Women’s Experiences of Management of Urinary Tract Infections using Complementary and Alternative Medications and Expectations for the Future: A Qualitative Study

Women’s Experiences of Management of Urinary Tract Infections using Complementary and Alternative Medications and Expectations for the Future: A Qualitative Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Women’s Experiences of Management of Urinary Tract Infections using Complementary and Alternative Medications and Expectations for the Future: A Qualitative Study Priyanka H Krishnaswamy, Eilidh Middleton, Suzanne Hagen, Karen Lesley Guerrero, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7573474/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 12 You are reading this latest preprint version Abstract Objective Complementary and Alternative medicines (CAMs) are used by women to self-manage and prevent symptoms of Urinary Tract Infections (UTIs). However, health care professionals lack awareness of the extent and nature of CAM usage, or potential effects and interactions with mainstream treatments such as antibiotics. The aim of this study was to explore women’s knowledge of CAMs to prevent and self-manage UTIs, their experiences using them, their attitudes to these products and expectations for the future. Methods A qualitative cross-sectional study was undertaken to explore women’s experiences of using CAMs. Women were recruited from four different settings: General Practitioner Clinics; general Gynaecology clinics; Urogynaecology clinics and social media. Reflexive thematic analysis was completed using Braun and Clarke’s five stage approach. Results Themes around participants knowledge of CAMs and the nature of self-managing UTI were identified, together with justifications for and challenges associated with CAM usage and expectations for UTI management in the future. All participants had tried a range of CAM therapies and/or changed behaviour to self-manage UTIs, with the purpose of avoiding or reducing antibiotic use cited as the main reason for this. Women from the Social Media group had extensive experience of using CAMs, reporting inadequate information from traditional sources and frustration with HCPs about lack of knowledge of CAMs and supposed overuse of antibiotics. Conclusion This study provides a unique insight into women’s perceptions of and experiences using a range of CAMs and provides further justification for research into their role in UTI management. Urinary Tract Infections Complementary Therapies Self-Management Anti-Bacterial Agents Anti-Infective Agents Urinary Social Media Figures Figure 1 Introduction Complementary and alternative medicine (CAM) is used to refer to treatments outside of mainstream healthcare including dietary supplements, herbal preparations and various forms of indigenous medicine [ 1 ]. Overall prevalence of CAM use in developed nations varies between 30 and 90% [ 2 ] with this used to self-manage symptoms of urinary tract infections (UTIs) [ 3 ]. 85% of women’s self-diagnosis of UTIs was demonstrated to be correct [ 4 ]. Use of CAMs was commonly seen in women consulting their doctor with symptoms of UTI, but up to 60% did not disclose CAM use [ 3 , 5 ] without being asked directly about it [ 6 , 7 ]. This indicates a lack of awareness of CAM usage, or recognition of potential effects and interactions with mainstream treatments among health care professionals (HCPs). Using CAMs such as cranberry products, D-mannose, probiotics including lactobacillus and yoghurt, or ascorbic acid (vitamin C) in UTI management is an appealing option for many because they are considered “natural” remedies. Although only limited evidence of efficacy exists, these remedies for prevention and self-management of UTIs could alleviate symptoms [ 8 ]. It is, therefore, important to better articulate the knowledge and understanding of CAM use in UTI self-management, since the strategies, advice, and remedies that some women find useful may also be beneficial for others. The aim of this study was to explore women’s knowledge of CAMs to prevent and self-manage UTI, their experiences using them, their attitudes to these kind of products and expectations for the future. Material & Methods A qualitative cross-sectional study was undertaken to explore women’s real-world experiences of using CAMs to self-manage UTI’s. This initial exploratory study formed the qualitative arm of a cross-sectional questionnaire-based study exploring the use of CAMs for the prevention and self-management of UTIs by women from four different settings: women attending their primary practice (GP) for any reason (GP Group); secondary care in a hospital out-patient setting attending with gynaecological issues (GG Group); tertiary care in a hospital out-patient setting attending for urogynaecological issues (UG Group) and online via requests placed on UTI support groups on social media (SM Group) Non-pregnant women over 18 years of age, able to comprehend information provided, when recruited into the initial questionnaire-based study were offered information about this qualitative arm. Willing participants contacted the team if they wished to participate in this, when informed consent was obtained (Fig. 1 ). Participants could choose between being interviewed in person or via telephone, video, at a convenient place and time. A semi-structured interview schedule (Supplementary Material 1) was developed to allow for deeper exploration of participant’s views and experiences. Given the methods used and the size of the study, it was designed to present an initial description of relevant factors in CAMs use by women and not designed to explain their behaviour. Each interview was digitally recorded, anonymised, transcribed verbatim and imported to NVivo 12.5.0 for data processing and analysis. No repeat interviews were performed and there was no further contact with participants. The first part of the study has been already published elsewhere [ 9 ]. Reflexive thematic analysis was completed using Braun and Clarke’s five stage approach [ 10 ]. Data familiarisation began with reading transcriptions to create initial reflexive thoughts and ideas about the meaning of the data. Initial phrase codes were generated on NVivo 12.5.0 [ 11 ] after line by line reading and re-reading. These codes were then reviewed, refined and collapsed into larger categories of similar meaning. Patterns and themes in the data were identified by combining, separating, discarding and collating concepts with similar meaning, comparing answers by different participants in an attempt to refine the analytic processes [ 10 ]. All authors agreed on the final analysis and interpretation of themes generated. This study was reviewed and approved by the Ethics Committee [Integrated Research Application System Research ID 283407]. Results This study was conducted between July 2020 and December 2020 during the COVID pandemic in the United Kingdom (UK). While some women in the SM group were based in England and the United States (US), most participants were based in Scotland, where there are no charges to be paid for medications prescribed by their GP. A flowchart of recruitment into the qualitative study is demonstrated in Figure 1. 23 participants were recruited and interviewed. Women’s interviews were anonymised, and their experience was reported using the abbreviation of the group they belonged to along with the participant number. All participants opted for telephone interviews which lasted on average for 15 minutes (Range: 3-46 minutes). The themes identified during the analysis (Table 1) are detailed below with relevant quotes in Supplementary Material 2-5. 1. Knowledge of CAMs and Nature of Self-management of UTI a. Range of Products Tried CAM use and/or changes in behaviour to self-manage UTIs were reported by all participants. Women in all groups had tried a range of oral agents, with a few trying local applied products like yoghurt and self-made preparations with witch hazel and castor oil. Cranberry-based oral products were the most reported by participants across all groups. Women in SM had tried more types of CAMs when compared to the others. Women in the first three groups mainly mentioned increasing their fluid intake to try and “flush out” (the UTI). Women in SM mentioned changes in behaviour such as urinating and/or washing after sex, cutting out sparkling water and fizzy drinks, not using thong underwear, altering their diet, trying different CAMs and including supplements in their routine (Table 2). b. Source of CAMs - information and products Sources seemed to be various internet sites, journals, medical specialists, support groups, friends, family, and colleagues with experience in managing recurrent UTIs. Women in SM described themselves as having extensively researched CAMs. All women in SM and some in the other groups mentioned seeking advice from HCPs, in addition to self-managing with CAMs. Women in all groups professed to being grateful for any input from HCPs, however in the GG, UG and GP groups most stated they had not discussed CAMs with HCPs. When discussion with HCPs took place, cranberry supplements were commonly mentioned. Women in SM described