Whether it’s “honeymoon cystitis” or recurrent bladder infections, any type of urinary tract infection is something we’d all love to avoid. Women of every age come to see me for help with urinary tract infections (UTIs) — some have minor problems, some more severe. Some women suffer only on rare occasions, while others have UTIs multiple times a year. Many don’t know that menopausal women suffer in unique ways from urinary tract infections due to hormonal changes.

In my experience, the best “cure” for UTIs — regardless of a woman’s age — comes from prevention. Unfortunately, the conventional medical approach to UTIs generally treats the infection once it has already developed. Doctors rarely spend much time discussing possible causes and methods to consider for avoiding reoccurrence. They simply hand out a prescription antibiotic and hope it works.

Antibiotics are certainly needed to cure urinary tract infections, but when women come to rely on repeat courses of antibiotics with recurrent infections, they increase their odds of additional infections, antibiotic resistance, and yeast infections, all of which erode the immune system.

The bottom line is, you don’t have to suffer or remain on endless doses of antibiotics! There are numerous physical and emotional factors that play a role in frequent urinary tract infections, and many natural ways to prevent them. Let’s learn more about UTIs and how to take better care of ourselves to avoid this painful experience.

What is the difference between bladder and kidney infections?

Your urinary tract is made up of an upper and lower section. Basically, the upper urinary tract includes your kidneys and the tubes that deliver urine from there to the bladder, the ureters; while the lower urinary tract includes your bladder and the urethra, the opening where urine is released from the body.

Urinary tract infections typically occur when bacteria invade the lower urinary tract at the urethra and travel up into the bladder, causing cystitis (the medical term for bladder infection). For the most part, these bacterial organisms (frequently E. coli, staph, Klebsiella, Enterobacter, Enterococcus, or Pseudomonas) are normal inhabitants in the GI system, rectum, colon or exterior of the body, but not normal inside the more delicate urinary tract.

Chlamydia, which is a bacterium transmitted through sex, can be an unsuspected culprit for UTIs. As a sexually transmitted disease (STD), it is frequently “silent” — ing the majority of women who have it experience no symptoms, though some do experience a burning sensation when urinating. Since the standard urine culture cannot detect it, your healthcare provider must make a special request to check for Chlamydia DNA in the urine sample.

Any of the above bacteria can cause irritation and infection to the tissue lining the urinary tract and bladder. The more serious the bacterial infection, the deeper the invasion into the tissue and the more advanced it may become, ultimately requiring more potent antibiotics. If your system cannot rally its defenses and flush the organism out, or if the infection is left untreated, the bacteria can eventually travel into the upper urinary tract, causing a kidney infection (pyelonephritis). This becomes a much more serious situation because it can lead to scarring and septicemia, a full-body struggle and poisoning from infection.

So how do you know you have a UTI?

Symptoms of a urinary tract infection

The exact symptoms you experience from a UTI will most likely be somewhat different from what other women experience. However, there are a few common symptoms. Here are some to watch for:

  • frequent urination
  • urgency
  • pain or burning with urination
  • fever
  • lower back pain
  • tenderness above the pubic bone
  • malodorous urine
  • blood in the urine

Some women don’t feel any of the usual symptoms of a bladder infection, which can allow it to become severe before identified. Even severe cases can sometimes fail to have a fever as an indicator. This is especially common in women as they get older, but I’ve had several patients, old and young, who had no idea they had a urinary tract infection until it became advanced. While it’s entirely possible to have a “silent” infection, when you pay attention, you’ll find your body will typically provide some signals that it is fighting infection. So if you feel a fever, chills, unusual fatigue or backache — or any of the more common symptoms of UTIs listed above — make sure you see your healthcare practitioner to investigate.

Physical causes of UTIs

Many women don’t realize the multiple ways bacteria can enter the urinary tract. Though not all of the following can be avoided, it helps to understand more about the specific situations that can make us more prone to bacterial infection in the urinary tract.

Improper wiping after a bowel movement is one common way bacteria can enter the urinary tract, which is why girls are always taught to “wipe front to back.”

Having a urinary catheter inserted during a hospital stay or while having a procedure can also provide a portal of entry for bacteria.

