Fluid intake

Recommendation
Women with a history of recurrent UTI should be advised to aim for a fluid intake of around 2.5 L a day of which at least 1.5 L is water.

To help achieve a fluid intake of around 2.5 L a day, it may be useful to express total fluid intake as 6 to 8 mugs a day (with a mug expected to hold around 350 ml).

Good practice point
Materials to support public awareness of the importance of hydration are available from Health Protection Scotland.

Good practice point
Exercise caution in women who are on fluid restriction for medical reasons (for example, those with chronic heart failure or on renal dialysis).

Spermicidal contraception

Recommendation
Consider offering women who are experiencing recurrent UTI an alternative to spermicide-containing contraceptives.

Voiding behaviours and hygiene

Two case-control studies found that postponing voiding can lead to an increased incidence of urinary tract infection.^99,100  Other voiding and hygiene factors associated with increased risk of UTI are wiping genitals back to front, not urinating and not drinking water within 15 minutes of sexual intercourse, and avoidance of washing genitals with soap after urinating.¹⁰⁰

Evidence – See section 5.1.1 in full guideline.

Efficacy

Recommendation
Consider prophylactic antimicrobials for women experiencing recurrent UTI after discussion of self-care approaches and the risks and benefits of antimicrobial treatment involved.

Recommendation
Long-term prophylactic antimicrobials for prevention of recurrent UTI should be used with caution in women aged 65 years and over, and careful consideration given to the risks and benefits involved.

Choice of agent for long-term prophylaxis of recurrent UTI

The BNF recommends monitoring of liver function and pulmonary function in any individual treated with nitrofurantoin for prophylaxis, and that the agent be discontinued if any deterioration in pulmonary function is found.⁴⁵

Duration of antimicrobial prophylaxis for prevention of recurrent UTI

Good practice point
To minimise the development of resistance, antimicrobial prophylaxis should be used as a fixed course of three to six months in women with recurrent UTI.

Evidence – See section 5.1.2 in full guideline.

No recommendations can be made for use of methenamine hippurate in recurrent UTI, due to the need for caution in interpreting the evidence.

Evidence – See section 5.1.3 in full guideline.

There are no SIGN recommendations for use of non-antimicrobials.

Antimicrobials are more effective than non-antimicrobial agents such as oral lactobacilli, and vaginal application of topical oestrogens, but there is some evidence that the non-metabolised sugar D-Mannose may perform similarly to daily prophylaxis with nitrofurantoin in preventing recurrent UTI without a statistically significant rise in adverse events. ⁹⁸

The use of vaginal or oral oestrogens has been proposed as a preventative strategy. There is some evidence for effectiveness of vaginal oestrogen. However the licensed indication for use of oestrogen vaginal products is to treat symptoms of vaginal atrophy in postmenopausal women. Use of these products for prevention of UTI is an unlicensed indication. In 2019 European Medicines Agency advice recommended that high-strength oestradiol creams containing 100 micrograms/gram (0.01%) should only be used for a single treatment period of a maximum of four weeks due to the risk of cardiovascular adverse effects and certain types of cancer. ¹⁰⁹

Evidence – See section 5.1.4 in full guideline.

There are no SIGN recommendations for any non-pharmacological treatments. The full SIGN guideline presents the evidence for the following treatments:

• Cranberry:  Evidence for the effectiveness of cranberry products in preventing UTI is conflicting.
• Herbal products
• Probiotics
• Acupuncture:  While acupuncture is not routinely used in Scotland for this indication, its use could be considered by individual patients who are unresponsive or intolerant to antibiotic prophylaxis.

Evidence – See section 5.1.5 in full guideline.

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