Learning Objectives:After participating in this continuing professional development activity, the provider should be better able to:
1. Describe diagnosis of women with recurrent urinary tract infection (UTI).
2. Identify genitourinary pathology that may present with recurrent UTI.
3. Select best practices for antibiotic selection and duration for treatment of recurrent UTI.
4. Synthesize a management plan for prevention of recurrent UTI.
Urinary tract infection (UTI) is one of the most common infections in women, with more than half of all women reporting UTI in their lifetime.1 Many women with UTI will experience a recurrence of UTI. Between 30% and 44% of women will experience a recurrent UTI within 6 months of a first UTI, and up to 50% of women will experience multiple recurrent UTIs.2,3
Recurrent UTI is a burdensome and costly condition. Women with recurrent UTI experience a negative impact on their quality of life.4,5 Beyond the individual disease burden, other costs of recurrent UTI include the expense of urgent and often unpredictable medical evaluation and treatments, and missed time out of work. Risks of frequent antibiotic use, such antibiotic side effects, the associated impact on the microbiome and other sequelae, and the possible emergence of drug-resistant bacteria are other concerns.
As providers of health care for women throughout their lifetime, obstetrician/gynecologists are uniquely poised to recognize, treat, and prevent recurrent UTIs in their patients. The goal of this document is to review the diagnostic criteria for recurrent UTI, suggested evaluation of women with recurrent UTI, recommendations for antibiotic selection and duration for treatment of recurrent UTI, and the management options for prevention of recurrent UTI.
Terminology and Definitions
Various definitions of UTI and recurrent UTI exist and have been used over the years. These include the following definitions.
Urinary Tract Infection
UTIs can include infection anywhere along the lower and/or upper urinary tract, including the urethra, bladder, ureters, and kidneys. UTI is diagnosed based on the presence of clinical symptoms and presence of a pathogen on laboratory studies. A more commonly used definition of UTI describes infection of the bladder, or cystitis. UTI is often used interchangeably to imply acute bacterial cystitis.
Recurrent UTI
There are multiple definitions of recurrent UTI. Both the American Urogynecologic Society and the American Urologic Association endorse use of the following clinically useful, culture-based definition: at least 2 culture-proven episodes of acute bacterial cystitis within 6 months or at least 3 within 1 year.6.7
Most diagnoses of recurrent UTI are believed to be caused by separate infectious events. This is defined as a subsequent UTI occurring more than 2 weeks after the initial UTI or being caused by a different pathogen. However, it is also possible to have a persistent UTI, where symptoms continue despite treatment, or relapses in UTIs where the same pathogen causes another infection within 2 weeks of completing appropriate treatment.
Uncomplicated Versus Complicated UTI
UTI can be categorized as either uncomplicated or complicated. For the purpose of this review, uncomplicated UTI is defined as absence of factors that increase a patient's age-related risk for UTI and/or predispose her to more severe infections or decreased treatment efficacy. Most cases of recurrent UTIs are uncomplicated infections.
Complicating factors include the following: evidence of systemic infection or upper urinary tract involvement (eg, pyelonephritis or urosepsis), a structurally abnormal genitourinary tract (eg, bladder diverticulum), kidney or bladder stones, neurogenic bladder (eg, spinal cord injury or multiple sclerosis), compromised immune system (eg, neutropenia or advanced HIV infection), and a history of infection with a multidrug-resistant bacterium. Pregnant patients and those with a history of renal transplantation have additional considerations that are not addressed here. Patients with diabetes mellitus are at increased risk from UTIs, though the presence of diabetes is not necessarily a complicating factor.
Asymptomatic Bacteriuria
Asymptomatic bacteriuria is a condition in which there is presence of bacteria of any magnitude in the urine that causes no symptoms or illness. The Infectious Diseases Society of America defines asymptomatic bacteriuria as 2 consecutive voided urine specimens with isolation of the same bacterial strain in quantitative counts of 105 colony-forming units or greater in the absence of UTI symptoms.8 Asymptomatic bacteriuria is common, with 5% of premenopausal women and up to 50% of institutionalized older women meeting criteria.8 Nonpregnant women should not be screened or treated for asymptomatic bacteriuria.