Friction to the area can push bacteria up into the urethra, including frequent cycling or spinning classes. Think of the ever-popular thong underwear, rubbing bacteria from back to front all day long! Then there’s the well known problem of UTIs brought on by the friction of sex. The classic “honeymoon cystitis” refers to a newlywed women having a lot of sex on her honeymoon and developing an infection. But this can occur in any woman with an active sex life. I’ve met some women who have this experience and decide to avoid sex instead of seeking help in preventing urinary tract infections.

One of my favorite 80-year-old patients had been widowed for over 20 years, then began having a passionate affair that resulted in several bladder infections within just a few months. She laughed when I told her it was caused by a combination of low estrogen to the urethra and honeymoon cystitis. She recalled that her first real honeymoon resulted in the same thing 60 years prior!

Difficulty fully emptying the bladder is another physical cause of UTIs. The bladder requires coordination of the muscles in the upper and lower parts of the urinary tract. The lower half has to relax while the upper half contracts in order to empty. Structural issues from loss of muscle tone in the pelvic floor or vaginal walls from childbirth, trauma or obesity can greatly impact the positioning of the bladder and its ability to empty fully on demand. The diagnostic term for this is urinary retention, and it can be described like overflow from a full cup — the bladder remains full despite some urine trickling out. What stays in the bladder, known as post-void residual urine, can cause discomfort and/or increased frequency to pass the overflow. When the bladder isn’t fully emptying, the small amount of bacteria that can make its way into the bladder accumulates over time and leads to infection instead of being flushed out. This problem often comes without warning symptoms and can be missed as a contributing factor in recurrent urinary tract infections.

Holding your urine can allow bacteria to linger and accumulate rather than getting flushed out. The more we hold our bladders when they’re full, the less sensitive we become to the need to empty them.

UTIs and holding it — why do we do this to ourselves?

As women, we have a tendency to put others’ needs before our own. Many of us hold our bladders far too long because we’re simply too busy — either with a large troop of kids or in a high-paced work environment. Classic UTI patients, for example, include hospital nurses and school teachers. I’ve heard stories about a surge of school teachers calling in with urinary tract infections after returning to the classroom following summer break!

I remember when I worked in a hospital on a hectic unit — I would sometimes end a 12-hour shift and realize I hadn’t gone to the bathroom all day! Little time for proper nutrition or hydration in that frantic working environment also meant less urine production overall. Eventually, while orienting to a new position, having driven long distances to relocate with little sleep, too much coffee and not enough water, I was surprised to have my first urinary tract infection.

Often I found myself urgently running to bathroom far more frequently than normal. I looked in the toilet, found blood and thought to myself, it’s not time for my period. Then it hit me: I’m not feeling well, I’m having urinary frequency, tingling, and now blood not from the vagina — I have a bladder infection! Soon I was on appropriate antibiotics and learned my lesson. I’ve never had another UTI since.

Women need to take time for themselves — even for such basic needs as getting to the bathroom. No matter how busy our lives are, we can make the time to drink enough water and empty our bladders frequently through the day, and especially after sex! If you have structural or retention issues, don’t be afraid to ask for help from your gynecologist, or request a referral to a urogynecologist. You might also try pelvic physical therapy (PPT) or a bladder retraining program — depending on your circumstances, these options can be extremely successful if you do the work! If you’re having a baby later in life, the post partum Kegel exercises are especially important, as you can never get back the first few critical weeks after childbirth to impact the strength and flexibility of your pelvic floor muscles.

The emotional side of urinary tract infections

Taking more time for ourselves also means addressing our emotions. In mind-body medicine, one school of thought proposes that bladder pain and infection can represent the trapped expression of anger or frustration in one’s life. I shared this theory with one sweet-natured woman who suffered from recurrent UTIs, and her response was, “Oh, that is me to a T — no wonder!” Along with drinking lots of water and getting to the bathroom frequently, it certainly can’t hurt to work on a full range of emotional expression instead of bottling things up inside.

Some women may be frightened or embarrassed to discuss urinary tract infections with their doctors. As I mentioned earlier, women in perimenopause and menopause, as well as those who are breastfeeding, may have low estrogen levels, which can leave vaginal tissues vulnerable and more fragile. Yet many avoid asking for help due to fears about hormone replacement therapy (HRT) or surgery. Fortunately, there are several low-risk natural estrogen options that can be used locally to significantly lower the risk and complications of UTIs (as well as vaginal dryness).

