Care with Roscoe Nelson, MD, board-certified urologist.
Why they keep coming back
Recurrent infection is a large part of my practice, and the job is never just treating the next one. It is finding out why they return. The usual culprits: estrogen loss after menopause thinning the tissue, a bladder that does not fully empty, bacteria hiding in the bladder wall inside biofilm, sex acting as a trigger in someone already vulnerable, constipation and pelvic floor trouble, a long antibiotic history that bred resistance, and occasionally a stone or a structural problem.
When every culture is negative
The standard culture dates from the 1950s and was built to grow a handful of common organisms in large numbers. The threshold it uses to call itself positive was borrowed from studies of women who had no symptoms, and it still decides today whether women with symptoms get treated. Bacteria in low counts, slow growers and anything embedded in biofilm slip right past it.
I use PCR and next generation sequencing routinely. They look for bacterial DNA instead of waiting for growth on a plate, and they regularly find what the culture missed, including infections with more than one organism. If you have been told again and again that nothing is wrong, you are not difficult and you are probably not out of options. The test was the limit, not you.
What I look at
- Your full culture history with dates and sensitivities, not just the last result
- Molecular testing of your urinary microbiome
- Which antibiotics you have had and what each one did
- The timing and pattern of episodes, and what you feel between them
- Whether the bladder empties, and how the pelvic floor and bowel behave
- Menopausal status and hormonal factors
- Imaging or cystoscopy when there is a reason for it
Bring whatever records you have. Gaps are something we discuss, not a reason to doubt you.
Clearing it, then preventing it
Those are two different jobs. Clearing means antibiotics chosen from the testing rather than a default, longer or combined courses when biofilm is involved, and antibiotic instilled directly into the bladder when oral therapy has not worked. Contributing factors get addressed at the same time.
Prevention starts with vaginal estrogen after menopause, one of the best-proven preventions we have and one of the least offered. Cranberry counts only if it is standardized to 36 milligrams of proanthocyanidins, the dose the studies actually used. Methenamine with vitamin C is a real alternative to a daily antibiotic. Add hydration, complete emptying, managing constipation and pelvic floor physical therapy where it fits. A preventive antibiotic has a place, chosen on purpose rather than by habit. Urinary discomfort can also come from causes other than infection, and the plan has to account for those.
Draper, and by video
I am licensed in Utah, Arizona, Florida, Georgia, Illinois, Indiana, Michigan, North Carolina, Ohio and Pennsylvania, and recurrent UTI is one of the problems I see by telehealth in those states. Some evaluation still needs an in-person visit, and where you physically are during a video visit matters.
Peri opens Late 2026. The waitlist is for opening news and is not watched for symptoms. If you have an active infection now, see an available clinician rather than waiting for us.