themselves as not having received enough information from HCPs. All women in SM group reported speaking to a specialist such as a Urologist, a Gynaecologist, nurse specialist, a Herbologist, CHM (Chinese Herbal Medicine) Practitioner or an acupuncturist. Most women in the first three groups commented that the HCPs advice met their expectations: the lack of discussion about CAMs was unsurprising as they expected to hear only about “medicine”. Some, however, stated that HCPs only prescribed antibiotics and recommended drinking plenty of water, which did not meet their needs. When women did mention taking CAMs to their GPs, they stated that they were either not given any additional advice or were told that while worth trying, it did not always work for everyone. This contrasts with all women in SM who were dissatisfied with their GPs and stated this reason for seeking advice regarding management of UTIs elsewhere. Women in all groups reported not having seen their GP in person for a UTI– either handing in a urine sample or having a telephone consultation before being prescribed antibiotics - a broad-spectrum antibiotic which was then changed to a targeted one. While this was easy for some, a few were unable to speak with their GP and reported struggling with symptoms. Women bought cranberry juice from the supermarket, food supplements at health food stores, sachets containing cranberry and Vitamin C at the chemist. They also bought different herbal drinks and food from the supermarket, antimicrobials from nutritional therapists, integrated doctors who prescribed CHMs, specific herbs from Herbologists and probiotics online imported from the US. c. Sources for Reassurance All women in SM and some in the other groups found online UTI support groups great sources of support because of free sharing and comparison of information. Some women mentioned being grateful for referral to a Specialist when requested. Women also sourced CAMs from overseas and alternative health practitioners. Women across all groups stated their belief that these products were natural, not harmful and were happy to try them because of their presumed safety. Women were also happy with their pharmacists who were able to give them advice on CAMs and prescribe antibiotics if required. 2. Justifications for CAM use a. Ideas about Causes of Recurrent UTIs Women stated various reasons for developing UTIs. In all four groups, some mentioned genetics with mothers and/or daughters having them, previous untreated childhood UTIs, being prone to developing UTIs and bacteria being “embedded” in their body for years. Women in SM spoke about recurrences being due to bacteria present in their gut, vagina and/or bladder, which were difficult to eradicate with oral antibiotics which they felt “only killed free floating bacteria”. b. Concerns about Antibiotics Women across all groups wished that CAMs had been discussed with them sooner, reporting adverse effects of antibiotics:– killing good bacteria, suppressing their immune system - being susceptible to frequent colds and vaginal thrush, with fears about antibiotic resistance from overuse. Some women in SM who used long-term high dose antibiotics to treat UTIs were concerned about side effects, feared having co-existent H pylori and gut problems and had concerns about using Gentamycin bladder instillations and the need to self-catheterise. Women were also concerned about being on low dose long term antibiotics because they felt bacteria were never killed and would become resistant to antibiotics, being eventually fatal. They wanted targeted antibiotics to prevent this. Additionally, women were concerned about not receiving “a complete prescription” of antibiotics:– receiving a three-day course from a pharmacist was felt by some to be inadequate, inducing resistance and the need to return for more. c. Rationale for use of CAMs ‘Desperation’ was the main reason reported across all groups, with reliance on word of mouth and hope that CAMs would work. Several women in the first three groups mentioned not having any problems with cranberry supplements, because they felt that it was worth a try, harmless, available over the counter, tasty, preferring this as they believed they were traditional, natural products and “home remedies” with a holistic approach to health. This seemed to be the case even when they felt that it did not address the cause of their UTIs, stating comfort and it being a matter of “trial and error”. All women in SM and many in the other groups mentioned the major reason for trying CAMs was their need to avoid or reduce use of antibiotics. They also wished to avoid taking too many medications, damaging their organs, troubling their doctor, being unable to get an appointment with their doctor, convenience and ability to self-manage themselves quickly and easily when required. Other perceived health benefits included: improving their digestion and having a better quality of life overall, preference for using agents like Vitamin C to acidify urine, Lactobacilli to help vaginal dysbiosis, water to flush bacteria away and bicarbonate of soda to neutralise urine to treat a presumed UTI. d. Perceived Effectiveness for UTI Prevention In the first three groups, most women believed that keeping themselves hydrated with water and cranberry supplements prevented recurrences. Some felt they did not take these agents as much or regularly enough to notice a benefit. All in SM and some in the first three groups believed that cranberry supplements did not work for them. Some in SM did not think that D Mannose helped. All of them mentioned various other CAMs and dietary modifications which they believed helped. They stated the need to find the right combination to help one’s own body and that they had tried different regimens before finding their current working plan. Women mentioned using agents like Methenamine Hippurate (MH): in combination with probiotics initially aiming to wean MH completely in future or using MH instead of antibiotics prophylactically before sex. There were concerns about using vaccines against UTIs, specifically about them having more bacteria in their body and the mechanism of action when they are already infected. e. Perceived Effectiveness for Self-management of Presumed UTIs In the first three groups, some felt cranberry products helped resolve their symptoms, particularly when on holiday or when they couldn’t reach their GP; others were unsure, unable to remember or did not know. When perceived that cranberry supplements did work for them, they reported taking it earlier or for longer than usual. They sometimes regretted awaiting spontaneous resolution and not starting this sooner. Some women mentioned cranberry products in combination with urinary alkalinising agents being more effective than cranberry alone, drinking lots of fluid and/or bicarbonate of soda helping symptoms but found application of yoghurt over the vulva unhelpful. While cranberry seemed to help initially for some, there was also a perceived need to treat with antibiotics stated for some stating that only antibiotics helped resolve their symptoms at the end. Women wondered if symptoms subsided with time anyway, if fluid helped flush the infection out of their system or if there was a psychological element to feeling cranberry supplements helped. Women accepted that stronger remedies were only available by prescription and that they didn’t expect over-the-counter products to be as effective, being a “gentler solution”. While some were hopeful that this would treat their symptoms for good, this was not always the case and others resorted to antibiotics straight away without trying CAMs. In SM, women mentioned trying cranberry as well as numerous CAMs unsuccessfully prior to their current regime believing that they had “an embedded infection”. The use of antibiotics and CAMs concurrently initially, gradually reducing the dose of antibiotics and later staying on CAMs alone to keep symptoms at bay, seemed to help avoid using longer courses of antibiotics and being symptom-free for longer. f. Future Plans A majority in the first three groups tried CAMs, even with symptoms of a UTI, and even if this had been unsuccessful in the past, stating an intention of using them in the future. Some women stated an intention of getting a prescription for antibiotics from their GP straightaway in the future. In SM, the women were sure they would continue using CAMs, advocating their use routinely, minimising the use of antibiotics to when absolutely required, if at all. 3. Challenges with use of CAMS a. Issues with use of CAMs- dosage and conflicting advice Across all four groups, women who tried cranberry juice were unsure about dosage: reported using information obtained online, guesswork, from previous work experience in hospices and nursing homes or through word of mouth. Dosage varied widely - drinking as much as possible, a small portion regularly with or without dilution and some believing that this varied between individuals. The majority expected better information about dosage of CAMs to be available. Some women in the first 3 groups and most in SM mentioned receiving conflicting information about dosages of