New Paradigms in the Management of Recurrent Urinary Tract Infections

Lior Taich; Hanson Zhao; Camila Cordero; Jennifer T. Anger


Curr Opin Urol. 2020;30(6):833-837. 

In This Article


A thorough medical history and pelvic examination are imperative to make an accurate diagnosis. History should emphasize irritative lower urinary tract symptoms (dysuria, frequency, urgency, nocturia, hematuria, or incontinence), flank or back pain, and specifically inquire regarding pneumaturia or fecaluria. Acute onset dysuria is the most specific symptom in the diagnosis.[6] Genitourinary and pelvic floor symptoms that occur during the time period between infections, such as overactive bladder symptoms, are also important to establish as a baseline. If patients are referred for positive cultures without UTI symptoms, these patients are considered to have ASB and are not considered to be rUTI patients. Potentially triggering factors should be addressed, such as urethral catheterization, spermicides, and contraception methods, frequency of sexual intercourse, menopausal status, use of estrogen-containing products, previous genitourinary or abdominopelvic surgery, and travel history.[5]

A positive urine culture with acute onset of symptoms is central to the diagnosis of rUTI. A urinalysis and urine culture should be obtained prior to initiating therapy for each episode. This allows the provider to tailor antibiotic therapy based on previous therapies. In addition, it helps reduce the need for excessive empiric treatment. If the cultures are persistently negative, then alternative diagnoses need to be considered, such as interstitial cystitis/bladder pain syndrome. Classically, a 'true' UTI was defined as more than 10[5] colony forming units (CFU)/ml on urine culture in the setting of acute onset of symptoms.[5] However, more than 102 CFU/ml Escherichia coli had been associated with an approximately 90% positive predictive value of a UTI if there are also symptoms. This lower threshold may be more clinically applicable in the evaluation of UTI and rUTI.[7]

Providers also need to also be aware of the potential for a contaminated sample, which may manifest as mucous or squamous cells on the urinalysis or with normal vaginal flora (Lactobacilli), multiple organisms, or known contaminants (Group β-hemolytic Streptococcus, Corynebacteria, nonsaprophyticus coagulase-negative staphylococcus) on the urine culture. A catheterized specimen may be obtained if the picture remains unclear.[5]

Imaging and cystoscopy to rule out anatomic abnormalities and evaluate for noninfectious causes should not be routinely obtained due to the low frequency of positive findings. However, if a patient fails to improve with treatment or had rapid recurrence (<2 weeks after treatment), this may be considered a complicated UTI and would therefore potentially warrant more extensive diagnostic workup.[5]