Urinary dysfunction can also be an issue women hesitate to talk about with their doctors out of embarrassment, or because they think there are no real options to help. Instead, they drink less water to prevent “accidents” and wind up with urinary tract infections. For many women, hormonal imbalance, structural issues, and muscle control are playing a role. There are lots of options available to alleviate or correct these problems, but healing starts with valuing your needs, getting comfortable with your emotions, and mustering the courage to ask for help.

UTIs and a weakened immune system

Unfortunately, avoiding a urinary tract infection is not just about drinking more water or releasing your emotions. Having a run-down immune system can make us especially vulnerable to health problems of all types, including UTIs. In looking at the big picture, our immune systems’ ability to repel infection is impacted by many things, including how well we eat, sleep, digest foods, and manage stress from day to day. We can interpret a UTI as a wake-up call to start taking care of ourselves in more ways than just emptying the bladder regularly.

With a strong immune system, our bodies can establish an environment that discourages infectious organisms. I talked above of the broader physical causes of UTIs, but when we look more closely, we see that immunity really is how our bodies gain the advantage against disease — through factors like hormonal balance, pH, and beneficial flora in the gut and vagina. Immune strength also involves a ready supply of immune factors that counter any opposing pathogens’ invasive factors. When it comes to the urinary tract, here are a few examples of what a compromised immune system can mean.

One mechanism by which E. coli gains a “toehold” in your urinary tract literally involves appendages protruding from the surfaces of invading bacterial cells. Certain strains of bacteria appear to have more heavily branched, finger-like projections (fimbriae) than less virulent strains. These fibers have adhesive factors that readily attach to receptors in the cell walls lining your urinary tract, providing the “glue” necessary for the bacteria to adhere and establish a colony. (See below to learn about the immune-boosting compounds in cranberries that stop this from happening.)

When we have decreased estrogen, which is a plumping hormone, our genital tissues can become drier, thinner, and more flattened. As a result of this thinning, both the mucosal layer and the cells it is designed to protect become less resistant to bacterial invasion. In the story above of my elderly patient, I mentioned how low estrogen leaves the urethra more prone to bacterial infection (known as atrophic urethritis). This is one reason why UTIs can become a problem for women in menopause and perimenopause. But low estrogen sometimes occurs in breastfeeding women, as well, so this is another time in a woman’s life when taking extra care of herself will help her avoid a UTI.

Estrogen can also affect immune factors in the vagina. As estrogen declines, immune factors decline. This allows infectious bacteria to grow, which then can lead to a decrease in the protective bacteria (lactobacilli) and an increase in pH, all of which facilitates E. coli colonization and its consequent spread into the urinary tract.

It’s not just estrogen levels that change the immunity in our vaginas. Other factors that can cause decreased immunity include illness, antibiotic use, douching, too much sugar in the diet, insulin resistance, and yeast overgrowth, to name a few.

In addition, there’s a theory linking systemic yeast (Candida), in both the intestinal tract and the vagina, with UTIs. Yeast overgrowth is believed to derail the immune system and impact the bladder as well to facilitate recurrent urinary tract infections in some women. Some women may have yeast in the bladder, or even higher up in the urinary tract, termed urinary candidiasis. Although it is not often suspected, yeast can be readily cultured out with a clean-catch urine sample and thereby identified. Treatment with an antifungal drug is generally required. (To learn more, read our article about systemic yeast.)

It is also worth mentioning that rates of urinary tract infections — both symptomatic and asymptomatic, and including yeast — are high among women with diabetes. This is thought to involve high urine glucose content and insufficient immune factors, but we do not have a full understanding of the reasons why women with diabetes are more prone, nor surefire ways to manage the problem. Suffice it to say that if you have diabetes, particularly if you take insulin, implementing our recommendations for boosting your immune system can aid in protection from infection and the more serious complications of UTIs.

The best advice I can offer regarding urinary tract infections is to find ways to prevent them.

Natural prevention of UTIs

I know that each woman is different and that an approach to prevention has to be tailored to the individual. One of my 40-year-old patients had a bladder infection practically every other month for a while. We remedied the situation by getting her back into wearing normal bikini underwear instead of the thongs, spending a little less time in the hot tub with irritating chemicals, using cranberry and uva ursi (bearberry) herbal support daily and especially after sex, allowing herself to more fully express her needs, and setting limits at home with her family. She felt great after that!

