How should I manage an adult patient with recurrent urinary tract infections, and when should I consider referral to a specialist?

Management of adult patients with recurrent urinary tract infections (UTIs):

• Ensure accurate diagnosis by confirming symptomatic UTI and excluding asymptomatic bacteriuria, which should not be treated with antibiotics.
• Advise on preventive measures such as adequate hydration, regular voiding, and addressing any contributing factors like constipation or dysfunctional voiding.
• Consider antimicrobial prophylaxis only after careful assessment and in line with antimicrobial stewardship principles, as routine prophylactic antibiotics are not recommended without clear indication.
• Investigate underlying causes if recurrent UTIs persist, including urinary tract imaging and assessment for anatomical or functional abnormalities.

When to consider referral to a specialist:

• Refer adults with recurrent UTIs who have atypical features such as non-E. coli infections, poor response to treatment, or suspected urinary tract abnormalities for specialist assessment.
• Refer patients with visible haematuria, increased frequency of UTIs, or other unexplained lower urinary tract symptoms for investigation including imaging and cystoscopy via a suspected cancer pathway referral.
• Consider referral for specialist urological or nephrological input if there is evidence of renal impairment, structural abnormalities, or neurogenic lower urinary tract dysfunction.

Providing patients with information about symptom recognition, prevention, and the importance of prompt treatment is essential for long-term management.

These recommendations align with NICE guidance on urinary tract infections and urinary incontinence in neurological disease, emphasizing tailored care and timely specialist referral when indicated ².