Management of recurrent lower urinary tract infection (UTI) in non-pregnant women

Defining recurrent UTI

The widely accepted definition of ‘recurrent UTI’ in women are three or more episodes of symptomatic lower UTI in 12 months or two or more episodes in 6 months. This does not include episodes of bacteriuria without UTI symptoms (asymptomatic bacteriuria).

Cystitis means inflammation of the bladder. It is usually but not always caused by a urine infection and is often self-limiting.

Reducing risks of recurrent UTI

Consider the following measures to reduce risks of recurrent UTI:

  • Encourage better hydration to ensure more frequent urination as this can reduce recurrence. Refer to the National Hydration Campaign Materials. If not contraindicated, recommend 2.5L of fluids daily and 1.5L should be water. (For individuals with a low baseline fluid intake, it is recommended that daily consumption be increased by approximately 1.5L).
  • Advise on hygiene practise such as “Keep clean by wiping from front to back after going to the toilet, do not douche, and try not to wear tight underwear.” Encourage urge initiated and postcoital voiding. Advise sexually active women that diaphragm and spermicide use may increase the risk of infection and discuss alternative contraception.
  • Poor control of diabetes is associated with increased risk of UTI so diet and adherence to diabetes medication and monitoring is essential.
  • Sodium-glucose co-transporter-2 (SGLT2) inhibitors (eg dapagliflozin) used in diabetes and heart failure management promote glycosuria. This increases the risk of candida genital infections and may increase recurrent UTI risk. If recurrent UTI is recognised, a risk benefit assessment should be made in discussion with the patient and the specialist.

Managing recurrent UTI

Step 1: Initial management

  • Obtain mid-stream urine for culture and to establish sensitivities.
  • Treat current lower UTI:
    • Consider use of a non-steroidal anti-inflammatory drug in women under 65 years, if appropriate, with non-severe symptoms after discussing risks and benefits.
    • Safety-net with advice for patients to seek medical attention if they develop fever, loin pain, or if symptoms worsen or are not improving in 48 hours or individual becomes systemically unwell.
  • Consider possible avoidable triggers and behaviour change for preventing UTI.
  • Consider prescribing intravaginal oestrogen to perimenopausal and postmenopausal women with risk factors such as atrophic vaginitis (unlicensed indication):
  • Consider and discuss with the patient other non-antibiotic therapies (see below).

Step 2: If the initial measures above including the use of intravaginal oestrogen are ineffective or inappropriate consider the following:

  • Single-dose antibiotic prophylaxis following exposure to UTI trigger. For example, for recurrent cystitis associated with sexual intercourse, offer trimethoprim 200mg (if sensitive) to be taken within 2 hours of intercourse. Review within 6 months.
  • Methenamine hippurate, 1g twice a day for minimum of 6 months and up to 1 year if improvement seen. Available evidence suggests no differences for most UTI outcomes when methenamine hippurate was compared with daily antibiotic treatment.
  • Methenamine hippurate requires acidic urine for its antiseptic properties to work so the use of alkalizing agents is not recommended. In addition, there is insufficient evidence to support the use of alkalizing agent in the management of UTI. Refer to section on “non-antibiotic therapies” below.

Step 3: If unresolved, assess underlying causes of recurrent UTI  

  • Consider renal tract ultrasound (to detect stones, cysts, tumours and other abnormalities) and post-void bladder residual volume scan (to detect voiding dysfunction).
  • For women with no obvious risk factors, consider referral to urology for further evaluation which may include cystoscopy, particularly if recurrent UTI is a recent problem.
  • If investigations are normal and problems continue after intravaginal oestrogen (for peri- and postmenopausal women), single-dose antibiotic or methenamine hippurate, then refer to local specialist and consider daily antibiotic prophylaxis.
  • Standby antibiotics may be considered in a small number of circumstances, usually following specialist advice.
  • Consider chlamydia testing for patients with recurring dysuria who are non-responsive to antibiotics.

Step 4: Consider initiating daily antibiotic prophylaxis

  • Antibiotic prophylaxis should not be considered in patients with indwelling urinary catheter.
  • Treat current UTI before initiating antibiotic prophylactic treatment.
  • Consider risks and benefits of starting daily antibiotic prophylaxis.

