Recurrent uncomplicated lower urinary tract infection (rUTI) is a highly prevalent urinary system disorder among adult women. Frequent recurrence significantly impairs patients' quality of daily life and may lead to adverse long-term outcomes, such as secondary bladder dysfunction, antimicrobial resistance, and renal injury. Due to the complexity of predisposing factors and significant individual variations in pathogenic triggers and disease characteristics, current clinical practice faces challenges including inconsistent diagnostic criteria, a lack of standardized anti-infective regimens, and imperfect long-term chronic disease management systems. Consequently, a large number of patients require repeated medical visits without achieving long-term disease control. Based on the current status of clinical practice in China, this consensus aims to unify clinical thinking and standardize diagnostic and therapeutic measures for recurrent uncomplicated lower UTIs in women. It clarifies standardized procedures for disease assessment, stratified treatment, and full-cycle follow-up management to guide clinicians in standardized diagnosis and treatment, thereby improving overall efficacy and enhancing the prognosis and quality of life for female patients.
I. Definition and Concepts
01 Core Definition
Definition of recurrent urinary tract infection (rUTI): ≥3 episodes of UTI within 1 year, or ≥2 episodes within 6 months.
02 Classification and Definition
Recurrent UTIs are classified into reinfection and relapse (persistent bacteriuria). Reinfection is triggered by new pathogenic bacteria invading the urinary system from the external environment and is categorized as an uncomplicated UTI. Relapse occurs due to the persistence of homologous pathogens within the urinary system, often accompanied by high-risk factors such as anatomical/structural abnormalities of the urinary tract, and is categorized as a complicated UTI.
[Recommendation]
The recurrent urinary tract infections (rUTIs) referred to in this consensus are strictly limited to cases of uncomplicated reinfection in women; complicated UTIs are not within the scope of this discussion (High-quality evidence; Strong recommendation).
II. Pathogenic Microorganisms
01 Main Pathogens
The pathogens causing rUTIs are predominantly Gram-negative bacilli, with Escherichia coli being the primary pathogen, accounting for 75%–95% of all cases. Other common pathogens include Klebsiella pneumoniae, Proteus mirabilis, and Enterococcus faecalis. Some patients may present with mixed infections involving multiple pathogens.
02 Pathogenic Mechanisms Related to Microbiota
The bladder of healthy asymptomatic women is not a sterile environment. 16S rRNA gene sequencing has confirmed the colonization of various microorganisms in the bladder, including uropathogenic strains and non-pathogenic commensal bacteria. Dysbiosis and imbalance in the microbiota contribute to the pathogenesis of rUTIs. Given the anatomical proximity of the female urethra, vagina, and perianal region, interactive dysregulation of the microecology in these three areas is also a significant trigger for rUTIs.
[Recommendation]
Clinical diagnosis and treatment should routinely rely on urine culture to identify the type of pathogen, while simultaneously monitoring the state of urogenital microecological balance (High-quality evidence; Strong recommendation).
III. Risk Factors
Currently identified risk factors for female rUTIs include:
① Sexual Activity: High frequency of sexual intercourse and failure to urinate promptly after sex are the primary susceptibility triggers for young women of reproductive age.
② Contraceptive Measures: The use of spermicides and diaphragm contraception increases the risk of recurrent UTIs.
③ History of Urinary Tract Infection: Patients with a previous history of UTI have a significantly higher probability of recurrence.
④ Genetic Susceptibility: Individuals with a family history of UTIs show increased susceptibility.
⑤ Anatomical and Physiological Characteristics: The relatively short female urethra and its proximity to the vagina are inherent physiological risk factors.
⑥ Daily Hygiene and Lifestyle: Incorrect hygiene practices, such as wiping from back to front after defecation, increase the probability of bacterial invasion.
⑦ Menopause-related Changes: Declining estrogen levels after menopause lead to atrophy of the urethral and vaginal mucosa and decreased bladder function, reducing the body's anti-infection capacity.
[Recommendation]
Clinicians should systematically screen and assess various risk factors during initial consultation and formulate individualized intervention plans to reduce the recurrence of UTIs (High-quality evidence; Strong recommendation).
IV. Clinical Assessment and Diagnostic Criteria
01 Laboratory Diagnosis
Urinalysis: Abnormal urinalysis results can indicate a urinary tract infection and serve as the basis for initial screening.