We don’t all wear thongs, though, or have the opportunity to sit in hot tubs on a regular basis! Sometimes the best approach to preventing urinary tract infections requires us to pay a little more attention to our own lives, to look at personal habits and ways to make small changes. Contrary to common belief, you don’t have to suffer repeated UTIs or remain on antibiotics for months. I've had success with not only the gentle treatment of urinary tract infections, but also in preventing them. Here are some options you may want to consider for prevention.

  • Flushing it out. Many women will try to flush out their systems at the earliest signs of a UTI by drinking lots of water and emptying their bladders more frequently. Don’t hold it in! Emptying the bladder before and after sex or any type of increased friction to the area is imperative in prevention. Pushing fluids is also important for prevention, and for many it works great with early signs of infection. But be mindful of your body, as a dear friend of mine was insisting on trying this with some homeopathic support and it failed, leading to a severe kidney infection. So there’s a balancing act between utilizing a natural approach to prevent and sidestep an infection, while being honest and attentive to signs and seeking appropriate medical care when needed.
  • The cranberry method — myth or magic? Long ago I heard a professor dismissing the cranberry UTI prevention strategy. A study at that time had indicated that no matter how much cranberry juice you consumed, you could hardly impact the pH of the urine, concluding that cranberries could not help UTIs in any way. However, that study was evaluating the wrong mechanism; urine pH has little to do with how cranberries work to prevent infection.

Currently at Rutgers University there is an entire cooperative extension service dedicated to blueberry and cranberry research. Fruits in the blueberry family — including blueberries, cranberries, the circumpolar species known as bearberries (Arctostaphylos uva ursi), and the lingonberries so popular in Scandinavia — have long been recognized for their natural ability to prevent bacteria from growth and reproduction. Modern research is now isolating and precisely quantifying the medicinal effects of the phytochemicals in these berries.

For now, the research shows that compounds in cranberries known as oligomeric proanthocyanidins (OPC’s or PAC’s) appear to function as anti-adhesive agents, inhibiting the attachment of bacteria. Consumption of cranberries and other berries in this family promote enzymes in the urine that bind with bacteria and prevent them from adhering to the bladder and urinary tract lining — warding off or reducing mild infection quite effectively! Studies also show that any type of cranberry juice has the potential to help you sidestep an infection if initiated early enough. And for those prone to infection, cranberry prophylaxis can be an effective preventative measure when used daily or after sex.

We recommend using natural cranberry juice, without added sugar. It’s extremely tart, so some women prefer to dilute it with water or herbal tea. But when traveling, or if you can’t tolerate the taste, don’t hesitate to use a less pure form — sometimes you have to take what you can get! It appears that eight ounces, three times a day can be very helpful. I followed this schedule after having a catheter in and it worked well.

Cranberry extract pills are also available, but quality and formulations vary, so you may want to start with TheraCran, the patented formula tested at Rutgers and found to be effective.

  • Take vitamin C. Many of my patients have success in warding off urinary tract infections by taking fairly high doses of vitamin C (pure ascorbic acid). For example, initiate 1000 mg three times daily at the very first sign of infection. Ascorbic acid is a water-soluble vitamin, so it’s important to drink plenty of water along with it. This is a great fall-back option when you can’t get to the store to purchase cranberry juice or extract.
  • Ditch the sugar and reduce systemic yeast. If you suspect yeast is playing a role in your UTIs, then you may want to avoid or eliminate yeast-rich foods, sugars and foods that are aged or fermented, all of which encourage systemic Candida overgrowth. There are also other aggressive anti-yeast measures. To learn more about this, read our article on candidiasis.
  • Rejuvenate tissues with topical bioidentical estrogen if needed. Women in perimenopause and menopause might consider localized application of natural estrogens to plump up the vaginal, vulvar and urethral tissues. This can prevent or alleviate an atrophic urethra and the resulting weakened defense against bacteria.

Data from the Heart and Estrogen-Progestin Replacement Study (HERS) showed higher rates of UTIs among women taking conventional, oral HRT. But these were conjugated equine estrogens and medroxyprogesterone acetate, none of which represent bioidentical hormones. Though a causal relationship was not specifically identified by the authors, this form of nonbioidentical HRT clearly did not protect women from UTIs. On the other hand, I’ve seen in my clinical experience that localized bioidentical estrogen products help immensely with vaginal comfort and atrophic urethritis. If women are experiencing more UTIs on this, it is probably only because they are able to have more sex again!

