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SIGN decision support

Recurrent UTI is a common condition in women of all ages with significant effects on the quality of life of affected individuals. It may be associated with a range of lifestyle and concurrent medical conditions.

As recurrent UTI is defined as recurrences of uncomplicated and/or complicated UTIs, with a frequency of at least three UTIs per year, or two UTIs in the last six months, diagnosis is made using the same criteria as an acute UTI and consideration of the previous history of UTI.

Decisions about management of recurrent UTI should be made in collaboration with the patient, taking into account their individual circumstances and priorities.

Self care

Fluid intake

Recommendation
Women with a history of recurrent UTI should be advised to aim for a fluid intake of around 2.5 L a day of which at least 1.5 L is water.

To help achieve a fluid intake of around 2.5 L a day, it may be useful to express total fluid intake as 6 to 8 mugs a day (with a mug expected to hold around 350 ml).

Good practice point
Materials to support public awareness of the importance of hydration are available from Health Protection Scotland.

Good practice point
Exercise caution in women who are on fluid restriction for medical reasons (for example, those with chronic heart failure or on renal dialysis).

Spermicidal contraception

Recommendation
Consider offering women who are experiencing recurrent UTI an alternative to spermicide-containing contraceptives.

Voiding behaviours and hygiene

Two case-control studies found that postponing voiding can lead to an increased incidence of urinary tract infection.99,100  Other voiding and hygiene factors associated with increased risk of UTI are wiping genitals back to front, not urinating and not drinking water within 15 minutes of sexual intercourse, and avoidance of washing genitals with soap after urinating.100

Evidence – See section 5.1.1 in full guideline.

Antimicrobials

Efficacy

Recommendation
Consider prophylactic antimicrobials for women experiencing recurrent UTI after discussion of self-care approaches and the risks and benefits of antimicrobial treatment involved.

Recommendation
Long-term prophylactic antimicrobials for prevention of recurrent UTI should be used with caution in women aged 65 years and over, and careful consideration given to the risks and benefits involved.

Choice of agent for long-term prophylaxis of recurrent UTI

The BNF recommends monitoring of liver function and pulmonary function in any individual treated with nitrofurantoin for prophylaxis, and that the agent be discontinued if any deterioration in pulmonary function is found.45

Duration of antimicrobial prophylaxis for prevention of recurrent UTI

Good practice point
To minimise the development of resistance, antimicrobial prophylaxis should be used as a fixed course of three to six months in women with recurrent UTI.

Evidence – See section 5.1.2 in full guideline.

Methenamine hippurate

No recommendations can be made for use of methenamine hippurate in recurrent UTI, due to the need for caution in interpreting the evidence.

Evidence – See section 5.1.3 in full guideline.

Non-antimicrobials

There are no SIGN recommendations for use of non-antimicrobials.

Antimicrobials are more effective than non-antimicrobial agents such as oral lactobacilli, and vaginal application of topical oestrogens, but there is some evidence that the non-metabolised sugar D-Mannose may perform similarly to daily prophylaxis with nitrofurantoin in preventing recurrent UTI without a statistically significant rise in adverse events. 98

The use of vaginal or oral oestrogens has been proposed as a preventative strategy. There is some evidence for effectiveness of vaginal oestrogen. However the licensed indication for use of oestrogen vaginal products is to treat symptoms of vaginal atrophy in postmenopausal women. Use of these products for prevention of UTI is an unlicensed indication. In 2019 European Medicines Agency advice recommended that high-strength oestradiol creams containing 100 micrograms/gram (0.01%) should only be used for a single treatment period of a maximum of four weeks due to the risk of cardiovascular adverse effects and certain types of cancer. 109

Evidence – See section 5.1.4 in full guideline.

Non-pharmacological treatment

There are no SIGN recommendations for any non-pharmacological treatments. The full SIGN guideline presents the evidence for the following treatments:

  • Cranberry:  Evidence for the effectiveness of cranberry products in preventing UTI is conflicting.
  • Herbal products
  • Probiotics
  • Acupuncture:  While acupuncture is not routinely used in Scotland for this indication, its use could be considered by individual patients who are unresponsive or intolerant to antibiotic prophylaxis.

Evidence – See section 5.1.5 in full guideline.

Prevention of recurrent catheter-associated LUTI

Click link and scroll down to 'Prevention of recurrent UTI' section. 

References

45 Joint Formulary Committee. British National Formulary (online) London BMJ Group and Pharmaceutical Press. [cited 20 Mar 2020]. Available from url: http://www.medicinescomplete.com
98 Ahmed H, Davies F, Francis N, Farewell D, Butler C, Paranjothy S. Long-term antibiotics for prevention of recurrent urinary tract infection in older adults: systematic review and metaanalysis of randomised trials. BMJ Open 2017;7(5):e015233.  Available from url: https://bmjopen.bmj.com/content/7/5/e015233
99 Albright TS, Gehrich AP, Buller JL, Davis GD. Acute dysuria among female soldiers. Mil Med 2005;170(9):735-8.  Available from url: https://doi.org/10.7205/MILMED.170.9.735
100 Al Demour S, Ababneh MA. Evaluation of behavioral and susceptibility patterns in premenopausal women with recurrent urinary tract infections: a case control study. Urol Int 2018;100(1):31-6.
109 European Medicines Agency. Four-week limit for use of high-strength estradiol creams. [cited 24 Mar 2020]. Available from url: https://www.ema.europa.eu/en/documents/press-release/four-week-limit-use-high-strength-estradiol-creams_en.pdf