The guidelines for recurrent urinary tract infection (rUTI) in women encompass several aspects including diagnostic investigations, risk stratification, medical management, and preventative measures.
Diagnostic investigations
- Urine tests: Urinalysis, urine culture, and sensitivity should be obtained with each symptomatic acute cystitis episode before initiating treatment in patients with rUTIs . Urine culture with susceptibility testing is also recommended
- Urinary tract imaging: Routine upper urinary tract imaging is not recommended in the index patient presenting with rUTI . However, upper urinary tract imaging should be obtained in patients with persistent hematuria or persistent growth of bacteria aside from E. coli
- Cystoscopy: Cystoscopy is recommended in patients with persistent hematuria or persistent growth of bacteria aside from E. coli
Risk stratification
- Risk factors: The main risk factors for rUTIs in menopausal patients without neurological diseases include urinary incontinence, previous gynecological surgery, the presence of diabetes mellitus, a cystocele, residual urine, and a history of rUTIs before menopause . In sexually active females, the frequency of sexual intercourse is a significant risk factor
Medical management
- Choice of antibiotics: Nitrofurantoin, trimethoprim-sulfamethoxazole (TMP/SMX), or fosfomycin should be administered depending on the local antibiogram data as first-line therapy in symptomatic patients with rUTIs
Preventative measures
- Antibiotic prophylaxis: Continuous or postcoital antibiotics, such as co-trimoxazole, nitrofurantoin, trimethoprim, fluoroquinolones, or cephalosporins, can be offered for 6-12 months to reduce the frequency of rUTIs. Fluoroquinolones should only be used when no other preventive strategy is available
- Immunoprophylaxis: Oral and intranasal vaccines against uropathogenic bacteria can be considered for the prevention of rUTIs
- Probiotics: Local or oral probiotics containing strains of proven efficacy for vaginal flora regeneration can be offered to prevent UTIs
- Vaginal estrogen: Vaginal estrogen therapy can be offered for the prevention of rUTIs in postmenopausal patients
- Fluid intake: Increasing fluid intake is advised to reduce the risk of rUTIs in premenopausal patients
In conclusion, the management of rUTIs in women requires a comprehensive approach that includes diagnostic investigations, risk stratification, medical management, and preventative measures. The choice of interventions should be individualized based on the patient's specific circumstances and risk factors.