  • Tap into the power of probiotics. Research supports that taking a well-balanced probiotic offers UTI-prone women two big health advantages: for starters, probiotics have a system-wide immune-boosting effect, which means your body stands better prepared to respond to any potential infection. Next, when you take an oral probiotic, the friendly organisms it contains make their away around the body, displacing pathogenic strains not just in the gut, but in the colon, vagina and urethra as well, forming both a physical and biochemical barrier against them.
In addition to looking at their system-wide benefits, researchers are carefully studying which specific probiotic organisms are most effective at protecting the health of the urogenital tract. Women prone to urinary candidiasis or vaginal candidiasis, for example, may benefit most from choosing one with a robust yeast component, like our Super Biotic. When looking for a probiotic to treat bacterial UTIs, some research has pinpointed Lactobacillus rhamnosus GR-1 and Lactobacillus fermentum RC as helpful, so you may want to try a product listing these strains on the label.

You may also want to consider jumpstarting healthy lactobacilli colonies in this region of your anatomy. Some studies indicate that inserting a probiotic gelcap containing lactobacilli directly into the vagina each night for a few nights in a row can help reestablish or maintain normal flora. Alternatively, some women insert a tampon dipped in fresh, plain live-culture yogurt into the vagina for an hour or so, twice daily for several days in a row. Consult with a qualified naturopath or functional medicine practitioner for more specifics.
  • Consider herbal support. Consult with an herbalist for options used in prevention and early intervention of UTIs. For example, the berry mentioned above commonly referred to as uva ursi (bearberry) was used prior to the invention of penicillin and other antibiotics and remains an option. Virographis is another proprietary product used to boost the body’s immune system; however, it’s only available through healthcare practitioners’ offices. Virographis contains extracts of the herbs Andrographis, licorice root, and Isatis tinctoria. Acupuncture and Traditional Chinese Medicine herbal formulations are also worth considering with the help of a certified practitioner.
  • Last but not least, ask for help if you have prolapse or incontinence issues. Don’t just cut back on fluids to address bladder dysfunction and difficulties with control of your urine. This can lead to infection. Ask around for a referral to the best urogynecologist in your area. An experienced urogynecologist can help identify the causes of your urinary symptoms, and will let you know if you are a candidate for bladder support repair (using a TVT, or transvaginal tape sling), pelvic physical therapy (PPT), or bladder retraining with biofeedback.

You don’t have to suffer with UTIs!

Urinary tract infections can severely impact our lives, and there is no reason for us to go on suffering. We at Women's Health Network feel that educating ourselves about our bodies and taking the steps to care for them physically and emotionally will always lead to greater health and happiness.

Take time to understand the causes of your urinary tract infections and ways to prevent them. Consider boosting your immune system’s defenses — this way you’re likely to experience greater immunity from infections of all kinds, not just UTIs. You will be surprised at the difference you can make!

References

1 Jhamb, M., et al. 2007. Urinary tract diseases and bladder cancer risk: A case-control study. Cancer Causes & Control [Epub ahead of print]. URL (abstract): http://www.springerlink.com/content/u37604140w7117n7/ (accessed 07.19.2007).

2 La Vecchia, C., et al. 1991. Genital and urinary tract diseases and bladder cancer. Cancer Res., 51 (2), 629–631.

3 Janković & Radosavljević. 2007. Risk factors for bladder cancer. Tumori, 93 (1), 4–12. URL (abstract): http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17455864 (accessed 07.19.2007).

4 Wikipedia.org. 2007. Urinary tract infection. URL: http://en.wikipedia.org/wiki/Urinary_tract_infection (accessed 08.06.2007).

5 Howell, A., et al. 1998. Inhibition of the adherence of P-fimbriated Escherichia coli to uroepithelial-cell surfaces by proanthocyanidin extracts from cranberries. Correspondence NEJM, 339 (19), 1085–1086. URL: http://content.nejm.org/cgi/content/full/339/15/1085 (accessed 08.06.2007).

6 University of Maryland Medical Center (UMMC). 2006. Urinary tract infection. URL: http://www.umm.edu/patiented/articles/what_risk_factors_urinary_tract_infections__000036_4.htm (accessed 08.06.2007).

