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