If you keep developing urinary tract infections (UTIs), you are not alone. Around 25–30% of women experience another UTI within six months of their first infection, and many go on to develop repeated infections that interfere with work, sleep, relationships and overall quality of life. A recurrent urinary tract infection is defined as having two or more infections within six months, or three or more within one year. These infections are usually caused by bacteria entering the bladder, most commonly Escherichia coli (E. coli), although other bacteria can also be responsible. They can cause burning when passing urine, frequent trips to the toilet, urgency, lower abdominal discomfort and, occasionally, blood in the urine.
For many people, repeated courses of antibiotics become frustrating. While antibiotics remain essential for treating an active bacterial infection, they do not always prevent the next infection from occurring. Repeated antibiotic use may also contribute to antimicrobial resistance, where bacteria become less sensitive to commonly used antibiotics, making future infections more difficult to treat. This has prompted increasing interest in non-antibiotic strategies that aim to prevent infections rather than repeatedly treating them.
One such treatment is intravesical hyaluronic acid (HA). Intravesical simply means that the treatment is placed directly into the bladder through a fine catheter. Instead of killing bacteria, hyaluronic acid aims to repair the bladder's natural protective lining, making it more difficult for bacteria to attach to the bladder wall and trigger another infection.
Over the past two decades, several clinical studies, systematic reviews and European guidelines have suggested that hyaluronic acid, often combined with chondroitin sulphate, can reduce the frequency of recurrent UTIs in carefully selected patients. However, it is not suitable for everyone, it is not a replacement for antibiotics during an acute infection, and it currently occupies a specialist role within international treatment guidelines.
This article explains how hyaluronic acid works, who may benefit, what the evidence shows, how the treatment is given, its advantages and disadvantages, and where it fits within current UK and European recommendations.
What is a recurrent urinary tract infection?
A urinary tract infection (UTI) is an infection affecting part of the urinary system, including the bladder, urethra, kidneys or ureters. Most recurrent infections involve the bladder and are therefore referred to as recurrent bacterial cystitis, where bacteria repeatedly infect the bladder lining.
According to the European Association of Urology (EAU), recurrent cystitis is defined as:
- Two or more confirmed urinary tract infections within six months, or
- Three or more confirmed urinary tract infections within twelve months.
This definition is important because many people experience urinary symptoms that do not result from bacterial infection. Conditions such as overactive bladder, interstitial cystitis (bladder pain syndrome), kidney stones, vaginal atrophy after the menopause and chronic pelvic pain can all mimic a UTI. For this reason, recurrent urinary symptoms should not automatically be assumed to represent recurrent bacterial infection.
Whenever possible, recurrent infections should be confirmed using a urine culture, where a urine sample is sent to the laboratory to identify the exact bacteria causing the infection and determine which antibiotics are likely to be effective. This helps distinguish genuine recurrent bacterial infection from other conditions and guides the most appropriate treatment.
Why do some people keep getting urinary tract infections?
Most recurrent UTIs are not simply due to "bad luck." They usually develop because one or more underlying factors make it easier for bacteria to repeatedly enter or remain within the urinary tract.
Common risk factors include:
- Previous urinary tract infections.
- Sexual intercourse.
- Menopause and reduced oestrogen levels.
- Incomplete bladder emptying.
- An enlarged prostate in men.
- Urinary catheters.
- Kidney or bladder stones.
- Diabetes.
- Neurological conditions affecting bladder emptying.
- Previous pelvic surgery.
- Congenital abnormalities of the urinary tract.
- Increasing antibiotic resistance.
The most common bacterium responsible is Escherichia coli (E. coli), which normally lives harmlessly within the bowel. It can spread from the skin around the anus to the urethra, travel into the bladder and multiply. Although antibiotics usually eliminate the bacteria during an acute infection, they do not necessarily correct the underlying reason that bacteria keep returning.
This explains why some people experience a cycle of repeated infections despite receiving multiple antibiotic courses. Breaking that cycle often requires preventing bacteria from becoming established in the bladder again rather than repeatedly treating each infection after it develops.
What is the bladder's protective GAG layer?
The inside of the bladder is lined with specialised cells called the urothelium, which act as a waterproof barrier between urine and the deeper bladder tissues.
