Guideline sources The following summarized guidelines for the evaluation and management of recurrent urinary tract infection in women (rUTI) are prepared by our editorial team based on guidelines from the European Association of Urology (EAU 2022), the American Urological Association (AUA/CUA/SUFU 2019), the Spanish Society of Clinical Microbiology and Infectious Diseases (SEIMC 2017), the Society of Obstetricians and Gynaecologists of Canada (SOGC 2017), and the American Association of Family Physicians (AAFP 2011). 1 2 3 4 5 Guidelines 1. Classification and risk stratification Risk factors: recognize that the main risk factor for recurrent UTIs in sexually active females is the frequency of sexual intercourse. B Show 2 more 2. Diagnostic investigations https://web.pathway.md/diseases/receR4xZVqAp47F3A 1/5 6/24/23, 2:57 PM Recurrent urinary tract infection in women Pathway History and physical examination: elicit a complete patient history and perform a pelvic examination in patients presenting with recurrent UTIs. E Urine tests: As per EAU 2022 guidelines, obtain urine culture to diagnose recurrent UTI. A As per AUA 2019 guidelines, document positive urine cultures associated with previous symptomatic episodes in order to make a diagnosis of recurrent UTIs. E Show 2 more As per SEIMC 2017 guidelines: Obtain pre-treatment urine culture in patients with an early symptomatic recurrence. B Avoid obtaining urological studies in sexually active patients with recurrent UTIs if there is no suspicion of underlying urological disease. D As per SOGC 2017 guidelines, obtain urinalysis and midstream urine culture and sensitivity with the first presentation of symptoms in order to establish a correct diagnosis of recurrent UTI. B As per AAFP 2011 guidelines, obtain urine culture in patients with a UTI recurred within 2-4 weeks after the completion of treatment. B Urinary tract imaging: As per EAU 2022 guidelines, do not obtain an extensive routine workup including abdominal ultrasound in < 40 years old patients with recurrent UTIs with no risk factors. D As per AUA 2019 guidelines, do not obtain upper urinary tract imaging routinely in the index patient presenting with recurrent UTI. D As per SOGC 2017 guidelines, obtain upper urinary tract imaging in patients with persistent hematuria or persistent growth of bacteria aside from E. coli. B 3. Diagnostic procedures Cystoscopy: As per EAU 2022 guidelines, do not obtain an extensive routine workup including cystoscopy in < 40 years old patients with recurrent UTIs with no risk factors. D As per AUA 2019 guidelines, do not perform cystoscopy routinely in the index patient presenting with recurrent UTI. D As per SOGC 2017 guidelines, perform cystoscopy in patients with persistent hematuria or persistent growth of bacteria aside from E. coli. B 4. Medical management Patient-initiated treatment: As per EAU 2022 guidelines, consider offering self-administered short-term antimicrobial therapy in patients with good compliance. B https://web.pathway.md/diseases/receR4xZVqAp47F3A 2/5 6/24/23, 2:57 PM Recurrent urinary tract infection in women Pathway As per AUA 2019 guidelines, consider offering patient-initiated treatment (self-start treatment) in selected patients with recurrent UTIs with acute episodes while awaiting urine cultures. C As per SEIMC 2017 guidelines, offer self-initiated treatment of cystitis in patients with < 3 UTIs per year as a convenient and effective strategy and to reduce the consumption of antibiotics associated with prophylaxis. B As per SOGC 2017 guidelines, restrict acute self-treatment to compliant and motivated patients with clearly documented recurrent UTIs. B Choice of antibiotics: administer nitrofurantoin, TMP-sulfamethoxazole, or fosfomycin depending on the local antibiogram data as first-line therapy in symptomatic patients with recurrent UTIs. B Show 2 more 5. Specific circumstances Patients with asymptomatic bacteriuria: do not treat patients with asymptomatic bacteriuria. D 6. Preventative measures Hygienic measures: avoid insisting on implementing hygiene measures in patients failed to prevent recurrent UTIs with hygiene. D Fluid intake: advise increasing fluid intake to reduce the risk of recurrent UTIs in premenopausal patients. B Spermicide use: advise sexually active patients experiencing recurrent UTIs and using spermicides to consider an alternative form of contraception. B Antibiotic prophylaxis: As per EAU 2022 guidelines, initiate continuous or postcoital antimicrobial prophylaxis to prevent recurrent UTIs if non-antimicrobial interventions have failed. Counsel patients regarding possible side effects. A As per AUA 2019 guidelines, consider initiating antibiotic prophylaxis, after discussing risks, benefits, and alternatives, to decrease the risk of future UTIs in patients of all ages previously diagnosed with UTIs. C As per SEIMC 2017 guidelines: Offer continuous or postcoital antibiotics, such as co-trimoxazole, nitrofurantoin, TMP, fluoroquinolones, or cephalosporins, B for 