Understanding The Burden of UTI Hospitalisations.

And How Low-Dose Vaginal Oestrogen Could Deliver Big Savings

Urinary tract infections (UTIs) don’t often make headlines, yet they quietly consume vast NHS resources. In England alone, 189,756 UTI-related hospital admissions were recorded in FY 2023–24, using 1.2 million bed-days. The UK Health Security Agency (UKHSA) estimates those admissions cost hospitals £604 million in that single year. More than half of admissions were in people aged 70 or over, and women accounted for 61.8% of all admissions. Even small reductions in preventable infections would free up beds, reduce antibiotic exposure, and release funds for other priorities. GOV.UK

This article synthesises the latest national data on the hospital burden of UTIs. It explores one underused, guideline-supported prevention strategy for a large, high-risk group: low-dose vaginal oestrogen for peri- and post-menopausal people with recurrent UTIs. We review the evidence, outline who stands to benefit, and model conservative, realistic savings for the NHS—without compromising safety or antimicrobial stewardship. GOV.UK+1

Key Takeaways:

• 189,756 UTI-related hospital admissions occurred in England during FY 2023-2024, resulting in 1.2 million NHS bed-days and costs exceeding £604 million
• 52.7% of UTI hospital admissions involved patients aged 70 years and older, with the highest admission rate (3,367 per 100,000) in those 90+ years old
• Women accounted for 61.8% of all UTI admissions, with a particularly high ratio (4:1) compared to men in working-age adults, when including pregnancy-related cases.
• There was a 9% increase in UTI hospitalisations compared to the previous year, though numbers remain below pre-pandemic levels.
• Seasonal variation exists, with the highest admission rates occurring during summer months (May-October) and the lowest during winter-spring (February-April)

The scale of the problem: beds, budgets, and who is most affected

Admissions and cost. UKHSA’s 2025 analysis of Hospital Episode Statistics (HES) shows 189,756 UTI-related admissions in England in 2023–24. These admissions generated 1.2 million bed-days, with a mean length of stay of 6.4 days, and cost >£604 million in 2023–24. About 34% of admissions were same-day cases, but the remaining two-thirds required at least one overnight stay, adding to system pressure. GOV.UK

Who is admitted? The burden skews older: 52.7% of admissions were in people aged 70+, and the highest admission rate occurred in those aged 90+. Overall, women accounted for 61.8% of admissions. Significantly for targeting prevention, women over 50 represented 37.1% of all UTI admissions—precisely the group in whom vaginal oestrogen can be considered for recurrent UTIs. GOV.UK

Seasonality and service impact. Admissions rise between May and October, but the background rate is high year-round. Preventing even a fraction of these infections would relieve pressure on emergency departments, acute medical wards, and discharge pathways—while also curbing antibiotic exposure and the downstream risks of resistance. GOV.UK

Why UTIs escalate after menopause

After menopause, oestrogen depletion leads to changes in the lower genital and urinary tract: thinning epithelium, reduced lubrication, elevated vaginal pH, and a drop in protective Lactobacillus species. Those shifts make the periurethral environment more hospitable to uropathogens (often E. coli), which helps explain the rising incidence and recurrence of UTIs with age. Restoring oestrogen locally can reverse many of these changes—lowering pH, improving epithelial integrity, and re-establishing lactobacilli, with corresponding reductions in UTI risk. PMC

What guidelines say about vaginal oestrogen for recurrent UTIs

NICE guidance (England). The NICE guideline on recurrent UTI (NG112) recommends considering vaginal oestrogen for peri- and post-menopausal people with recurrent UTIs (typically defined as ≥2 UTIs in 6 months or ≥3 in 12 months) when behavioural measures alone are ineffective or inappropriate. NICE emphasises shared decision-making, notes that serious adverse effects are infrequent, and highlights that vaginal oestrogen is absorbed locally with minimal systemic absorption. NG112 also advises reviewing treatment within 12 months and, if needed, trying single-dose antibiotic prophylaxis or methenamine hippurate before daily antibiotics—an important antimicrobial stewardship message. NICE

NICE menopause guidance. The menopause guideline (NG23) also recommends vaginal oestrogen for genitourinary symptoms (GSM) and signposts clinicians to NG112 for people with recurrent UTIs. It reiterates that systemic absorption is minimal and advises tailored discussions—especially for people with a personal history of breast cancer—while still allowing carefully considered use in many such cases through shared decision-making. NICE

The evidence: does low-dose vaginal oestrogen prevent recurrent UTIs?

