Recurrent UTI

Recurrent UTI is defined as two positive MSU in last 6 months or three positive MSU in last 12 months

If MSU confirmation is not possible then ALL symptoms of

• Frequency¹
• Dysuria¹
• Urgency +/- bladder pain¹
• Prompt resolution with antibiotics²

Fluid intake³ 2.5 L per day (of which 1.5 L is water)

• Intercourse advice – lubrication, pre- and post-coital voiding, personal hygiene³
• STI screening
• Hygiene – wipe front to back³
• Avoid perfumed products and soap for all intimate hygiene
• Treat constipation
• OTC supplements of D-mannose or cranberry supplements can be considered

• Women: Request US urinary tract (not renal US) to include post-void residual volume
  If residual vol. >150 mL, refer to Urology as Routine
• Men: Assess for LUTS and follow male LUTS guidance AND refer to Urology as Routine 

• Topical vaginal oestrogen³ if peri-menopausal
  AND trial of methenamine hippurate^2,3 +
  AND post-coital antibiotics – e.g. trimethoprim single dose or as per sensitivities within 2 h of intercourse
  OR Self-start antibiotics – 3-day course of antibiotics as per recent sensitivities, depending on patient's circumstances
  GGC Medicines: Preparations for vaginal and vulval changes
  
  
• If symptoms persist despite the above, consider 3 months of antibiotic prophylaxis^2,3

• Methanamine Hippurate can be trialled for up to six months and then should be withdrawn to assess if still required. GGC Medicines: Some other antibacterials

• Red flag features as above (Urgent)
• Continued symptoms despite above measures
  • <60 years – Routine referral
  • >60 years – Urgent referral

Self-help information for women with cystitis: information from The British Association of Urological Surgeons (BAUS) about bladder infections 

• BMI, body mass index
• LUTS, lower urinary tract symptoms
• MSU, midstream specimen of urine
• OTC, over the counter
• STI, sexually transmitted infection
• US, ultrasound
• UTI, urinary tract infection

1. British Association of Urological Surgeons (BAUS). Self help information for women with cystitis. 2023. Available at: www.baus.org.uk/_userfiles/pages/files/Patients/Leaflets/Recurrent%20cystitis.pdf (Accessed: January 2025)
2. NICE. Scenario: Recurrent UTI (no haematuria, not pregnant or catheterized). 2024. Available at: cks.nice.org.uk/topics/urinary-tract-infection-lower-women/management/recurrent-uti-no-haematuria-not-pregnant-or-catheterized/ (Accessed: January 2025)
3. NICE. Urinary tract infection (recurrent): antimicrobial prescribing. 2024. Available at: www.nice.org.uk/guidance/ng112?UID=461809709202516163513 (Accessed: January 2025)
4. CfSD Modernising Patient Pathways Programme: Recurrent Urinary Tract Infection (Draft). December 2024.