What is the treatment for recurrent urinary tract infections (UTIs) that occur after sexual intercourse?

Treatment for Recurrent UTIs Associated with Sexual Intercourse

For premenopausal women with recurrent UTIs associated with sexual intercourse, low-dose post-coital antibiotic prophylaxis taken within 2 hours of sexual activity is the recommended first-line treatment. 1, 2

Diagnostic Criteria for Recurrent UTIs

• Recurrent UTIs are defined as ≥2 symptomatic episodes in 6 months or ≥3 episodes in 1 year 1
• Confirmation through urine culture is essential before initiating prophylactic treatment
• Assess whether infections are temporally related to sexual activity

Treatment Algorithm for Post-Coital UTIs

First-Line Treatment:

• Low-dose post-coital antibiotic prophylaxis to be taken within 2 hours of sexual intercourse 1, 2
  • Preferred agents:
    • Nitrofurantoin 50 mg
    • Trimethoprim-sulfamethoxazole 40/200 mg
    • Trimethoprim 100 mg

Antibiotic Selection Considerations:

• Base selection on:
  • Previous urine culture results and susceptibility patterns
  • Patient's medication allergies
  • Antibiotic stewardship principles
• Avoid fluoroquinolones as first-line agents due to risk of adverse effects 2
• Duration of prophylactic therapy: typically 6-12 months 1
• Consider rotating antibiotics every 3 months to prevent resistance development 1

Non-Antibiotic Alternatives:

For patients who prefer to avoid antibiotics or have contraindications:

• Methenamine hippurate (1 gram twice daily) 2
• Lactobacillus-containing probiotics 1
• For postmenopausal women: vaginal estrogen therapy with or without probiotics 1

Behavioral and Lifestyle Modifications

All patients should be counseled on preventive measures:

• Voiding before and after sexual intercourse
• Adequate hydration
• Avoiding prolonged urine retention
• Avoiding harsh cleansers that disrupt vaginal flora
• Avoiding sequential anal and vaginal intercourse 1

Efficacy of Post-Coital Prophylaxis

Post-coital trimethoprim-sulfamethoxazole has been shown to significantly reduce UTI recurrence rates (from 3.6 to 0.3 infections per patient-year) with minimal side effects and excellent compliance 3.

Treatment Pitfalls to Avoid

• Using broad-spectrum antibiotics unnecessarily
• Prescribing prolonged antibiotic courses (>5 days) for acute UTI treatment
• Failing to confirm diagnosis with urine culture before starting prophylaxis
• Not reassessing efficacy after 6-12 months of prophylaxis
• Overlooking complicating factors that may require additional evaluation

Follow-Up

• Post-treatment follow-up with urine culture is not necessary for asymptomatic patients 2
• If symptoms persist despite prophylaxis, obtain a urine culture before prescribing additional antibiotics 1
• Consider urologic evaluation if prophylaxis fails or if anatomic abnormalities are suspected

This approach to post-coital UTI prophylaxis is based on evidence showing it can reduce recurrence rates by approximately 90% when properly implemented 4.