Risk Factors for Recurrent UTI
Recurrent UTIs affect women of all ages. However, recurrent UTIs are commonly seen in a bimodal age distribution, with women ages 18 to 34 years and older than 55 years having the highest incidence of recurrent UTI.9 Risk factors for recurrent UTIs also include recent sexual intercourse, new sexual partner, intercourse frequency, spermicide use, pelvic organ prolapse, urinary incontinence, accidental bowel leakage, a history of urogynecologic surgery, incomplete bladder emptying, diabetes, functional disability, and family history (eg, mother with a history of UTIs).9,10 Postmenopausal women with recurrent UTI often have a history of premenopausal UTI and cystocele.11 Patients with diabetes treated with sodium-glucose co-transporter 2 inhibitors, which inhibit renal glucose absorption, have an increased risk of UTI.12
Some of these risk factors may predispose patients to vaginal colonization with uropathogens. This could be related to decreased presence of lactobacillus (eg, nonoxynol-9 is toxic to lactobacillus), genetic predisposition to express receptors that bind uropathogenic bacteria (eg, nonsecretor phenotype), and introital colonization with uropathogens.13
Diagnosis of UTI and Recurrent UTI
UTI is diagnosed based on symptoms and presence of a pathogen on laboratory findings. Clinical symptoms of UTI include acute dysuria, urinary frequency, urinary urgency, and suprapubic pain in the absence of vaginal symptoms. The probability of UTI is 50% in women who present with 1 or more symptoms, and increased to 90% in women with dysuria and urinary frequency without vaginal discharge or irritation.14 Women with infrequent episodes of UTIs with classic clinical presentations can often be treated without additional laboratory testing.
Additional evaluation is warranted when women have frequent or recurrent symptoms of UTI, if presenting without classic symptoms of dysuria, urinary frequency, urinary urgency, or suprapubic pain, or if there is an unclear clinical picture. Women with frequent UTI symptoms may experience diagnostic delay or receive inappropriate treatment if clinicians do not carefully review the history and confirm with laboratory findings.
To establish the diagnosis of recurrent UTI, it is recommended that symptomatic UTI episodes are confirmed with urine culture on 2 occasions within 6 months, or 3 occasions within 12 months. Women who have frequent UTI symptoms should have their diagnosis confirmed with urine culture and have additional evaluation as explained next.
Evaluation of Women With Recurrent UTI
The evaluation of a patient with recurrent UTIs begins with a comprehensive history and physical examination. This is an important step toward identifying patients who may benefit from further work-up.
A thorough characterization of symptoms that are present during episodes of UTI should be elicited. The presence of dysuria is critical to an accurate diagnosis. Additional symptoms, including urinary frequency, urinary urgency, hematuria, new-onset urinary incontinence, and suprapubic pain, may or may not be present. Systemic symptoms such as fevers, chills, or flank pain should be elicited. Other diagnoses that may be considered include vaginitis, urethritis, vulvitis, overactive bladder, and painful bladder syndrome. A careful review of other vulvovaginal symptoms will help to clarify the diagnosis. If symptoms are limited to those such as urine odor or cloudy appearing urine, or there is an absence of any urinary symptoms, this suggests a diagnosis of asymptomatic bacteriuria.
When patients present with a history of recurrent UTI, clinicians should attempt to determine whether prior symptomatic episodes were confirmed with urinalysis and urine culture. This may entail review of prior and/or outside laboratory results. If symptoms are consistent with recurrent UTI but without laboratory testing, then the patient should be instructed to have an evaluation of the urine with urinalysis and urine culture during future symptomatic episodes. It can be helpful to provide the patient with a laboratory order and instructions for future symptomatic episodes. If a review of laboratory findings does not confirm the diagnosis of recurrent UTI, alternate diagnoses should be considered.