CAMs, researching this and drawing their own conclusions. Conflicting advice about MH from specialists in UTIs was reported. Some specialists recommended it, some stated it might not work, that it could cause kidney damage. Some women stated that it was unusual for it to be prescribed, that their GP would not prescribe it, and that it was for older women only. Women reported worrying about reasons why it was not usually prescribed, what side effects they had and their severity, especially with life-long use. There was also a concern that it would only work if the UTI was caused by specific bacteria such as Escherichia coli. Some also stated hearing that MH greatly helped other women - which reassured them and that when they tried it, it had worked well, increasing their confidence in its use. b. Perceived Adverse Effects Some women in all groups expressed concern about D-Mannose or cranberry juice increasing the level of sugar in their body, especially with concurrent medical conditions like diabetes mellitus, Polycystic Ovarian Syndrome (PCOS), being on anticoagulants like warfarin and being overweight. Most in the first three groups reported no or few concerns taking CAMs, some taking them routinely and enjoying the taste. However, some women did not like the taste of cranberry juice or bicarbonate of soda, finding cranberry juice nauseating and causing a struggle with symptoms of bladder overactivity. While most preferred to drink a lot of water, some women also reported finding this challenging. The SM women reported a number of perceived adverse effects of CAMs including: constipation from Kefir yogurt, digestive issues from bicarbonate of soda or other alkalinizing agents, cranberry juice causing a sensitive stomach and worsening of haematuria as well as reluctance to try MH due to formaldehyde “burning their bladder”. There were concerns about inability to continue longer courses of natural antimicrobial agents due to potential side effects, even though it worked for them and about taking too many chemicals when trialling different types and combinations of CAMs, with or without antibiotics. There were worries about using CAMs based on information from non-medical people with UTIs, forums and bloggers online, concerns about using CAMs without long-term knowledge about the impact on their body, that they might stop working for them over time, that they might work differently for different people and their impact on future fertility. Some women stated no other choice but to turn to alternative medications despite these perceived adverse effects because traditional medications had failed them. 4. Expectations for future UTI management a. Better testing Women in SM were upset about the lack of information about and testing for embedded UTIs being freely available in the UK. They stated that reliable testing for UTIs overall needed a major overhaul, as unreliable urine dipsticks were still routinely used. Women were concerned that they were not being tested to check for urinary retention, even by specialists, and were worried about further investigations like cystoscopies for UTIs because of further risks of UTIs and/or pyelonephritis. b. HCPs being Educated Some women in all groups felt doctors did not discuss all options available for managing UTIs apart from antibiotics as their knowledge was inadequate. Women in SM believed that doctors should help when requested about CAMs, felt that they were not listened to, did not get answers despite asking, were not pointed in the direction of a specialist in UTIs and were inadequately counselled on prevention techniques following investigations like a cystoscopy. Women were also angry that despite investigations, antibiotics were always prescribed, and some CAMs were never mentioned, meaning that they had to seek information and support from alternative sources. Women expressed their frustration with HCPs when they had negative urine tests despite being symptomatic, sometimes being accused of having mental health problems. They expressed anger at not being told about the role of vaginal atrophy on UTI occurrence; when their ovaries were removed surgically, not being offered an alternative when one type of vaginal oestrogen did not work; or being expected to accept being in pain and needing to be stubborn to find a solution. c. Further Research Women in SM were concerned about the lack of adequate funding for research into UTIs, expressing a keenness to help due to their experiences, and gratitude for ongoing research. They were also concerned about lack of information about natural remedies, stating that if there was more knowledge about them, people would make better-informed decisions. d. Testing for embedded UTIs Women in SM spoke about testing for embedded UTIs using broth tests and MicroGenDX tests which they described as being popular in the US. They believed that these helped to identify the bacteria causing their UTI, meaning they could be prescribed specific antibiotics and choose probiotics that suited them, reporting success in other women in their support groups. e. Bring phage therapy to the UK Women in SM spoke about targeted phage therapy being used in Europe against specific bacteria with no side effects and that antibiotics were adopted only for cost effectiveness and quick action. Naming a clinic in Russia which provided this, one woman mentioned that she would been there if it hadn’t been for the COVID pandemic, was trying to get this shipped with concerns about practicality of learning to instil it into her bladder. Women seemed motivated by other success stories with ongoing research in other countries stating that the UK “needed phage therapy” and more research in this, an uncertainty about efficacy, variance of effectiveness of oral phages, the need for custom made phages, their potential short-term nature of relief as well as prohibitive costs. Discussion The purpose of this study was to explore women’s thoughts and experiences regarding CAMs for prevention and self-management of UTIs. The use of a large range of CAMs were reported with cranberry-based oral products being the most used in keeping with literature [ 8 ]. Women were open to trying CAMs first, especially if this had perceived therapeutic potential [ 12 ] and not everyone was inclined to tell their doctor what strategies they had used to self-manage UTIs [ 6 , 7 , 13 ] which was similar in the first three groups in our study. However, women in SM, who seemed to be most troubled with UTIs, not only spoke to their GPs about them, but were dissatisfied with this in keeping with literature where women experienced negative clinician interactions, perceived inadequate care, lack of knowledge and awareness surrounding UTIs [ 14 ], choosing to seek specialist care or consulting with CAM practitioners [ 15 ]. A general aversion towards antibiotics and resentment of the medical profession for using this [ 16 ] was noted in this study. Additionally, women valued being involved in their treatment [ 17 ] [ 18 ], with a need for HCPs to address specific worries [ 19 ], modify management strategies to address concerns and empower patients [ 16 ] being identified in literature. The need for advice incorporating self-care, tailored shared decision making with HCPs and safety netting when trialling CAMs [ 17 ] as seen in this study. Worries from participants regarding the cause for their UTIs [ 20 ] with a relative openness to alternative methods of managing UTIs [ 21 ], fears over frequent antibiotic use [ 20 ] and especially in women with recurrent UTIs was also reflected in literature. Women in SM also spoke of concerns regarding research gaps in UTI diagnostics and treatment which was reflected in other literature [ 14 ] as well as a need to devote more research efforts to improving non-antibiotic options [ 16 ], more and appropriate information provision [ 22 ], effectiveness and safety, better regulation of herbal practitioners, and assurance about herbal quality control and potential herb–drug interactions[ 23 ]. Literature also demonstrated the value of the existing close-knit global community on social media with extensive knowledge about risk factors, ongoing research and noting a potential influence on trends in CAM use [ 24 ]. However, as at least 29% of UTI prevention strategies using CAMs recommended here were demonstrated to have little to no evidence and the need for further education and research due to a clearly high demand and use of these approaches [ 24 ] was identified. The similarity of results with previous literature makes this study credible with transparency regarding methods and results ensuring reliability, validity and authenticity. However, as an initial exploratory and descriptive study, this was not designed to be explanatory or completely interpretive. This is also not completely representative of women’s experiences as UTIs were self-reported with unknown clinical histories and biases based on past experiences and recruitment groups. Findings from the SM group were likely a reflection of the severe end of the spectrum and warrants cautious interpretation of results with transcripts not returned for comments and no feedback obtained on