Female UTI

 

Definition: > 3 proven urinary tract infections within 12 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.

Indications for referral:

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

• 2ww Urology if  Persistent haematuria after treatment of infection

(https://rms.cornwall.nhs.uk/rms/primary_care_clinical_referral_criteria/rms/primary_care_clinical_referral_criteria/urology/haematuria)

 

C&B referral

• Abnormal USS: refer to appropriate speciality depending on abnormality.
• Women with rec UTI and definite suggestion of bladder outflow obstruction (Residual Volume  RV >100ml)
• Recurrent upper UTIs
• Pregnant – consider A&G
• In those who have had the treatments suggested below, eg. low-dose abx, with normal USS and RV, but are still very symptomatic and distressed may be referred for review. Consider via A&G However, it is likely that there is little else to offer.

 

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 prior to referral:

• Send MSU prior to starting antibiotics and change according to sensitivities. Consider treatment for 1-2 weeks.
• Request USS renal tract. 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)
• Lifestyle advice: adequate fluid intake/hygiene/void after intercourse
• Topical oestrogens (intravaginal) in post-menopausal women

 

Antibiotic prophylaxis

Consider if above measures ineffective/ inappropriate

Discuss risks long term antibiotic use including resistance

Taking into account antibiotic sensitivities on recent MSUs

If pregnant please consider which A/bio are safe at different stages of pregnancy

• Consider single dose prophylaxis if identifiable trigger such as post sexual intercourse
  • Trimethoprim 200mg stat dose or Nitrofurantoin (if eGFR >45 ml/min) 100mg stat dose

• Daily Prophylactic antibiotic course for six months if no identifiable triggers
  • Trimethoprim 100mg nocte or Nitrofurantoin (if eGFR >45ml/min) 50-100mg nocte

Advise If breakthrough infection – needs medical rev, send msu, treat with different antibiotic to prophylaxis antibiotic

 

 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

 

Contributors

Mr Christopher Blake, Consultant Urologist, RCHT

Dr B Wesson, GP & Kernow RMS Urology Guideline lead

Review date: March 2022

Next review due March 2023