Covering these cells is a thin protective coating known as the glycosaminoglycan (GAG) layer. A glycosaminoglycan is a naturally occurring complex sugar molecule that forms part of the bladder's protective surface. Two important components of this layer are hyaluronic acid and chondroitin sulphate.
You can consider the GAG layer to be the bladder's protective waterproof coating. This barrier keeps bacteria, toxins, and other irritating substances in urine from sticking directly to the bladder wall when the bladder is healthy.
Repeated infections, inflammation, radiation treatment, bladder surgery, and some long-term bladder problems can damage this protective layer. When the barrier becomes disrupted, bacteria may find it easier to adhere to the bladder lining, while urine itself can irritate the underlying tissues, contributing to inflammation, urgency, pain and recurrent infection.
This theory forms the basis of GAG replacement therapy. Rather than targeting bacteria directly, treatment attempts to restore the bladder's natural protective barrier and reduce the opportunity for bacteria to attach to the bladder lining.
How does hyaluronic acid help prevent recurrent UTIs?
Unlike antibiotics, hyaluronic acid does not kill bacteria. Instead, it aims to restore one of the bladder's own natural defence mechanisms.
After being placed directly into the bladder, hyaluronic acid coats the bladder lining and contributes to rebuilding the damaged GAG layer. Chondroitin sulphate is frequently combined with hyaluronic acid because both substances are natural components of the bladder's protective surface and may have complementary effects.
Although the exact biological mechanisms continue to be studied, current evidence suggests that restoring this protective layer may:
- Reduce bacterial attachment to the bladder wall.
- Improve the integrity of the bladder lining.
- Reduce chronic inflammation.
- Decrease irritation caused by substances within urine.
- Lower the likelihood of recurrent bacterial infection.
Importantly, this treatment is designed to prevent future infections, not to treat an active UTI. Patients with symptoms of an acute bacterial infection may still require appropriate antibiotics based on urine culture results. Hyaluronic acid therefore complements, rather than replaces, conventional antibiotic treatment.
This different mechanism of action is one of its major attractions. By reducing the number of future infections, successful treatment may also reduce repeated antibiotic exposure and contribute to improved antibiotic stewardship—an increasingly important goal as antimicrobial resistance continues to rise worldwide.
Does hyaluronic acid bladder treatment actually work for recurrent UTIs?
This is probably the most important question patients ask, and the answer is encouraging but requires careful interpretation.
Several clinical studies have shown that intravesical hyaluronic acid (HA), either alone or combined with chondroitin sulphate (CS), can reduce the number of recurrent urinary tract infections (UTIs) and increase the time before another infection develops. However, the quality of the evidence varies between studies, and treatment should be viewed as a specialist option rather than a guaranteed solution.
Overall, the available evidence suggests that hyaluronic acid helps many carefully selected patients with recurrent UTIs, particularly those who continue to experience infections despite standard preventive measures.
What did the largest systematic review find?
The strongest evidence comes from a systematic review and meta-analysis published in 2018. A systematic review combines all available high-quality studies on a topic, while a meta-analysis statistically combines the results to provide a more reliable estimate of treatment effectiveness than any single study.
This review analysed eight clinical studies involving approximately 800 women with recurrent urinary tract infections.
Bladder instillations containing hyaluronic acid alone or combined with chondroitin sulphate were associated with:
- 2.56 fewer urinary tract infections per patient per year
- Around 130 additional days before another UTI occurred
- Improvements in several studies of urinary symptoms and quality of life
These findings suggest that restoring the bladder's protective lining can reduce the frequency of recurrent infections in appropriately selected patients.
How many fewer infections can patients expect?
One of the difficulties in answering this question is that not everyone starts with the same number of infections.
For example, someone experiencing three infections each year has less room for improvement than someone experiencing ten infections each year.
Across all the published studies, the average reduction was approximately 2–3 fewer infections each year. However, some individual studies reported even greater improvements.
One study found that the average number of infections fell from approximately:
- 4.1 infections per year before treatment
- to 0.4 infections per year after treatment
Another real-world study reported a reduction from approximately 10 infections each year to 2 infections each year
These results are impressive but should be interpreted cautiously. They come from relatively small observational studies and may not represent the outcome every patient will achieve in routine clinical practice.
The most reliable estimate remains the pooled result from the systematic review, which demonstrated an average reduction of 2.56 infections per year.