findings. Additionally, financial impact may play a role on women’s perspectives in England, where prescription charges are applicable and in the US with limited access to public health funds. It may be postulated that the initial experiences of women in SM may have been similar to the other 3 groups, but traditional treatments may have been ineffective, that they were more severely impacted by their UTIs or that this maybe a chronic condition. Additionally, women in SM trialled a combination of CAMs with antibiotics, tapering and then stopping antibiotics altogether which may be a potential management tool for recurrent UTIs. These women seemed to have extensive knowledge and experience with CAM use, stating inadequate information and input from traditional medical sources which also suggests the need for ongoing support, currently not available from formal medical services. Further information about experiences and concerns from HCPs and CAM users and safety information regarding CAMs is a research need that was identified during this study. Conclusion This study provides a unique insight into women’s perceptions of and experiences with CAMs and provides justification for further research into the role of CAMs in UTI management and the use of CAMs by women. Abbreviations CAMs Complementary and Alternative medicines UTIs Urinary Tract Infections HCPs Health Care Professionals GP General Practice UK United Kingdom US United States CHM Chinese Herbal Medicine MH Methenamine Hippurate PCOS Polycystic Ovarian Syndrome Declarations Acknowledgements No acknowledgments to note Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Competing Interests The authors have no relevant conflicts of interest, financial or non-financial, to declare. Ethics approval Consent to participate Written Informed consent was obtained from all individual participants included in the study. Full Ethics Statement: The study protocol and paperwork were reviewed and approved by the regional Research Ethics Committee [Integrated Research Application System Research ID 283407]. All study procedures were conducted in accordance with the Declaration of Helsinki and Good Clinical Practice guidelines. Consent to Participate: Written informed consent was obtained from all participants prior to their inclusion in the study. All participants were provided with detailed information about the study objectives, procedures, and their right to withdraw at any time. Participants explicitly consented to audio recording of interviews and use of anonymized quotes in publications. Conflicts of interest: The authors have no relevant conflicts of interest, financial or non-financial, to declare. 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Antimicrobial Resistance & Infection Control,. 2019;8:148. https://doi.org/10.1186/s13756-019-0567-6 Bey L, Touboul P, Mondain V. Recurrent cystitis: patients’ needs, expectations and contribution to developing an information leaflet – a qualitative study. BMJ Open. 2022;12:e062852. https://doi.org/10.1136/bmjopen-2022-062852 . Flower A, Winters D, Bishop F, Lewith G. The challenges of treating women with recurrent urinary tract infections in primary care: A qualitative study of GPs’ experiences of conventional management and their attitudes towards possible herbal options. Prim Health Care Res Dev. 2015;16:597–606. https://doi.org/10.1017/S1463423615000201 . Burton C, Gonzalez G, Almario C, Arnold C, Spiegel B, Anger J. Lower urinary tract disease prevention strategies recommended onsocial media platforms: mixed correlation with evidence. Abstracts Neurourol Urodynamics. 2020;39:6–281. https://doi.org/10.1002/nau.24307 . Tables Tables 1 and 2 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Tables.docx SupplementaryTables.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 06 Jan, 2026 Reviews received at journal 22 Dec, 2025 Reviews received at journal 16 Dec, 2025 Reviewers agreed at journal 02 Dec, 2025 Reviewers agreed at journal 02 Dec, 2025 Reviews received at journal 25 Nov, 2025 Reviewers agreed at journal 19 Nov, 2025 Reviewers invited by journal 18 Nov, 2025 Editor invited by journal 15 Oct, 2025 Editor assigned by journal 06 Oct, 2025 Submission checks completed at journal 06 Oct, 2025 First submitted to journal 09 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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07:07:11","extension":"html","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":94584,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7573474/v1/b2a82f564946fe838424156e.html"},{"id":96968883,"identity":"ac8bff4c-c9ce-4cfd-be81-971c861895e4","added_by":"auto","created_at":"2025-11-28 07:07:02","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":34620,"visible":true,"origin":"","legend":"\u003cp\u003eRecruitment to study\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7573474/v1/86e5ce21b9686420b554d711.png"},{"id":97144768,"identity":"25612fe4-85a5-49e4-9501-1efef8c90b56","added_by":"auto","created_at":"2025-12-01 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07:07:03","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":27801,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryTables.docx","url":"https://assets-eu.researchsquare.com/files/rs-7573474/v1/653174f8374e2402fb5a2474.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Women’s Experiences of Management of Urinary Tract Infections using Complementary and Alternative Medications and Expectations for the Future: A Qualitative Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eComplementary and alternative medicine (CAM) is used to refer to treatments outside of mainstream healthcare including dietary supplements, herbal preparations and various forms of indigenous medicine [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Overall prevalence of CAM use in developed nations varies between 30 and 90% [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] with this used to self-manage symptoms of urinary tract infections (UTIs) [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e85% of women\u0026rsquo;s self-diagnosis of UTIs was demonstrated to be correct [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Use of CAMs was commonly seen in women consulting their doctor with symptoms of UTI, but up to 60% did not disclose CAM use [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] without being asked directly about it [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. This indicates a lack of awareness of CAM usage, or recognition of potential effects and interactions with mainstream treatments among health care professionals (HCPs).\u003c/p\u003e\u003cp\u003eUsing CAMs such as cranberry products, D-mannose, probiotics including lactobacillus and yoghurt, or ascorbic acid (vitamin C) in UTI management is an appealing option for many because they are considered \u0026ldquo;natural\u0026rdquo; remedies. Although only limited evidence of efficacy exists, these remedies for prevention and self-management of UTIs could alleviate symptoms [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. It is, therefore, important to better articulate the knowledge and understanding of CAM use in UTI self-management, since the strategies, advice, and remedies that some women find useful may also be beneficial for others.\u003c/p\u003e\u003cp\u003eThe aim of this study was to explore women\u0026rsquo;s knowledge of CAMs to prevent and self-manage UTI, their experiences using them, their attitudes to these kind of products and expectations for the future.\u003c/p\u003e"},{"header":"Material \u0026 Methods","content":"\u003cp\u003eA qualitative cross-sectional study was undertaken to explore women\u0026rsquo;s real-world experiences of using CAMs to self-manage UTI\u0026rsquo;s.\u003c/p\u003e\u003cp\u003eThis initial exploratory study formed the qualitative arm of a cross-sectional questionnaire-based study exploring the use of CAMs for the prevention and self-management of UTIs by women from four different settings: women attending their primary practice (GP) for any reason (GP Group); secondary care in a hospital out-patient setting attending with gynaecological issues (GG Group); tertiary care in a hospital out-patient setting attending for urogynaecological issues (UG Group) and online via requests placed on UTI support groups on social media (SM Group)\u003c/p\u003e\u003cp\u003eNon-pregnant women over 18 years of age, able to comprehend information provided, when recruited into the initial questionnaire-based study were offered information about this qualitative arm. Willing participants contacted the team if they wished to participate in this, when informed consent was obtained (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eParticipants could choose between being interviewed in person or via telephone, video, at a convenient place and time. A semi-structured interview schedule (Supplementary Material 1) was developed to allow for deeper exploration of participant\u0026rsquo;s views and experiences. Given the methods used and the size of the study, it was designed to present an initial description of relevant factors in CAMs use by women and not designed to explain their behaviour. Each interview was digitally recorded, anonymised, transcribed verbatim and imported to NVivo 12.5.0 for data processing and analysis. No repeat interviews were performed and there was no further contact with participants. The first part of the study has been already published elsewhere [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eReflexive thematic analysis was completed using Braun and Clarke\u0026rsquo;s five stage approach [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Data familiarisation began with reading transcriptions to create initial reflexive thoughts and ideas about the meaning of the data. Initial phrase codes were generated on NVivo 12.5.0 [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] after line by line reading and re-reading. These codes were then reviewed, refined and collapsed into larger categories of similar meaning. Patterns and themes in the data were identified by combining, separating, discarding and collating concepts with similar meaning, comparing answers by different participants in an attempt to refine the analytic processes [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. All authors agreed on the final analysis and interpretation of themes generated.