• Nicole Cozean, PT, DPT, WCS

Naturally Treat and Prevent UTIs - Both Real and Phantom!

Urethral Burning, Urgency/Frequency and Pelvic Floor Dysfunction


Identifying the cause of urethral burning, urinary urgency and pelvic pain can be extremely difficult. Both urinary tract infections (UTIs) and pelvic floor dysfunction (PFD) can cause all of these symptoms.


So how can we tell if it's a real or phantom UTI? How can we prevent UTIs from happening in the first place? And how do we break the cycle of UTIs and pelvic floor dysfunction that is so common?


Is it a Urinary Tract Infection (UTI) or Pelvic Floor Dysfunction (PFD)?


It can be difficult to tell the difference between a UTI and pelvic floor dysfunction. Pelvic floor dysfunction can cause almost all the symptoms of a UTI, including urethral burning, urinary urgency/frequency, pelvic or bladder pain, and other symptoms.


Almost half of women experience urethral burning, pelvic pain and urinary urgency/frequency as the result of a confirmed UTI during their lives. Others have these symptoms but test negative for bacteria - these are 'phantom UTIs'. Often doctors treat these phantom UTIs with antibiotics, even when there is no evidence of a bacterial infection.


How Does a UTI Cause Pelvic Floor Dysfunction?


Part of the difficulty is a UTI, almost by definition, causes pelvic floor dysfunction. When there is pain and irritation in an area, the muscles 'lock down' to try and protect it. These pelvic floor muscles can have a hard time relaxing, even after the UTI is cleared with antibiotics. Often symptoms linger even after the bacteria is cleared.


Many patients have a true UTI to begin, have it treated and then have a series of phantom UTIs and eventually realize their symptoms are now primarily due to pelvic floor dysfunction.


How To Tell Between a True and Phantom UTI


It's not easy to tell between a UTI and Pelvic Floor Dysfunction just by the symptoms. Urethral burning, urinary urgency/frequency and pelvic pain can occur with both.


Often a true UTI will have cloudy or bad-smelling urine accompanying it; that's a sign of a bacterial infection and you should definitely get treated for the infection.

Pelvic floor dysfunction often has other symptoms associated with it that a UTI would not cause. Painful intercourse is really common with pelvic floor dysfunction. It can also cause low back pain, constipation or GI upset, or general pelvic pain.


With pelvic floor dysfunction you may also notice difficulty in relaxing the pelvic floor muscles enough to actually go to the bathroom. Many patients experience the strong urge to go, rush to the bathroom and then have trouble actually starting or maintaining a stream once they sit down - this is all evidence of pelvic floor dysfunction.


Risk Factors and Recurring UTIs

Risk factors for frequent or recurring UTIs include sexual activity, pelvic organ prolapse, voiding dysfunction (more on that later!) and any condition that compromises the immune system. Post-menopausal women are at higher risk, because the changing hormones also change the vaginal pH and reduce the good bacterial flora that naturally exists in the vagina. More than 90% of UTIs are caused by e. Coli.

Recurring UTIs are defined as two or more UTIs within a 6 month period, or 3 UTIs within a year. Often these are re-infections, where the original infection is not completely eliminated and eventually returns. Standard treatment is with systemic antibiotics, but it is possible to address the underlying issues and treat and prevent UTIs without medication.

Physical Therapy for Recurrent UTIs

There’s typically a pelvic floor component to recurrent UTIs. The muscles of the pelvic floor are responsible for controlling the flow of urine. They remain locked on throughout the day, keeping us continent, and have to be consciously relaxed when it’s time to go. If these muscles are tight or overstrained, it can be difficult for them to disengage enough to go to the bathroom properly.

Many patients with recurrent UTIs notice they have difficult in starting a stream, stops and starts in their urine stream, or feel like they can’t fully empty the bladder. In these cases, residual urine is often trapped in the bladder.

You can imagine this like a slow-draining sink. When working properly, the bladder system quickly and efficiently flushes out all the waste in the bladder. However, if it’s not emptying fully or correctly, it can leave that sediment behind. In the sink this leads to gunk building up; in the bladder, it can lead to recurring urinary tract infections.

Manual physical therapy that helps to relax these muscles opens that sink back up, making sure it’s able to flush all of the urine and bacteria from the bladder.

Should I Kegel with a UTI or Pelvic Pain?


Absolutely not - you should never do Kegels (the voluntary contraction of the pelvic floor) with pelvic pain or UTIs. In fact, Kegels can definitely make pain worse. Those muscles are overly tight and irritated already; asking them to repeatedly contract is the exact opposite of what we would want to do. We want to help the pelvic floor muscles relax, releasing pressure on the pelvic nerves and reducing pain.


How do I know if I have Interstitial Cystitis?


Another scary diagnosis, many women worry they have interstitial cystitis. There's a ton of misinformation online about the condition.


All an "IC" diagnosis means is you have pelvic pain and urinary urgency/frequency in the absence of an infection. That's it! It's just a description of the symptoms.


This can generally be resolved with pelvic floor physical therapy, and the sooner you get treatment the better. Many patients end up wasting a lot of time with bladder-focused treatments or "IC drugs" when in reality pelvic floor dysfunction is really underlying their issues.


