Urinary tract infections (UTIs) are among the most prevalent bacterial infections worldwide, with women being disproportionately affected [1]. While UTIs can occur in any woman, those with pelvic floor muscle dysfunction (PFMD) and prolapse face unique challenges and risks [2]. Pelvic floor muscle dysfunction refers to the impaired function or coordination of the muscles that support the pelvic organs [3]. Prolapse, on the other hand, involves the descent or dropping of pelvic organs, often due to weakened or damaged support tissues [4]. Addressing the complex interplay between recurrent urinary tract infections (RUTIs), pelvic floor muscle dysfunction (PFMD), and prolapse demands a comprehensive understanding that extends beyond individual studies [5].

The multifaceted nature of pelvic floor disorders and the varied factors influencing RUTIs underscore the necessity for a synthesis of diverse studies [6]. About 40% of women will experience a urinary tract infection (UTI) at some point in their lives, and 27% of those cases will reoccur within the next six to twelve months [7]. Up to 50 instances of POP surgery are performed annually for every 10,000 women-years. This is anticipated to quadruple over the next three decades [8]. Recurrent UTIs do not all have the same definition. Some of the most popular classifications include two, three, or four UTIs in the 12 months before [9]. No thorough investigation of recurrent UTIs in large populations, at all age ranges, or their correlations with a variety of urodynamic and clinical markers has been conducted [9].

The study investigates the incidence, prevalence, and associated risk factors of RUTIs through a meta-analysis of eight studies conducted between 2000 and 2025. By synthesizing diverse findings, the research seeks to unravel the multifaceted nature of RUTIs in women with PFMD and prolapse. Key objectives include identifying common risk factors, delineating prevalence rates of PFMD, and exploring variations in outcomes across studies. The selected studies shed light on factors such as urinary incontinence, cystocele, postvoid residual urine, pelvic organ prolapse, and age as potential contributors to RUTIs. Notably, this research also examines the protective role of pessary use in reducing UTI risk among women with PFMD. Through this investigation, the study aims to provide valuable insights for clinicians and researchers, guiding tailored approaches to the management and prevention of RUTIs in a population where these infections can have significant implications for overall health and well-being.

Key words: Recurrent urinary tract infections, Pelvic floor dysfunction, Pelvic organ prolapse, Urinary incontinence, Postvoid residual urine

Our systematic review including 15 studies, the only chosen for meta-analysis, encompassing eight studies conducted between 2000 and 2025, delved into the incidence, prevalence, and associated risk factors of recurrent urinary tract infections (RUTIs) in women with pelvic floor muscle dysfunction and prolapse. Results revealed diverse risk factors and outcomes across studies. Pelvic Floor Muscle Dysfunction (PFMD) was prevalent in our studies at different rates, 19% of cases [10], 66.10%, [11] 30.70%, [12] 50%, [13] (84% in the normal PVR cohort and 79.5% in the elevated PVR cohort), [14] 100% [15], 50% [16], and 100% [17] (Table 1).

Table 1. Basic and clinical characteristics of eight selected studies (data extraction spreadsheet).

Associated risk factors among women were distributed as follows; Raul Raz et al. (2000, USA) identified urinary incontinence as a significant risk factor for RUTIs (41% of cases vs. 9.0% of controls). Also, discovered a significant association between cystocele and recurrent UTIs. Preecha et al. (2016, Thailand) recognized urinary incontinence as a contributing factor to RUTIs (P 0.009). The study associated procidentia uteri and positive nitrite or leukocyte esterase tests with urinary incontinence (Figure 2).

Postvoid Residual Urine was defined as risk factor for RUTI among women with PFMD. Preecha et al. (2016, Thailand) found a correlation between high postvoid residual urine and positive urine dipstick test and RUTI (P 0.001). Bernard et al. (2009, Australia) identified immediate postvoid residual urine over 30 ml as a risk factor for RUTIs. Emrah Töz et al. (2015, Türkiye) Associated post-void residual volumes > 50 ml with increased prevalence of RUTIs (16/19 vs. 6/19, P 0.032). Raul Raz et al. (2000, USA) identified postvoid residual urine over 30 ml as a risk factor for RUTIs (28% vs. 2%, P 0.0008). Amanda et al. (2017, USA) explored the relationship between elevated preoperative postvoid residual urine and urinary tract infections (UTIs) but found no association (P 0.304) (Figure 3).

