International Urogynecology Journal

, Volume 26, Issue 6, pp 795–804 | Cite as

Recurrent urinary tract infections in women

  • Abdullatif Aydin
  • Kamran AhmedEmail author
  • Iftikhar Zaman
  • Muhammad Shamim Khan
  • Prokar Dasgupta
Review Article


Introduction and hypothesis

Recurrent urinary tract infections (UTIs) are more common in women and are frequently defined as ≥2 episodes in the last 6 months or ≥3 episodes in the last 12 months. In a primary care setting, 53 % of women above the age of 55 years and 36 % of younger women report a recurrence within 1 year. Thus, management and prevention of recurrent UTI is of utmost significance. This review aims to highlight the latest research in prevention strategies and suggest a management pathway.


A search was conducted on MEDLINE, Embase and the Cochrane Database of Systematic Reviews databases for the latest systematic reviews and high-quality randomized controlled trials. Special emphasis was placed on the remit “recurrent” and strongly adhered to. Furthermore, a Google search was conducted for current guidelines on the management of UTIs.


Current prevention strategies include eliminating risk factors that increase the risk of acquiring recurrent UTI and continuous, post-coital and self-initiated antimicrobial prophylaxis. Other prospective preventative strategies, currently under trial, include use of vaccinations, D-mannose and lactobacillus (probiotics).


Although risk factors should be identified and addressed accordingly, individualized antibiotic prophylaxis remains the most effective method of management. Non-antibiotic prevention strategies such as cranberry, vitamin C and methenamine salts lack strong evidence to be introduced as routine management options and as alternatives to antibiotics. Based on current evidence and guidelines, a management pathway is recommended. Emerging therapies require further evaluation before they can be recommended.


Recurrent urinary tract infection Recurrent UTI Women Management Prevention Pathway 


