how close are we to a vaccine for recurrent UTIs?

Agony awaited Carolina the first time she had sex. She was 16 years old and it wasn't the sex that hurt, more the agonising shooting pains that followed. For the best part of the next decade, she would get up to six urinary tract infections - or UTIs - a year. Each infection was treated with a course of antibiotics, but nothing seemed to prevent it from returning a few weeks later.

Carolina is one of the roughly 1.6 million women in the UK who suffer from recurrent UTIs. Defined as two or more infections within six months or three or more infections in a year, chronic UTIs can become a frequent source of physical pain and anxiety. While anyone can get a UTI, people with vaginas are more susceptible because their urethras are shorter, which makes it easier for bacteria to travel from the outside of the body into the bladder. For some, the first infection occurs in childhood, but for most, it begins after becoming sexually active. Up to 50% of cis women will get a UTI at least once in their lives, and one in five will experience recurrent infections. This makes UTIs one of the most common infections that doctors have to treat.

Yet UTIs are often dismissed as just part of being a woman, another inconvenient discomfort to learn to put up with, like periods or thrush. But the truth is different - we’ve all either had a UTI or know someone who has. Getting a UTI once is painful and annoying. Getting them three or more times a year can become overwhelming, having a knock-on effect on relationships, work and mental health. That’s not to mention how agonising they can be.

Most people with vaginas are familiar with that burning sensation. It’s sometimes described as ‘pissing needles’ because that’s what it feels like. Left untreated, UTIs can spread to the kidneys where they cause a more serious infection. And multiple concurrent urinary tract infections lead to inflammation of the bladder. This is what means each infection can feel like the inside of your bladder is covered in tiny cuts being soaked in lemon juice. Symptoms can be life-limiting, leaving you curled up in pain, unable to walk far, get to sleep or go to work.

On the plus side, antibiotics can clear up most UTIs within a week. The main course of treatment for recurrent infections is a low dose of daily antibiotics or postcoital antibiotics to be taken after sex. Some doctors are hesitant to prescribe daily antibiotics because long term antibiotic use comes with its own issues — gut problems, yeast infections and the risk of bacteria becoming antibiotic-resistant. The European Association of Urology has described the present state of resistance development due to repeated courses of antibiotics as “alarming.”

But there is a glimmer of hope on the horizon. For years, new studies have been carried out to develop potential vaccines for recurrent UTIs. These would be a game changer for chronic UTI treatment and reduce the need for lots of antibiotics. Some sources suggest that a UTI vaccine is already available in the UK, but no vaccines have been licensed for widespread use, so they’re only used in a few private clinics on a very small, named patient basis. So, what actually is the vaccine and how long will it be before it’s available on the NHS?

In the 2000s, a Spanish medical company called Immunotek set about developing a targeted immune-boosting vaccine to prevent recurrent infections, be they chest infections, fungal infections or urinary tract infections. The science behind this won the Nobel Prize for medicine in 2010. This UTI vaccine is called Uromune, or MV140.

When a team of urologists in the UK, led by Steve Foley, heard about Uromune, they reached out to the company about doing further trials. The first round of trials in the UK were promising. Of the 75 women who completed the three month-long treatment, 78% had no subsequent UTIs in the following 12 months and there were minimal side effects.

The team were meant to roll straight into the second and third trial to get the vaccine approved for public use (by a body called the National Institute for Clinical Excellence or NICE), but then the pandemic happened, shutting down all other trials. Since then, Foley says, they’ve struggled to get funding, but a 2022 clinical trial also showed promise. Out of the 240 women with recurrent UTIs, nearly 60% of those who received the vaccine had no UTI episodes in the nine-month follow-up period, compared to 25% of those who received a placebo.

Calling Uromune a vaccine is somewhat misleading. There are no needles involved. Instead, it’s administered using a pineapple flavoured spray that stimulates the immune system. “It’s just a spray you put under your tongue everyday for two months,” says urologist Steve Foley who is leading the team trialling Uromune in the UK. “It does two things. It increases your natural ability to fight all bacteria when they’re in the wrong place and it also seems to reduce the inflammation in the bladder.” In essence, it’s a super targeted immune booster that can help those susceptible to UTIs fight off the infection naturally at the start rather than having to take antibiotics.

This sounds promising, but Foley estimates that we’re still at least two years away from the UTI vaccine being approved in the UK. The main barrier is funding. The vaccine isn’t owned by a big pharma company who would have the drive and resources to push it through sooner and there are no government targets for this kind of treatment.

“Although urinary tract infections are very common, for most people, they’re fairly mild and therefore it’s not a priority,” says Foley. “NHS hospitals are too swamped, so if you’ve got chronic infections, but everything looks structurally fine, they say, take some antibiotics and go away. We’re too busy. There’s no ability, no space left in the system to look after the massive number of patients who are really struggling.”

Funding for UTI research has always been limited, which is why there is so much conflicting information about how to treat and prevent infections. The golden rule of peeing after sex (to help flush out any rogue bacteria that's made its way up the urethra) is generally the best course of action, but isn’t a surefire way to prevent a UTI. “What we’re learning is that all women have some bugs in their bladder most of the time,” says Foley. “When you have sex, bugs will be pushed in the bladder. You can’t do anything to stop that. For 80% of women, it’s not a problem and you just wee it out. The other 20% aren’t coping with that small number of bugs that actually shouldn’t cause a problem. That's why our push is fundamentally to change the immune system and make the bladder stronger rather than just keeping them on antibiotics.”