How much longer before another infection occurs?
Preventing infections is only one measure of success.
Another important question is how long patients remain free from infection after treatment.
The largest meta-analysis found that hyaluronic acid treatment delayed the next infection by approximately 130 days, equivalent to just over four months.
An earlier meta-analysis reported an even greater delay of approximately 187 days, or just over six months.
For many patients, increasing the infection-free period can make a substantial difference to quality of life by reducing repeated antibiotic courses, time away from work and disruption to everyday activities.
Does hyaluronic acid improve quality of life?
Yes, several studies have reported improvements beyond simply reducing infection numbers.
Patients commonly described:
- fewer episodes of bladder pain;
- reduced urinary urgency;
- less urinary frequency;
- fewer emergency medical appointments;
- reduced need for antibiotics; and
- improved overall quality of life.
However, these improvements were not measured consistently across every study, making it difficult to calculate an exact average benefit.
What are the limitations of the current evidence?
Although the published results are encouraging, it is important not to overstate the evidence.
Most studies involved relatively small numbers of patients, almost all participants were women, and different researchers used different treatment schedules, follow-up periods and combinations of hyaluronic acid with chondroitin sulphate. Such variability makes direct comparison between studies more difficult.
Some studies were randomised controlled trials, while others were observational studies, which are generally considered to provide lower-quality evidence because they are more susceptible to bias.
These limitations explain why the European Association of Urology (EAU) supports hyaluronic acid as a treatment option for selected patients but currently gives it a weak recommendation. A weak recommendation does not mean that the treatment is ineffective. Rather, it reflects that more large, well-designed randomised controlled trials are needed before stronger recommendations can be made.
For patients, the practical message is straightforward. The current evidence indicates that hyaluronic acid bladder instillations can reduce recurrent UTIs and prolong the time before another infection occurs, but the degree of benefit varies between individuals. It should therefore be viewed as an evidence-based option for carefully selected patients rather than a treatment that guarantees complete freedom from future infections.
What do the EAU and NICE guidelines recommend?
Clinical studies provide valuable evidence, but doctors also rely on national and international guidelines when deciding which treatments are appropriate. These guidelines carefully review all available research before making recommendations, taking into account not only how well a treatment works but also its safety, quality of evidence and practicality.
What does the European Association of Urology (EAU) recommend?
The European Association of Urology (EAU) includes intravesical hyaluronic acid (HA), either alone or combined with chondroitin sulphate (CS), as one of the treatment options for preventing recurrent bacterial cystitis.
However, the EAU does not recommend it as the first treatment for everyone with recurrent UTIs.
Instead, bladder instillations are generally considered after simpler, less invasive preventive measures have failed, particularly in patients who continue to experience repeated, culture-confirmed infections despite appropriate management.
The EAU based this recommendation on the available systematic reviews and meta-analyses, which indicated that HA treatment can:
- reduce the number of recurrent UTIs by approximately 2.6 infections per patient per year;
- increase the average time before another infection by around 130 days;
- improve bladder symptoms and quality of life in several studies; and
- have a favourable safety profile, with few serious treatment-related complications reported.
Despite these encouraging findings, the EAU classifies its recommendation as weak.
This does not mean the treatment is ineffective. A weak recommendation simply reflects that the available studies are relatively small, use different treatment protocols and include limited numbers of high-quality randomised controlled trials. Larger, well-designed studies are still needed before stronger recommendations can be made.
What does NICE recommend?
The National Institute for Health and Care Excellence (NICE) takes a slightly different approach.
At present, the NICE guideline on recurrent urinary tract infections does not specifically recommend intravesical hyaluronic acid as part of its routine treatment pathway.
Instead, NICE focuses on a stepwise approach that includes:
- lifestyle and behavioural measures;
- adequate hydration;
- identifying and managing underlying causes;
- vaginal oestrogen for postmenopausal women when appropriate;
- methenamine hippurate (Hiprex®) as an alternative to long-term antibiotics in selected patients;
- targeted antibiotic prophylaxis when other preventive measures have been unsuccessful.
This difference between the EAU and NICE does not mean that one organisation believes the treatment works while the other does not. Rather, they have interpreted the available evidence differently.
The EAU considers the current evidence sufficient to support HA bladder instillations as a specialist treatment option for selected patients, whereas NICE believes there is currently insufficient high-quality evidence to include it within routine UK guidance.