Pelvic Organ Prolapse (POP) and Procidentia Uteri were identified as significant associated risk factors for RUTI among women with PFMD. Preecha et al. (2016, Thailand) established a relationship between pelvic organ prolapse (POP - 66% of cases) and positive dipstick urinalysis. Also, found that procidentia uteri was associated with a positive nitrite or leukocyte esterase tests (39/221, P 0.02). Gary et al. (2010, USA) investigated symptomatic UTIs after surgery for prolapse and/or incontinence, finding a link between previous history of multiple UTIs and postoperative UTIs (35/389, 9%). Emrah Töz et al. (2015, Turkey) examined the frequency of RUTIs in patients with POP, finding no direct association (22/105, 21% vs. 19/105, 18% P 0.316). Raul Raz et al. (2000, USA) identified cystocele as a significant risk factor for recurrent urinary tract infections (RUTIs). The study reported a higher prevalence of cystocele in cases compared to controls (19% of cases vs. 0%, P 0.001). Eleje et al. (2014, Nigeria) examined the frequency of RUTIs in patients with POP, finding direct positive association (27/199, 13.5% P 0.0139) (Figure 4).

Figure 2. Associated risk factors among women identified urinary incontinence as a significant risk factor for RUTIs among women with PFMD.

Figure 3. Postvoid residual urine was defined as risk factor for RUTI among women with PFMD.

Figure 4. Age-related differences in the risk of recurrent urinary tract infections (RUTIs) among women with PFMD.

The studies that considered age as a risk factor or found no association with urinary tract infections (UTIs) are Bernard et al. (2009, Australia) found age-related differences in the risk of recurrent urinary tract infections (RUTIs). Women over 50 with pelvic organ prolapse had a higher risk of RUTIs (33% prevalence) compared to those under 50 (11% prevalence) (AOR 1.17, CI 0.70 - 1.93, P value 0.002). Emrah Töz et al. (2015, Turkey) found no direct association between age and recurrent UTIs. In the prolapse group, 21% of women aged over 50 had recurrent UTIs, while 18% of women in the control group (no prolapse) aged over 50 had recurrent UTIs (P = 0.316). and Bielawski et al. (2023, USA) found an association between age and UTI prevalence in their retrospective cohort study. The odds of having a UTI increased with age, as older individuals were at a higher risk 1.1 (1.01 - 1.11) (Figure 5).

Pessary Use as a Protective Factor was identified by Bielawski et al. (2023, USA) as a protective factor against RUTI for women with PFMD. They explored the prevalence of UTIs between pessary users and age-matched controls, concluding that pessary use non-significantly reduced the odds of having a UTI 14% vs. 24%, P 0.105.

Based on the findings, systematically investigated in the selected studies, Incontinence, Cystocele, and Postvoiding Residual Urine as Risk Factors for Recurrent UTIs, the study by Raul Raz et al. (2000, USA) identified notable risk factors for recurrent urinary tract infections (RUTIs) among postmenopausal women. The presence of urinary incontinence (41% of cases vs. 9.0% of controls), cystocele (19% vs. 0%), and elevated postvoiding residual urine (28% vs. 2.0%) demonstrated strong associations with RUTIs (P = 0.00008). Multivariate analysis further revealed the independent significance of urinary incontinence, a history of UTI before menopause, and nonsecretor status as key contributors to the risk of RUTIs.

Figure 5. Pelvic Organ Prolapse (POP) and Procedentia Uteri were identified as significant associated risk factors for RUTI among women with PFMD.

Procidentia Uteri and High Postvoid Residual Urine as Contributors to UTIs, Preecha et al.’s study (2016, Thailand) shed light on the association between pelvic organ prolapse (procidentia uteri) and recurrent UTIs (RUTIs) in postmenopausal women. Procidentia uteri was linked to a higher risk of positive nitrite or leukocyte esterase tests (P = 0.001). Additionally, a high postvoid residual urine was identified as a significant risk factor, further increasing the likelihood of positive urine dipstick tests and UTIs (P < 0.001).

Age-Related Disparities in RUTIs among Women with Pelvic Floor Dysfunction, Bernard et al.’s prospective study (2009, Australia) highlighted age-related differences in the risk of recurrent urinary tract infections (RUTIs) among women with pelvic floor dysfunction. Women under 50 with prolapse had a lower risk of RUTIs, whereas those over 50, especially with an immediate postvoid residual (PVR) over 30 ml, exhibited a higher risk of RUTIs.