7 Raz, R., & Stamm, W. 1993. A controlled trial of intravaginal estriol in postmenopausal women with recurrent urinary tract infections. NEJM, 329 (11), 753–756. URL: http://content.nejm.org/cgi/content/full/329/11/753?ijkey=46ce5700ccea13a4c3c0bf52a51de89c2b1ca597
http://content.nejm.org/cgi/content/full/329/11/753?ijkey=46ce5700ccea13a4c3c0bf52a51de89c2b1ca597 (accessed 08.06.2007).

8 Howes, D. e-Medicine — Urinary tract infection, female. URL: http://www.emedicine.com/emerg/topic626.htm (accessed 08.08.2007).

9 Nicolle, L. 2005. Urinary tract infection in diabetes. Curr. Opin. Infect. Dis., 18 (1), 49–53. URL (abstract): http://www.ncbi.nlm.nih.gov/sites/entrez?Db=PubMed&Cmd=ShowDetailView&TermToSearch=15647700
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=PubMed&Cmd=ShowDetailView&TermToSearch=15647700 (accessed 08.06.2007).

10 Karaunajeewa, H., et al. 2005. Asymptomatic bacteriuria as a predictor of subsequent hospitalisation with urinary tract infection in diabetic adults: The Fremantle Diabetes Study. Diabetologia, 48 (7), 1288–1291. URL (abstract): http://www.ncbi.nlm.nih.gov/sites/entrez?Db=PubMed&Cmd=ShowDetailView&TermToSearch=15918016
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=PubMed&Cmd=ShowDetailView&TermToSearch=15918016 (accessed 08.06.2007).

  Hoepelman, et al. 2003. Pathogenesis and management of bacterial urinary tract infections in adult patients with diabetes mellitus. Int. J. Antimicrob. Agents, 22 (Suppl. 2), 35–43. URL (abstract): http://www.ncbi.nlm.nih.gov/sites/entrez?Db=PubMed&Cmd=ShowDetailView&TermToSearch
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=PubMed&Cmd=ShowDetailView&TermToSearch=14527769 (accessed 08.06.2007).

11 Rutgers University. [No date listed.] Philip E. Marucci Center for Blueberry and Cranberry Research and Extension — Medicinal Research/Cranberries. URL: http://cook.rutgers.edu/~bluecran/medicinalresearchpage.htm (accessed 08.07.2007).

12 Wikipedia.org. 2007. Bearberry. URL: http://en.wikipedia.org/wiki/Bearberry (accessed 08.06.2007).

13 Foo, L., et al. 2000. A-type proanthocyanidin trimers from cranberry that inhibit adherence of uropathogenic P-fimbriated Escherichia coli. J. Nat. Prod., 63, 1225–1228. URL (abstract): http://pubs.acs.org/cgi-bin/abstract.cgi/jnprdf/2000/63/i09/abs/np000128u.html (accessed 06.20.2007).

14 Brown, J., et al. 2001. Urinary tract infections in postmenopausal women: Effect of hormone therapy and risk factors. Ob. Gyn., 98, 1045–1052. URL (full text): http://www.greenjournal.org/cgi/content/full/98/6/1045 (accessed 06.20.2007).

15 Falagas, M. et al. 2006. Probiotics for prevention of recurrent urinary tract infections in women: A review of the evidence from microbiological and clinical studies. Drugs, 66 (9), 1253–1261. URL (abstract): http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=16827601 (accessed 10.04.2007).

   Marelli, G., et al. 2004. Lactobacilli for prevention of urogenital infections: A review. Eur. Rev. Med. Pharmacol. Sci., 8 (2), 87–95. URL (abstract): http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch
"http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=15267122 (accessed 10.04.2007).

   Reid, G., et al. 2003. Oral use of Lactobacillus rhamnosus GR-1 and L. fermentum RC-14 significantly alters vaginal flora: Randomized, placebo-controlled trial. FEMS Immunol. Med. Microbiol., 25 (20), 131–134. http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=12628548 (accessed 10.04.2007).

16 Uehara, S., et al. 2006. A pilot study evaluating the safety and effectiveness of Lactobacillus vaginal suppositories in patients with recurrent urinary tract infection. Int. J. Antimicrob. Agents, 28, Suppl. 1, S30–S34. URL: http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=16859900 (accessed 10.04.2007)