I have a history of recurrent urinary tract infections (UTIs) and my current provider won't do any additional testing or treat me, what should I do?

What to Do When Your Provider Won't Test or Treat Your Recurrent UTIs

You should advocate for proper documentation of your recurrent UTIs with urine cultures before each treatment episode, as this is a clinical principle required for diagnosis and management of recurrent UTIs. 1

Understanding the Core Issue

Your provider may be hesitant to pursue additional testing because most women with recurrent uncomplicated UTIs have structurally normal urinary tracts and do not require extensive imaging or invasive procedures. 1 However, this does NOT mean you should go untreated—it means the approach should be systematic and evidence-based.

What You Are Entitled To

Required Documentation

• Clinicians must obtain urinalysis, urine culture and sensitivity with each symptomatic acute cystitis episode prior to initiating treatment in patients with recurrent UTIs. 1
• This is not optional—it's necessary to establish the diagnosis of recurrent UTI, track resistance patterns, and guide appropriate antibiotic selection. 1
• If your provider refuses to obtain cultures, this represents a deviation from established guidelines. 1

Appropriate Initial Evaluation

Your provider should perform:

• Complete history including assessment of dysuria, frequency, urgency, nocturia, incontinence, hematuria, and documentation of prior positive cultures with organism types. 1
• Physical examination including abdominal and detailed pelvic exam to assess for vaginal atrophy and pelvic organ prolapse. 1
• Risk factor assessment for complicated UTI (diabetes, neurological disease, catheter use, structural abnormalities). 1

What Testing You DON'T Need (Initially)

• Cystoscopy and upper tract imaging should NOT be routinely obtained in the index patient presenting with recurrent UTI. 1
• Most women with recurrent uncomplicated UTIs have normal urinary tracts and do not require CT, MRI, or ultrasound imaging in the absence of risk factors. 1
• These are only indicated if you have complicated features (fever, flank pain, treatment failures, known structural abnormalities, or are non-responders to conventional therapy). 1

Treatment Options Your Provider Should Offer

For Acute Episodes

First-line antibiotics for acute cystitis include: 2

• Nitrofurantoin 100 mg twice daily for 5-7 days 3, 2
• Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 7 days (if local resistance <20%) 3, 2
• Fosfomycin trometamol 3 grams single dose (women only) 3
• Trimethoprim alone for 3 days 2

Your provider may offer patient-initiated treatment (self-start therapy) where you begin antibiotics at symptom onset while awaiting culture results. 1 This is a reasonable approach for select patients with well-documented recurrent UTIs. 1, 3

Prevention Strategies (Non-Antibiotic First)

Before resorting to antibiotic prophylaxis, your provider should offer: 3, 4

• Increased fluid intake to 1.5-2 liters daily 3, 4
• Methenamine hippurate 1 gram twice daily (highly effective non-antimicrobial option) 3, 4, 2
• Immunoactive prophylaxis (OM-89/Uro-Vaxom) to boost immune response 3, 4
• Vaginal estrogen replacement (if postmenopausal): weekly doses ≥850 µg, which reduces recurrent UTIs by up to 75% 3, 4
• Cranberry products 2

Antibiotic Prophylaxis (Only After Non-Antibiotic Measures Fail)

If non-antimicrobial interventions fail: 3, 4

• Trimethoprim-sulfamethoxazole 40/200 mg daily or post-coitally 3, 4
• Nitrofurantoin 50-100 mg daily (if kidney function normal) 3, 4
• Patient-initiated short-term therapy at symptom onset (preferred over continuous prophylaxis to reduce antibiotic exposure) 3, 4

Critical Red Flags Your Provider May Be Missing

What Should NOT Happen

• Never treat asymptomatic bacteriuria (bacteria in urine without symptoms)—this does not prevent symptomatic episodes and fosters antimicrobial resistance. 3, 4
• Do not fail to obtain urine culture before treatment in recurrent cases—this is essential for tracking resistance patterns. 3, 4
• Avoid broad-spectrum antibiotics when narrower options are available based on culture results. 3
• Do not continue antibiotics beyond recommended duration—extended courses don't improve outcomes and increase resistance. 3, 4

Specific Action Steps

1. Request documentation: Ask your provider to document each symptomatic episode with urine culture and sensitivity testing before prescribing antibiotics. 1

2. Ask about non-antibiotic prevention: Specifically request methenamine hippurate, increased fluids, and (if postmenopausal) vaginal estrogen. 3, 4, 2

3. Clarify if you have "complicated" features: If you have diabetes, kidney disease, neurological conditions, or structural abnormalities, you may need different management. 1, 3, 4

4. Consider self-start therapy: Ask if you're a candidate for patient-initiated treatment where you keep antibiotics on hand and start them at symptom onset while sending a culture. 1, 3

5. Seek a second opinion or specialist referral if:

   • Your provider refuses to obtain urine cultures during symptomatic episodes 1
   • You have frequent reinfections or relapses despite appropriate therapy 4, 5
   • You have signs of upper tract involvement (fever, flank pain) 1
   • You're being treated for asymptomatic bacteriuria without symptoms 3, 4

When Specialist Referral IS Appropriate

Consider urological evaluation for: 1, 4

• Relapsing infections (same organism within 2 weeks) despite appropriate therapy 4
• Non-response to conventional therapy 1
• Known underlying risk factors or structural abnormalities 1
• Suspected incomplete bladder emptying or stones 4

The bottom line: You deserve proper documentation with cultures, evidence-based treatment of acute episodes, and a stepwise approach to prevention starting with non-antibiotic measures. 1, 3, 4 If your provider won't provide this standard of care, seek another opinion.