Why do guideline recommendations differ?
Patients are often surprised that respected medical organisations can make different recommendations despite reviewing many of the same studies.
This is because guideline panels assess more than whether a treatment appears to work. They also consider:
- the overall quality of the evidence;
- the size and design of the clinical studies;
- consistency of the published results;
- treatment costs;
- availability within healthcare systems;
- patient preferences; and
- whether the expected benefits clearly outweigh the disadvantages.
In the case of hyaluronic acid bladder instillations, both organisations acknowledge that the published studies are encouraging. The difference lies in the level of confidence they place in the available evidence.
For patients with recurrent UTIs who still have infections despite standard preventive measures, hyaluronic acid is an evidence-based option supported by European guidance, but it is not yet part of routine NICE recommendations.
Who is hyaluronic acid bladder treatment suitable for?
Hyaluronic acid bladder instillation is not the right treatment for everyone with urinary symptoms. It is a specialist preventive treatment designed for carefully selected patients who continue to experience recurrent, culture-confirmed urinary tract infections (UTIs) despite appropriate conservative measures.
The first step is always to establish whether the symptoms are genuinely caused by repeated bacterial infections. Many bladder conditions can mimic a UTI but require completely different treatment.
Who is most likely to benefit?
Current evidence suggests that hyaluronic acid bladder treatment may be most beneficial for people who:
- have two or more confirmed UTIs within six months, or three or more within one year;
- continue to develop infections despite lifestyle measures and standard preventive strategies;
- wish to reduce repeated antibiotic use;
- have bacteria that are becoming resistant to multiple antibiotics;
- cannot tolerate long-term antibiotic prophylaxis because of side effects;
- experience significant disruption to their daily life because of recurrent infections; or
- have recurrent bacterial cystitis where no surgically correctable cause has been identified.
The treatment appears to be particularly useful in women with recurrent bacterial cystitis, as this is the group in which most clinical studies have been performed.
Who may not be suitable?
Not everyone with urinary symptoms benefits from GAG replacement therapy.
Hyaluronic acid is unlikely to be effective if symptoms are caused by another underlying condition rather than recurrent bacterial infection.
Examples include:
- overactive bladder, where the bladder muscle contracts too frequently;
- bladder pain syndrome (interstitial cystitis), although different HA treatment protocols may sometimes be used in specialist centres;
- bladder stones;
- urinary tract cancers;
- untreated urinary obstruction;
- significant residual urine due to incomplete bladder emptying;
- poorly controlled diabetes contributing to recurrent infection; or
- persistent urinary symptoms without positive urine cultures.
In these situations, treating the underlying cause is usually more important than attempting to repair the bladder lining.
Does the treatment work equally well in men?
Most published studies have involved women, meaning the evidence in men is considerably more limited.
This distinction is important because recurrent UTIs in men are relatively uncommon and often indicate an underlying problem that requires investigation.
Possible causes include:
- an enlarged prostate causing incomplete bladder emptying;
- chronic bacterial prostatitis;
- urethral stricture disease;
- bladder stones;
- previous urinary tract surgery;
- neurological bladder disorders; or
- urinary tract abnormalities.
For this reason, recurrent UTIs in men should not simply be assumed to represent uncomplicated recurrent cystitis.
Identifying and treating the underlying cause often provides greater long-term benefit than preventive bladder instillations alone.
Should recurrent UTIs be investigated before considering hyaluronic acid?
Usually, yes—but the extent of investigation depends on the individual patient.
Not everyone with recurrent UTIs requires extensive testing. For example, the EAU advises that routine cystoscopy or imaging is generally unnecessary in otherwise healthy women with uncomplicated recurrent bacterial cystitis because the likelihood of finding a significant abnormality is low.
However, further investigation becomes more important when certain warning signs are present.
These include:
- visible blood in the urine (haematuria);
- recurrent kidney infections (pyelonephritis);
- recurrent UTIs in men;
- urinary retention or difficulty emptying the bladder;
- recurrent infections caused by unusual bacteria;
- suspected urinary stones;
- previous pelvic surgery;
- urinary tract abnormalities;
- neurological conditions affecting bladder function; or
- persistent urinary symptoms despite repeated negative urine cultures.
