How should you manage this elderly woman with recurrent UTIs?

Clinical Conundrum: GPSI in urology Dr Jon Rees discusses this case of an elderly woman who has recently been experiencing recurrent episodes of urinary tract infection (UTI) including prophylactic treatment options

Case: A 78-year-old woman presents to your emergency surgery saying, ‘It’s my cystitis again’. She has the classic symptoms of urgency, dysuria and frequency, of three days duration, but is otherwise well. As you are prescribing her an antibiotic, she asks: ‘Is there anything that can be done to stop these infections?’ Talking it through and looking at the notes, you realise that this is her seventh episode in the last year, many of which were confirmed by MSU. Prior to this, she’d only had a couple of UTIs in her lifetime.

In a case like this, how can the GP decide whether to manage within primary care or to refer? And when referral might be indicated, how can we decide which should be under the urgent pathway and which routine?

This is an incredibly common scenario in primary care, and the majority of patients with recurrent urinary tract infection (UTI) can be safely managed in a primary care setting.

In order to decide whether to refer or not it is useful for the clinician to ask themselves:

1. Am I confident this person is having recurrent UTI? Are the symptoms convincing, and does the patient experience a good response to antibiotic treatment? Are urine tests supportive of the diagnosis – so, the presence of nitrites or leucocytes if the urine has been dipped, or the presence of pyuria or growth of a urinary pathogen on culture? But remember that tests can be misleading – asymptomatic bacteriuria is common in older patients, leading to misdiagnosis, while many patients with recurrent UTI send samples that repeatedly fail to grow any organisms on culture. So, taking a good history and assessing response to antibiotic treatment will be the mainstay of diagnosis.
2. Is there anything about this patient that worries me? Are they a heavy smoker, do they have persistent haematuria even in between infections, are their symptoms actually not responding at all to antibiotics? NICE suspected cancer guidelines advise that we consider a non-urgent referral for patients over 60 with recurrent or persistent unexplained UTI – note the guidance does not say to refer all patients with recurrent UTI – some clinical judgement is required.

Work published by the Academy of Medical Royal Colleges in 2024 aims to help with this decision over who to refer. The guidance suggests that all women with recurrent UTI should have a renal ultrasound requested in primary care, including a measurement of post-micturition residual volume.

Specialty urology referral should be offered to women where any of the following clinical criteria are met:

• Prior urinary tract surgery, pelvic organ prolapse surgery, abdominopelvic malignancy or trauma.
• Visible or non-visible haematuria after resolution of infection (this should be managed as per NICE suspected cancer guidance — gynaecological cancer; urological cancer).
• Urea-splitting bacteria on culture (e.g. Proteus, Yersinia) in the presence of a stone, or atypical infections (e.g. tuberculosis, anaerobic bacteria)
• Bacterial persistence or on-going lower urinary tract symptoms after sensitivity-based therapy.
• Pneumaturia or faecaluria.
• Voiding symptoms (straining, weak stream, intermittency, hesitancy).

OR if any of the following features are present on renal ultrasound:

• Hydroureter or hydronephrosis.
• Bladder OR ureteric OR obstructive renal stones (for non-obstructive renal stones use advice and guidance).
• Post-micturition residual volume greater than 150ml.

This guidance is clear that the risk of significant findings on cystoscopy, including malignancy, for women with uncomplicated recurrent UTI is extremely low – a systematic review showed only 1 out of 656 cystoscopies revealed a significant malignancy – and use of these recommendations can help reduce unnecessary referral of low-risk patients.

Primary care clinicians should be alert to patients who are at higher risk – persistent unexplained storage symptoms (frequency, urgency) with absence of response to treatment with antibiotics or overactive bladder medications, particularly in the presence of haematuria (visible or non-visible) and in a patient with a significant smoking history should be a trigger for urgent referral (on urgent suspected cancer referral pathway if they meet the criteria, e.g. over 60 with dysuria and non-visible haematuria; otherwise via other urgent referral) as these patients are exhibiting symptoms that could represent undiagnosed bladder cancer.

If, ultimately, prophylactic antibiotics are indicated, which are the best to choose, how long should they be used for and should they be rotated? How are intercurrent infections while on prophylaxis best managed?

The term ‘prophylactic antibiotics’ refers to the use of longer courses of (usually) low-dose antibiotics – truly prophylactic antibiotics are used for the prevention of recurrent infection but longer courses of low-dose antibiotics will also sometimes be used for the treatment of chronic/persistent urine infection. In this acute scenario the antibiotic is not being used for prevention and non-antibiotic alternatives for prophylaxis will not be effective, although may be used as follow-on treatment once the persistent infection has been cleared.

NICE gives guidance on the use of prophylactic antibiotics. This guidance points out that there are other measures that can often be used to reduce prescribing of low-dose antibiotic prophylaxis (and the subsequent increased risk of antimicrobial resistance) – single dose prophylaxis can be considered for patients where sexual intercourse is the usual trigger for their UTIs, and non-antibiotic prophylaxis (see answer below) should always be considered and/or trialled before embarking on prolonged antibiotic treatment (for prevention of UTI – this is different in the persistent UTI scenario described above).

If low-dose antibiotic prophylaxis is required (due to failure of non-antibiotic measures) the choice of antibiotic should be driven by local microbiological guidance – in most scenarios, trimethoprim or nitrofurantoin will be first line. However, it is vital that the prescriber is aware of the risks of prescribing longer courses of nitrofurantoin, in terms of pulmonary or hepatic reactions – detailed by the MHRA and in this BJGP Open article from 2025.

The prescriber should always aim to minimise duration of treatment with prophylactic antibiotics – switching to non-antibiotic prophylaxis, as detailed below, ideally after 3-6 months. The evidence base for these measures means that use of prophylactic antibiotics as first-line, or on an indefinite basis, can no longer be justified for the vast majority of patients.

I’ve seen increasing numbers of patients being put on methenamine hippurate by specialists. What is this and how does it work? Can GPs confidently start this in primary care, and when should it be used? How long is it used for?

Methenamine hippurate (Hiprex) is a urinary antiseptic agent (it converts to a weak formaldehyde in the presence of acidic urine) that has been shown to be non-inferior to prophylactic antibiotics for the prevention of recurrent UTI.

It is recommended by NICE guidance and should always be considered ahead of prophylactic antibiotics for prevention. It can only be used for prevention – it does not treat acute or persistent infection.

Specifically, NICE suggests use of methenamine hippurate for women who have recurrent UTI that has not been adequately improved by behavioural and personal hygiene measures, vaginal oestrogen or single-dose antibiotic prophylaxis (if any of these have been appropriate and are applicable).

GPs should definitely consider prescribing this in primary care, and there is no good rationale for restricting this drug to secondary care initiation. When prescribing, aim for approximately 6 months of treatment and then consider stopping – however longer-term use can be considered if the patient has responded well but continues to relapse on discontinuation.

Remember there is also strong evidence for the use of vaginal oestrogen in peri/post-menopausal women with recurrent UTI.  This can be co-prescribed alongside methenamine hippurate, and potentially continued in the long term after discontinuation of methenamine hippurate.

Some patients will also use over-the-counter measures such as cranberry and D-mannose – however, the evidence base for these measures is weaker, so it is difficult to strongly recommend these.

Dr Jon Rees is a GPSI in urology and chair of the Primary Care Urology Society