Pertinent medical history should be assessed. Some notable examples include history of congenital anomalies of the urinary tract, neurologic conditions such as spinal cord injury or multiple sclerosis, immunosuppression therapy, diabetes and medications used for management, renal insufficiency, chronic corticosteroid use, history of organ transplantation, urinary incontinence, pelvic organ prolapse symptoms, chronic diarrhea or fecal incontinence, symptoms suggestive of urinary retention, and history of kidney stones. Pertinent gynecologic history includes menstrual history, menopausal status, sexual history, and contraceptive use (eg, spermicide-coated condoms or diaphragms). Additionally, it is critical to be aware of prior genitourinary procedures (such as vaginal mesh-based surgeries or prior urinary incontinence surgery).
The pelvic examination should pay careful attention to vulvovaginal tissues. Pertinent findings include estrogen status of the tissues in peri- and postmenopausal patients, significant vulvitis, which may cause vulvar dysuria, the presence of any significant anterior compartment pelvic organ prolapse, suburethral mass or tenderness that could be indicative of urethral diverticulum, and presence of any foreign bodies such as vaginal mesh. If there is clinical concern for urinary retention, then assessment of bladder emptying with post-void residual volume should be considered.
Urine Collection and Testing
A clean-catch, midstream voided urine is adequate most often. Patients should be instructed on proper collection technique, which includes use of local disinfectant, separation of the labia to minimize contact of the urine stream with the vulva, discarding the initial urine, and then collecting the midstream urine sample. Some patients with recurrent UTI may perform urine collection at home, and can be provided a sterile container for collection. They should be instructed after collection to tightly close the lid of the sample and to place it immediately in a refrigerator until it is transported to the laboratory. Urine samples collected with the first morning void typically have the highest concentration of bacteria. Samples collected later in the day may have lower colony counts and may not be accurate due to more dilute urine and with prior voids decreasing bacterial concentration.
Consideration of collecting a urine specimen by catheterization is reasonable in some instances, including in women for whom the diagnosis of recurrent UTI is unclear. Examples include women who may have difficulty collecting an adequate voided clean-catch due to pelvic organ prolapse, vulvitis, when prior urine specimens appear contaminated or growing multiple organisms, or patient inability to collect an adequate specimen.
Urinalysis
Urinalysis is often used as a diagnostic test for UTI. It is indicated in patients with recurrent UTI and those patients without classic symptoms of UTI.
Dipstick Testing
Dipstick testing can detect the presence of leukocyte esterase and nitrites in a urine sample. Leukocyte esterase is present in white blood cells and is suggestive of pyuria. The presence of nitrites is indicative of bacteriuria. Certain uropathogens produce nitrate reductase, an enzyme that transforms urine nitrate, a metabolite of alimentary origin, into nitrite that is detected by dipstick. Bacteria that produce nitrate reductase include Escherichia coli, Proteus mirabilis, and Klebsiella. Not all uropathogens produce nitrate reductase; therefore, a urine dipstick with negative nitrites does not rule out a UTI.
The sensitivity of a urine dipstick with a positive leukocyte esterase is 75% to 96%, with a specificity of 41% to 87%. The sensitivity of a urine dipstick with positive nitrites is 34% to 42%, with a specificity of 94% to 98%. Diagnostic performance of the urine dipstick is best when leukocyte esterase and nitrites are both positive, which yields an approximate sensitivity of 75% and specificity of 82%. Diagnostic accuracy is largely dependent on pretest probability, which is highest in patients with urinary frequency and dysuria in the absence of vaginal discharge. In such patients, when the dipstick has both leukocyte esterase and nitrites, the posttest probability of UTI goes up to 97%.15
Urine Microscopy
White Blood Cells
Women with UTI should have pyuria on urine microscopy. Pyuria is defined as at least 10 white blood cells per high-power field.9 The absence of pyuria in the setting of a positive urine culture suggests bacterial colonization of the urinary tract, not infection. White blood cell casts may be found in pyelonephritis or other renal inflammatory conditions, such as glomerulonephritis.