As for chugging loads of cranberry juice a ‘cure’ that many people swear by, it won’t get rid of a UTI once it’s already developed. Cranberries contain a substance that can prevent bacteria from sticking on the walls of the bladder and have moderate antibacterial effects. While there is some evidence that they might help prevent UTIs, they can’t cure them. You’re better off hydrating with just water to try and flush out the infection, but you’ll probably still need to go to the doctors for antibiotics. Supplements like probiotics, D-mannose and cranberry supplements are also recommended for prevention, but they don't work for everyone.

Without an easily accessible vaccine, people who get recurrent UTIs are often left trying various different treatments through trial and error. Cranberry supplements have helped Carolina manage her UTIs, but it took her more than a decade to find something that worked. “Since I’ve been taking daily cranberry supplements, my UTIs have massively subsided,” she says. “If I start feeling some mild discomfort, I will go at the cranberry sachets. If things become really bad, I then ask for an antibiotic.”

Like many recurrent UTI sufferers, Carolina is anxious about the long term effects of taking so many antibiotics, which is why they’re her last resort. If a vaccine was made available, she would jump at the chance to try it. “That would be the dream if it could finally solve my issues,” she says. “If it had been available to me first thing, it would have spared me a lot of pain. Living in fear is the worst part. It would be nice not to have to live in fear of sex. I have to constantly think about it. I’m always thinking I should be doing this or I shouldn’t be doing that. If I’m going on holiday, I need to bring so many possible things with me because I might have a UTI.”

Even if the Uromune vaccine that Foley and his team are trialling doesn’t end up getting licensed, there are several other UTI vaccines at various stages of development. Foley worked briefly on Uro-vaxom, a UTI vaccine administered in tablet form. Patients take an oral tablet with 18 heat killed strains of E coli bacteria, the same bacteria that causes most UTIs. This stimulates white blood cells and promotes the production of antibodies to prevent infections. Clinical studies on this vaccine date back to the 1980s. A 2020 trial found that there was a significant decrease in the number of UTIs in the year following the initiation of Uro-Vaxom and the treatment was safe and effective. It’s recommended by the European Association of Urology, but it’s currently unlicensed in the UK.

Another option is Solco Urovak. It works as a vaginal suppository containing 10 uropathogenic bacterial strains. A 2014 trial in Georgia found a 92% rate of improvement of symptoms among participants who took it. The results allowed it to be recommended within reference of the Georgian National Guideline of Urologic Infections. Last year, scientists at Duke University in North Carolina tested another vaccine that showed promising results in mice and rats. It dissolves under the tongue and proved as effective as high dose antibiotics for preventing UTIs. The team hopes the results can lead to human clinical trials.

So, the future of UTI treatment could look very different from how it has in the past and how it does right now. Rather than spending decades cycling through painful infections, antibiotics and dismissive doctors' appointments, people living with recurrent UTIs could get effective treatment at the very start. “Most of the women who come to see me have had this since they were 16 years old,” says Foley. “I think there are a lot of very long suffering people out there. If this vaccine carries on and is as good as it looks, there’s no reason why women should have more than two courses of antibiotics a year, but we’re still a long way off.”

Even if a vaccine for UTIs is eventually approved and made available under the NHS, getting doctors to take UTI pain seriously is a whole other battle. According to a 2022 report by Garmin, 40% of young women with recurrent UTIs say they have been accused of over-exaggerating symptoms or being “overdramatic” while 45% say they’ve had their symptoms written off as “part of being a woman.” If female pain is not taken seriously, it makes it harder for patients to advocate for themselves and get the right treatment. Hopefully, a vaccine will become available, but unless medical professionals listen to patients with chronic UTIs, it might remain difficult to access.

It was only in February this year that the NICE guidelines were updated so that anyone with two or more symptoms of a UTI can get treatment without doing a dipstick test. The standard tests for UTIs use urine samples and the parameters of what a UTI actually is are based on a small study of 88 pregnant women with acute kidney infections. This test was also conducted in 1957. This means the test doesn't always accurately diagnose a UTI. The reform to the rules on what and what isn't classed as a UTI has been a long time coming, but it suggests that healthcare bodies are starting to take UTI diagnosis and treatment more seriously than they have done in the past.

We’re not there yet, but we’re moving in the right direction. Each new trial gets these vaccines closer to being approved. Hopefully, one day soon, people who get recurrent UTIs won’t have to go 10 years before finding a way to manage their symptoms. They can access a vaccine to prevent them early on. For women like Carolina, this would be life changing. It could mean living free from the constant worry of getting an infection, free from the fear of being in pain after every time she has sex.

“It might not be this vaccine,” Foley concludes. “It might be another variety of it or another route of administration, but I think vaccines and stimulating the immune system are definitely the way forward. I think the future looks a lot better for women in the next 10 years than it has in the last 10 years.”