Dr Couchman, urological surgeon, explains that some symptoms of urinary tract infections (UTIs) are easy to miss because they don’t look like the usual signs people expect. In older adults, a UTI might show up as confusion, irritability, or simply feeling unsettled. In children, it can appear as unusual tiredness or sleeping more than usual. These symptoms are often vague and non-specific, and the person might just seem a bit off or unwell, which is why they’re often mistaken for something else.

Changes in behaviour or alertness during a UTI often stem from how the body responds to infection. While many people experience the classic urinary symptoms such as frequency, urgency, and a burning sensation when passing urine, these signs may not always be obvious. Older adults, individuals with diabetes, or those with certain neurological conditions may not feel bladder-related symptoms as clearly.

When the infection triggers a systemic response, the signs can be non-specific. In older adults especially, a UTI may present as confusion, increased sleepiness, or even unexpected aggression. Body temperature may be high or low, and some may experience sweating or shivering.

It’s advisable to seek medical attention whenever these symptoms appear or if there are concerns about changes in a person’s behaviour or alertness. Having a clinician such as a GP, nurse, or urologist who’s familiar with the patient’s usual baseline can make assessment faster, more accurate, and more reassuring for families and caregivers.

If treatment is delayed, the progression of a urinary tract infection (UTI) to more serious complications can happen surprisingly fast, especially in children, older adults, or those with weakened immune systems. It can take just a few days or even a few hours for the infection to spread. Complications may start locally, with symptoms such as lower abdominal pain and frequent urination, before advancing to a kidney infection or even a kidney abscess. In severe cases, the infection can lead to sepsis, which is life-threatening and requires urgent medical attention.

Dr Couchman points out that maintaining the natural balance of vaginal bacteria, particularly lactobacilli, is essential for a healthy urogenital environment. These bacteria help protect against infections by keeping the vaginal pH at an optimal level. Vaginal washes or other feminine hygiene products, however, are not helpful in preventing urinary tract infections (UTIs). In fact, they can disrupt this delicate balance and alter the pH, which may increase the risk of infection rather than reduce it.

Gentle cleansing with water is usually sufficient to keep the groin area clean and maintain its natural balance. For individuals with a foreskin, it’s important to gently retract it and clean the head of the penis with water. Stronger products are generally unnecessary and may irritate the sensitive genital skin.

If there is visible faecal soiling, warm water is adequate for cleaning the area. It’s best not to delay cleaning after a bowel accident to reduce irritation and maintain good hygiene.

When people suspect a urinary tract infection (UTI), it’s common to turn to cranberry products, over-the-counter remedies, or even leftover antibiotics. From a clinical perspective, some of these approaches have evidence behind them, while others can do more harm than good.

Dr Couchman notes that there is emerging evidence that first-line therapy aimed at relieving irritative symptoms can help reduce the risk of progression to infection. Discomfort and urinary frequency can be influenced by factors such as diet, hydration habits, oestrogen levels, and associated skin conditions of the vulva. It can be helpful to increase fluid intake and consider urine-alkalising solutions such as Ural. However, if symptoms do not improve within 24 hours, medical attention should be sought, as there is a risk of the infection progressing.

Among over-the-counter products, the most studied options include:

• Cranberry supplementation: Cranberries contain a natural compound called proanthocyanidins (PAC), which helps prevent E. coli bacteria from adhering to the bladder wall. For this to be effective, more than 36 mg of PAC per day is required. This is best achieved through a well-formulated cranberry tablet rather than juice, as the amount of juice needed to reach that concentration would be impractical.
• Methenamine hippurate (Hiprex): This compound converts into formaldehyde in acidic urine, which creates an environment that is hostile to bacteria. It tends to work better when taken together with vitamin C, which helps maintain the acidic conditions required for its effectiveness.
• D-mannose: This sugar binds to E. coli and Klebsiella bacteria, helping to flush them out during urination. While it may be useful for reducing bacterial presence, it can cause gastrointestinal discomfort if used for more than six months, and there is limited evidence of its safety during pregnancy.

These options are supported by clinical evidence and are included in current guidelines in Australia. However, Dr Couchman cautions that antibiotics should never be taken without medical supervision, as inappropriate use can lead to resistance and delay proper treatment.

Recurrent urinary tract infections (UTIs) and rising antibiotic resistance are now major public health concerns that require a more coordinated and thoughtful response. UTI is a complex condition that can present in many different ways, and current culture testing methods are not always reliable. The sporadic and excessive use of antibiotics has contributed to increasing resistance, which in turn makes managing severe infections such as sepsis much more difficult.

Diagnosis needs to be approached carefully, taking into account not only the current culture results but also a patient’s history of previous urine cultures. Preventive or pre-emptive antibiotic therapy should be guided by both individual patient data and the local antibiogram, which refers to the regional pattern of bacterial resistance, to ensure the most effective treatment choices.

It’s also important to move away from viewing UTIs as a simple or minor condition. They have a significant impact on patients’ quality of life, contributing to morbidity, loss of income, and missed workdays. More research is needed to understand antibiotic resistance mechanisms, refine the diagnosis of UTI and recurrent UTI, and better distinguish between bacterial colonisation and infection.

Alongside research, improving access to care and enabling earlier detection of UTIs remain priorities, particularly in resource-limited settings. Greater awareness and education about the complexities and pitfalls of UTI diagnosis and management are urgently needed, both within healthcare systems and among the general public.