Cystoscopy and upper tract imaging: not required in an index (uncomplicated) patient, only find abnormalities in 2-6% of patients (and usually suspected based on history/physical)
Indications for cystoscopy and imaging
Consider if patient does not respond to adequate UTI treatment or high suspicion, helps to assess anatomic/functional abnormalities that increase risk for UTI
Imaging choice: renal/bladder US should be first choice, only consider CT if high concern or abnormal findings on US
VCUG: obtain if VUR is suspected
MRI: obtain if concern for urethral diverticulum
UTI management algorithm, from Campbell's
Management
Antibiotic therapy options
Self-start therapy: indicated for a reliable patient who will provide UCx and immediately starts taking abx
Post-coital abx: prescribe if clear pattern related to coitus
Prophylactic abx: recommended for 6-12mo duration, but risk of abx resistance
Vaginal estrogen
Benefits: peri/post-menopausal women without obvious contraindications, can help if UTI during breastfeeding, minimal systemic absorption, low risk of breast cancer recurrence (can discuss with patient's oncologist if concerned), low risk for DVT/PE
17b-estradiol cream: 2g daily x2 weeks, then 1g 2-3x per week
Equine estrogen cream: 0.5g daily x2 weeks, then 0.5g 2x per week
Vaginal tablet (estradiol hemihydrate): 10mcg daily x2 weeks, then 10mcg 2-3x per week
Vaginal ring (17b): 2mg ring releases 7.5mcg daily for 3mo
Non-abx proven therapies
Cranberry: proanthocyanidins prevent bacterial adhesion to urothelium, lower rUTI (RR=0.67), tablets are better than juice (sugar), take BID, take 36mg-72mg PAC equivalents
Increased water intake: benefit if baseline UOP < 1.5L
Timed voiding: warranted if hx holding urine for long periods
Non-abx less proven therapies
Methenamine: converted to formaldehyde in urine, take 1g BID, take with 1-4g ascorbic acid (acidified urine increases effects), do not take if CrCl < 50, no benefit if catheter present (needs time to dwell in bladder)
D-mannose: reportedly reduces rUTI, proper dosing not known
Trimethoprim/Sulfamethoxazole: DS BID x3 days, covers most uropathogens
Nitrofurantoin: 100mg BID x5 days, covers E coli and S saprophyticus
Fosfomycin: 3g single dose, covers VRE, ESBL GNRs, consider fosfomycin susceptibility testing prior to starting IV antibiotics
Second line: beta-lactams, fluoroquinolones
Prophylaxis
TMP: 100mg QD
TMP/SMX: SS QD, SS 3x/week
Nitrofurantoin (monohydrate): 50mg QD, 100mg QD
Cephalexin: 125mg QD, 250 QD
Fosfomycin: 3g q10d
Post-Coital Antibiotics
TMP/SMX: SS or DS
Nitrofurantoin: 50mg or 100mg
Cephalexin: 250mg
References
AUA Core Curriculum
Anger, Jennifer, et al. "Recurrent uncomplicated urinary tract infections in women: AUA/CUA/SUFU guideline." The Journal of urology 202.2 (2019): 282-289.
Cooper, K. L., G. M. Badalato, and M. P. Rutman. "Infections of the urinary tract." Campbell-Walsh-Wein Urology. 12th ed. Elsevier (2020): 1129-1201.
Wieder JA: Pocket Guide to Urology. Sixth Edition. J.Wieder Medical: Oakland, CA, 2021.