Conflicts of interest



  1. 1.
    Fihn SD (2003) Clinical practice. Acute uncomplicated urinary tract infection in women. N Engl J Med 349(3):259–266CrossRefPubMedGoogle Scholar
  2. 2.
    Griebling TL (2005) Urologic diseases in America project: trends in resource use for urinary tract infections in women. J Urol 173(4):1281–1287CrossRefPubMedGoogle Scholar
  3. 3.
    Foxman B (1990) Recurring urinary tract infection: incidence and risk factors. Am J Public Health 80(3):331–333CrossRefPubMedCentralPubMedGoogle Scholar
  4. 4.
    Scholes D, Hooton TM, Roberts PL, Stapleton AE, Gupta K, Stamm WE (2000) Risk factors for recurrent urinary tract infection in young women. J Infect Dis 182(4):1177–1182CrossRefPubMedGoogle Scholar
  5. 5.
    Hooton TM (2001) Recurrent urinary tract infection in women. Int J Antimicrob Agents 17(4):259–268CrossRefPubMedGoogle Scholar
  6. 6.
    Ikäheimo R, Siitonen A, Heiskanen T, Kärkkäinen U, Kuosmanen P, Lipponen P et al (1996) Recurrence of urinary tract infection in a primary care setting: analysis of a 1-year follow-up of 179 women. Clin Infect Dis 22(1):91–99CrossRefPubMedGoogle Scholar
  7. 7.
    Kodner CM, Thomas Gupton EK (2010) Recurrent urinary tract infections in women: diagnosis and management. Am Fam Physician 82(6):638–643PubMedGoogle Scholar
  8. 8.
    Epp A, Larochelle A, Lovatsis D, Walter JE, Easton W, Farrell SA et al (2010) Recurrent urinary tract infection. J Obstet Gynaecol Can 32(11):1082–1101PubMedGoogle Scholar
  9. 9.
    Nosseir SB, Lind LR, Winkler HA (2012) Recurrent uncomplicated urinary tract infections in women: a review. J Womens Health (Larchmt) 21(3):347–354CrossRefGoogle Scholar
  10. 10.
    Gillenwater JY, Grayhack JT, Howards SS, Mitchell ME (2002) Adult and paediatric urology, 4th edn. Lippincott Williams & Wilkins, PhiladelphiaGoogle Scholar
  11. 11.
    Franco AV (2005) Recurrent urinary tract infections. Best Pract Res Clin Obstet Gynaecol 19(6):861–873CrossRefPubMedGoogle Scholar
  12. 12.
    American College of Obstetricians and Gynecologists (2008) ACOG Practice Bulletin No. 91: treatment of urinary tract infections in nonpregnant women. Obstet Gynecol 111:785–794CrossRefGoogle Scholar
  13. 13.
    Hooton TM, Gupta K (2014) Recurrent urinary tract infection in women. Available via
  14. 14.
    Johnson JR, Clabots C (2006) Sharing of virulent Escherichia coli clones among household members of a woman with acute cystitis. Clin Infect Dis 43(10):e101–e108CrossRefPubMedGoogle Scholar
  15. 15.
    Hooton TM, Stapleton AE, Roberts PL, Winter C, Scholes D, Bavendam T et al (1999) Perineal anatomy and urine-voiding characteristics of young women with and without recurrent urinary tract infections. Clin Infect Dis 29(6):1600–1601CrossRefPubMedGoogle Scholar
  16. 16.
    Nseir W, Taha M, Nemarny H, Mograbi J (2013) The association between serum levels of vitamin D and recurrent urinary tract infections in premenopausal women. Int J Infect Dis 17(12):e1121–e1124CrossRefPubMedGoogle Scholar
  17. 17.
    Gupta K, Stapleton AE, Hooton TM, Roberts PL, Fennell CL, Stamm WE (1998) Inverse association of H2O2-producing lactobacilli and vaginal Escherichia coli colonization in women with recurrent urinary tract infections. J Infect Dis 178:446–450CrossRefPubMedGoogle Scholar
  18. 18.
    Gupta K, Trautner BW (2013) Diagnosis and management of recurrent urinary tract infections in non-pregnant women. BMJ 346:f3140CrossRefPubMedGoogle Scholar
  19. 19.
    Zaffanello M, Malerba G, Cataldi L, Antoniazzi F, Franchini M, Monti E et al (2010) Genetic risk for recurrent urinary tract infections in humans: a systematic review. J Biomed Biotechnol 2010:321082CrossRefPubMedCentralPubMedGoogle Scholar
  20. 20.
    Lundstedt AC, Leijonhufvud I, Ragnarsdottir B, Karpman D, Andersson B, Svanborg C (2007) Inherited susceptibility to acute pyelonephritis: a family study of urinary tract infection. J Infect Dis 195(8):1227–1234CrossRefPubMedGoogle Scholar
  21. 21.
    British Infection Association/Health Protection Agency (2011) Diagnosis of UTI: quick reference guide for primary care (09.07.2014). Available via
  22. 22.
