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Recurrent UTI

Definition: > 3 proven urinary tract infections within 12 months (positive msu or symptoms of cystitis associated with nitrite positive dipstick).

 

Women have a 50% lifetime risk of UTI and this increases with age. There is often no significant underlying identifiable cause.

 

Possible causes:

  • Increasing age with atrophic vaginitis post menopause
  • Intercourse
  • Pregnancy
  • Diabetes
  • Urinary tract abnormality (anatomical/functional/stones/indwelling catheter)
  • Residential care
  • Immunocompromise

 

Differential diagnoses:

  • STD
  • Chronic pelvic pain syndrome
  • Drug induced cystitis eg ketamine

 

Management prior to referral:

  • Send MSU prior to starting antibiotics and change according to sensitivities. Consider treatment for 1-2 weeks.
  • Request USS renal tract. If this is normal further investigation is not usually required.
  • Lifestyle advice: adequate fluid intake/regular cranberry/hygiene/void after intercourse
  • Topical oestrogens (intravaginal) in post menopausal women
  • Antibiotic dose after intercourse if a predisposing factor
  • Prophylactic antibiotic course for six months. If breakthrough infection send msu, treat for 2 weeks and change antibiotics according to sensitivities.

 

Indications for referral:

  • Emergency referral if features of systemic sepsis: pyrexia/confusion/tachycardia/tachypnoea/hypotension/severe nausea and vomiting.
  • Clinical suspicion of obstructed kidney in the presence of sepsis requires urgent imaging and emergency drainage of kidney if confirmed.
  • Persistent haematuria after treatment of infection refer as per 2WW haematuria guidelines
  • Abnormal USS: refer to appropriate speciality depending on abnormality.
  • Women with rec UTI and definite suggestion of bladder outflow obstruction (RV>100ml)
  • In those who have had the treatments suggested above, eg. low-dose abx, with normal USS and RV, but are still very symptomatic and distressed may be referred for review. However, it is likely that there is little else to offer.