Female UTI

 This guideline applies to adults aged 16 years and older

Introduction

Recurrent UTI is defined as more than 3 UTIs within twelve months OR more than 2 UTIs within six months (positive MSU or symptoms of cystitis associated with nitrite positive dipstick).

Women have a 50% lifetime risk of UTI and this increases with age. There is often no significant underlying identifiable cause.

All women with recurrent UTIs should be offered a kidneys, ureters and bladder ultrasound (KUB USS) in primary care. This should include measurement of a postmicturition residual volume as standard.

Possible causes:

• Increasing age with atrophic vaginitis post menopause
• Prolapse
• Intercourse
• Pregnancy
• Diabetes
• Urinary tract abnormality (anatomical/functional/stones/indwelling catheter)
• Residential care
• Immunocompromise

 Differential diagnoses:

• STD
• Chronic pelvic pain syndrome
• Drug induced cystitis eg ketamine

 

Management Optimisation

• Send MSU prior to starting antibiotics and change according to sensitivities. Consider treatment for 1-2 weeks.
• Request USS renal tract including post micturition residual volume.   If this is normal further investigation is not usually required.
• Examine for and manage prolapse (see https://rms.cornwall.nhs.uk/rms/primary_care_clinical_referral_criteria/primary_care_clinical_referral_criteria/gynae/prolapse)

UTI Prophylaxis

Please see NICE CKS  and Cornwall and IOS guidelines for further information on antibiotic prophylaxis, topical oestrogen and methenamine hippurate.  A visual summary of prevention of recurrent UTI can be found here.   

 

Advice and Guidance

Send Urology advice and guidance via eRS in patients with normal USS and residual volume and managed adequately in primary care and there is clinical concern or uncontrolled symptoms.

 

Referral

Emergency admission
If features of systemic sepsis: pyrexia/confusion/tachycardia/tachypnoea/hypotension/severe nausea and vomiting.

Fast track suspected urological cancer if persistent haematuria after treatment of infection, please see here

Urgent referral

• Pneumaturia or faecaluria
• Hydroureter or hydronephrosis seen on renal ultrasound or CT renal tract

 

Routine referral

Offer routine urology for women with recurrent UTIs and:

• Recurrent upper UTIs
• Pregnant – consider A&G
• Prior urinary tract surgery, pelvic organ prolapse surgery or trauma.
• Prior abdominopelvic malignancy.
• Urea-splitting bacteria on culture (e.g. Proteus, Yersinia) in the presence of a stone, or atypical infections (e.g. tuberculosis, anaerobic bacteria)
• Bacterial persistence or on-going lower urinary tract symptoms after sensitivity-based therapy.
• Voiding symptoms (straining, weak stream, intermittency, hesitancy).

OR

if any of the following features are present on renal ultrasound:

• Bladder OR ureteric OR obstructive renal stones (for non-obstructive renal stones please use advice and guidance).
• Post-micturition residual volume greater than 150ml.

 

 Patient information

 https://www.baus.org.uk/_userfiles/pages/files/Patients/Leaflets/Recurrent%20cystitis.pdf

 

References

NICE NG112, Urinary tract infection, October 2018

NICE, CKS, Suspected recurrent Urinary Tract Infection in women, June 2021

Antimicrobial guidelines for primary and community services

Commissioning policies and evidence-based interventions

NG112 Urinary tract infection (recurrent): antimicrobial prescribing

 

Page Review Information

Mr Christopher Blake, Consultant Urologist, RCHT

Dr B Wesson, GP & Kernow RMS Urology Guideline lead, Dr Melanie Schick

Review date: 23/5/2025

Next review due 23/5/2026