Sterile pyuria is defined as the presence of pyuria with a negative urine culture. In patients with recurrent UTI symptoms who are found to have sterile pyuria, alternative diagnoses should be considered. The differential diagnosis of sterile pyuria includes contamination of the urine specimen from vaginal leukocytes or disinfectant solution, painful bladder syndrome/interstitial cystitis, kidney or bladder stones, infection with atypical organisms (eg, Chlamydia trachomatis, Ureaplasma urealyticum, or Mycobacterium tuberculosis), urinary tract malignancy, and inflammatory renal disease.
Red Blood Cells
UTI can cause both gross and microscopic hematuria. Patients with UTI and hematuria should be evaluated for resolution of hematuria after treatment of UTI. Gross hematuria in the absence of UTI symptoms or confirmatory urine culture should prompt an evaluation of the urinary tract. Persistent microscopic hematuria (>=3 red blood cells per high-powered field) in the absence of infection should prompt risk stratification and further evaluation of microscopic hematuria if indicated.16
Crystals
Crystals may be seen in the urine sediment. Crystals are commonly found in normal patients, but may also be a sign of nephrolithiasis. Calcium oxalate crystals may be seen with calcium oxalate nephrolithiasis, the most common stone type. Uric acid crystals may be observed in those with uric acid nephrolithiasis. Struvite stones should be considered with magnesium ammonium phosphate crystals, especially if urine also has alkaline pH (>8) and UTI is due to urease-producing organisms.17
Microorganisms
Oftentimes bacteria and yeast can be seen on urine microscopy. Presence of bacteria on microscopy is not diagnostic of UTI. The presence of bacteria in the absence of pyuria, especially when various strains are found, may be due to asymptomatic bacteriuria, or due to contamination during urine collection. Yeast can also commonly be seen on microscopy and most likely represents colonization.
Urine Culture
A urine culture sent before antibiotic treatment can help to confirm the diagnosis of UTI and provide information regarding antibiotic susceptibility. Traditionally, a positive urine culture includes a colony count of 105 colony-forming units of 1 or 2 organisms. There is no single definition of a positive urine culture that is uniformly accepted across the major societies in North America. Some organizations, including the Society of Obstetricians and Gynaecologists of Canada, consider 102 colony-forming units to be positive if the patient has symptoms.18 The traditional definition of 105 colony-forming units has 94% specificity and 50% to 70% sensitivity in detecting UTI.15 Using the lower threshold of 102 colony-forming units increases sensitivity to 88%.19
Some laboratories only report growth of greater than 104 colony-forming units, which may lead to false-negative urine cultures. It is also notable to remember that bacterial colony counts can be influenced by urine collection technique, and hydration status, and diuretic use, which may dilute the urine bacteria. Urine cultures that grow more than 2 organisms are generally considered contaminated. If the clinical picture is concerning for UTI, repeat urine culture can be performed with consideration of the urine sample being collected by catheterization.6,9
Common uropathogens identified on standard urine cultures include E coli, Klebsiella pneumoniae, Proteus mirabilis, and Enterococcus faecalis. The current standard urine culture technologies have been tailored to detect these common, fast-growing aerobic uropathogens.20 However, DNA sequencing of urine has revealed that additional uropathogens exist, which are not always detected by the standard urine culture technique. Enhanced urine culture techniques have been developed with use of larger urine volumes, anaerobic conditions, longer incubation periods, and alternate agars. These enhanced technique may help to identify more uropathogens, but they are not widely available or routinely used.21
Additional Evaluation
Additional evaluation with imaging or cystoscopy is not routinely indicated in women with recurrent UTI. Consideration of additional imaging, cystoscopy, and referral for consultation to urology or urogynecology can be considered in some instances. Possible examples include relapsing UTIs, cultures notable for Proteus species, suspicion of bladder or urethral foreign body, unresolved microscopic hematuria, or structural abnormalities.