Investigations may include urine culture, bladder ultrasound, measurement of the amount of urine left in the bladder after passing urine (post-void residual), flexible cystoscopy or, in selected patients, CT imaging.
The purpose of these investigations is not simply to confirm that infections are occurring. Their role is to identify a treatable cause that may be responsible for the repeated infections.
Can hyaluronic acid be used alongside other preventive treatments?
Yes. Hyaluronic acid is not an "either-or" treatment.
Depending on the underlying cause of recurrent infection, it may form part of a broader prevention strategy that also includes:
- improving fluid intake;
- avoiding unnecessary antibiotics;
- vaginal oestrogen in postmenopausal women where appropriate;
- methenamine hippurate (Hiprex®);
- behavioural measures;
- management of bladder emptying problems;
- treatment of bladder stones or urinary obstruction; and
- careful treatment of active infections guided by urine culture results.
For many patients, combining several preventive strategies rather than relying on a single treatment alone achieves the best outcomes.
Ultimately, the aim is not simply to reduce the number of infections but to improve quality of life, minimise repeated antibiotic exposure and address the underlying reason why infections continue to occur.
How is hyaluronic acid bladder treatment given, and what should I expect?
One of the most common concerns patients have is whether bladder instillation is painful or complicated. In reality, the procedure is relatively straightforward and is usually performed as an outpatient treatment, meaning you can go home shortly afterwards without staying overnight.
The treatment involves placing hyaluronic acid (HA), sometimes combined with chondroitin sulphate (CS), directly into the bladder through a fine sterile catheter. Delivering the medication directly into the bladder allows it to coat the bladder lining, where it can help restore the damaged glycosaminoglycan (GAG) layer.
The appointment usually takes around 20–30 minutes, although the actual catheterisation and instillation generally take only a few minutes.
What happens during the procedure?
Although the exact protocol varies slightly between hospitals, treatment usually follows the same general steps.
First, you will be asked to empty your bladder.
The healthcare professional then cleans the urethral opening using an antiseptic solution to reduce the risk of introducing bacteria into the bladder.
A lubricating gel is applied before a fine, flexible catheter is gently passed through the urethra into the bladder. Most patients describe this as uncomfortable rather than painful, although individual experiences vary. Men often experience slightly more discomfort because the male urethra is longer than the female urethra.
If urine remains within the bladder, it is drained through the catheter.
The hyaluronic acid solution is then slowly instilled into the bladder before the catheter is removed.
The procedure itself usually takes only a few minutes.
How long does the treatment stay in the bladder?
After the catheter has been removed, patients are usually asked to retain the solution inside the bladder for 30 to 60 minutes, depending on the product being used and local treatment protocols.
During this time, the medication comes into contact with the bladder lining, allowing the hyaluronic acid to coat the urothelium.
After the recommended time has passed, the bladder can be emptied normally.
How many treatments will I need?
There is no single treatment schedule that is used worldwide.
Different clinical studies have used different regimens, which is one reason why comparing studies can sometimes be difficult.
A commonly used schedule consists of:
- one bladder instillation every week for four consecutive weeks;
- followed by one treatment every month for approximately five months.
Some patients may require additional maintenance treatments depending on how well they respond and whether infections recur.
Because treatment schedules differ between studies and products, your treating urologist may recommend a slightly different programme.
Is hyaluronic acid bladder treatment painful?
Most patients tolerate the procedure well.
The greatest source of discomfort is usually the temporary passage of the catheter rather than the medication itself.
During or shortly after treatment, some patients experience:
- mild burning when passing urine;
- temporary bladder irritation;
- increased urinary urgency;
- increased urinary frequency;
- mild discomfort within the urethra; or
- slight bladder discomfort for a few hours.
These symptoms usually settle without specific treatment.
Published studies consistently report that serious treatment-related complications are uncommon.
Can bladder instillation cause a urinary tract infection?
Because a catheter is passed into the bladder, there is a small theoretical risk of introducing bacteria during the procedure.
For this reason, bladder instillations are performed using sterile technique to minimise the risk of infection.
Although this may seem contradictory, clinical studies have shown that patients receiving hyaluronic acid bladder instillations experience fewer recurrent UTIs overall, despite the need for repeated catheterisation.
The long-term preventive benefit appears to outweigh the minimal risk associated with catheter insertion.
