Referral criteria from primary care - recurrent UTIs in a woman

Investigation and referral if recurrent UTI in woman

Guidance defines recurrent urinary tract infections as (1):

• 2 or more symptomatic lower UTIs in six months or 3 or more symptomatic lower UTIs in one year

Urinary tract infection (UTI) is defined as (1):

• typical symptoms of infection (such as dysuria, nocturia, change in urine appearance or odour) with a clinical response to antibiotics, even in the
  absence of microbiological confirmation, or,
• typical symptoms of infection with a positive urine dipstick (positive for nitrite or leukocyte and red blood cells), or,
• typical symptoms of infection with a positive urine culture

Although culture remains the gold standard for diagnosis of recurrent uncomplicated UTI, clinical discretion should be applied in accepting a history of positive dipstick tests, microscopy and symptomatology as surrogate markers of UTI episodes (2).

Recommendations below provide referral guidance for primary care clinicians when managing non-pregnant women over the age of 18 with recurrent lower UTI (1)

All women with recurrent UTIs

• should be offered a kidneys, ureters and bladder ultrasound (KUB USS) in primary care
  • should include measurement of a postmicturition residual volume as standard

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 or trauma
• prior abdominopelvic malignancy
• visible and non-visible haematuria after resolution of infection (this should be managed as per NICE suspected cancer guidance)
• 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 please use advice and guidance)
• post-micturition residual volume greater than 150ml

Women who do not meet the above criteria for speciality referral should be managed in primary care where possible (1)

• management will differ depending on menopausal status, may include lifestyle modifications, non-antibiotic, and antibiotic based treatments, and should follow the recommendations set out in NICE guideline NG112
• if concerns persist, or symptoms remain uncontrolled despite optimal primary care management, primary care clinicians should use 'advice and guidance' to seek specialist advice in the first instance, prior to referral

NICE guidance states with respect to referral and seeking specialist advice for recurrent UTI (3):

Refer or seek specialist advice on further investigation and management for:

• men, and trans women and non-binary people with a male genitourinary system, aged 16 and over
• people with recurrent upper UTI
• people with recurrent lower UTI when the underlying cause is unknown
• pregnant women, and pregnant trans men and non-binary people
• children and young people aged under 16 years, in line with NICE's guideline on urinary tract infection in under 16s
• people with suspected cancer, in line with NICE's guideline on suspected cancer: recognition and referral

Notes:

• relapsed urinary tract infection — where the same organism is identified in the urine within two weeks of appropriate antimicrobial treatment (1)
  • relapsed or persistent infections should not be counted as 'new' infections when defining a woman with recurrent UTIs.
  • if the same organism is identified more than two weeks after completion of antibiotic therapy, this should be counted as a new infection
• an uncomplicated UTI is one that occurs in a healthy host in the absence of structural or functional abnormalities of the urinary tract (2)
  • all other UTIs are considered complicated UTIs
  • although uncomplicated UTI includes both lower tract infection (cystitis) and upper tract infection (pyelonephritis), repeated pyelonephritis should prompt consideration of a complicated aetiology

Reference:

1. Academy of Medical Royal Colleges on behalf of the Evidence-based Interventions Programme Board (January 2024). Evidence-based Interventions - Clinical guidance Release 4 - Urology
2. 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
3. NICE (December 2024). Urinary tract infection (recurrent): antimicrobial prescribing