What is the recommended workup and treatment for a patient with a urinary tract infection (UTI) presenting to urology, particularly those with a history of recurrent UTIs, underlying urinary tract abnormalities, or immunocompromised status?

Urologic Workup for UTI

When to Refer to Urology

Most patients with recurrent UTIs do not require extensive urologic workup unless they have specific risk factors or fail standard preventive measures. 1, 2

Patients Who Need Imaging/Workup

• Women under 40 years with no risk factors do NOT need routine cystoscopy or full abdominal ultrasound 2
• Men and women >40 years with recurrent UTI should undergo imaging to identify structural abnormalities, particularly bladder outlet obstruction 1
• Patients with repeated pyelonephritis require evaluation for complicated etiology rather than simple recurrence 1
• Patients with persistent fever after 72 hours of treatment or clinical deterioration need contrast-enhanced CT scan or excretory urography 2
• Patients with high urine pH should have upper urinary tract ultrasound evaluation 2

Essential History Elements

• Timing relative to sexual activity 1
• Menopausal status 1
• Presence of urinary incontinence 1
• Incomplete bladder emptying 1
• Prior antimicrobial exposures 1
• Assessment for high postvoid residual urine volume in postmenopausal women 2

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Diagnostic Confirmation

Always confirm recurrent UTI via urine culture before initiating preventive therapy—defined as ≥2 culture-positive UTIs in 6 months OR ≥3 in 12 months. 3, 1, 2

Critical Diagnostic Pitfalls to Avoid

• Never classify patients with recurrent uncomplicated UTI as "complicated"—this leads to unnecessary broad-spectrum antibiotics with prolonged durations 1
• Never treat asymptomatic bacteriuria—this fosters antimicrobial resistance and increases recurrent UTI episodes 3, 1
• Symptom clearance is sufficient; routine post-treatment cultures are not recommended 3

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Acute Episode Treatment

First-Line Antibiotics for Women

• Fosfomycin trometamol 3g single dose (1 day) 1, 2
• Nitrofurantoin 100mg twice daily for 5 days 1, 2, 4
• Trimethoprim-sulfamethoxazole 160/800mg twice daily for 3 days (only if local E. coli resistance <20%) 1, 5, 4

First-Line Antibiotics for Men

• Trimethoprim-sulfamethoxazole 160/800mg twice daily for 7 days (if local resistance patterns permit) 2, 4
• Nitrofurantoin for 7 days 4
• Fluoroquinolones based on local susceptibility testing 2

Antibiotic Selection Principles

• Base choice on prior culture data and local antibiograms to account for resistance patterns 1
• Consider patient allergies, renal function, drug interactions (especially in elderly), and cost 1
• Avoid fluoroquinolones as first-line empiric therapy due to increasing resistance and adverse effects 2
• Older males have broader microbial spectrum (E. coli, Proteus, Klebsiella, Pseudomonas, Enterococcus) and require culture before treatment 1

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Prevention Strategy: Stepwise Algorithm

The European Urology guidelines recommend a stepwise prevention strategy starting with non-antimicrobial interventions, reserving continuous antibiotic prophylaxis only when these measures fail. 1, 2

Step 1: First-Line Non-Antimicrobial Prevention

For Postmenopausal Women (STRONG RECOMMENDATION)

Vaginal estrogen cream is the cornerstone intervention, reducing recurrent UTIs by 75% (RR 0.25). 3, 1, 2

• Estriol cream 0.5mg nightly for 2 weeks, then 0.5mg twice weekly for at least 6-12 months 3
• Vaginal estrogen rings show more modest benefit (36% reduction) and are less effective than cream 3
• Do NOT withhold vaginal estrogen due to presence of uterus—minimal systemic absorption makes endometrial effects negligible 3
• Do NOT prescribe oral/systemic estrogen for UTI prevention—it is completely ineffective (RR 1.08) and carries unnecessary risks 3
• Patients already on systemic estrogen therapy should still receive vaginal estrogen for UTI prevention 3
• Patients with breast cancer history should discuss with oncology team, but vaginal estrogen is not an absolute contraindication due to minimal systemic absorption 3

For All Age Groups

• Methenamine hippurate 1g twice daily (strong evidence for women without urinary tract abnormalities) 1, 2
• Advise premenopausal women to increase fluid intake 2
• Counsel regarding avoidance of risk factors 2

Step 2: If Vaginal Estrogen Fails (Postmenopausal Women)

• Add lactobacillus-containing probiotics (vaginal or oral) as adjunctive therapy 3
• Immunoactive prophylaxis with OM-89 (Uro-Vaxom) if available (strong recommendation after vaginal estrogen failure) 3, 2
• Continue methenamine hippurate if not already initiated 3

Step 3: Reserve Antimicrobial Prophylaxis as Last Resort

Continuous antimicrobial prophylaxis should only be used when all non-antimicrobial interventions have failed. 3, 1

• Nitrofurantoin 50mg nightly for 6-12 months 3
• Trimethoprim-sulfamethoxazole 40/200mg nightly for 6-12 months 3, 5
• Trimethoprim 100mg nightly for 6-12 months 3
• Antibiotic choice should be guided by prior organism susceptibility patterns and drug allergies 3

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Special Population Considerations

Postmenopausal Women

• Start with vaginal estrogen ± lactobacillus probiotics before considering antibiotics 1
• Assess for high postvoid residual urine volume 2
• Vaginal estrogen restores lactobacillus colonization (61% vs 0% in placebo) and reduces vaginal pH 3

Premenopausal Women

• Frequency of sexual intercourse is the strongest predictor of recurrent UTIs 6
• Consider postcoital prophylactic antibiotics if recurrences are temporally related to sexual activity 6
• Behavioral modification and cranberry products may be helpful 4, 6

Men

• Always obtain culture before treatment due to broader microbial spectrum 1
• Consider possibility of urethritis and prostatitis in men with UTI symptoms 4
• Imaging recommended for men >40 years with recurrent UTI to identify structural abnormalities 1

Immunocompromised or Structural Abnormalities

• These patients have complicated UTIs and require broad-spectrum antibiotics initially 6
• Urine culture to guide subsequent therapy is mandatory 6
• Renal imaging studies if structural abnormalities are suspected 6
• No attempt should be made to eradicate infection unless foreign bodies (stones, catheters) are removed and correctable urological abnormalities are addressed 7