Can I drive home afterwards?
In most cases, yes.
Hyaluronic acid bladder instillation is performed under local lubrication and does not usually require sedation or a general anaesthetic.
Most patients are able to resume normal daily activities soon afterwards.
However, if you experience significant discomfort, bladder irritation or feel unwell after the procedure, it is sensible to postpone driving until you feel comfortable.
When should I seek medical advice after treatment?
Although complications are uncommon, medical advice should be sought if you develop:
- a fever or chills;
- worsening pain rather than gradual improvement;
- heavy bleeding in the urine;
- inability to pass urine;
- persistent severe burning lasting longer than expected; or
- symptoms suggesting a urinary tract infection that continue to worsen.
These symptoms are uncommon but should be assessed promptly, as they may indicate infection or another complication requiring treatment.
How quickly will I notice an improvement?
Hyaluronic acid is designed to reduce future infections rather than provide immediate symptom relief.
Some patients notice improvement within the first few weeks of treatment, whereas others require several instillations before experiencing fewer infections.
For this reason, the success of treatment is usually assessed over several months rather than after a single bladder instillation.
Patience is important. The aim is not to make one infection disappear immediately but to reduce the likelihood of repeated infections over the months and years that follow.
Hyaluronic acid for recurrent urinary tract infections: myths and facts
Myth: Hyaluronic acid is an antibiotic.
Fact: Hyaluronic acid does not kill bacteria. Instead, it aims to restore the bladder's natural protective glycosaminoglycan (GAG) layer, making it more difficult for bacteria to attach to the bladder lining.
Myth: Hyaluronic acid cures an active urinary tract infection.
Fact: No. Hyaluronic acid is designed to help prevent future infections, not treat an active bacterial infection. If you develop symptoms of an acute UTI, antibiotics may still be required depending on urine culture results.
Myth: One bladder treatment is enough.
Fact: Most published studies use a course of bladder instillations over several weeks or months. The benefits are usually assessed over time rather than after a single treatment.
Myth: Everyone with recurrent UTIs should have hyaluronic acid.
Fact: Hyaluronic acid is a specialist treatment for carefully selected patients. Current European guidelines recommend considering it after simpler preventive measures have been unsuccessful.
Myth: There is no scientific evidence that hyaluronic acid works.
Fact: Several systematic reviews and meta-analyses have shown that hyaluronic acid, either alone or combined with chondroitin sulphate, can reduce recurrent UTIs and increase the time before another infection occurs. However, further high-quality clinical trials are still needed, which is why current guideline recommendations remain cautious.
Frequently asked questions about hyaluronic acid for recurrent urinary tract infections
How long does hyaluronic acid take to work?
Hyaluronic acid works gradually. Most patients require several bladder instillations before the protective effects become apparent. Treatment success is usually assessed over several months rather than after a single instillation.
How long do the benefits last?
The duration of benefit varies between patients. Clinical studies have indicated that many patients remain infection-free for significantly longer after treatment, although some may require maintenance therapy if infections recur.
Can hyaluronic acid completely prevent future UTIs?
No treatment can guarantee that another urinary tract infection will never occur. Hyaluronic acid reduces the risk of recurrence in many patients, but the degree of benefit varies depending on the underlying cause of recurrent infection.
Can hyaluronic acid be used together with antibiotics?
Yes. Hyaluronic acid and antibiotics have different roles. Antibiotics treat active bacterial infections, whereas hyaluronic acid is used to reduce the likelihood of future infections.
Is hyaluronic acid available in the UK?
Yes. Hyaluronic acid bladder instillations are available in specialist urology units within the UK, although availability varies between hospitals and healthcare providers.
Is the procedure safe?
Published studies suggest that patients generally tolerate hyaluronic acid bladder instillation well. Temporary burning, bladder irritation or discomfort related to catheter insertion may occur, while serious complications appear to be uncommon.
Does hyaluronic acid work for men?
Most published research has involved women with recurrent bacterial cystitis. There is currently much less evidence in men, where recurrent UTIs often require investigation to identify an underlying cause such as an enlarged prostate, bladder stones or chronic bacterial prostatitis.
Does hyaluronic acid reduce antibiotic resistance?
Hyaluronic acid does not reverse antibiotic resistance. However, by reducing the number of recurrent infections in some patients, it may reduce the need for repeated antibiotic courses, supporting better antibiotic stewardship.
