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Recurrent urinary tract infection in women

Key sources
The following summarized guidelines for the evaluation and management of recurrent urinary tract infection in women are prepared by our editorial team based on guidelines from the American Academy of Family Physicians (AAFP 2024), the European Association of Urology (EAU 2023), the American College of Obstetricians and Gynecologists (ACOG 2023), the American Urological Association (AUA/CUA/SUFU 2019), the Spanish Society of Clinical Microbiology and Infectious Diseases (SEIMC 2017), and the Society of Obstetricians and Gynaecologists of Canada (SOGC 2017).
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Guidelines

1.Classification and risk stratification

Risk factors: recognize that the main risk factor for rUTIs in sexually active females is the frequency of sexual intercourse.
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2.Diagnostic investigations

History and physical examination: elicit a complete patient history and perform a pelvic examination in patients presenting with rUTIs.
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  • Urine tests

  • Urinary tract imaging

3.Diagnostic procedures

Cystoscopy: as per EAU 2023 guidelines, do not obtain an extensive routine workup including cystoscopy in < 40 years old patients with rUTIs with no risk factors.
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4.Medical management

Patient-initiated treatment: as per EAU 2023 guidelines, consider offering self-administered short-term antimicrobial therapy in patients with good compliance.
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  • Choice of antibiotics

5.Specific circumstances

Pregnant patients: insufficient evidence to guide management after a rUTI in pregnancy. Consider initiating antimicrobial urinary suppression for the remainder of the pregnancy after treating a recurrent acute infection, preferably using a lower single daily dose of an antibacterial drug to which the bacterium isolated was susceptible.
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  • Patients with asymptomatic bacteriuria

6.Preventative measures

Hygienic measures: avoid insisting on implementing hygiene measures in patients failed to prevent rUTIs with hygiene.
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  • Fluid intake

  • Spermicide use

  • Antibiotic prophylaxis

  • Vaginal estrogen

  • Cranberry

  • Immunoprophylaxis

  • Intravesical hyaluronic acid

  • D-mannose

  • Probiotics

  • Vitamin C

  • Methenamine hippurate

  • Acupuncture

7.Follow-up and surveillance

Follow-up: do not obtain surveillance urine testing, including urine culture, in asymptomatic patients with rUTIs.
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