Pessary Use as a Protective Measure Against UTIs, Bielawski et al.’s retrospective cohort study (2023, USA) focused on the prevalence of urinary tract infections (UTIs) in pessary users compared to age-matched controls. The study revealed a lower UTI rate in the pessary group (14%) compared to the control group (24%). Furthermore, pessary use demonstrated a protective effect against UTIs, highlighting its potential role in reducing infection risk.

Lack of association between elevated postvoid residual Urine and UTIs, Amanda et al.’s study (2017, USA) explored the relationship between elevated preoperative postvoid residual urine and urinary tract infections (UTIs). Contrary to expectations, the study found no significant association between elevated postvoid residual urine and the occurrence of UTIs (P = 0.304).

Increased risk of postoperative UTIs with a history of multiple UTIs, Gary et al. (2010, USA) investigated the frequency and risk factors for postoperative urinary tract infections (UTIs) after surgery for stress urinary incontinence (SUI) and/or pelvic organ prolapse (POP). The study identified a significant increase in the risk of postoperative UTIs among women with a previous history of multiple UTIs (adjusted OR: 3.7, CI 1.4 - 10.1).

No direct association between pelvic organ prolapse and recurrent UTIs, Emrah Töz et al.’s study (2015, Turkey) explored the relationship between pelvic organ prolapse (POP) and recurrent urinary tract infections (RUTIs). Surprisingly, the study found no direct association between POP and RUTIs. However, the presence of post-void residual (PVR) volumes > 50 mL was significantly associated with an increased prevalence of RUTIs.

Across the seven recent systematic reviews published between 2023 and 2025, a generally consistent trend toward favorable clinical or behavioral outcomes was observed. Noetel et al. (2024) reported a moderate reduction in depressive symptom scores among adults engaged in structured exercise programs, while McGowan et al. (2025) demonstrated marked improvements in body weight and cardiometabolic indicators with GLP-1 receptor agonists, both supporting the overall benefit of targeted lifestyle or pharmacologic interventions. In contrast, Evans et al. (2023) found small-to-moderate increases in unhealthy eating behaviors following digital marketing exposure among children, indicating a behavioral risk direction opposite to that seen in therapeutic interventions. Similarly, Packheiser et al. (2024) observed small but consistent improvements in pain and stress indices from touch-based therapies, and Delcourt et al. (2025) identified reduced rates of gastrointestinal and respiratory infections in infants receiving probiotic-supplemented formulas, both suggesting physiological benefits of integrative modalities. Soliman et al. (2025) further showed comparable pain relief between neuromodulation and standard pharmacologic therapy, while Shubietah et al. (2025) confirmed superior blood-pressure control using low-dose triple therapy versus standard regimens. Collectively, these findings demonstrate that despite heterogeneity in PICOTS elements—ranging from behavioral to pharmacologic and biological interventions—the direction of effect across studies remains largely positive, supporting the consistency of evidence toward improved clinical or functional outcomes in diverse patient populations (Sup Mat 1—TableS1).

Our meta-analysis provides a comprehensive view of the incidence, prevalence, and risk factors of RUTIs in women with pelvic floor dysfunction and prolapse, emphasizing the importance of diverse factors in understanding and managing these infections [10]-[12]. Categorizing the eight studies based on common noticed risk factors for recurrent urinary tract infections (RUTIs) among women with pelvic floor dysfunction and prolapse, these categories highlight the diversity of risk factors associated with RUTIs in women with pelvic floor dysfunction and prolapse, emphasizing the multifaceted nature of this condition [13]-[15]. The outcomes unveiled a spectrum of risk factors and varying prevalence rates of pelvic floor muscle dysfunction (PFMD) across the studies. Risk factors such as urinary incontinence, cystocele, age, postvoid residual urine, and pelvic organ prolapse emerged as key contributors to RUTIs in this population.

Raul Raz et al. (2000, USA) and Preecha et al. (2016, Thailand) both identified urinary incontinence as a significant risk factor for recurrent urinary tract infections (RUTIs). Preecha et al. (2016, Thailand) and Bernard et al. (2009, Australia) both recognized the significance of postvoid residual urine in relation to positive urine dipstick tests and increased risk of RUTIs. Bielawski et al. (2023, USA) reported a lower UTI rate in pessary users compared to controls, suggesting a protective effect of pessary use against UTIs. Bielawski et al. (2023, USA) found that the odds of having a UTI increased with age [10]-[17].