\u003c/p\u003e\u003cp\u003e This study was reviewed and approved by the Ethics Committee [Integrated Research Application System Research ID 283407].\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThis study was conducted between July 2020 and December 2020 during the COVID pandemic in the United Kingdom (UK). While some women in the SM group were based in England and the United States (US), most participants were based in Scotland, where there are no charges to be paid for medications prescribed by their GP.\u003c/p\u003e\n\u003cp\u003eA flowchart of recruitment into the qualitative study is demonstrated in Figure 1. \u0026nbsp;23 participants were recruited and interviewed. Women\u0026rsquo;s interviews were anonymised, and their experience was reported using the abbreviation of the group they belonged to along with the participant number.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll participants opted for telephone interviews which lasted on average for 15 minutes (Range: 3-46 minutes). The themes identified during the analysis (Table 1) are detailed below with relevant quotes in Supplementary Material 2-5.\u003c/p\u003e\n\u003cp\u003e1. \u003cstrong\u003eKnowledge of CAMs and Nature of Self-management of UTI\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ea. Range of Products Tried\u003c/p\u003e\n\u003cp\u003eCAM use and/or changes in behaviour to self-manage UTIs were reported by all participants. Women in all groups had tried a range of oral agents, with a few trying local applied products like yoghurt and self-made preparations with witch hazel and castor oil. Cranberry-based oral products were the most reported by participants across all groups. Women in SM had tried more types of CAMs when compared to the others.\u003c/p\u003e\n\u003cp\u003eWomen in the first three groups mainly mentioned increasing their fluid intake to try and \u0026ldquo;flush out\u0026rdquo; (the UTI). Women in SM mentioned changes in behaviour such as \u0026nbsp;urinating and/or washing after sex, cutting out sparkling water and fizzy drinks, not using thong underwear, altering their diet, trying different CAMs and including supplements in their routine (Table 2).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eb. Source of CAMs - information and products\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSources seemed to be various internet sites, journals, medical specialists, support groups, friends, family, and colleagues with experience in managing recurrent UTIs. Women in SM described themselves as having extensively researched CAMs.\u003c/p\u003e\n\u003cp\u003eAll women in SM and some in the other groups mentioned seeking advice from HCPs, in addition to self-managing with CAMs. Women in all groups professed to being grateful for any input from HCPs, however in the GG, UG and GP groups most stated they had not discussed CAMs with HCPs. When discussion with HCPs took place, cranberry supplements were commonly mentioned. Women in SM described themselves as not having received enough information from HCPs. All women in SM group reported speaking to a specialist such as a Urologist, a Gynaecologist, nurse specialist, a Herbologist, \u0026nbsp;CHM (Chinese Herbal Medicine) Practitioner or an acupuncturist.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMost women in the first three groups commented that the HCPs advice met their expectations: \u0026nbsp;the lack of \u0026nbsp;discussion about CAMs was unsurprising as they expected to hear only about \u0026ldquo;medicine\u0026rdquo;. Some, however, stated that HCPs only prescribed antibiotics and recommended drinking plenty of water, which did not meet their needs. When women did mention taking CAMs to their GPs, they stated that they were either not given any additional advice or were told that while worth trying, it did not always work for everyone. This contrasts with all women in SM who were dissatisfied with their GPs and stated this reason for seeking advice regarding management of UTIs elsewhere.\u003c/p\u003e\n\u003cp\u003eWomen in all groups reported not having seen their GP in person for a UTI\u0026ndash; either handing in a urine sample or having a telephone consultation before being prescribed antibiotics - a broad-spectrum antibiotic which was then changed to a targeted one. While this was easy for some, a few were unable to speak with their GP and reported struggling with symptoms.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWomen bought cranberry juice from the supermarket, food supplements at health food stores, sachets containing cranberry and Vitamin C at the chemist. They also bought different herbal drinks and food from the supermarket, antimicrobials from nutritional therapists, integrated doctors who prescribed CHMs, specific herbs from Herbologists and probiotics online imported from the US.\u003c/p\u003e\n\u003cp\u003ec. Sources for Reassurance\u003c/p\u003e\n\u003cp\u003eAll women in SM and some in the other groups found online UTI support groups great sources of support because of free sharing and comparison of information. Some women mentioned being grateful for referral to a Specialist when requested. Women also sourced CAMs from overseas and alternative health practitioners.\u003c/p\u003e\n\u003cp\u003eWomen across all groups stated their belief that these products were natural, not harmful and were happy to try them because of their presumed safety. Women were also happy with their pharmacists who were able to give them advice on CAMs and prescribe antibiotics if required.\u003c/p\u003e\n\u003cp\u003e2. \u003cstrong\u003eJustifications for CAM use\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ea. Ideas about Causes of Recurrent UTIs\u003c/p\u003e\n\u003cp\u003eWomen stated various reasons for developing UTIs. In all four groups, some mentioned genetics with mothers and/or daughters having them, previous untreated childhood UTIs, being prone to developing UTIs and bacteria being \u0026ldquo;embedded\u0026rdquo; in their body for years. Women in SM spoke about recurrences being due to bacteria present in their gut, vagina and/or bladder, which were difficult to eradicate with oral antibiotics which they felt \u0026ldquo;only killed free floating bacteria\u0026rdquo;.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eb. Concerns about Antibiotics\u003c/p\u003e\n\u003cp\u003eWomen across all groups wished that CAMs had been discussed with them sooner, reporting adverse effects of antibiotics:\u0026ndash; killing good bacteria, suppressing their immune system - being susceptible to frequent colds and vaginal thrush, with fears about antibiotic resistance from overuse. Some women in SM who used long-term high dose antibiotics to treat UTIs were concerned about side effects, feared having co-existent H pylori and gut problems and had concerns about using Gentamycin bladder instillations and the need to self-catheterise. \u0026nbsp;Women were also concerned about being on low dose long term antibiotics because they felt bacteria were never killed and would become resistant to antibiotics, being eventually fatal. They wanted targeted antibiotics to prevent this. Additionally, women were concerned about not receiving \u0026ldquo;a complete prescription\u0026rdquo; of antibiotics:\u0026ndash; receiving a three-day course from a pharmacist was felt by some to be \u0026nbsp;inadequate, inducing resistance and the need to return for more.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ec. Rationale for use of CAMs\u003c/p\u003e\n\u003cp\u003e\u0026lsquo;Desperation\u0026rsquo; was the main reason reported across all groups, with reliance on word of mouth and hope that CAMs would work. Several women in the first three groups mentioned not having any problems with cranberry supplements, because they felt that it was worth a try, harmless, available over the counter, tasty, preferring this as they believed they were traditional, natural products and \u0026ldquo;home remedies\u0026rdquo; with a holistic approach to health. This seemed to be the case even when they felt that it did not address the cause of their UTIs, stating comfort and it being a matter of \u0026ldquo;trial and error\u0026rdquo;.