Management of Acute UTI in Women With Recurrent UTI
There are several key differences in the management of acute UTI for women with recurrent UTI. Women with recurrent UTI should ideally submit a urine specimen for evaluation. The information obtained from urine culture results and local resistance patterns should be used to guide therapy. Avoiding empiric antibiotics with greater than 20% resistance in the community and in women with a history of multidrug-resistant UTI should be considered.7
Symptoms of UTI can initially be managed with the use of over-the-counter analgesics. Some UTIs are self-limited and may resolve without the use of antibiotics, and some patients may prefer to delay antibiotic use to avoid related side effects. Nonsteroidal anti-inflammatory agents, acetaminophen, and phenazopyridine can decrease discomfort in patients who do not have contraindications to these medications.22
First-line antibiotic treatment for an acute UTI is similar for patients with recurrent and intermittent UTIs. Preferred antibiotic treatment regimens for acute UTI and common contraindications are shown in Table 1.23 An extended or prolonged course of antibiotic treatment is not recommended in patients with recurrent UTIs. Use of increased doses of antibiotics in patients with recurrent UTI is also not recommended. There is insufficient data to suggest that increased dose or duration of antibiotic use is more effective. Increased duration of antibiotic use is more likely to result in loss of periurethral and vaginal protective microbiome; this may inadvertently result in more recurrences of UTI.
Certain clinical scenarios may be encountered in women with recurrent UTI. These include patients with recurrent UTI who experience UTI despite antibiotic prophylaxis. In this situation, patients should be instructed to stop prophylactic antibiotics before initiating treatment for the acute breakthrough UTI. Antibiotic prophylaxis can typically be resumed after completion of treatment course. It is also reasonable to avoid treating an acute UTI with the same antibiotic that is being used for suppression.
Management of Asymptomatic Bacteriuria
Women incidentally found to have asymptomatic bacteriuria should not be treated with antibiotics. Bacterial colonization is not associated with adverse outcomes. Treatment of asymptomatic bacteriuria does not decrease the risk of symptomatic UTI nor decrease future episodes of asymptomatic bacteriuria.8 These patients should be counseled regarding this diagnosis and aware that this may be chronic colonization.
Strategies for Prevention of Recurrent UTI
Patients with recurrent UTIs should be offered treatments to decrease the frequency of UTIs, although no treatment has been proven to reliably eliminate UTI.
Lifestyle and Behavioral Modifications
Many women attempt lifestyle and behavioral modifications in an effort to prevent UTI; however, few of these modifications have been shown to effectively decrease recurrent UTI. Limited evidence suggests that increasing fluid intake by at least 250 mL per day may be beneficial at reducing recurrent UTI in the short term.24 Other behavioral modifications, including the direction a patient wipes after toileting, avoidance of hot tubs, douching, voiding habits before and after intercourse, frequency of urination, or avoiding delaying urination have not reliably been found to prevent recurrent UTI.
Despite the lack of strong evidence, it is reasonable to discuss potential behavioral modifications, including voiding after intercourse, avoiding excessive and prolonged holding of urination, and avoiding subsequent vaginal intercourse after anal intercourse. It is also prudent for women to avoid overcleansing of the vulvovaginal area, which may result in disruption of the normal vaginal microbiota. When reviewing preventative strategies, it is important to avoid blame, as many women may continue to have recurrent UTI despite these modifications. Additional strategies should be offered.
Management of Potential Underlying Contributors
Potential underlying contributors that are identified during evaluation should be addressed and modified, if possible. Sexually active women who are using spermicide should be counseled regarding the association between spermicide use and UTI and offered nonspermicidal forms of contraception. Patients with diabetes with inadequate control of blood sugars or using medications, which increase the risk of UTI, should be identified, and if recurrent UTIs cannot be controlled with other measures, consultation with the prescribing provider regarding alternate treatment options should be considered. Consider referral for evaluation and management of underlying conditions such as known or suspected renal stones, urethral diverticulum, advanced stage prolapse pelvic organ prolapse, bowel conditions such as chronic diarrhea or fecal incontinence.