Randomised trial evidence. In a landmark randomised, placebo-controlled trial, intravaginal estriol markedly reduced UTI incidence in post-menopausal women with recurrent infections: 0.5 vs 5.9 episodes per patient-year with placebo, a dramatic difference that has informed practice for decades. A 2008 Cochrane review concluded that vaginal oestrogens reduced UTI frequency versus placebo, though it noted small sample sizes and heterogeneity of preparations and treatment durations. New England Journal of Medicine+1

Contemporary data. More recent observational work in large, real-world cohorts has found ~50% reductions in UTI frequency over the year following a vaginal oestrogen prescription for hypo-oestrogenic women, suggesting meaningful effectiveness at scale. A 2024 trial of ultra-low-dose 0.005% estriol gel reported a 26% reduction in UTI incidence and improvements in vaginal pH—evidence that very low doses can still deliver clinically relevant benefits. Mechanistic and clinical reviews reinforce that vaginal oestrogen both lowers UTI risk and improves GSM symptoms with a strong safety profile. PubMed+2PubMed+2

Limits and nuance. A UK rapid evidence review (Dec 2024) found no eligible studies on primary prevention of UTIs using vaginal oestrogen in women without prior UTIs, underscoring that the best-supported use remains secondary prevention in those with recurrent infections. GOV.UK

Safety and acceptability

NICE advises candid conversations about benefits, risks, and product choice (cream, gel, tablet/pessary, or ring). Vaginal oestrogen is off-label for UTI prevention but endorsed in NG112 with shared decision-making. Systemic absorption is minimal, which is particularly relevant for people worried about systemic HRT risks. For those with a personal history of breast cancer, NG23 outlines when vaginal oestrogen may still be considered (often in collaboration with the oncology team). Most formulations start with a two-week daily “loading” phase, followed by twice-weekly maintenance or a 3-monthly ring—flexibility that supports adherence. NICE+1

What does it cost to prevent a UTI this way?

Vaginal oestrogen is relatively inexpensive in the NHS:

• Estradiol 10 microgram vaginal tablets (generic Vagirux®/estradiol pessaries): ~£11–£11.34 for 24 tablets. With twice-weekly maintenance after loading, annual drug cost is typically ~£44–£50 per patient. cptv.org.uk
• Estring® (estradiol 7.5 microgram/24 h vaginal ring): NHS indicative price ~£31.42 per ring, replaced every 3 months (≈ £126/year). BNF

Even allowing for initial loading doses and follow-up, these figures are tiny compared with the ~£3,183 average cost per UTI admission implied by UKHSA’s national totals. GOV.UK

Back-of-the-envelope savings for England: a conservative model

Let’s anchor this to UKHSA’s 2023–24 data:

• Total UTI admissions: 189,756
• Women >50 (target group): 37.1% of all admissions ≈ , 70,400 admissions
• Mean length of stay (all ages): 6.4 days
• Average cost per admission: ~£3,183 (derived from £604m/189,756) GOV.UK

Now consider two scenarios (purely illustrative) for peri-/post-menopausal women with recurrent UTIs:

Scenario A — Conservative, grounded in ultra-low-dose data

• Eligibility & uptake: 25% of women >50 admitted with a UTI are identified as having recurrent UTIs and start vaginal oestrogen (≈ 17,600 people).
• Effect size: 26% reduction in UTIs (from the 0.005% estriol gel study). PubMed
• Admissions averted: ≈ 4,576 per year.
• Gross savings: 4,576 × £3,183 ≈ £14.6 million.
• Drug cost: 17,600 × ~£44/year ≈ £0.78 million (tablets; ring would cost more but still a fraction of savings).
• Net savings: ~£13.8 million, plus ~29,000 bed-days freed (assuming 6.4 days/admission).

Scenario B — Moderately ambitious, reflecting real-world cohort data

• Eligibility & uptake: 50% of women >50 with a UTI admission and documented recurrence start therapy (≈ 35,200 people).
• Effect size: 50% reduction in UTIs (observational data). PubMed
• Admissions averted: ≈ 17,600 per year.
• Gross savings: 17,600 × £3,183 ≈ £56.0 million.
• Drug cost: 35,200 × ~£44/year ≈ £1.55 million.
• Net savings: ~£54.5 million, plus ~113,000 bed-days freed.

Caveats. These are illustrative calculations that assume (a) treated women would otherwise have similar admission risk to the overall women->50 cohort, (b) reductions in recurrent UTIs translate proportionally into fewer hospitalisations, and (c) consistent adherence. In reality, effect sizes and admission risks vary; some savings will occur in primary care (fewer GP visits, community antibiotics) rather than hospital. The point is not precision but scale: even modest uptake and effectiveness yield multi-million-pound savings and thousands of bed-days released, while advancing antibiotic stewardship. NICE

Implementation: a practical pathway for systems and clinicians

1) Identify the right patients.
Focus on peri- and post-menopausal people with recurrent UTIs (≥2 in 6 months or ≥3 in 12 months), especially those aged >50, recently admitted with a UTI, or frequently treated in urgent care. Consider implementing simple EHR flags for repeated UTI codes or antibiotic courses, and add discharge prompts after a UTI admission to evaluate for recurrence. NICE

2) Optimise shared decision-making.
Use a standardised conversation: outline likely benefits (fewer UTIs, improved GSM symptoms), low systemic exposure, rare serious adverse effects, and options (cream/gel/tablet/pessary/ring). Offer a patient leaflet plus dosing schedule (two-week loading, then maintenance). Document clear review points (e.g., at 3–6 months and 12 months). NICE+1

3) Build a “prevention-first” sequence consistent with NICE.
Start with behavioural advice and self-care (hydration, timed voiding, addressing constipation), then vaginal oestrogen for recurrent UTIs. Reserve single-dose antibiotics for triggers (e.g., post-coital) or methenamine hippurate as alternatives before daily antibiotic prophylaxis. This preserves antibiotic options and helps contain resistance. NICE

4) Make prescribing frictionless.