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll women in SM and many in the other groups mentioned the major reason for trying CAMs was their need to avoid or reduce use of antibiotics. They also wished to avoid taking too many medications, damaging their organs, troubling their doctor, being unable to get an appointment with their doctor, convenience and ability to self-manage themselves quickly and easily when required. Other perceived health benefits included: improving their digestion and having a better quality of life overall, preference for using agents like Vitamin C to acidify urine, Lactobacilli to help vaginal dysbiosis, water to flush bacteria away and bicarbonate of soda to neutralise urine to treat a presumed UTI.\u003c/p\u003e\n\u003cp\u003ed. Perceived Effectiveness for UTI Prevention\u003c/p\u003e\n\u003cp\u003eIn the first three groups, most women believed that keeping themselves hydrated with water and cranberry supplements prevented recurrences. Some felt they did not take these agents as much or regularly enough to notice a benefit.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll in SM and some in the first three groups believed that cranberry supplements did not work for them. Some in SM did not think that D Mannose helped. All of them mentioned various other CAMs and dietary modifications which they believed helped. They stated the need to find the right combination to help one\u0026rsquo;s own body and that they had tried different regimens before finding their current working plan. Women mentioned using agents like Methenamine Hippurate (MH): \u0026nbsp;in combination with probiotics initially aiming to wean MH completely in future or using MH instead of antibiotics prophylactically before sex. There were concerns about using vaccines against UTIs, specifically about them having more bacteria in their body and the mechanism of action when they are already infected.\u003c/p\u003e\n\u003cp\u003ee. Perceived Effectiveness for Self-management of Presumed UTIs\u003c/p\u003e\n\u003cp\u003eIn the first three groups, some felt cranberry products helped resolve their symptoms, particularly when on holiday or when they couldn\u0026rsquo;t reach their GP; others were unsure, unable to remember or did not know. When perceived that cranberry supplements did work for them, they reported taking it earlier or for longer than usual. They sometimes regretted awaiting spontaneous resolution and not starting this sooner. Some women mentioned cranberry products in combination with urinary alkalinising agents being more effective than cranberry alone, drinking lots of fluid and/or bicarbonate of soda helping symptoms but found application of yoghurt over the vulva unhelpful. While cranberry seemed to help initially for some, there was also a perceived need to treat with antibiotics stated for some stating that only antibiotics helped resolve their symptoms at the end.\u003c/p\u003e\n\u003cp\u003eWomen wondered if symptoms subsided with time anyway, if fluid helped flush the infection out of their system or if there was a psychological element to feeling cranberry supplements helped. Women accepted that stronger remedies were only available by prescription and that they didn\u0026rsquo;t expect over-the-counter products to be as effective, being a \u0026ldquo;gentler solution\u0026rdquo;. While some were hopeful that this would treat their symptoms for good, this was not always the case and others resorted to antibiotics straight away without trying CAMs.\u003c/p\u003e\n\u003cp\u003eIn SM, women mentioned trying cranberry as well as numerous CAMs unsuccessfully prior to their current regime believing that they had \u0026ldquo;an embedded infection\u0026rdquo;. The use of antibiotics and CAMs concurrently initially, gradually reducing the dose of antibiotics and later staying on CAMs alone to keep symptoms at bay, seemed to help avoid using longer courses of antibiotics and being symptom-free for longer.\u003c/p\u003e\n\u003cp\u003ef. Future Plans\u003c/p\u003e\n\u003cp\u003eA majority in the first three groups tried CAMs, even with symptoms of a UTI, and even if this had been unsuccessful in the past, stating an intention of using them in the future. Some women stated an intention of getting a prescription for antibiotics from their GP straightaway in the future.\u003c/p\u003e\n\u003cp\u003eIn SM, the women were sure they would continue using CAMs, advocating their use routinely, minimising the use of antibiotics to when absolutely required, if at all.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3. \u0026nbsp; Challenges with use of CAMS\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ea. Issues with use of CAMs- dosage and conflicting advice\u003c/p\u003e\n\u003cp\u003eAcross all four groups, women who tried cranberry juice were unsure about dosage: reported using information obtained online, guesswork, from previous work experience in hospices and nursing homes or through word of mouth. Dosage varied widely - drinking as much as possible, a small portion regularly with or without dilution and some believing that this varied between individuals. The majority expected better information about dosage of CAMs to be available.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSome women in the first 3 groups and most in SM mentioned receiving conflicting information about dosages of CAMs, researching this and drawing their own conclusions. Conflicting advice about MH from specialists in UTIs was reported. Some specialists recommended it, some stated it might not work, that it could cause kidney damage. Some women stated that it was unusual for it to be prescribed, that their GP would not prescribe it, and that it was for older women only. Women reported worrying about reasons why it was not usually prescribed, what side effects they had and their severity, especially with life-long use. There was also a concern that it would only work if the UTI was caused by specific bacteria such as Escherichia coli. Some also stated hearing that MH greatly helped other women - which reassured them and that when they tried it, it had worked well, increasing their confidence in its use.\u003c/p\u003e\n\u003cp\u003eb. Perceived Adverse Effects\u003c/p\u003e\n\u003cp\u003eSome women in all groups expressed concern about D-Mannose or cranberry juice increasing the level of sugar in their body, especially with concurrent medical conditions like diabetes mellitus, Polycystic Ovarian Syndrome (PCOS), being on anticoagulants like warfarin and being overweight. Most in the first three groups reported no or few concerns taking CAMs, some taking them routinely and enjoying the taste. However, some women did not like the taste of cranberry juice or bicarbonate of soda, finding cranberry juice nauseating and causing a struggle with symptoms of bladder overactivity. While most preferred to drink a lot of water, some women also reported finding this challenging.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe SM women reported a number of perceived adverse effects of CAMs including: constipation from Kefir yogurt, digestive issues from bicarbonate of soda or other alkalinizing agents, cranberry juice causing a sensitive stomach and worsening of haematuria as well as reluctance to try MH due to formaldehyde \u0026ldquo;burning their bladder\u0026rdquo;. There were concerns about inability to continue longer courses of natural antimicrobial agents due to potential side effects, even though it worked for them and about taking too many chemicals when trialling different types and combinations of CAMs, with or without antibiotics. There were worries about using CAMs based on information from non-medical people with UTIs, forums and bloggers online, concerns about using CAMs without long-term knowledge about the impact on their body, that they might stop working for them over time, that they might work differently for different people and their impact on future fertility. Some women stated no other choice but to turn to alternative medications despite these perceived adverse effects because traditional medications had failed them. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4. \u0026nbsp; Expectations for\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003efuture UTI management\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ea. Better testing\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWomen in SM were upset about the lack of information about and testing for embedded UTIs being freely available in the UK. They stated that reliable testing for UTIs overall needed a major overhaul, as unreliable urine dipsticks were still routinely used. Women were concerned that they were not being tested to check for urinary retention, even by specialists, and were worried about further investigations like cystoscopies for UTIs because of further risks of UTIs and/or pyelonephritis.