Guidelines for the diagnosis and management of recurrent urinary tract infection in women

Abstract

Recurrent uncomplicated urinary tract infection (UTI) is a common presentation to urologists and family doctors. Survey data suggest that 1 in 3 women will have had a diagnosed and treated UTI by age 24 and more than half will be affected in their lifetime.1 In a 6-month study of college-aged women, 27% of these UTIs were found to recur once and 3% a second time.2 The following topics are reviewed in this guideline. We also include a summary of recommendations (Text box 1). Text box 1. Summary of recommendations Definition of recurrent uncomplicated UTI An uncomplicated UTI is one that occurs in a healthy host in the absence of structural or functional abnormalities of the urinary tract. Recurrent uncomplicated UTI may be defined as 3 or more uncomplicated UTIs in 12 months (Level 4 evidence, Grade C recommendation). Recurrent UTIs occur due to bacterial reinfection or bacterial persistence. Persistence involves the same bacteria not being eradicated in the urine 2 weeks after sensitivity-adjusted treatment. A reinfection is a recurrence with a different organism, the same organism in more than 2 weeks, or a sterile intervening culture (Level 4 evidence, Grade C recommendation). Diagnosis of recurrent uncomplicated UTI Clinical diagnosis of each UTI episode is supported by symptoms of dysuria, frequency, urgency, hematuria, back pain, self-diagnosis of UTI, nocturia, costovertebral tenderness and the absence of vaginal discharge or irritation (Level 1 evidence, Grade A recommendation). Complicated causes of UTI may also be ruled out on history and physical examination (Table 1). Uroflowmetry and determining post void residual are optional tests in post-menopausal women to exclude complicated causes of UTI (Level 3 evidence, Grade C recommendation). Culture and sensitivity analysis should be performed when symptomatic and in 2 weeks from sensitivity-adjusted treatment to confirm UTI, guide further treatment and exclude persistence. (Level 4 evidence, Grade C recommendation) Investigation of recurrent uncomplicated UTI Cystoscopy and imaging are not routinely necessary in all women with recurrent UTI (Level 2 evidence, Grade B recommendation). Women with risk factors (Table 2) for a complicated cause for recurrent urinary tract infection should be evaluated by cystoscopy and imaging. Women suspected of having a complicated UTI (Table 2) without knowledge of a specific abnormality (Table 1) should receive a CT urogram or abdominopelvic ultrasound +/− abdominal x-ray. Women suspected of having a specific cause of UTI (Table 1) should be imaged in consultation with a radiologist or the 2011 ACR guidelines (Level 4 evidence, Grade C Recommendation). Indications for specialist referral Specialist referral is recommended for investigation of women with risk factors for complicated UTI (Table 2), surgical correction of a cause of UTI (Table 1), or when the diagnosis of recurrent uncomplicated UTI is uncertain (Level 4 evidence, Grade C Recommendation). Prophylactic measures against recurrent uncomplicated UTI Conservative measures including limiting spermicide use and postcoital voiding lack evidence for their efficacy but are unlikely to be harmful (Level 4 evidence, Grade C recommendation). Cranberry products have conflicting evidence for their efficacy (Level 1 evidence, Grade D recommendation). Continuous antibiotic prophylaxis (Table 3) is effective at preventing UTI. (Level 1 evidence, Grade A recommendation). Postcoital antibiotic prophylaxis (Table 3) within 2 hours of coitus is also effective at preventing UTI (Level 1 evidence, Grade A recommendation). Self-start antibiotic therapy with a 3-day treatment dose antibiotic at the onset of symptoms is another safe option for the treatment of recurrent uncomplicated UTI (Level 1 evidence, Grade A recommendation). Vaginal estrogen creams or rings may also reduce the risk of clinical UTI relative to placebo or no treatment in postmenopausal women (Level 1 evidence, Grade A recommendation). Due to a lack of comparative evidence, the decision to begin therapy, choice of therapy and duration should be based on patient preference, allergies, local resistance patterns, prior susceptibility, cost and side effects (Level 4 evidence, Grade C recommendation). View it in a separate window UTI: urinary tract infection; ACR: American College of Radiology.