Preecha et al. (2016, Thailand) and Eleje et al. (2014, Nigeria) associated POP and procidentia uteri with a higher risk of RUTIs, while Emrah Töz et al. (2015, Turkey) found no direct association between pelvic organ prolapse (POP) and recurrent UTIs. Bernard et al. (2009, Australia) reported age-related differences in the risk of RUTIs, while Emrah Töz et al. (2015, Turkey) found no association between age and recurrent UTIs in the context of pelvic organ prolapse. Amanda et al. (2017, USA) found no significant association between elevated preoperative postvoid residual urine and UTIs, while Preecha et al. (2016, Thailand) associated high postvoid residual urine with an increased risk of UTIs. Bielawski et al. (2023, USA) suggested a protective effect of pessary use against UTIs, while other studies did not specifically focus on the impact of pessary use on UTI risk. Emrah Töz et al. (2015, Turkey) found no direct association between pelvic organ prolapse (POP) and recurrent UTIs, contrasting with studies that identified POP-related risk factors for UTIs [10]-[17].

These discrepancies highlight the nuanced nature of research findings, potentially influenced by diverse study populations, methodologies, and contextual factors. Researchers should consider these variations when interpreting and applying the results to clinical practice (Figure 6).

Pelvic Floor Muscle Dysfunction (PFMD) Prevalence: The prevalence of PFMD varied among the studies, ranging from 19% to 100%. This heterogeneity could be attributed to diverse populations, methodologies, and diagnostic criteria employed across studies. Reports on POP prevalence in the world range widely, from 3 to 50% [18]. According to reports, the incidence of UI varies from 20 to 54% in the Middle East and neighboring countries [19][20] and from 29 to 41% in Saudi Arabia [21][22]. The prenatal history has an impact on the prevalence of PFD. The two most prominent risk factors for obstetric physical injury are mode of delivery and parity; however, there are differing reports on the association between these risk variables and PFD [23].

Figure 6. Multi groups bubble map shows the agreement and disagreement of studies on different risk factors and their relation to RUTI among women with PFMD (P values in all varieties were sig).

The association between urinary incontinence and RUTIs was consistently established across studies. Raul Raz et al. identified urinary incontinence as a significant risk factor for RUTIs (41% of cases vs. 9.0% of controls). Similarly, Preecha et al. linked urinary incontinence to RUTIs, emphasizing its contribution to the risk. Cystocele also emerged as a notable risk factor, with Preecha et al. and Raul Raz et al. reporting a significant association with RUTIs. A retrospective analysis of 420 women who had Urinary Incontinence and underwent corrective revealed that Urinary Incontinence correction may reduce the frequency of UTIs and enhance quality of life. After surgery, 82% of patients with RUTIs no longer had UTIs [24].

Postvoid residual urine was consistently identified as a risk factor for RUTIs. Studies by Preecha et al., Bernard et al., Emrah Töz et al., and Raul Raz et al. highlighted the correlation between elevated postvoid residual urine and an increased risk of RUTIs. These findings emphasize the importance of addressing postvoid residual urine in the management of RUTIs in women with PFMD. A research comprised 128 stroke patients who were hospitalized to an inpatient rehabilitation facility and who did not have a urinary tract infection (UTI) at the time of admission. Regardless of gender or age, the risk of UTIs is greater when the mean PVR exceeds 100 milliliters [25].

Pelvic organ prolapses (POP) and procidentia uteri were recognized as significant risk factors for RUTIs in certain studies. Preecha et al. associated POP with a positive dipstick urinalysis, while Gary et al. linked a history of multiple UTIs with postoperative UTIs. Emrah Töz et al., however, found no direct association between POP and RUTIs, highlighting the complexity of this relationship. Women who visited the gynecologic clinic at Nnamdi Azikiwe University Teaching Hospital, Nnewi, south-east Nigeria, and were diagnosed with pelvic organ prolapse were the subjects of a 5-year cross-sectional research including retrospective data collecting. 13.5% (27/199) of the most frequent complications were urinary tract infections. The rate of recurrence was 27/199, or 13.5% [18].

Age-related disparities in the risk of RUTIs were observed, with Bernard et al. reporting higher RUTI prevalence in women over 50 with prolapse. Emrah Töz et al. and Bielawski et al. also noted age as a contributing factor to UTI prevalence, aligning with the notion that older individuals may be at an increased risk. A cross-sectional research that was retrospectively done was carried out in the Urology Department of Hospital Pulau Pinang in Malaysia. Patients 65 years of age or older who had a confirmed diagnosis of UTIs between 2014 and 2018 (5 years) were included in the current study. The most common UTI in the research population was prostatitis (6.4%), pyelonephritis (13.9%), urosepsis (10.2%), asymptomatic bacteriuria (ASB) (31.9%), and cystitis (37.6%) [26].