    European Association of Urology (EAU) (2014) Guidelines on urological infections (updated 06.06.2014). Available via
  23. 23.
    McIsaac WJ, Moineddin R, Ross S (2007) Validation of a decision aid to assist physicians in reducing unnecessary antibiotic drug use for acute cystitis. Arch Intern Med 167(20):2201–2206CrossRefPubMedGoogle Scholar
  24. 24.
    Dason S, Dason JT, Kapoor A (2011) Guidelines for the diagnosis and management of recurrent urinary tract infection in women. Can Urol Assoc J 5(5):316–322CrossRefPubMedCentralPubMedGoogle Scholar
  25. 25.
    Nicolle LE, Mayhew WJ, Bryan L (1987) Prospective randomized comparison of therapy and no therapy for asymptomatic bacteriuria in institutionalized elderly women. Am J Med 83:27–33CrossRefPubMedGoogle Scholar
  26. 26.
    Scottish Intercollegiate Guidelines Network (2012) SIGN Guideline 88. Management of suspected bacterial urinary tract infection in adults. Available via
  27. 27.
    Ninan S, Walton C, Barlow G (2014) Investigation of suspected urinary tract infection in older people. BMJ 349:g4070CrossRefPubMedGoogle Scholar
  28. 28.
    Bonkat G, Müller G, Berini A, Frei R, Goldenberger D, Regeniter A et al (2014) Combination of matrix-assisted laser desorption/ionization time of flight (MALDI-TOF) and UX-2000 urine flow-cytometry for rapid detection and identification of urinary tract pathogens. Eur Urol Suppl 13(1):e456CrossRefGoogle Scholar
  29. 29.
    Health Protection Agency (2012) Management of infection guidance for primary care for consultation and local adaptation (updated 22 May 2013). Available via
  30. 30.
    Stamm WE, Counts GW, Wagner KF, Martin D, Gregory D, McKevitt M et al (1980) Antimicrobial prophylaxis of recurrent urinary tract infections: a double-blind, placebo-controlled trial. Ann Intern Med 92(6):770–775CrossRefPubMedGoogle Scholar
  31. 31.
    Nicolle LE (1992) Prophylaxis: recurrent urinary tract infection in women. Infection 20(Suppl 3):S203–S205, discussion S206–S210CrossRefPubMedGoogle Scholar
  32. 32.
    Al-Badr A, Al-Shaikh G (2013) Recurrent urinary tract infections management in women: a review. Sultan Qaboos Univ Med J 13(3):359–367CrossRefPubMedCentralPubMedGoogle Scholar
  33. 33.
    Albert X, Huertas I, Pereiró II, Sanfélix J, Gosalbes V, Perrota C (2004) Antibiotics for preventing recurrent urinary tract infection in non-pregnant women. Cochrane Database Syst Rev 3:CD001209PubMedGoogle Scholar
  34. 34.
    Eells SJ, Bharadwa K, McKinnell JA, Miller LG (2014) Recurrent urinary tract infections among women: comparative effectiveness of 5 prevention and management strategies using a Markov chain Monte Carlo model. Clin Infect Dis 58(2):147–160CrossRefPubMedCentralPubMedGoogle Scholar
  35. 35.
    National Institute for Health and Care Excellence (NICE) (2009) Clinical knowledge summaries. Urinary tract infection (lower) - women (22 May 2013). Available via
  36. 36.
    Hickling DR, Nitti VW (2013) Management of recurrent urinary tract infections in healthy adult women. Rev Urol 15(2):41–48PubMedCentralPubMedGoogle Scholar
  37. 37.
    Holmberg L, Boman G, Böttiger LE, Eriksson B, Spross R, Wessling A (1980) Adverse reactions to nitrofurantoin. Analysis of 921 reports. Am J Med 69(5):733–738CrossRefPubMedGoogle Scholar
  38. 38.
    Madani Y, Mann B (2012) Nitrofurantoin-induced lung disease and prophylaxis of urinary tract infections. Prim Care Respir J 21(3):337–341CrossRefPubMedGoogle Scholar
  39. 39.
    Lichtenberger P, Hooton TM (2011) Antimicrobial prophylaxis in women with recurrent urinary tract infections. Int J Antimicrob Agents 38(Suppl):36–41CrossRefPubMedGoogle Scholar
  40. 40.
    Perrotta C, Aznar M, Mejia R, Albert X, Ng CW (2008) Oestrogens for preventing recurrent urinary tract infection in postmenopausal women. Cochrane Database Syst Rev 2:CD005131PubMedGoogle Scholar
  41. 41.
    Wong ES, McKevitt M, Running K, Counts GW, Turck M, Stamm WE (1985) Management of recurrent urinary tract infections with patient-administered single-dose therapy. Ann Intern Med 102(3):302–307CrossRefPubMedGoogle Scholar
  42. 42.
