Common Questions About Recurrent Urinary Tract Infections in Women

 


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Recurrent urinary tract infections (UTIs) are common in women, including healthy women with normal genitourinary anatomy. Recurrent UTI is typically defined as three or more UTIs within 12 months, or two or more occurrences within six months. The same species that caused previous infections is typically responsible for recurrences. In premenopausal women, sexual intercourse three or more times per week, spermicide use, new or multiple sex partners, and having a UTI before 15 years of age are established risk factors. In postmenopausal women, risk is primarily increased by sequelae of lower estrogen levels. Episodes of recurrent UTI are typically characterized by dysuria and urinary frequency or hesitancy. Findings from the history or physical examination that suggest complicated infection or another disease process warrant additional evaluation. At least one symptomatic episode should be verified by urine culture to confirm the diagnosis and guide treatment. Imaging is rarely warranted. Short courses of antibiotics are as effective as longer courses. Patient-initiated treatment lowers the cost of diagnosis, number of physician visits, and number of symptomatic days compared with physician-initiated treatment. It also reduces antibiotic exposure compared with antibiotic prophylaxis. Antibiotic prophylaxis effectively limits UTI recurrence but increases the risk of antibiotic resistance and adverse effects. Cranberry products may reduce recurrent UTIs in premenopausal women, but are less effective than antibiotic prophylaxis, and data are conflicting. Optimal dosing is unknown. Postmenopausal women with atrophic vaginitis may benefit from topical estrogen therapy.

Urinary tract infections (UTIs) are the most common bacterial infection in women of all ages.1 An estimated 30% to 44% of women will have a second UTI within six months of an initial infection.24 Healthy women with normal urologic anatomy account for most patients who have recurrent UTIs.15

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

In patients who are candidates for prophylactic or self-initiated treatment of recurrent UTI, at least one episode should be confirmed by a urine culture demonstrating at least 102 bacterial colonies per mL of a known urinary pathogen when the patient is symptomatic.

C

3, 5, 11, 15, 17, 22

Imaging and cystoscopy are rarely necessary in healthy women with recurrent UTIs, unless risk factors for complicated infection are present.

B

2628

A three-day course of trimethoprim/sulfamethoxazole, a one-day course of fosfomycin (Monurol), or a five-day course of nitrofurantoin is as effective as longer treatment courses in achieving clinical cure of an isolated or recurrent UTI.

A

1, 2932

Both continuous daily and postcoital low-dose antibiotic prophylaxis regimens decrease recurrence of symptomatic UTIs.

A

5, 11, 16

Prophylaxis with daily estrogen vaginal cream in postmenopausal women may reduce the risk of future UTIs.

B

46, 51, 52

Prophylaxis with daily cranberry tablets may reduce the risk of future UTIs in premenopausal women, but data are conflicting.

B

4650


UTI = urinary tract infection.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

In patients who are candidates for prophylactic or self-initiated treatment of recurrent UTI, at least one episode should be confirmed by a urine culture demonstrating at least 102 bacterial colonies per mL of a known urinary pathogen when the patient is symptomatic.

C

3, 5, 11, 15, 17, 22

Imaging and cystoscopy are rarely necessary in healthy women with recurrent UTIs, unless risk factors for complicated infection are present.

B

2628

A three-day course of trimethoprim/sulfamethoxazole, a one-day course of fosfomycin (Monurol), or a five-day course of nitrofurantoin is as effective as longer treatment courses in achieving clinical cure of an isolated or recurrent UTI.

A

1, 2932

Both continuous daily and postcoital low-dose antibiotic prophylaxis regimens decrease recurrence of symptomatic UTIs.

A

5, 11, 16

Prophylaxis with daily estrogen vaginal cream in postmenopausal women may reduce the risk of future UTIs.

B

46, 51, 52

Prophylaxis with daily cranberry tablets may reduce the risk of future UTIs in premenopausal women, but data are conflicting.

B

4650


UTI = urinary tract infection.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

Recurrent UTI is typically defined as three or

The Authors

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JAMES J. ARNOLD, DO, FAAFP, is an associate program director at the National Capital Consortium Family Medicine Residency in Fort Belvoir, Va., and an assistant professor of family medicine at the Uniformed Services University of the Health Sciences, Bethesda, Md....

LAURA E. HEHN, MD, is a third-year family medicine resident at the National Capital Consortium Family Medicine Residency.

DAVID A. KLEIN, MD, MPH, FAAFP, is a faculty member at the National Capital Consortium Family Medicine Residency and an assistant professor of family medicine and pediatrics at the Uniformed Services University of the Health Sciences.

Address correspondence to James J. Arnold, DO, FAAFP, Fort Belvoir Community Hospital, 9300 DeWitt Loop, Fort Belvoir, VA 22060 (e-mail: james.j.arnold3@us.af.mil). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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