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eb. HCPs being Educated\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSome women in all groups felt doctors did not discuss all options available for managing UTIs apart from antibiotics as their knowledge was inadequate.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWomen in SM believed that doctors should help when requested about CAMs, felt that they were not listened to, did not get answers despite asking, were not pointed in the direction of a specialist in UTIs and were inadequately counselled on prevention techniques following investigations like a cystoscopy. Women were also angry that despite investigations, antibiotics were always prescribed, and some CAMs were never mentioned, meaning that they had to seek information and support from alternative sources.\u003c/p\u003e\n\u003cp\u003eWomen expressed their frustration with HCPs when they had negative urine tests despite being symptomatic, sometimes being accused of having mental health problems. They expressed anger at not being told about the role of vaginal atrophy on UTI occurrence; when their ovaries were removed surgically, not being offered an alternative when one type of vaginal oestrogen did not work; or being expected to accept being in pain and needing to be stubborn to find a solution.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ec. Further Research\u003c/p\u003e\n\u003cp\u003eWomen in SM were concerned about the lack of adequate funding for research into UTIs, expressing a keenness to help due to their experiences, and gratitude for ongoing research. They were also concerned about lack of information about natural remedies, stating that if there was more knowledge about them, people would make better-informed decisions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ed. Testing for embedded UTIs\u003c/p\u003e\n\u003cp\u003eWomen in SM spoke about testing for embedded UTIs using broth tests and MicroGenDX tests which they described as being popular in the US. They believed that these helped to identify the bacteria causing their UTI, meaning they could be prescribed specific antibiotics and choose probiotics that suited them, reporting success in other women in their support groups.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ee. Bring phage therapy to the UK\u003c/p\u003e\n\u003cp\u003eWomen in SM spoke about targeted phage therapy being used in Europe against specific bacteria with no side effects and that antibiotics were adopted only for cost effectiveness and quick action. Naming a clinic in Russia which provided this, one woman mentioned that she would been there if it hadn\u0026rsquo;t been for the COVID pandemic, was trying to get this shipped with concerns about practicality of learning to instil it into her bladder. Women seemed motivated by other success stories with ongoing research in other countries stating that the UK \u0026ldquo;needed phage therapy\u0026rdquo; and more research in this, an uncertainty about efficacy, variance of effectiveness of oral phages, the need for custom made phages, their potential short-term nature of relief as well as prohibitive costs.\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe purpose of this study was to explore women\u0026rsquo;s thoughts and experiences regarding CAMs for prevention and self-management of UTIs. The use of a large range of CAMs were reported with cranberry-based oral products being the most used in keeping with literature [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Women were open to trying CAMs first, especially if this had perceived therapeutic potential [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] and not everyone was inclined to tell their doctor what strategies they had used to self-manage UTIs [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] which was similar in the first three groups in our study. However, women in SM, who seemed to be most troubled with UTIs, not only spoke to their GPs about them, but were dissatisfied with this in keeping with literature where women experienced negative clinician interactions, perceived inadequate care, lack of knowledge and awareness surrounding UTIs [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], choosing to seek specialist care or consulting with CAM practitioners [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. A general aversion towards antibiotics and resentment of the medical profession for using this [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] was noted in this study. Additionally, women valued being involved in their treatment [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], with a need for HCPs to address specific worries [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], modify management strategies to address concerns and empower patients [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] being identified in literature. The need for advice incorporating self-care, tailored shared decision making with HCPs and safety netting when trialling CAMs [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] as seen in this study.\u003c/p\u003e\u003cp\u003eWorries from participants regarding the cause for their UTIs [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] with a relative openness to alternative methods of managing UTIs [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], fears over frequent antibiotic use [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] and especially in women with recurrent UTIs was also reflected in literature. Women in SM also spoke of concerns regarding research gaps in UTI diagnostics and treatment which was reflected in other literature [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] as well as a need to devote more research efforts to improving non-antibiotic options [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], more and appropriate information provision [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], effectiveness and safety, better regulation of herbal practitioners, and assurance about herbal quality control and potential herb\u0026ndash;drug interactions[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Literature also demonstrated the value of the existing close-knit global community on social media with extensive knowledge about risk factors, ongoing research and noting a potential influence on trends in CAM use [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. However, as at least 29% of UTI prevention strategies using CAMs recommended here were demonstrated to have little to no evidence and the need for further education and research due to a clearly high demand and use of these approaches [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] was identified.\u003c/p\u003e\u003cp\u003eThe similarity of results with previous literature makes this study credible with transparency regarding methods and results ensuring reliability, validity and authenticity. However, as an initial exploratory and descriptive study, this was not designed to be explanatory or completely interpretive. This is also not completely representative of women\u0026rsquo;s experiences as UTIs were self-reported with unknown clinical histories and biases based on past experiences and recruitment groups. Findings from the SM group were likely a reflection of the severe end of the spectrum and warrants cautious interpretation of results with transcripts not returned for comments and no feedback obtained on findings. Additionally, financial impact may play a role on women\u0026rsquo;s perspectives in England, where prescription charges are applicable and in the US with limited access to public health funds.\u003c/p\u003e\u003cp\u003eIt may be postulated that the initial experiences of women in SM may have been similar to the other 3 groups, but traditional treatments may have been ineffective, that they were more severely impacted by their UTIs or that this maybe a chronic condition. Additionally, women in SM trialled a combination of CAMs with antibiotics, tapering and then stopping antibiotics altogether which may be a potential management tool for recurrent UTIs. These women seemed to have extensive knowledge and experience with CAM use, stating inadequate information and input from traditional medical sources which also suggests the need for ongoing support, currently not available from formal medical services. Further information about experiences and concerns from HCPs and CAM users and safety information regarding CAMs is a research need that was identified during this study.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study provides a unique insight into women\u0026rsquo;s perceptions of and experiences with CAMs and provides justification for further research into the role of CAMs in UTI management and the use of CAMs by women.