What is the recommended workup and treatment for relapsing Urinary Tract Infections (UTIs) in women?

Workup for Relapsing UTI in Women

For otherwise healthy women with recurrent UTIs, obtain urine culture with antimicrobial susceptibility testing before each symptomatic episode, perform a thorough history and pelvic examination, but avoid routine cystoscopy and imaging unless complicated features are present. 1, 2

Diagnostic Confirmation

Document positive urine cultures with prior symptomatic episodes to confirm the diagnosis of recurrent UTI (≥3 UTIs per year or ≥2 UTIs in 6 months). 1, 2

• Obtain urinalysis and urine culture with antimicrobial susceptibility testing prior to initiating antibiotics with each acute symptomatic episode 1, 2
• If the initial specimen is suspect for contamination, obtain a catheterized specimen 1, 2
• At least one symptomatic episode should be verified by urine culture to confirm diagnosis and guide treatment 3
• A positive culture with >10² colony-forming units per mL is diagnostic in symptomatic patients 4

Essential Clinical Evaluation

Obtain a complete history focusing on UTI frequency, antimicrobial usage history, prior culture results, and risk factors for complicated infection. 1

History Components:

• Lower urinary tract symptoms: dysuria (central to diagnosis), frequency, urgency, nocturia, incontinence, hematuria, pneumaturia, fecaluria 1
• Baseline genitourinary symptoms between infections 1
• Sexual history (frequency of intercourse is the strongest predictor of recurrence in premenopausal women) 4, 3
• Spermicide use, new or multiple sex partners 3
• History of UTI before age 15 3
• Comorbid conditions: diabetes, immunosuppression, neurological disease, anatomic/functional urinary tract abnormalities 1

Physical Examination:

• Perform abdominal examination 1
• Detailed pelvic examination to assess for structural or functional abnormalities, specifically vaginal atrophy and pelvic organ prolapse 1
• In postmenopausal women, evaluate for atrophic vaginitis 3

Imaging and Cystoscopy: When NOT to Order

Cystoscopy and upper tract imaging should NOT be routinely obtained in otherwise healthy women presenting with recurrent uncomplicated UTI. 1

• Imaging is usually NOT appropriate for recurrent uncomplicated lower UTIs in women with no known underlying risk factors 1
• Imaging is rarely warranted in the absence of complicated features 3

When Imaging IS Indicated:

Consider CT urography (CTU) or MR urography (MRU) only for women with suspected complicated UTI, nonresponders to conventional therapy, frequent reinfections/relapses, or known underlying risk factors. 1

• Complicating factors include: congenital urinary tract abnormalities, spinal cord injury, transplant recipients, neurogenic bladder, immunosuppression, chemotherapy, nephrolithiasis, or recent surgery 1
• Ultrasound may be useful as an initial screening tool for obstructive uropathy and postvoid residual volume determination 1
• CTU and MRU are considered equivalent alternatives (order only one) 1

Critical Pitfalls to Avoid

• Never classify recurrent UTI patients as "complicated" unless they have structural/functional urinary tract abnormalities, immunosuppression, or pregnancy - this leads to unnecessary broad-spectrum antibiotics 2
• Do not treat asymptomatic bacteriuria in otherwise healthy women 1
• Avoid unnecessary antibiotic treatment unless there is high suspicion of UTI; expectant management with analgesics can be attempted while awaiting cultures 1
• Do not routinely order cystoscopy or imaging in uncomplicated cases, as this increases cost without improving outcomes 1
• Dysuria must be present for UTI diagnosis; other symptoms alone (frequency, urgency) without dysuria should prompt consideration of alternative diagnoses 1
• Avoid fluoroquinolones for empiric treatment due to increased resistance rates and collateral damage to normal flora 2

Treatment Approach for Acute Episodes

Treat acute cystitis episodes with short-course antibiotics (≤7 days) using agents selected based on prior culture data and local antibiograms. 2

First-Line Antibiotic Options:

• Nitrofurantoin 100 mg twice daily for 5 days 2

• Fosfomycin trometamol 3 g single dose (women only) 2

• Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 3 days 2

• Patient-initiated treatment (self-start) may be offered to select patients with acute episodes while awaiting urine cultures 1

• For treatment failures, assume the organism is not susceptible and retreat with a 7-day regimen using another agent 2

• Nitrofurantoin is preferred for re-treatment since resistance is low and decays quickly if present 2