• Add formulary-preferred vaginal oestrogen options with costs (e.g., estradiol 10 mcg pessaries, Estring) to primary-care templates and discharge summaries.
• Include the dose-loading instruction and then twice-weekly maintenance (or a 3-monthly ring).
• Record the indication as recurrent UTI prevention (off-label, in line with NG112) and GSM if present. cptv.org.uk+2BNF+2

5) Monitor outcomes.
Track: (a) number of UTI courses per patient, (b) UTI-related ED attendances and admissions, (c) antibiotic days supplied, and (d) patient-reported GSM symptom relief. Set review points at 6 and 12 months; continue if effective and well-tolerated.

6) Integrate with frailty and care-home pathways.
Older women (70+) account for over half of UTI admissions; embedding recurrent-UTI prevention into frailty MDTs and care-home in-reach could amplify impact—particularly where catheter use, dehydration risk, or delirium are common concerns. GOV.UK

Addressing common questions and concerns

Is vaginal oestrogen “HRT”?
It is local (not systemic) therapy. NICE notes minimal systemic absorption, which makes safety and contraindication profiles different from systemic HRT. Many people who cannot—or prefer not to—use systemic HRT can still use vaginal oestrogen. NICE

What about people with a history of breast cancer?
NICE NG23 allows consideration of vaginal oestrogen for persistent GSM after non-hormonal options, with shared decision-making and, where relevant, input from the oncology team. Decisions should be individualised. NICE

Will this replace antibiotics?
No. Vaginal oestrogen is a prevention strategy for those with recurrent UTIs. When infections occur, treat according to antimicrobial guidance. But prevention often reduces the need for frequent antibiotics, which supports stewardship and may reduce resistant infections that are costlier to treat. GOV.UK

Is there evidence for “primary prevention” (in people without prior UTIs)?
No robust evidence yet; the best-supported indication remains recurrent UTI. GOV.UK

Why this matters now

UTI hospitalisations rose ~9% year-on-year in 2023–24 and already cost £604m, with peak pressure in older age groups and women. Vaginal oestrogen is inexpensive, guideline-endorsed, and clinically effective for recurrent UTIs. A targeted rollout—especially post-discharge after a UTI admission or via primary-care registers of recurrent UTIs—could save millions, free tens of thousands of bed-days, and reduce antibiotic exposure across England. Even conservative assumptions deliver double-digit million-pound savings against a tiny drug bill. GOV.UK+2NICE+2

Conclusion

UTIs are a primary, under-recognised driver of hospital use and cost in England. The UKHSA data show a heavy burden concentrated among older adults—particularly women over 50—and a system already contending with bed pressures and antimicrobial resistance. Against that backdrop, low-dose vaginal oestrogen stands out: it is safe, cheap, and effective at reducing recurrent UTIs in peri- and post-menopausal people. NICE already recommends considering it for the right patients.

Implementing a prevention-first pathway—behavioural advice, then vaginal oestrogen, before stepping up to single-dose antibiotic prophylaxis, methenamine, or daily antibiotics—aligns clinical practice with antimicrobial stewardship and unlocks meaningful, near-term savings. Targeted at women most at risk, this simple measure could return millions to the NHS, deliver better patient experiences, and reduce pressure on beds—all while cutting avoidable antibiotic use. That’s value medicine in action. GOV.UK+1

FAQ

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Sources

• UKHSA. Understanding the burden of UTI hospitalisations in England (published 15 July 2025). Key figures on admissions, bed-days, cost, age/sex distribution, and trends. GOV.UK
• NICE NG112. Urinary tract infection (recurrent): antimicrobial prescribing. Oestrogen recommendations, sequencing before antibiotic prophylaxis, and shared decision-making. NICE
• NICE NG23. Menopause: identification and management. Genitourinary symptoms, minimal systemic absorption, and considerations for breast cancer history. NICE
• Raz & Stamm. A controlled trial of intravaginal estriol in postmenopausal women. NEJM 1993: significant reduction in UTI incidence vs placebo. New England Journal of Medicine
• Tan-Kim et al. Efficacy of vaginal estrogen for recurrent UTI prevention in hypoestrogenic women. AJOG 2023: ~50% reduction over 12 months. PubMed
• Fernández et al. 2024: Ultra-low-dose estriol 0.005% gel reduced UTI incidence by 26% and improved vaginal pH. PubMed
• Rosenblum et al. 2020: Mechanisms (pH, Lactobacillus), safety and efficacy overview for vaginal oestrogen. PMC
• Cost references: Drug Tariff/BNF indicative prices for estradiol pessaries and Estring. cptv.org.uk+1

Note: This article is informational and not a substitute for individual clinical judgment. Clinicians should apply NICE guidance and patient preferences to each case.