Urine infections can be treated with pill that doctors won't prescribe

Why won’t doctors prescribe simple antiseptic pill that would help thousands suffering from agonising urine infections?

• Methenamine hippurate is antiseptic treatment that wipes out bacteria in urine
• Tablet sidesteps common problems with traditional antibiotic treatments that can damage liver and kidneys or even become useless in the face of antibiotic-resistant bacteria
• Also known by brand name Hiprex, studies show it can be just as effective when used to tackle persistent infections as antibiotics; many doctors may not even know it exists as an alternative
• Each year more than a million Britons, 80% of them women, develop a bladder or urinary tract infection

Thousands of people suffering with agonising and recurring bladder infections are missing out on a simple antiseptic treatment that wipes out the bacteria in urine.

The tablet – methenamine hippurate – sidesteps increasingly common problems with traditional antibiotic treatments that can damage the liver and kidneys or even become useless in the face of antibiotic-resistant bacteria.

Also known by the brand name Hiprex, studies show it can be just as effective when used to tackle persistent infections as antibiotics. Yet experts warn that too few patients are benefiting from it, owing to outdated prescribing guidance and that many doctors may not even know it exists as an alternative.

Each year more than a million Britons, 80 per cent of them women, develop a bladder or urinary tract infection (UTI). Symptoms include burning pain when passing urine, frequent urination and a feeling of needing the loo even when the bladder is empty.

Older people are more at risk, as the bladder works less well with age and may not empty fully when going to the toilet, so bacteria remain in the urinary tract.

Thousands of people suffering with agonising and recurring bladder infections are missing out on a simple antiseptic treatment that wipes out the bacteria in urine. The tablet – methenamine hippurate – sidesteps increasingly common problems with traditional antibiotic treatments that can damage the liver and kidneys or even become useless in the face of antibiotic-resistant bacteria

Post-menopausal women are also more prone as the female sex hormone oestrogen helps maintain the lower urinary tract’s tissues and, as its levels drop, they become more vulnerable to infections.

One in ten women over 65, and nearly three in ten women over 85, will have experienced a UTI in the past year. In older patients they can cause a dementia-like condition called delirium, and there is also a risk of sepsis, which leads to about 10,000 deaths a year.

For most, a short course of antibiotics clears up the infection within days, but as many as 1.6 million people in the UK suffer from chronic UTIs – classed as three or more infections a year. 

The first-line treatment for these patients is to stay on a low-dose antibiotics permanently, but about a fifth experience side effects that can damage the liver and kidneys. Antibiotics are also increasingly ineffective as the bacteria become resistant to the drugs.

‘Hiprex has changed my life,’ says Helen Rawnsley (above), 27, from Birmingham. She was prescribed the drug in October 2020 by a private urologist when, after suffering for three months from repeat UTIs, antibiotics stopped working

Hiprex offers an alternative option for these patients. The drug is broken down by the body, releasing ammonia and formaldehyde which inhibit bacterial growth – and experts believe the pathogens that cause UTIs are incapable of becoming resistant to them.

Reports from women suffering chronic UTIs suggest that the drug is highly effective.

‘Hiprex has changed my life,’ says Helen Rawnsley, 27, from Birmingham. She was prescribed the drug in October 2020 by a private urologist when, after suffering for three months from repeat UTIs, antibiotics stopped working.

‘It was hell,’ she says. ‘I remember breaking down, thinking, ‘I can’t live like this.’ ‘ Her last bout of severe symptoms was in June 2021. Since then she has taken two Hiprex tablets each day.

However, not all women are able to access the drug as quickly as she was. This newspaper has heard the accounts of numerous women who either cannot get a prescription for Hiprex or cannot get their pharmacist to sign off a prescription, even when it’s provided by a consultant urologist.

Dr Cat Anderson, a women’s health expert who runs a clinic in London specialising in recurrent urine infections, repeated a claim made by a number of experts contacted by The Mail on Sunday that it is common for GPs to have never even heard of methenamine.

She adds: ‘Many doctors, GPs and pharmacists are uncomfortable with prescribing methenamine hippurate due to a lack of knowledge about how it works.

What’s the difference… between efficacy and effectiveness?

The terms are often used synonymously. However, in a medical context they have very different meanings.

Broadly speaking, efficacy relates to how well drugs or other interventions perform in clinical trials. 

So, for example, the trial results of a new vaccine might show it has an efficacy of 80 per cent – meaning those who had the jab had an 80 per cent lower risk of infection than those who didn’t.

Effectiveness, in medicine, refers to how well a treatment performs in the real world. 

This is because that same new vaccine might become gradually less potent over time – as we saw in Covid, which was due to protective antibodies waning and the virus mutating. It might then be deemed to be, say, just 30 per cent effective.

‘From the 1950s onward, antibiotics were seen as a sort of panacea, and other treatments were pushed into the background. But we now know that antibiotics alone aren’t enough to treat many chronic urinary tract infections.’

Guidelines set by the UK’s drugs watchdog, the National Institute for Health and Care Excellence (NICE), state that methenamine hippurate is ‘less effective’ than antibiotics for treating recurrent UTIs. This, however, is based on an outdated 2016 study.

A 2019 review suggested it was effective, particularly in middle-aged and older women, while another study, published earlier this year, concluded, on average, women on methenamine hippurate had no more than one extra UTI a year than those on antibiotics.

Professor Chris Harding, a consultant urologist at Newcastle Hospitals NHS Trust who led the trial, said he was optimistic that the results could encourage a shift in prescribing guidelines.

Mother-of-two Lisa Walton, 50, from Fleet, Hampshire, has spent thousands on methenamine privately over the past five years as her NHS GP refuses to prescribe it. 

Before this, Lisa tried multiple rounds of antibiotics, saw a series of doctors and even underwent surgery to expand her urethra – the narrow tube through which urine leaves the body – to prevent bacteria getting trapped.

She says methenamine has been absolutely crucial to her recovery, adding: ‘I’m grateful I can afford it, but it’s absolutely essential more people have access to it.’

Some GPs have refused to prescribe methenamine for long-term use due to the potential health risks from the release of formaldehyde, a known carcinogen – something that could cause cancer.

However, Prof Harding believes the levels of formaldehyde are too low to pose a risk, while Dr Anderson says the benefits of taking methenamine far outweigh this risk, adding: ‘Patients with chronic UTIs suffer a living hell. Many would see improvements if only they could get hold of this drug.’

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