Management of patients prescribed prophylactic antibiotics

1. If daily antibiotic prophylaxis is prescribed

  • Counsel patient that antibiotic prophylaxis is prescribed for a fixed period (usually 3-6 months) to allow bladder to heal and is not usually a life-long treatment. More information for patients can be found at Recurrent cystitis in women.
  • Where possible, refer to recent culture and bacterial sensitivity results before prescribing.
  • Consider prescribing trimethoprim (100mg nightly) or nitrofurantoin (50mg–100mg at night if estimated glomerular filtration rate is 45ml/minute or more) as first line antibiotic or cefalexin (125mg at night) as second line antibiotic if indicated by sensitivity results.
  • Ensure patient is aware to seek medical attention if they develop UTI symptoms while on prophylactic antibiotics. This includes if they develop fever, loin pain or if individual becomes systemically unwell.
  • Rotation of prophylactic antibiotics to address issues of resistance is not encouraged.

2. Stopping a prolonged course of prophylactic antibiotics

  • Review antibiotic prophylaxis after 3-6 months of use with a view to stopping them as there is no evidence of additional benefit beyond 3-6 months. Document review date in medical notes and on prescription.
  • Patients may feel anxious about stopping antibiotic prophylaxis in case they develop UTIs. Advise patient that a prolonged period of antibiotic allows the bladder wall to ‘heal’, and in most cases, this makes UTIs less likely
  • Advise patient on continuing the measures previously outlined to prevent UTI.
  • Advise patient on how to access treatment if they have new UTI symptoms.
  • Consider and discuss with the patient the risks of long-term antibiotics in terms of vulvovaginal candidiasis, Clostridioides difficile and other local side-effects and increased likelihood of infection with resistant organisms.
  • Patients on UTI prophylaxis should undergo review at 6 months if not initiated sooner

3. Managing ‘breakthrough’ UTIs in patients on antibiotic prophylaxis

  • Initial management:
    • Obtain a urine sample for culture and sensitivity testing.
    • While awaiting culture results, start a treatment dose of an antibiotic that differs from the current prophylactic agent. The choice of antibiotic should be guided by local guidance and resistance patterns and the patient's clinical situation.
    • Stop the prophylactic agent while the patient receives treatment course of antibiotics.
  • Follow up on culture results and adjust antibiotic choice if the culture and sensitivity results indicate a more appropriate option.
  • Safety-net with advice to seek medical attention if they develop fever, loin pain, or if symptoms worsen/are not improving by 48 hours or individual becomes systemically unwell.
  • A breakthrough infection often indicates that the current prophylactic regimen is no longer effective, and a review is necessary. If the organism demonstrates resistance to the prophylactic agent, or if multiple breakthrough UTIs occur (ie two or more UTI episodes in 6 months), the prophylaxis should be considered ineffective and discontinued
  • Re-emphasise and consider non-antibiotic preventative measures as detailed above.

4. Recurrence of UTI after stopping antibiotic prophylaxis

  • Ensure patient is complying with the simple measures previously outlined to prevent UTI.
  • Consider renal tract ultrasound (to detect stones, cysts, tumours and other abnormalities) and post-void bladder residual volume scan (to detect voiding dysfunction) if not already done. Consult with local specialists.
  • If appropriate investigations show no abnormality, there are no concerning ‘red flag’ symptoms, and other management options are unsuccessful, then consider continuing prophylaxis. The ongoing need for antibiotic prophylaxis should be reviewed after 3 months.

 

Non-antibiotic therapies

  • Cranberry products: There is uncertainty regarding the benefits of cranberry products in preventing recurrent UTIs in non-pregnant women. There is no evidence to suggest benefit in older women.
  • D-mannose: Available evidence suggests D-mannose (taken as 200ml of 1 % solution once daily in the evening) may be effective in  preventing recurrent UTI in non-pregnant women. The sugar in these products should be considered in daily sugar intake.
  • Probiotics (lactobacillus): There is inconclusive evidence regarding the benefits of lactobacillus in reducing the risk of recurrent UTI.
  • Alkalising Agents: There is insufficient evidence to recommend the use of alkalising agents in the management of UTI (including preventing recurrent UTIs) and should no longer be recommended.
  • Immunoactive prophylaxis: Use on specialist advice only. Published reviews suggest that immunoactive prophylaxis with Uro-Vaxom® or Uromune® (MV 140, polybacterial sublingual vaccine) may be effective in reducing the recurrence of UTI. Studies included in the reviews were mostly retrospective and non-randomised, and results should be interpreted with caution. This use is unlicensed in the UK.
  • Topical intravaginal oestrogen to perimenopausal and postmenopausal women with risk factors such as atrophic vaginitis (unlicensed indication).

 

Content updated April 2026
Scottish Antimicrobial Prescribing Group (SAPG) | January 2026 for review January 2029