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCAMs\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eComplementary and Alternative medicines\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eUTIs\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eUrinary Tract Infections\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHCPs\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHealth Care Professionals\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eGP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eGeneral Practice\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eUK\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eUnited Kingdom\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eUS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eUnited States\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCHM\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eChinese Herbal Medicine\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eMH\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMethenamine Hippurate\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePCOS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePolycystic Ovarian Syndrome\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo acknowledgments to note\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no relevant conflicts of interest, financial or non-financial, to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten Informed consent was obtained from all individual participants included in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFull Ethics Statement:\u003c/strong\u003e The study protocol and paperwork were reviewed and approved by the regional Research Ethics Committee [Integrated Research Application System Research ID 283407]. All study procedures were conducted in accordance with the Declaration of Helsinki and Good Clinical Practice guidelines.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Participate:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from all participants prior to their inclusion in the study. All participants were provided with detailed information about the study objectives, procedures, and their right to withdraw at any time. Participants explicitly consented to audio recording of interviews and use of anonymized quotes in publications.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of interest:\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors have no relevant conflicts of interest, financial or non-financial, to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSources of funding:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization Geneva. 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Am J Public Health. 2006;96:1236\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eScott V, Thum L, Sadun T, Markowitz M, Maliski S, Ackerman A, et al. Fear and Frustration among Women with Recurrent Urinary Tract Infections: Findings from Patient Focus Groups. J Urol. 2021;206:688\u0026ndash;95. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/JU.0000000000001843\u003c/span\u003e\u003cspan address=\"10.1097/JU.0000000000001843\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLecky D, Howdle J, Butler C, McNulty C. Optimising management of UTIs in primary care: a qualitative study of patient and GP perspectives to inform the development of an evidence-based, shared decision-making resource. 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BMC Urol. 2020;20:190. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12894-020-00764-6\u003c/span\u003e\u003cspan address=\"10.1186/s12894-020-00764-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCutajar E, Currie K, Flowers P, Dickson A, on behalf of SHIP research Group - Safeguarding Health through Infection Prevention. Exploring Maltese Women\u0026rsquo;s Experiences Of Urinary Tract Infection: A Qualitative Study. In Abstracts from the 5th International Conference on Prevention \u0026amp; Infection Control (ICPIC 2019). 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The challenges of treating women with recurrent urinary tract infections in primary care: A qualitative study of GPs\u0026rsquo; experiences of conventional management and their attitudes towards possible herbal options. Prim Health Care Res Dev. 2015;16:597\u0026ndash;606. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1017/S1463423615000201\u003c/span\u003e\u003cspan address=\"10.1017/S1463423615000201\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBurton C, Gonzalez G, Almario C, Arnold C, Spiegel B, Anger J. Lower urinary tract disease prevention strategies recommended onsocial media platforms: mixed correlation with evidence. Abstracts Neurourol Urodynamics. 2020;39:6\u0026ndash;281. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/nau.24307\u003c/span\u003e\u003cspan address=\"10.1002/nau.24307\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 and 2 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-complementary-medicine-and-therapies","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcam","sideBox":"Learn more about [BMC Complementary Medicine and Therapies](https://bmccomplementmedtherapies.biomedcentral.com/)","snPcode":"","submissionUrl":"","title":"BMC Complementary Medicine and Therapies","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Urinary Tract Infections, Complementary Therapies, Self-Management, Anti-Bacterial Agents, Anti-Infective Agents, Urinary, Social Media","lastPublishedDoi":"10.21203/rs.3.rs-7573474/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7573474/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eComplementary and Alternative medicines (CAMs) are used by women to self-manage and prevent symptoms of Urinary Tract Infections (UTIs). However, health care professionals lack awareness of the extent and nature of CAM usage, or potential effects and interactions with mainstream treatments such as antibiotics.\u003c/p\u003e\n\u003cp\u003eThe aim of this study was to explore women’s knowledge of CAMs to prevent and self-manage UTIs, their experiences using them, their attitudes to these products and expectations for the future.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA qualitative cross-sectional study was undertaken to explore women’s experiences of using CAMs. Women were recruited from four different settings: General Practitioner Clinics; general Gynaecology clinics; Urogynaecology clinics and social media. Reflexive thematic analysis was completed using Braun and Clarke’s five stage approach.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThemes around participants knowledge of CAMs and the nature of self-managing UTI were identified, together with justifications for and challenges associated with CAM usage and expectations for UTI management in the future.\u003c/p\u003e\n\u003cp\u003eAll participants had tried a range of CAM therapies and/or changed behaviour to self-manage UTIs, with the purpose of avoiding or reducing antibiotic use cited as the main reason for this. Women from the Social Media group had extensive experience of using CAMs, reporting inadequate information from traditional sources and frustration with HCPs about lack of knowledge of CAMs and supposed overuse of antibiotics.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study provides a unique insight into women’s perceptions of and experiences using a range of CAMs and provides further justification for research into their role in UTI management.\u003c/p\u003e","manuscriptTitle":"Women’s Experiences of Management of Urinary Tract Infections using Complementary and Alternative Medications and Expectations for the Future: A Qualitative Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-28 07:06:58","doi":"10.21203/rs.3.rs-7573474/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-06T17:49:14+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-22T08:35:27+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-17T00:52:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"230601918579624101698714309461902796246","date":"2025-12-03T04:28:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"275679680297648915047493656604857376707","date":"2025-12-02T08:16:17+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-25T21:47:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"266745785476513892107179559596552886691","date":"2025-11-19T13:21:43+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-18T10:46:56+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-10-15T09:33:20+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-06T07:54:37+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-06T07:53:50+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Complementary Medicine and Therapies","date":"2025-09-09T11:42:04+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-complementary-medicine-and-therapies","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcam","sideBox":"Learn more about [BMC Complementary Medicine and Therapies](https://bmccomplementmedtherapies.biomedcentral.com/)","snPcode":"","submissionUrl":"","title":"BMC Complementary Medicine and Therapies","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"53b6d458-81f0-4206-bfec-6604df83ddd2","owner":[],"postedDate":"November 28th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-10T10:23:15+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-28 07:06:58","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7573474","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7573474","identity":"rs-7573474","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}