    Gupta K, Hooton TM, Roberts PL, Stamm WE (2001) Patient-initiated treatment of uncomplicated recurrent urinary tract infections in young women. Ann Intern Med 135(1):9–16CrossRefPubMedGoogle Scholar
  43. 43.
    Schaeffer AJ, Stuppy BA (1999) Efficacy and safety of self-start therapy in women with recurrent urinary tract infections. J Urol 161(1):207–211CrossRefPubMedGoogle Scholar
  44. 44.
    Gupta K, Hooton TM, Naber KG, Wullt B, Colgan R, Miller LG et al (2011) International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: a 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis 52(5):e103–e120CrossRefPubMedGoogle Scholar
  45. 45.
    Stamm WE, Raz R (1999) Factors contributing to susceptibility of postmenopausal women to recurrent urinary tract infections. Clin Infect Dis 28(4):723–725CrossRefPubMedGoogle Scholar
  46. 46.
    Raz R (2001) Hormone replacement therapy or prophylaxis in postmenopausal women with recurrent urinary tract infection. J Infect Dis 183(Suppl 1):S74–S76CrossRefPubMedGoogle Scholar
  47. 47.
    Weiderpass E, Baron JA, Adami HO, Magnusson C, Lindgren A, Bergström R et al (1999) Low-potency oestrogen and risk of endometrial cancer: a case-control study. Lancet 353(9167):1824–1828CrossRefPubMedGoogle Scholar
  48. 48.
    Schmidt DR, Sobota AE (1988) An examination of the anti-adherence activity of cranberry juice on urinary and nonurinary bacterial isolates. Microbios 55:173PubMedGoogle Scholar
  49. 49.
    Zafriri D, Ofek I, Adar R, Pocino M, Sharon N (1989) Inhibitory activity of cranberry juice on adherence of type 1 and type P fimbriated Escherichia coli to eucaryotic cells. Antimicrob Agents Chemother 33(1):92–98CrossRefPubMedCentralPubMedGoogle Scholar
  50. 50.
    Jepson RG, Williams G, Craig JC (2012) Cranberries for preventing urinary tract infections. Cochrane Database Syst Rev 10:CD001321PubMedGoogle Scholar
  51. 51.
    Wang CH, Fang CC, Chen NC, Liu SS, Yu PH, Wu TY et al (2012) Cranberry-containing products for prevention of urinary tract infections in susceptible populations: a systematic review and meta-analysis of randomized controlled trials. Arch Intern Med 172(13):988–996CrossRefPubMedGoogle Scholar
  52. 52.
    Micali S, Isgro G, Bianchi G, Miceli N, Calapai G, Navarra M (2014) Cranberry and recurrent cystitis: more than marketing? Crit Rev Food Sci Nutr 54(8):1063–1075CrossRefPubMedGoogle Scholar
  53. 53.
    Beerepoot MA, ter Riet G, Nys S, van der Wal WM, de Borgie CA, de Reijke TM et al (2011) Cranberries vs antibiotics to prevent urinary tract infections: a randomized double-blind noninferiority trial in premenopausal women. Arch Intern Med 171(14):1270–1278CrossRefPubMedGoogle Scholar
  54. 54.
    Stapleton AE, Dziura J, Hooton TM, Cox ME, Yarova-Yarovaya Y, Chen S et al (2012) Recurrent urinary tract infection and urinary Escherichia coli in women ingesting cranberry juice daily: a randomized controlled trial. Mayo Clin Proc 87(2):143–150CrossRefPubMedCentralPubMedGoogle Scholar
  55. 55.
    Carlsson S, Govoni M, Wiklund NP, Weitzberg E, Lundberg JO (2003) In vitro evaluation of a new treatment for urinary tract infections caused by nitrate-reducing bacteria. Antimicrob Agents Chemother 47(12):3713–3718CrossRefPubMedCentralPubMedGoogle Scholar
  56. 56.
    Carlsson S, Wiklund NP, Engstrand L, Weitzberg E, Lundberg JO (2001) Effects of pH, nitrite, and ascorbic acid on nonenzymatic nitric oxide generation and bacterial growth in urine. Nitric Oxide 5(6):580–586CrossRefPubMedGoogle Scholar
  57. 57.
    Foxman B, Chi JW (1990) Health behavior and urinary tract infection in college-aged women. J Clin Epidemiol 43(4):329–337CrossRefPubMedGoogle Scholar
  58. 58.
    Mayrer AR, Andriole VT (1982) Urinary tract antiseptics. Med Clin North Am 66:199–208PubMedGoogle Scholar
  59. 59.
    Cronberg S, Welin CO, Henriksson L, Hellsten S, Persson KM, Stenberg P (1987) Prevention of recurrent acute cystitis by methenamine hippurate: double blind controlled crossover long term study. Br Med J (Clin Res Ed) 294(6586):1507–1508CrossRefGoogle Scholar
  60. 60.
