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Referral criteria from primary care - recurrent UTIs in a woman

Last reviewed dd mmm yyyy. Last edited dd mmm yyyy

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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 NG1123
  • 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


  • relapsed urinary tract infection — where the same organism is identified in the urine within two weeks of appropriate antimicrobial treatment
    • 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


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