very low certainty. A large placebo-controlled trial published since found no effect. Adherence in that trial was low.
• Oral oestrogen: four reviews. None found a significant benefit.
• Herbal medicine, acupuncture and vaccines: the reviews call for stronger evidence. Some vaccine results look promising, but the studies vary too much to recommend routine use.

Gaps in the evidence

Only three of the 27 reviews reported on adherence or acceptability. The team found no reviews of trials for common behavioural advice, apart from drinking more. This includes wiping front to back and passing urine after sex. That advice rests on observational data.¹

The authors also say vaginal oestrogen is badly underused. Uptake is lowest in more deprived areas. Some women do not link urinary symptoms with the menopause. Others fear the risks they link with HRT, such as breast cancer. But vaginal oestrogen is barely absorbed, so its risks are negligible.¹

The authors conclude that there is good evidence for alternatives to long-term antibiotics. They name vaginal oestrogen for perimenopausal or postmenopausal women, and oral methenamine hippurate. They call cranberry promising, especially in tablet form, though the right dose is unclear.¹

What does this mean in primary care?

• Several non-antibiotic options for recurrent UTI have trial evidence. But the strength of that evidence varies.
• Vaginal oestrogen has evidence in postmenopausal women. It is underused, especially in more deprived areas.
• Methenamine hippurate performed similarly to antibiotic prophylaxis in trials. What happens after stopping is less clear.
• Cranberry tablets and powder did better than juice in trials. The right dose is not known.
• Drinking more has only been shown to help women who drink little to start with.
• Popular over-the-counter options, such as D-mannose and probiotics, lack convincing trial evidence.

Intended for UK healthcare professionals only. This article reports on published clinical data and does not constitute prescribing advice.

References

1. Santer M, Miller S, Fraser S, et al. Non-antibiotic interventions to prevent recurrent urinary tract infections in women: overview of systematic reviews of randomised controlled trials. Br J Gen Pract. 2026; published online 19 October. doi:10.3399/BJGP.2026.0055

The BJGP authors also discuss the findings in a podcast: Episode 244: Recurrent UTIs, which non-antibiotic approaches actually work?