Does hyaluronic acid work for recurrent urinary tract infections?
For carefully selected patients, the answer is yes.
Current evidence shows that intravesical hyaluronic acid, particularly when combined with chondroitin sulphate, can reduce the frequency of recurrent urinary tract infections and increase the time before another infection occurs. The largest systematic review reported an average reduction of approximately 2.6 infections per patient per year, with patients remaining infection-free for around 130 additional days compared with control treatments.
Importantly, hyaluronic acid should not be viewed as a replacement for antibiotics or a cure for every patient with recurrent UTIs. Instead, it is a specialist, non-antibiotic treatment that aims to restore the bladder's natural protective barrier and break the cycle of repeated infection.
Current European Association of Urology (EAU) guidelines support its use in selected patients whose recurrent infections persist despite simpler preventive measures, although further high-quality research is still needed. The NICE recurrent UTI guideline does not currently include hyaluronic acid within its routine treatment pathway, reflecting differences in how guideline groups interpret the available evidence.
As our understanding of recurrent urinary tract infections continues to evolve, bladder-directed therapies such as hyaluronic acid are likely to play an increasingly important role in reducing antibiotic exposure and improving quality of life for appropriately selected patients. Although it is not suitable for everyone, it represents an evidence-based option that should be considered as part of a comprehensive strategy for preventing recurrent urinary tract infections.
Does hyaluronic acid work for recurrent urinary tract infections?
For carefully selected patients, the answer is yes.
Current evidence suggests that intravesical hyaluronic acid, particularly when combined with chondroitin sulphate, can reduce the frequency of recurrent urinary tract infections and increase the time before another infection occurs. The largest systematic review found an average reduction of approximately 2.6 urinary tract infections per patient per year, with patients remaining infection-free for around 130 additional days compared with control treatments.
Importantly, hyaluronic acid is not a replacement for antibiotics during an active infection, nor is it the right treatment for everyone with recurrent UTIs. Instead, it is a specialist, non-antibiotic treatment that aims to restore the bladder's natural protective barrier and break the cycle of repeated infection.
Current European Association of Urology (EAU) guidelines support hyaluronic acid as a treatment option for selected patients whose recurrent infections persist despite simpler preventive measures, although further high-quality clinical trials are still required. The NICE recurrent UTI guideline does not currently include hyaluronic acid within its routine treatment pathway, reflecting differences in how international guideline groups interpret the available evidence.
For patients who continue to experience recurrent, culture-confirmed urinary tract infections despite conventional preventive strategies, hyaluronic acid represents an evidence-based treatment that may reduce future infections, decrease antibiotic exposure and improve quality of life.
About Mr Edward Calleja
Mr Edward Calleja is a consultant urological surgeon in the United Kingdom specialising in recurrent urinary tract infections, prostatitis, enlarged prostate, bladder disorders and robotic surgery for prostate and bladder cancer. He is especially interested in evidence-based, non-antibiotic strategies to prevent recurrent urinary tract infections, which help patients reduce repeated infections and support responsible antibiotic use. His patient information articles are based on current international guidelines and peer-reviewed medical research, with the aim of helping patients understand their condition and make informed decisions about their treatment options.
References
International guidelines
- European Association of Urology. EAU Guidelines on Urological Infections. Latest edition.
- National Institute for Health and Care Excellence (NICE). Urinary tract infection (recurrent): antimicrobial prescribing (NG112).
Systematic reviews and meta-analyses
- Goddard JC, Janssen DAW. Intravesical hyaluronic acid and chondroitin sulphate for recurrent urinary tract infections: systematic review and meta-analysis. International Urogynecology Journal. 2018.
- De Vita D, et al. Intravesical therapies for recurrent urinary tract infection: a systematic review and meta-analysis. 2022.
- Systematic review of glycosaminoglycan replacement therapy for recurrent urinary tract infections. 2024.
Landmark clinical studies
- Damiano R, et al. Prevention of recurrent urinary tract infections by intravesical administration of hyaluronic acid and chondroitin sulphate.
- Lipovac M, et al. Intravesical hyaluronic acid for recurrent urinary tract infections.
- Constantinides C, et al. Intravesical hyaluronic acid in women with recurrent urinary tract infections.