Nonantibiotic Preventative Measures
Multiple nonantibiotic options are commonly used to prevent recurrent UTI. There is an uncertain benefit associated with these measures. Having an effective, nonantibiotic option would help some patients to avoid or limit use of antibiotics, thereby decreasing antibiotic-associated risks. Commonly used nonantibiotic measures include cranberry products, probiotics, D-mannose, and methenamine salts.
Cranberry
Cranberries are composed primarily of water and a complex mixture including organic acids, fructose, ascorbic acid, flavonoids, anthocyanidins, and proanthocyanidins. The anthocyanidins and proanthocyanidins may function as a natural plant defense against microbial infections and are the components believed to be clinically relevant for UTI prevention. Although unclear, the proposed mechanism of action is related to inhibition of adherence of uropathogens to uroepithelial cells.
Despite its widespread use, clinical studies to date have not consistently shown benefits of cranberry products to prevent recurrent UTI.25 This may be attributable to limitations in study design, heterogeneous study populations, and variation in administration and dosing of cranberry products, including the active ingredients. Routine use of cranberry products including cranberry juice, tablets, and capsules is not recommended. The risk of cranberry products is likely low, so for women who choose to use cranberry, it is reasonable.
Probiotics
Probiotics are live microorganisms that have beneficial properties for the host. Probiotics are thought to have the potential to protect against vaginal colonization by uropathogens. Common probiotics include many strains of lactic acid bacilli (e.g., Lactobacillus and Bifidobacterium). The potential proposed mechanisms of action include blocking adherence, producing hydrogen peroxide, which damages uropathogens, maintaining a low pH, and inducing an anti-inflammatory cytokine response in epithelial cells.
Administration of probiotics to prevent recurrent UTI has not shown overwhelming benefit.26 However, data are limited. Both oral and vaginal formulations of probiotics are available. Administration of an oral probiotic has not been consistently shown to lead to vaginal colonization with the probiotic strain. Delivery of probiotics through vaginal formulation has been shown to increase vaginal colonization with the same strain. Limited data suggest that this may decrease recurrent UTI in premenopausal women.27
D-Mannose
D-Mannose is a monosaccharide, which is a natural sugar similar to glucose. It is available in various formulations (eg, capsule and powder mixed in water) with a wide range of dosing. It is administered orally, rapidly absorbed, metabolized, and then excreted in the urine. Its structure is similar to receptors on the bladder urothelium, and thus, it is thought to prevent UTI by blocking the adhesion of bacteria (specifically E. coli) to urothelial cells.
The data to support the routine use of D-mannose in women with recurrent UTI are weak.28 There is some evidence to suggest that D-mannose may help to decrease recurrent UTI compared with placebo and be similarly effective as antibiotic prophylaxis. D-Mannose is generally well-tolerated and is associated with minimal side effects, the most common being diarrhea. The use of D-mannose is not routinely recommended, but this could be considered in patients who are interested in avoiding antibiotic use and can be continued in patients who experience benefit.
Methenamine Salts
Methenamine salts, including methenamine hippurate, are commonly used for prevention of recurrent UTI. Methenamine hippurate likely acts as a bacteriostatic agent in the bladder. Methenamine is converted to formaldehyde in acidified urine and is proposed to have general antibacterial activity. Acquired resistance to methenamine salts does not develop.
There is weak evidence to support the use of methenamine salts to prevent recurrent UTI.29 Methenamine hippurate may be effective for preventing UTI in patients without renal tract abnormalities, particularly when used for short-term prophylaxis. It does not appear to work in patients with neuropathic bladder or in patients who have renal tract abnormalities. The rate of adverse events was low, and mostly common are mild gastrointestinal upset, but poorly described. However, given the low risk, this could be considered, especially in women who desire to avoid or limit antibiotic exposure, and women with multidrug-resistant UTIs.