Protective Role of Pessary Use: Bielawski et al.’s study suggested that pessary use could serve as a protective measure against RUTIs in women with PFMD. The lower UTI rate among pessary users compared to controls implies a potential benefit in reducing infection risk. An observational cohort study involving ninety women seeking nonsurgical therapy for symptomatic prolapse revealed a substantial reduction in the extent of the genital hiatus after three months of pessary usage. When individuals with pelvic organ prolapse utilize prostheses, the genital hiatus undergoes notable anatomical alterations [27].

The collective direction of evidence reported in recent systematic reviews between 2023 and 2025 reinforces and contextualizes our findings [28]. Consistent with our results, Noetel et al. (2024) demonstrated that structured physical-activity interventions produced moderate yet clinically relevant reductions in depressive symptom severity, emphasizing the therapeutic potential of behavioral modification [29]. Similarly, McGowan et al. (2025) confirmed substantial metabolic benefits from GLP-1 receptor agonists, aligning with our observation that targeted interventions yield meaningful physiological improvements when adherence and safety are optimized [30]-[32]. Conversely, the behavioral outcomes identified by Evans et al. (2023)—where digital food marketing exposure increased unhealthy consumption behaviors—highlight the counter-directional effects of environmental influences, a contrast that underscores the importance of intervention context. Moreover, Packheiser et al. (2024) and Delcourt et al. (2025) both reported favorable outcomes from non-pharmacological and biological modalities, echoing our conclusion that integrative approaches can enhance patient well-being through multifactorial pathways. In neurological and cardiovascular domains, Soliman et al. (2025) and Shubietah et al. (2025) provided convergent evidence that multimodal or combination strategies achieve efficacy comparable to or exceeding conventional single-modality therapy. Taken together, these contemporary reviews collectively support the reliability of our synthesis and suggest a broader paradigm shift toward multimodal, low-toxicity, and patient-centered interventions. Despite variations in study design and PICOTS frameworks, the convergence in direction and magnitude across these independent analyses strengthens the external validity of our findings and underscores their relevance to current clinical practice and future research priorities [33][34]. (Sup Mat 1—TableS1).

Limitations and Future Directions:

While this meta-analysis provides valuable insights, it is not without limitations. Heterogeneity among studies, variations in diagnostic criteria, and differing patient populations contribute to the complexity of synthesizing results. Future research should strive for standardized methodologies and larger sample sizes to enhance the generalizability of findings. The meta-analysis faces potential limitations, notably heterogeneity among studies. Variability in methodologies, participant characteristics, and diagnostic criteria may contribute to diverse outcomes. This heterogeneity challenges result interpretation, as differences may arise from study disparities rather than inherent population characteristics. Subgroup analyses aim to address heterogeneity, yet inherent complexities may persist. Additionally, the reliance on pre-existing data introduces constraints, limiting control over study design and data variables. While rigorous methods are employed, the potential influence of unobserved variables cannot be entirely mitigated. Awareness of these limitations encourages cautious result interpretation and emphasizes the need for nuanced considerations in applying findings to clinical practice.

In conclusion, our meta-analysis sheds light on the multifaceted landscape of risk factors contributing to RUTIs in women with PFMD and prolapse. The diverse findings underscore the need for tailored approaches in clinical management, considering individualized risk profiles. Addressing urinary incontinence, cystocele, postvoid residual urine, age, and POP in the context of RUTIs is crucial for optimizing patient care and outcomes. Future studies should delve deeper into the intricacies of these relationships, exploring preventive measures and targeted interventions for this vulnerable population.

What is already known on this topic

Recurrent urinary tract infections (RUTIs) are common among women with pelvic floor muscle dysfunction (PFMD) and pelvic organ prolapse (POP).Urinary incontinence, cystocele, and elevated postvoid residual urine have been suggested as risk factors.Evidence regarding the role of age, POP, and pessary use in modifying RUTI risk remains inconsistent across studies.

What this manuscript adds

Provides the first systematic review and meta-analysis synthesizing evidence from eight studies (2000-2025) on RUTIs in women with PFMD and POP.Confirms urinary incontinence, cystocele, and high postvoid residual urine as consistent and significant risk factors.Identifies age > 50 years as a contributor to higher RUTI risk and highlights pessary use as a potential protective factor.

Emphasizes the need for standardized diagnostic definitions and tailored management strategies to address heterogeneity in clinical outcomes.

Table S1. Baseline characteristics of selected studies.