referral criteria from primary care - recurrent UTIs in a woman

Last edited 11/2018 and last reviewed 08/2022

Investigation and referral if recurrent UTI in woman

The first thing to consider is what is the definition for what is a recurent UTI in a woman.

The Canadian Urological Association (1) state that:

• definition of recurrent uncomplicated UTI
  • an uncomplicated UTI is one that occurs in a healthy host in the absence of structural or functional abnormalities of the urinary tract
  • recurrent uncomplicated UTI may be defined as 3 or more uncomplicated UTIs in 12 months
  • recurrent UTIs occur due to bacterial reinfection or bacterial persistence. Persistence involves the same bacteria not being eradicated in the urine 2 weeks after sensitivity-adjusted treatment. A reinfection is a recurrence with a different organism, the same organism in more than 2 weeks, or a sterile intervening culture

The Clinical Knowledge Summaries website is not so specific and states (2):

• recurrent UTI:
  • repeated UTI, which may be due to relapse or reinfection
  • relapse is recurrent UTI with the same strain of organism
    • relapse is the likely cause if infection recurs within a short period (for example within 2 weeks) after treatment
  • reinfection is recurrent UTI with a different strain or species of organism
    • reinfection is the likely cause if UTI recurs more than 2 weeks after treatment
      
      
  • the number of recurrences that is regarded as clinically significant depends on the risks of infection and the impact of cystitis on the woman

When is further investigation and referral appropriate in women with recurrent UTIs.

Referral from primary care (2):

• recurrent UTI - (no visible haematuria, not pregnant or catheterized)
  
  
  • urgent referral is recommended for women with recurrent urinary tract infections (UTIs) associated with haematuria (visible or non-visible) for investigations to exclude urological cancer
    
    
  • routine referral is recommended for women with recurrent UTIs:
    • who have a risk factor for an abnormality of the urinary tract including women with:
      • a past history of urinary tract surgery or trauma
      • a past history of bladder or renal calculi
      • obstructive symptoms such as straining, hesitancy, poor stream
      • urea splitting bacteria on culture of the urine such as Proteus or Yersinia
      • persistent bacteriuria despite appropriate antibiotic treatment
      • a past history of abdominal or pelvic malignancy
      • symptoms of a fistula such as pneumaturia
        
        
    • who are immunocompromised or who have diabetes
      
      
    • who have a known abnormality of their renal tract who might benefit from surgical correction, such as cystocele, vesicoureteric reflux, or bladder outlet obstruction
      
      
    • who have not responded to preventive treatments

Investigation of recurrent uncomplicated UTI:

• cystoscopy and imaging are not routinely necessary in all women with recurrent UTI (1)

NICE state (3)

• in patients under 50 years of age with microscopic haematuria, the urine should be tested for proteinuria and serum creatinine levels measured
  • those with proteinurea or raised serum creatinine should be referred to a renal physician. If there is no proteinuria and serum creatinine is normal, a non- urgent referral to a urologist should be made
    
    
• in patients aged 50 years and older who are found to have unexplained microscopic haematur ia, an urgent referral should be made
  
  
• in male or female patients with symptoms suggestive of a urinary infection who also present with macroscopic haematuria, investigations should be undertaken to diagnose and treat the infection before consideration of referral. If infection is not confirmed the patient should be referred urgently
  
  
• in all adult patients aged 40 years and older who present with recurrent or persistent urinary tract infection associated with haematuria, an urgent referral should be made

Reference:

• Dawson S et al. Guidelines for the diagnosis and management of recurrent urinary tract infection in women.Can Urol Assoc J. Oct 2011; 5(5): 316-322
• Clinical Knowledge Summaries (Accessed 18/11/2018).Urinary tract infection (lower) - women.
• NICE (June 2005). Referral guidelines for suspected cancer.