Vaginal Estrogen
Vaginal estrogen treatment is effective at preventing recurrent UTI in postmenopausal women and its use should be considered in women with low estrogen state.30 Estrogen receptors are not only present in the vagina, but also in the urethra and trigone of the bladder. The proposed mechanism of action includes increased vaginal colonization with lactobacilli, which in turn maintains a low, or acidic, pH, which inhibits colonization with uropathogens. The use of systemic estrogen therapy has not been shown to be effective at reducing recurrent UTI.
Vaginal estrogen treatment for recurrent UTI is generally administered at doses recommended for the genitourinary syndrome of menopause (Table 2). Topical preparations include intravaginal cream, vaginal rings, and vaginal tablets. Potential side effects of vaginal estrogen treatment are typically mild and may include vaginal irritation, burning or itching, nonphysiologic discharge, and vaginal bleeding. Vaginal estrogen has not been shown to increase the risk of cancer recurrence in women with or at high risk of estrogen-dependent cancers (eg, breast cancer). However, consideration could be considered after consultation with a patient's oncologist.
Antibiotic Prophylaxis
Antibiotic prophylaxis should be considered in women in whom diagnosis of recurrent UTI has been confirmed and who continue to have recurrent UTI despite conservative measures, and for women with severe recurrent UTI. Antibiotic prophylaxis is the most effective treatment for recurrent UTI, although it does not eliminate recurrent UTIs.31 The choice of antibiotic is based on history, and susceptibility patterns of the strains of bacteria causing prior episodes of UTI, history of drug allergies, and potential interactions with other medications. Antibiotic prophylaxis can be administered postcoitally or in continuous fashion.
Postcoital Prophylaxis
Postcoital prophylaxis should be considered in women who endorse recurrent UTI temporally related to intercourse. Doses for postcoital prophylaxis are shown in Table 3. Postcoital antibiotics are administered as a single oral dose taken after intercourse. Depending on the frequency of sexual activity, it is likely that postcoital prophylaxis decreases antibiotic exposure when compared with continuous prophylaxis.
Continuous Prophylaxis
For patients with recurrent UTIs that are not prompted by a clear trigger, daily prophylaxis is an effective treatment option. Daily prophylaxis can be taken at any time of day. Doses for daily antibiotic prophylaxis are shown in Table 3. Prophylaxis is often continued for 3 to 12 months, with periodic reassessment of necessity.
Other Treatments
Other treatments have limited supporting evidence and are not routinely used in the treatment of recurrent UTI. These include herbal medicine, acupuncture, antibiotic bladder irrigation, nonantibiotic bladder irrigation, and immunoactive prophylaxis.
Conclusion
Recurrent UTI is a painful and debilitating condition that is common in women. Most patients can be safely managed with antibiotic prophylaxis or with nonantibiotic interventions. Postmenopausal women with recurrent UTIs should be started on vaginal estrogen. Prophylactic treatments should be reevaluated periodically. A breakthrough UTI in the setting of recurrent UTIs should be confirmed by urine culture, and, if positive, treated with antibiotics at doses and durations recommended for acute UTIs. Patients with complicated infections or risk factors should be referred to a subspecialist for further evaluation.
Practice Pearls
* UTI is diagnosed based on clinical symptoms confirmed by laboratory findings. Dysuria is the key symptom of a UTI, with other symptoms including frequency, urgency, hematuria, new-onset incontinence, and suprapubic pain variably present.
* First-line antibiotic options for the treatment of UTI in women with recurrent UTI include nitrofurantoin, trimethoprim-sulfamethoxazole, and fosfomycin.
* Over-the-counter analgesics including nonsteroidal anti-inflammatory agents, acetaminophen, and phenazopyridine can effectively provide relief of UTI symptoms.
* Vaginal estrogen is an evidence-based nonantibiotic option for prevention recurrent UTIs in postmenopausal women without contraindications to estrogen therapy. It is administered at doses used to treat genitourinary syndrome of menopause.
* Antibiotic prophylaxis is effective at preventing recurrent UTI and should be considered in women with recurrent UTI who have failed conservative measures. It can be administered either postcoitally or continuously for at least 3 months.
References