    Gundersen R, Høivik HO, Osmundsen K (1986) Frequent cystitis in elderly women. A double-blind comparison of Hiprex and placebo in general practice (in Norwegian). Tidsskr Nor Laegeforen 106(25):2048–2049PubMedGoogle Scholar
  61. 61.
    Høivik HO, Gundersen R, Osmundsen K, Halvorsen P, Hjortdahl P, Stokke JG (1984) Prevention of recurrent cystitis in fertile women. A double-blind comparison of Hiprex and placebo in general practice (in Norwegian). Tidsskr Nor Laegeforen 104(16):1150–1152PubMedGoogle Scholar
  62. 62.
    Lee BB, Simpson JM, Craig JC, Bhuta T (2007) Methenamine hippurate for preventing urinary tract infections. Cochrane Database Syst Rev 4:CD003265PubMedGoogle Scholar
  63. 63.
    Altarac S, Papeš D (2014) Use of D-mannose in prophylaxis of recurrent urinary tract infections (UTIs) in women. BJU Int 113(1):9–10CrossRefPubMedGoogle Scholar
  64. 64.
    Bouckaert J, Berglund J, Schembri M, De Genst E, Cools L, Wuhrer M et al (2005) Receptor binding studies disclose a novel class of high-affinity inhibitors of the Escherichia coli FimH adhesin. Mol Microbiol 55(2):441–455CrossRefPubMedGoogle Scholar
  65. 65.
    King SS, Young DA, Nequin LG, Carnevale EM (2000) Use of specific sugars to inhibit bacterial adherence to equine endometrium in vitro. Am J Vet Res 61(4):446–449CrossRefPubMedGoogle Scholar
  66. 66.
    Kranjčec B, Papeš D, Altarac S (2014) D-mannose powder for prophylaxis of recurrent urinary tract infections in women: a randomized clinical trial. World J Urol 32(1):79–84CrossRefPubMedGoogle Scholar
  67. 67.
    Stapleton AE, Au-Yeung M, Hooton TM, Fredricks DN, Roberts PL, Czaja CA et al (2011) Randomized, placebo-controlled phase 2 trial of a Lactobacillus crispatus probiotic given intravaginally for prevention of recurrent urinary tract infection. Clin Infect Dis 52(10):1212–1217CrossRefPubMedCentralPubMedGoogle Scholar
  68. 68.
    Beerepoot MA, ter Riet G, Nys S, van der Wal WM, de Borgie CA, de Reijke TM et al (2012) Lactobacilli vs antibiotics to prevent urinary tract infections: a randomized, double-blind, noninferiority trial in postmenopausal women. Arch Intern Med 172:704CrossRefPubMedGoogle Scholar
  69. 69.
    Bauer HW, Alloussi S, Egger G, Blümlein HM, Cozma G, Schulman CC et al (2005) A long-term, multicenter, double-blind study of an Escherichia coli extract (OM-89) in female patients with recurrent urinary tract infections. Eur Urol 47(4):542–548, discussion 548CrossRefPubMedGoogle Scholar
  70. 70.
    Magasi P, Pánovics J, Illés A, Nagy M (1994) Uro-Vaxom and the management of recurrent urinary tract infection in adults: a randomized multicenter double-blind trial. Eur Urol 26(2):137–140PubMedGoogle Scholar
  71. 71.
    Schulman CC, Corbusier A, Michiels H, Taenzer HJ (1993) Oral immunotherapy of recurrent urinary tract infections: a double-blind placebo-controlled multicenter study. J Urol 150(3):917–921PubMedGoogle Scholar
  72. 72.
    Tammen H (1990) Immunobiotherapy with Uro-Vaxom in recurrent urinary tract infection. The German Urinary Tract Infection Study Group. Br J Urol 65(1):6–9CrossRefPubMedGoogle Scholar
  73. 73.
    Hopkins WJ, Elkahwaji J, Beierle LM, Leverson GE, Uehling DT (2007) Vaginal mucosal vaccine for recurrent urinary tract infections in women: results of a phase 2 clinical trial. J Urol 177(4):1349–1353, quiz 1591CrossRefPubMedGoogle Scholar
  74. 74.
    Uehling DT, Hopkins WJ, Elkahwaji JE, Schmidt DM, Leverson GE (2003) Phase 2 clinical trial of a vaginal mucosal vaccine for urinary tract infections. J Urol 170(3):867–869CrossRefPubMedGoogle Scholar
  75. 75.
    Naber KG, Cho YH, Matsumoto T, Schaeffer AJ (2009) Immunoactive prophylaxis of recurrent urinary tract infections: a meta-analysis. Int J Antimicrob Agents 33(2):111–119CrossRefPubMedGoogle Scholar

Copyright information

© The International Urogynecological Association 2014

Authors and Affiliations

  • Abdullatif Aydin
    • 1
  • Kamran Ahmed
    • 1
    Email author
  • Iftikhar Zaman
    • 1
  • Muhammad Shamim Khan
    • 1
  • Prokar Dasgupta
    • 1
  1. 1.Department of Urology, Guy’s and St. Thomas’ NHS Foundation Trust, King’s Health PartnersMRC Centre for Transplantation, King’s College LondonLondonUK

Personalised recommendations