Genitourinary Infections in Diabetes: Understanding Risk and Guiding the Diabetes Care Team

Pathophysiology

Multiple mechanisms contribute to the increased infection risk seen in diabetes. Hyperglycemia impairs both innate and adaptive immunity, reducing neutrophil and granulocyte function and downregulating antimicrobial peptides such as psoriasin, which compromises epithelial integrity and promotes bacterial colonization by Escherichia coli.^5,7 Glucosuria, a result of chronic hyperglycemia or sodium-glucose cotransporter 2 (SGLT2) inhibitor therapy, provides a nutrient-rich environment for pathogens and increases risk for both UTIs and genital mycotic infections.^8-12 Additional factors that increase infection risk in people with diabetes include metabolic, neurologic, and structural abnormalities and medication-related effects (Table 1).

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Table 1

Risk Factors and Mechanisms Contributing to Genitourinary Infection Risk in Diabetes^{1-7 ,10-13}

Category	Specific factors	Mechanisms or effects
Metabolic	Hyperglycemia	Impairs neutrophil and granulocyte function; reduces antimicrobial peptides (eg, psoriasin); promotes Escherichia coli colonization
Renal	Glucosuria (from hyperglycemia or SGLT2 inhibitors)	Provides nutrient-rich medium for bacterial and fungal growth
Neurologic	Autonomic neuropathy	Causes incomplete bladder emptying and increased postvoid residual urine
Structural/functional	Nephropathy, incontinence, catheter use	Leads to urinary stasis and bacterial proliferation
Demographic	Female sex, advanced age	Shorter urethra and postmenopausal mucosal changes increase infection risk
Medication-related	SGLT2 inhibitor therapy	Increases genital mycotic infections; rare cases of Fournier gangrene reported

Abbreviation: SGLT2, sodium-glucose cotransporter 2.

Clinical Manifestations

Patients with diabetes experience more frequent and severe UTIs, including complicated infections such as emphysematous pyelonephritis, emphysematous cystitis, renal papillary necrosis, and perinephric abscess.^2,3,13 Fungal infections, especially Candida species, are also common. Genital mycotic infections, such as vulvovaginitis and balanitis, are particularly increased among patients taking SGLT2 inhibitors.^8-17

SGLT2 Inhibitors and GUI Risk

SGLT2 inhibitors are associated with a 3- to 5-fold increased risk of genital mycotic infections, which are generally mild and manageable. The association with UTIs, however, is less consistent across studies.^11,12,15-19 Although rare, severe complications such as Fournier’s gangrene have prompted FDA warnings and warrant clinician vigilance and patient education.^11,15,19

Given these risks, diabetes care and education specialists (DCESs) play an essential role in supporting safe and effective SGLT2 inhibitor use. DCESs reinforce practical self-care behaviors, such as maintaining daily genital hygiene, staying well hydrated, and recognizing early signs of infection, and ensure patients understand when to contact their care team. They also help contextualize mild genitourinary symptoms within the broader benefits of SGLT2 therapy, addressing concerns that might otherwise lead to discontinuation. Through individualized education and close communication with prescribers, DCESs help patients balance infection risk with the significant glycemic and cardiorenal advantages of these agents.

Implications for the Diabetes Care Team

Effective prevention and management of GUIs in diabetes require proactive, team-based strategies. DCESs and other diabetes team members play a key role in assessing risk, providing education, and coordinating care. Prevention and management of GUIs require a proactive, multidisciplinary approach centered on education, risk assessment, and timely intervention. Key strategies for diabetes care teams are outlined in Table 2.

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Table 2

Prevention and Management Strategies for Genitourinary Infections in Diabetes^8-19

Intervention area	Key actions for the diabetes care team	Clinical considerations
Risk assessment	Review history of GUIs, incontinence, and catheter use prior to SGLT2 inhibitor initiation	Identifies patients at elevated risk
Patient selection	Use caution with SGLT2 inhibitors in those with recurrent infections or urologic abnormalities	Balance GUI risk with glycemic and cardiorenal benefits
Patient education	Teach genital hygiene, symptom recognition, and early reporting of GUI symptoms	Reduces recurrence and promotes adherence
Prompt management	Treat infections per standard guidelines; refer recurrent or complicated cases	Ensures timely and effective resolution
Interdisciplinary coordination	Collaborate across endocrinology, nephrology, and primary care	Promotes safe medication use and comprehensive care

Abbreviations: GUI, genitourinary infection; SGLT2, sodium-glucose cotransporter 2.

Special Considerations in Women

Urinary incontinence is common among postpartum and postmenopausal women with diabetes and increases risk for recurrent UTIs and skin infections. Glucosuria in the context of incontinence can lead to severe skin infections, including necrotizing fasciitis. Addressing incontinence prior to SGLT2 inhibitor initiation and reinforcing hygiene and skin care strategies can reduce these risks.^2,3,19

Conclusion

GUIs represent a common and clinically meaningful complication of diabetes, driven by the combined effects of hyperglycemia-related immune dysfunction, glucosuria, and diabetes-associated neurologic and structural abnormalities.^1-6,13 The expanding use of SGLT2 inhibitors further underscores the need for careful risk assessment because these agents provide substantial glycemic, cardiovascular, and renal benefits while increasing susceptibility to genital mycotic infections and, rarely, severe infectious complications.^8-12,15,19 Effective management therefore extends beyond treatment of active infection and requires proactive, preventive strategies embedded within routine diabetes care. DCESs and other members of the diabetes care team are uniquely positioned to translate pathophysiologic risk into practical self-care behaviors, support informed and sustained medication use, and facilitate early recognition and intervention for genitourinary symptoms.^14-16 By integrating patient-centered education, anticipatory guidance, and interdisciplinary collaboration into diabetes management, care teams can reduce infection-related morbidity, promote therapeutic persistence, and optimize outcomes for people living with diabetes.^15,16 ■