Management of Recurrent Urinary Tract Infections (rUTIs)

Diagnosis and Definition

The European Association of Urology defines recurrent UTI as ≥3 UTIs in 12 months or ≥2 UTIs in 6 months 2, 3
Document positive urine cultures with each symptomatic episode before initiating treatment, as recommended by the American Urological Association 2, 3
Obtain repeat urine studies when contamination is suspected, considering catheterized specimens, according to the European Urology guidelines 2
Routine cystoscopy and upper tract imaging are not recommended for uncomplicated rUTI in women <40 years without risk factors, as stated by the European Urology association 1, 2

Increase fluid intake to reduce risk of recurrent UTIs, as recommended by the European Urology association 1, 4
Encourage urge-initiated voiding and post-coital voiding, as suggested by the American College of Radiology 5, 4
Avoid spermicide-containing contraceptives, according to the American College of Radiology guidelines 5

For postmenopausal women: Use vaginal estrogen replacement (strong recommendation), as recommended by the European Urology association 1, 4
Use immunoactive prophylaxis to reduce recurrent UTIs (strong recommendation), according to the European Urology guidelines 1, 4
Use methenamine hippurate for women without urinary tract abnormalities (strong recommendation), as stated by the European Urology association 1, 4
Consider cranberry products, though evidence is contradictory and of low quality, as noted by the European Urology association 1, 4
Consider D-mannose supplementation, though evidence is weak, according to the European Urology guidelines 1, 4
Consider probiotics containing strains effective for vaginal flora regeneration, as suggested by the European Urology association 1
For patients with unsuccessful less invasive approaches: Consider endovesical instillations of hyaluronic acid or combination with chondroitin sulfate, according to the European Urology guidelines 1, 4

Use first-line antibiotics based on local antibiogram, as recommended by the American Urological Association 2, 1
Treat for as short a duration as reasonable, generally no longer than 7 days, according to the American Urological Association guidelines 2
Obtain urine culture before initiating antibiotics, as stated by the American Urological Association 2, 3

Implement continuous or postcoital antimicrobial prophylaxis when non-antimicrobial interventions have failed (strong recommendation), as recommended by the European Urology association 1, 4
For patients with good compliance, consider self-administered short-term antimicrobial therapy at symptom onset, according to the European Urology guidelines 1, 2

Recurrence: New infection with different organism or same organism >2 weeks after treatment, as defined by the American Urological Association 3
Relapse: Same organism within 2 weeks of completing treatment (suggests bacterial persistence), according to the American Urological Association guidelines 3
Relapse UTIs may require imaging to identify structural abnormalities, as suggested by the American College of Radiology 5, 3

Premenopausal women: Sexual activity, diaphragm/spermicide use, as noted by the American College of Radiology 5
Postmenopausal women: Atrophic vaginitis, urinary incontinence, cystocele, high postvoid residual, according to the European Urology association 1, 5

Treating asymptomatic bacteriuria, which increases antimicrobial resistance, as warned by the American Urological Association 4, 3
Failing to obtain cultures before initiating treatment in recurrent cases, according to the American Urological Association guidelines 2, 3
Not considering structural abnormalities in patients with relapsing infections, as noted by the American Urological Association 3
Continuing antibiotics beyond recommended duration, as warned by the American Urological Association 4

Obtain periodic urine cultures during symptomatic episodes to guide antimicrobial selection, as recommended by the American Urological Association 4