When a UTI Becomes “Complicated”: What Postmenopausal Women Should Know

Simple, or common UTIs, most frequently occur in the bladder and are usually caused by a bacteria that’s easy to treat. Complicated UTIs are infections that can occur anywhere in the urinary tract system and are more difficult to treat or have an increased risk of serious problems and complications.

“A simple UTI is usually just a plain old bladder infection,” explained Rebecca Lane, M.D., a urogynecologist with 18 years of experience.

“A complicated UTI is an infection that has progressed beyond the bladder and probably up to the kidney,” Lane said. “It can also occur when an infection is difficult to [get rid of] because of resistant bacteria or health conditions such as diabetes or a compromised immune system.”

One of the most significant complications of a UTI is a kidney infection. In severe cases, bacteria can also enter the bloodstream and potentially lead to sepsis, a life-threatening response to infection.

Urinary tract infections are one of the most common bacterial infections in women, with around 50%–60% of women developing UTIs sometime in their lives. After menopause, around 10% to 15% of women experience recurrent or complicated urinary tract infections.

Menopause itself isn't necessarily what makes a UTI “complicated.” But it does create changes that can make urinary infections more common.

The reason largely comes down to estrogen.

Estrogen helps support the tissues and environment of the vagina and urinary tract, keeping them elastic and moist. As estrogen levels fluctuate during perimenopause and decline postmenopause, that environment changes, often thinning vaginal tissues, causing dryness and irritation.

“The low-estrogen environment in the bladder postmenopause makes the bladder a more hospitable place for the bacteria to set up, reproduce and stay,” Lane said.

For Norlian, she'd had urinary problems as an infant because of an unusually narrow urethra but said she didn't experience significant problems with UTIs until after menopause.

For several years, she recalled experiencing UTIs as frequently as once or twice a month. She eventually learned that her urethra was bent, although she wasn't retaining urine, and her doctors didn't blame all of her infections on that anatomical difference.

She suspected the timing of her frequent infections wasn't coincidental.

“I still believe that I got a lot of them because of the hormones that were doing less and less,” Norlian said.

A typical bladder infection may cause burning or pain when urinating, a persistent urge to urinate and increased urinary frequency.

The symptoms that should raise more concern are those suggesting that the infection has moved beyond the bladder.

“If you're having fevers, throwing up or having back pain, those are signs that you might have a kidney infection,” Lane said.

Those symptoms can mean that what started as a bladder infection has progressed and needs more intensive treatment.

Symptoms can also be less obvious in some older adults. Lane noted that an infection may sometimes be considered when an older patient develops an unexplained change in mental status.

Norlian experienced that firsthand: She remembers becoming delirious when her infection progressed to sepsis. She was hospitalized and treated with a strong IV antibiotic.

Treatment for cUTIs depends on how severe the infection is and where it's located.

An uncomplicated bladder infection is generally treated with a short course of oral antibiotics. Broad-spectrum antibiotics are generally the first course of action. A cUTI typically requires a longer course of antibiotics since the infection is severe and often caused by bacteria that are resistant to treatment. Although some cUTIs require hospitalization for treatment, some patients may be able to receive oral treatments at home.

“If you're able to keep antibiotics down, you don't necessarily need to be hospitalized for a complicated UTI or kidney infection,” Lane said.

But someone who is vomiting and unable to keep oral medication down may need to go to the hospital for IV antibiotics. Severe infections, including those that have entered the bloodstream, can also require hospitalization.

Because antibiotic resistance can make some infections more difficult to treat, determining which bacteria are causing the infection and selecting an appropriate antibiotic may also become important.

For Lane, one of the most important tools that she uses to help prevent bladder infections and avoid cUTIs in postmenopausal women is vaginal estrogen.

Vaginal estrogen is a prescription hormone therapy used to treat changes caused by low estrogen levels during or after menopause. Vaginal estrogen is used directly in the vaginal area and restores estrogen to vaginal and urinary tissues.

There are other preventive strategies that women may think about as well. Lane mentioned cranberry extract and vaginal probiotics as possible options, although she emphasized vaginal estrogen as the primary preventive approach she recommends.

A gynecologist may also prescribe low-dose antibiotics for six months or more to help keep UTIs at bay for some women. Although this is an effective approach, long-term use of antibiotics is also linked to antimicrobial resistance, which can ultimately make UTIs harder to treat.

There are also a variety of over-the-counter supplements available that claim to prevent UTIs, but women considering supplements should discuss them with a clinician. Evidence supporting UTI supplements varies, and supplements can interact with medications or health conditions.

There are behavioral and lifestyle changes that can help too, such as drinking plenty of fluids daily to dilute urine and flush out bacteria, emptying your bladder after sex, and avoiding holding urine for long periods of time during the day.

Postmenopausal women who find themselves dealing with UTIs shouldn't assume they simply have to live with them. Talking with a clinician about why the infections are happening and figuring out their options is an important step toward preventing complicated UTIs and their ripple effects.

For Norlian, finding a prevention strategy that worked has made a dramatic difference after years of frequent and sometimes frightening infections.

She has also learned to recognize her symptoms early and take them seriously.

Her experience is an important reminder for other postmenopausal women: Getting treatment for a UTI shouldn’t be delayed, and talking to a clinician about prevention and treatment options may help women find relief — and avoid a cUTI.