6-12 months to reduce the frequency of recurrent UTIs. A Use fluoroquinolones only when no other preventive strategy is available. B Restart the same prophylaxis regimen for a longer period (1-2 years) if UTI recurs after cessation of prophylaxis. B As per SOGC 2017 guidelines, do not initiate antibiotic prophylaxis for recurrent UTI until a negative culture 1-2 weeks after treatment has confirmed eradication of the UTI. D Show 2 more https://web.pathway.md/diseases/receR4xZVqAp47F3A 3/5 6/24/23, 2:57 PM Recurrent urinary tract infection in women Pathway Vaginal estrogen: As per EAU 2022 guidelines, offer vaginal estrogen therapy for the prevention of recurrent UTIs in postmenopausal patients. A As per AUA 2019 guidelines, offer vaginal estrogen therapy, if not contraindicated, to reduce the risk of future UTIs in peri- and postmenopausal patients with recurrent UTIs. B As per SEIMC 2017 guidelines: Offer vaginal estrogens A to reduce the frequency of recurrent UTIs in patients with associated vaginal atrophy and in all postmenopausal patients. B Do not use oral estrogen for the prevention of recurrent UTIs. D As per SOGC 2017 guidelines, offer vaginal estrogen to prevent episodes of UTI in postmenopausal patients with recurrent UTIs. A Cranberry: As per EAU 2022 guidelines, advise patients using cranberry products to reduce recurrent UTI episodes, recognizing that the quality of evidence underpinning this is low with contradictory findings. B As per AUA 2019 guidelines, consider advising cranberry prophylaxis in patients with recurrent UTIs. C As per SEIMC 2017 guidelines, offer cranberry products, such as proanthocyanidins 72 mg, for a 6-12-month period for the prevention of recurrent UTIs. A Recognize that cranberries are not effective in patients with few episodes of UTIs A and are inferior to antibiotic prophylaxis. B As per SOGC 2017 guidelines, inform patients that cranberry products are effective in reducing recurrent UTIs. A Immunoprophylaxis: As per EAU 2022 guidelines, offer immunoprophylaxis with uropathogenic bacteria to reduce recurrent UTIs in all age groups. A As per SEIMC 2017 guidelines, consider offering oral and intranasal vaccines against uropathogenic bacteria for the prevention of recurrent UTIs. C As per SOGC 2017 guidelines, do not offer mucosal or parenteral vaccines against uropathogenic bacteria for the prevention of recurrent UTIs. D Intravesical hyaluronic acid: perform intravesical instillations of hyaluronic acid or a combination of hyaluronic acid and chondroitin sulfate to prevent recurrent UTIs if less invasive preventive approaches have been unsuccessful, recognizing that further studies are needed to confirm the results of initial trials. B D-mannose: As per EAU 2022 guidelines, offer D-mannose to reduce recurrent UTI episodes, recognizing that further studies are needed to confirm the results of initial trials. B https://web.pathway.md/diseases/receR4xZVqAp47F3A 4/5 6/24/23, 2:57 PM Recurrent urinary tract infection in women Pathway As per SEIMC 2017 guidelines, offer D-mannose for a 6-month period to reduce the frequency of recurrent UTIs. B Probiotics: As per EAU 2022 guidelines, offer local or oral probiotics containing strains of proven efficacy for vaginal flora regeneration to prevent UTIs. B As per SEIMC 2017 guidelines, insufficient evidence to support the use of vaginal lactobacilli for the prevention of recurrent UTIs. I As per SOGC 2017 guidelines, do not offer probiotics for the prevention of recurrent UTIs. D Vitamin C: do not use vitamin C for the prevention of recurrent UTIs. D Acupuncture: consider offering acupuncture as an alternative for the prevention of recurrent UTIs in patients unresponsive to or intolerant of antibiotic prophylaxis. B 7. Follow-up and surveillance Follow-up: do not obtain surveillance urine testing, including urine culture, in asymptomatic patients with recurrent UTIs. D Show 2 more References 1. Anger J, Lee U, Ackerman AL et al. Recurrent Uncomplicated Urinary Tract Infections in Women: AUA/CUA/SUFU Guideline. J Urol. 2019 Aug;202 2 282 289. Open 2. G. Bonkat, R. Bartoletti, F. Bruy re et al. EAU Guidelines on Urological Infections. EAU. 2022. Open 3. de Cueto M, Aliaga L, Al s JI et al. Executive summary of the diagnosis and treatment of urinary tract infection: Guidelines of the Spanish Society of Clinical Microbiology and Infectious Diseases SEIMC . Enferm Infecc Microbiol Clin. 2017 May;35 5 314 320. Open 4. Annette Epp, Annick Larochelle. No. 250 Recurrent Urinary Tract Infection. J Obstet Gynaecol Can. 2017 Oct;39 10):e422-e431. Open 5. Richard Colgan, Mozella Williams. Diagnosis and treatment of acute uncomplicated cystitis. Am Fam Physician. 2011 Oct 1;84 7 771 6. Open 6. Chris Harding, Helen Mossop, Tara Homer et al. Alternative to prophylactic antibiotics for the treatment of recurrent urinary tract infections in women: multicentre, open label, randomised, non-inferiority trial. BMJ. 2022 Mar 9;376:e068229. Open https://web.pathway.md/diseases/receR4xZVqAp47F3A 5/5