Key messages
• Compared to antibiotics (medicines used to treat a wide range of infections or diseases caused by bacteria), NSAIDs (medicines that reduce inflammation, pain and fever) probably result in less short-term resolution of urinary tract infection symptoms (1 to 4 days), and may result in less medium-term resolution of symptoms (5 to 10 days).
• NSAIDs may result in a longer duration of symptoms and probably result in more women needing antibiotic treatment by day 30.
What is an uncomplicated urinary tract infection?
The majority of urinary tract infections (UTIs) in women (a condition where bacteria gets into the urine and travels up to the bladder) are uncomplicated (occurring in a healthy person with no urinary tract abnormalities or other medical conditions) and self-limiting (get better without treatment). The symptoms often experienced are a burning sensation while passing urine, increased urinary frequency, and urgency.
How are urinary tract infections treated?
When symptoms are bothersome, treatment is often sought, and antibiotics (medicines used to treat a wide range of infections or diseases caused by bacteria) are commonly used. With both patients and doctors becoming more aware of the negative impacts of repeated antibiotic use, more work is being done to evaluate non-antibiotic treatments for the control of UTI symptoms. Non-steroidal anti-inflammatory drugs (NSAIDs) are medicines that reduce inflammation, pain and fever. It has been suggested that the anti-inflammatory effect of NSAIDs may alleviate the symptoms of UTIs.
What did we want to find out?
We wanted to find out if NSAIDs were better than antibiotics at improving UTI symptoms, reducing their severity and duration, and reducing the reliance on antibiotics. We also wanted to find out if NSAIDs were associated with any unwanted effects.
What did we do?
We searched for studies that looked at NSAIDs compared with antibiotics or other interventions in women with uncomplicated UTIs.
We compared and summarised the results of the studies and rated our confidence in the information based on factors such as study methods and sizes.
What did we find?
We included six studies randomising 1646 women. The mean age ranged from 28 to 50 years, and previous UTIs were reported in 7.2% to 77% of women. Five studies were undertaken in multiple centres, and the studies were carried out in Denmark, Germany, Korea, Norway, Sweden, Switzerland, and the UK.
Compared to antibiotics, NSAIDs probably result in less short-term resolution of symptoms (1 to 4 days) and may also result in less medium-term resolution of symptoms (5 to 10 days). NSAIDs probably make little or no difference to the number of adverse events by day 30. NSAIDs may result in a longer duration of symptoms and may result in a lower proportion of women experiencing microbiological resolution (no bacteria in the urine) by day 10. NSAIDs probably result in more women needing antibiotic treatment by day 30.
Compared to placebo, NSAIDs may reduce the need for antibiotic treatment but may make little or no difference to adverse events by day 30. Compared to a herbal product, NSAIDs may make little or no difference to adverse events.
What are the limitations of the evidence?
The small number of studies (per comparison) and the small size of the studies were limitations in this review. Not all the studies provided data about the outcomes we were interested in. We are moderately confident that compared to antibiotics, NSAIDs result in less short-term resolution of UTI symptoms and more women needing antibiotic treatment by day 30. We are less certain about their effect on the duration of symptoms.
How up to date is the evidence?
The evidence is current to 18 November 2024.
The use of NSAIDs for symptomatic management of uncomplicated UTIs probably results in less short-term resolution of symptoms and greater use of rescue antibiotics by day 30 compared to primary antibiotic treatment. Future studies should consider the various confounders such as degree of symptoms, microbiology, type and resistance patterns of bacteria involved and number of UTI episodes in the months prior to commencement of treatment.
Almost half of all women will have at least one symptomatic urinary tract infection (UTI) in their lifetime. Although usually self-remitting, 74% of women contacting a health professional are prescribed an antibiotic, and in rare instances, they may progress to more severe infections. Therefore, the standard of care for the treatment of symptomatic uncomplicated UTIs is oral antibiotic therapy, which aims to achieve symptom resolution and prevent the development of complications such as pyelonephritis. Given that a number of UTIs are self-remitting, non-antibiotic treatments that may help reduce the severity or duration of symptoms or reduce the need for antibiotics may be of benefit.
This review aims to investigate the benefits and risks associated with the use of non-steroidal anti-inflammatory drugs (NSAIDs) in the treatment of symptomatic uncomplicated UTIs in non-pregnant adult women.
We searched the Cochrane Kidney and Transplant Register of Studies up to 18 November 2024 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal and ClinicalTrials.gov.
We included all randomised controlled trials (RCTs) and quasi-RCTs looking at the effectiveness of NSAIDs in the treatment of symptomatic uncomplicated UTIs in non-pregnant adult women. The outcomes of interest were: 1) short-term resolution of symptoms (days 1 to 4); 2) medium-term resolution of symptoms (days 5 to 10); and 3) incidence of adverse events (including progression to sepsis or complicated UTI, hospitalisation or need for intravenous antibiotics, gastrointestinal complications, or death) up to 30 days from randomisation.
Screening, abstract selection, and data extraction were carried out independently by two authors, and any disagreements were resolved by discussion with a third author.
Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes and mean difference (MD) and 95% CI for continuous outcomes. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.
Six studies (1646 randomised women) published between 2010 and 2019 met our inclusion criteria. The mean age ranged from 28 to 50 years; previous UTIs were reported in 7.2% to 77% of participants. There were five multicentre studies, and studies were carried out in Denmark, Germany, Korea, Norway, Sweden, Switzerland, and the UK. Overall, the risk of bias was low or unclear.
Compared to antibiotics, NSAIDs probably result in less short-term resolution of symptoms (4 studies, 1144 participants: RR 0.67, 95% CI 0.49 to 0.91; I2 = 75%; moderate certainty) and may also result in less medium-term resolution of symptoms (4 studies, 1140 participants: RR 0.84, 95% CI 0.71 to 1.01; I2 = 78%; low certainty). NSAIDs probably make little or no difference to the number of adverse events by day 30 (4 studies, 1165 participants: RR 1.08, 95% CI 0.88 to 1.33; I2 = 64%; moderate certainty). NSAIDs may result in longer duration of symptoms (2 studies, 553 participants: MD 1.00 day, 95% CI 0.61 to 1.39; I2 = 0%; low certainty). NSAIDs may result in a lower proportion of women experiencing microbiological resolution by day 10 compared to antibiotics (2 studies, 322 participants: RR 0.76, 95% CI 0.68 to 0.85; I2 = 0%; low certainty) and probably result in more women using rescue antibiotic treatment by day 30 (4 studies, 1165 participants: RR 3.14, 95% CI 2.23 to 4.42; I2 = 49%; moderate certainty).
Compared to placebo, NSAIDs may reduce the use of rescue antibiotic treatment (1 study, 183 participants: RR 0.56, 95% CI 0.36 to 0.87; low certainty evidence) but may make little or no difference to adverse events at day 30.
Compared to the herbal product Uva-Ursi, NSAIDs may make little or no difference to adverse events by day 30.