What is the appropriate assessment and management for patients with recurrent Urinary Tract Infections (UTIs)?

Assessment for Recurrent UTI

Confirm recurrent UTI with urine culture for each symptomatic episode before initiating treatment, as this is essential for guiding appropriate management and avoiding unnecessary antibiotic use. 1

Definition and Diagnostic Confirmation

• Recurrent UTI is defined as ≥3 culture-positive UTIs within 12 months OR ≥2 UTIs within 6 months. 1, 2, 3
• Obtain urinalysis and urine culture with antimicrobial susceptibility testing for every symptomatic episode to document infection and guide antibiotic selection. 1, 3
• Distinguish between relapse (same organism, suggesting incomplete treatment or underlying pathology) versus reinfection (different organism, suggesting behavioral or anatomical risk factors). 4

Initial Assessment: History and Physical Examination

Focus your history on specific risk factors that drive management decisions:

• Sexual activity patterns: frequency of intercourse, new sexual partners, spermicide use, and post-coital voiding habits. 5
• Voiding behaviors: fluid intake adequacy, habitual delayed urination, incomplete bladder emptying symptoms. 1, 5
• Menopausal status: presence of atrophic vaginitis, vaginal dryness, or urogenital symptoms in postmenopausal women. 1, 3
• Urinary symptoms: urinary incontinence, sensation of incomplete emptying, or obstructive symptoms. 1, 3
• Medical comorbidities: diabetes mellitus, immunosuppression, history of urolithiasis, or neurogenic bladder. 2
• Prior UTI history: childhood UTIs, maternal history of UTIs, previous pyelonephritis episodes. 5

Physical examination should assess for:

• Pelvic organ prolapse (cystocele) in women, which increases post-void residual volume. 1, 3
• Signs of atrophic vaginitis in postmenopausal women (vaginal pallor, loss of rugae, friability). 3
• Suprapubic or costovertebral angle tenderness suggesting upper tract involvement. 1
• Prostate examination in men to assess for benign prostatic hyperplasia. 2

Diagnostic Workup: When to Image and When to Stop

The extent of workup depends on patient age, sex, and risk factors:

For Women Under 40 Years Without Risk Factors:

• Do NOT perform extensive routine workup (cystoscopy, full abdominal ultrasound) in women younger than 40 years with recurrent UTI and no risk factors. 1, 6
• This avoids unnecessary invasive procedures that rarely change management in this low-risk population. 1

For Women Over 40 Years or With Risk Factors:

• Measure post-void residual urine volume (by bladder scan or ultrasound) to assess for incomplete emptying. 2, 3
• Consider renal/bladder ultrasound if there is history of urolithiasis, hematuria, or recurrent pyelonephritis. 1
• Cystoscopy is reserved for patients with hematuria, recurrent infections despite appropriate management, or suspicion of anatomical abnormalities. 1

For All Men With Recurrent UTI:

• UTIs in men are always considered complicated and require more extensive evaluation. 2
• Evaluate for urinary tract obstruction (benign prostatic hyperplasia), foreign bodies (catheters, stents), and incomplete bladder emptying with post-void residual measurement. 2
• Consider upper tract imaging (ultrasound or CT) to rule out stones, hydronephrosis, or structural abnormalities. 2
• Screen for diabetes mellitus and immunosuppression. 2

For Patients With Neurogenic Lower Urinary Tract Dysfunction (NLUTD):

• Evaluate both upper and lower urinary tracts with imaging and cystoscopy in NLUTD patients with recurrent UTI. 1
• If imaging and cystoscopy are unremarkable, consider urodynamic evaluation to assess for elevated post-void residual and vesicoureteral reflux. 1

Risk Factor Assessment and Modification

Identify and address modifiable risk factors:

• Behavioral modifications: increase fluid intake (may reduce recurrence risk), avoid prolonged holding of urine, practice post-coital voiding. 1, 3
• Sexual hygiene: counsel on wiping front to back after defecation, avoiding spermicide use, considering post-coital voiding. 5
• Anatomical/functional issues: assess for high post-void residual volume, cystocele, or urinary incontinence requiring intervention. 1, 3
• Hormonal status: identify postmenopausal women who would benefit from vaginal estrogen therapy. 1, 3

Special Considerations

Distinguishing Cystitis from Silent Pyelonephritis:

• If "cystitis" symptoms relapse within 4 weeks with the same organism after appropriate treatment, consider subclinical pyelonephritis requiring prolonged antibiotic therapy (14 days initially, then 6 weeks if recurrence persists). 7
• Obtain follow-up urinalysis and cultures 2 and 4 weeks after therapy to document clearance. 7

Asymptomatic Bacteriuria:

• Do NOT treat asymptomatic bacteriuria in non-pregnant patients, as this promotes antibiotic resistance without clinical benefit. 1
• The exception is pregnancy or prior to urologic procedures with anticipated urothelial disruption. 1

Common Pitfalls to Avoid

• Avoid prescribing antibiotics without documented bacterial infection, as this causes harm through resistance development without clinical benefit. 6
• Do not perform surveillance urine cultures in asymptomatic patients, as most bacteriuria does not progress to symptomatic UTI and treatment increases resistance. 1
• Do not use daily antibiotic prophylaxis in NLUTD patients managing with clean intermittent catheterization or indwelling catheters who do NOT have recurrent UTI, as this increases bacterial resistance without reducing symptomatic infections. 1
• Recognize that extensive workup in young, healthy women without risk factors is low-yield and potentially harmful. 1, 6