Intended for healthcare professionals

Clinical Review

Diagnosis and management of recurrent urinary tract infections in non-pregnant women

BMJ 2013; 346 doi: (Published 29 May 2013) Cite this as: BMJ 2013;346:f3140
  1. Kalpana Gupta, associate professor of medicine and infectious diseases1,
  2. Barbara W Trautner, associate professor of medicine and infectious diseases2
  1. 1Departments of Medicine, VA Boston Healthcare System and Boston University School of Medicine, Boston, MA 02132 and National Center for Occupational Health and Infection Control, Office of Public Health, Veterans Health Administration, Gainesville, FL 32608, USA
  2. 2Health Services Research and Development (HSR&D) Center of Excellence, Michael E DeBakey Veterans Affairs (VA) Medical Center and Section of Infectious Diseases, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
  1. Correspondence to: K Gupta Kalpana.Gupta{at}

Summary points

  • Recurrent urinary tract infection is common in otherwise healthy women

  • Use of products containing spermicide and sexual intercourse increase the risk of recurrences

  • No studies have shown that hygiene, direction of wiping, or tightness of clothing increase the risk of recurrence

  • Management can include self initiated antibiotics for each episode but depends on good communication between patient and physician

  • Recurrences can be prevented with regular low dose antibiotics. The choice and dose of antibiotic should be decided on the basis of previous infections and local microbiological guidance and availability of antibiotics

  • Non-antimicrobial prevention strategies are promising but have not yet been shown to be as effective as antimicrobial prophylaxis

Recurrent acute cystitis, or recurrent urinary tract infection (UTI), is common in women, and most primary care providers will encounter this clinical entity many times in their practice. Women who have two or more infections in six months or three or more in one year meet the traditional definition of recurrent UTI that has been used for studies on prophylaxis, risk factors, and self initiated management.1 2 3 4 5 6 However, from a clinical perspective, any second episode of UTI warrants consideration as a recurrence and requires an informed approach to diagnosis and management. Most of these recurrences are considered to be reinfections rather than relapse or failure of initial therapy, although reinfection with the same strain can occur. Modifiable risk factors are few, and retrospective case-control observational studies indicate that genetic predisposition may play a role.7 8

This review will focus on the causes of recurrent UTI, when and how to investigate women who present with this problem, and how to manage and prevent recurrent infections. The recommendations are limited to non-pregnant adult women without comorbidities apart from diabetes. It is important to distinguish between this population …

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