If you've been diagnosed with IC, there's definitely hope! We have an online course, the IC: Roadmap to Healing ($87) that goes through the entire condition, how to assemble a good medical team, self-care tips and how to find lasting relief!

Phantom UTIs

Urinary tract infections also put a high strain upon the pelvic floor muscles. They may react to the inflammatory response happening at the bladder. They’re also having to squeeze and clench as you fight the urge to go until you find a bathroom. They’re supposed to be controlling a urine stream 4-6 times per day - with a UTI, their workload can easily double or triple for an entire week. For many of our patients, pelvic floor dysfunction begins with a urinary tract infection. But when the bacteria are eliminated, the symptoms remain.

The muscles and nerves of the pelvic floor can cause all of the symptoms of a UTI - urinary urgency/frequency, burning pain with urination, chronic pelvic pain, and pain that feels like it’s coming from the bladder or in the lower abdomen. The infection can cause or exacerbate pelvic floor dysfunction that persists after the infection has been resolved. Often patients are diagnosed with ‘phantom’ UTIs, where the symptoms are present but there is no bacteria detected. In many cases, this leads to round after round of unsuccessful treatment with antibiotics. Since there is no infection to cure, this can just cause significant side effects - killing off the good flora of the gut and vaginal tissue, causing constipation or diarrhea, or amplifying pain.

Patients can spend six months or more in this medical purgatory of taking antibiotics for infections that don’t exist, ‘just to be safe.’ Instead they can be finding and treating the underlying cause - the over-tight muscles of the pelvic floor.

D-Mannose Supplement for UTIs

Fortunately, there’s a highly effective natural supplement that can treat current UTIs and prevent future ones. D-Mannose is a type of sugar found in many fruits and vegetables, including cranberries, apples, oranges, and broccoli. D-Mannnose has a unique property in the body - it binds itself to e. Coli. As the body processes D-Mannose, it goes through the kidneys and into the bladder for elimination, where it attaches to any e. Coli bacteria in the system. Instead of latching onto the bladder wall or the urethra, the bacteria are bound by the sugar and then flushed from the system.

In studies, 2 grams of D-Mannose daily was actually more effective than antibiotic treatment in preventing UTIs, with only 15% of women with recurring UTIs getting another one after starting in the supplement (as compared to 60% who didn’t take anything). It’s also used to treat a current UTI infection. At 3 grams a day for an acute infection, D-Mannose successfully resolved symptoms for 43 out of 45 women. The brand we carry in the clinic is from NOW Foods - you can find it on Amazon here.

D-Mannose isn’t effective against UTIs that aren’t caused by e. Coli, but fortunately nearly 90% of infections are due to this bacteria. If you have a urine culture that shows that the majority of your infections are caused by a different bacteria, D-Mannose won’t be effective in preventing those. As always, check with your doctor before starting a new supplement.

Other Tips for Recurring UTI Treatment

There are a few other things that may help patients deal with UTI symptoms. An over-the-counter medication, Azo, is an analgesic for the bladder and urethra. It may reduce pain and discomfort while urinating, but should not be taken for extended periods of time, as it thickens the urine and can strain the kidneys (it also turns your urine a bright orange or blue color).

Urinating both before and after sexual activity can flush the urethra and reduce the risk of bacteria reaching the bladder. If possible, you can also shower before sexual activity and ask your partner to shower as well.

If you've been through multiple rounds of antibiotics (as many patients with UTIs have), you may also want to look into a probiotic to help restore the natural flora of your gut. We recommend one by Thorne to our patients you can find here.

Beyond Antibiotics for Recurring UTIs

There’s a lot more we can do for recurring urinary tract infections beyond throwing antibiotics at them. There’s often an underlying pelvic floor dysfunction that is the root cause that needs to be addressed in order to prevent these from being a life-long issue. Symptoms can be coming from the infection itself, from the tight pelvic floor muscles, or - most likely - a combination of the two. Naturally supplementing with D-Mannose can flush the e. Coli from the urinary symptom, and a healthy diet can boost your immune system to fight any remaining bacteria.


Concerned you may have Interstitial Cystitis? Find out more about the condition, how to get a great medical team and relieve symptoms at home with the IC: Roadmap to Healing online course!

Note: This article contains affiliate links to some of the products mentioned in the article. If you click on them the price you pay doesn't change, but we do get a small commission that goes into a coffee fund that gives us the caffeine to do more articles like these. As always, we only recommend products we truly believe in and that are supported by strong scientific evidence.

Additional Resources

Dr. Nicole Cozean is the founder of PelvicSanity physical therapy, Orange County's premier pelvic floor physical therapy clinic. One of only 270 PTs to be board-certified in the pelvic floor, and the first PT to serve on the ICA Board of Directors, Nicole is the author of the acclaimed and best-selling book The Interstitial Cystitis Solution (2016). She is an adjunct professor at her alma mater, Chapman University. The PelvicSanity blog focuses on presenting practical, positive information to help patients beyond the walls of Nicole's clinic.


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