Urine Culture: Collecting clean-catch midstream urine for bacterial culture before initiating anti-infective therapy is a reliable basis for diagnosing rUTIs. A colony count ≥10³ CFU/mL is considered positive. If sample contamination is suspected, repeated urine cultures are required to confirm the diagnosis.
[Recommendation]
For the clinical diagnosis of rUTIs, urinalysis screening should be completed, and pre-treatment midstream urine culture should be routinely submitted to identify pathogens and antibiotic susceptibility results (High-quality evidence; Strong recommendation).
02 Physical Examination: Gynecological Specialty Examination
The patient is placed in the lithotomy position. Visual inspection is performed to observe the caliber, anatomical position, and mucosal morphology of the urethral meatus to check for abnormalities such as vaginal wall prolapse. Palpation of the urethra and surrounding tissues is conducted, and pressure on masses in the anterior vaginal wall should be observed for purulent discharge from the urethral meatus. When necessary, a vaginal speculum is inserted to visually inspect the characteristics of vaginal secretions and collect samples for testing.
[Recommendation]
Gynecological examination should be routinely performed during the initial diagnosis of rUTI patients to comprehensively evaluate the local anatomy and pathological status of the urogenital tract (Moderate-quality evidence; Strong recommendation).
03 Special Examinations
Urinary system ultrasound can identify organic abnormalities such as anatomical malformations, calculi, cysts, and tumors in the upper urinary tract. For patients presenting with dysuria, residual bladder volume should be routinely measured. Invasive special examinations such as cystoscopy, urodynamics, and urethrography are not routinely recommended for women under 40 years of age with no clear risk factors.
[Recommendation]
Selective urinary system ultrasound can be performed based on clinical symptoms and the needs of the condition. Invasive special examinations are not routinely recommended for women under 40 years of age without relevant risk factors (Moderate-quality evidence; Weak recommendation).
V. Antimicrobial Therapy
01 Pharmacotherapy for Acute Episodes
During acute episodes, antimicrobial agents should be selected individually based primarily on recent urine culture and susceptibility test results. In the absence of bacteriological results, short-course empirical anti-infective therapy may be administered.
First-line Regimens
Oral fosfomycin trometamol 3 g, every other day, for 1–3 doses; OR nitrofurantoin 100 mg, three times daily for 5 days; OR co-trimoxazole (trimethoprim-sulfamethoxazole) 960 mg, twice daily for 3 days.
Alternative Regimens
Oral levofloxacin 500 mg, once daily for 3 days; OR amoxicillin/clavulanate (2:1 ratio) 375 mg, twice daily for 3 days; OR second-generation cephalosporins such as cefuroxime axetil or cefaclor. Routine oral use of carbapenems should be avoided.
Medication for Pregnant Patients
Penicillins, cephalosporins, and fosfomycin trometamol may be used in pregnant patients. Specifically, nitrofurantoin is contraindicated in patients with glucose-6-phosphate dehydrogenase deficiency and in the late stages of pregnancy; trimethoprim is contraindicated in the first trimester; co-trimoxazole is contraindicated in the third trimester. Clinical practice must strictly adhere to these contraindications.
[Recommendation]
During acute episodes of rUTIs, priority should be given to selecting antimicrobial agents based on susceptibility test results; short-course empirical therapy should be adopted in the absence of such data. Pregnant patients must strictly adhere to the contraindications of various antimicrobial agents to ensure standardized medication use (High-quality evidence; Strong recommendation).
02 Treatment of Asymptomatic Bacteriuria During Intervals
Except for pregnant women and specific populations scheduled for urological surgery, the vast majority of rUTI patients do not require antimicrobial therapy for asymptomatic bacteriuria during symptom-free intervals, as antimicrobial intervention does not reduce the risk of subsequent symptomatic UTI recurrence.
[Recommendation]
Routine antimicrobial therapy is not recommended for asymptomatic bacteriuria during intervals, except for pregnant populations and those requiring urological surgery (High-quality evidence; Strong recommendation).
VI. Prevention During Intervals
01 Lifestyle Intervention
Increasing water intake appropriately and urinating immediately after sexual intercourse are recommended to reduce infection recurrence through these healthy lifestyle modifications.
[Recommendation]
All rUTI patients should implement behavioral interventions as a fundamental measure to prevent recurrence (High-quality evidence; Strong recommendation).
02 Non-antimicrobial Prevention
Local Estrogen
For perimenopausal and postmenopausal rUTI patients with urogenital atrophy and no contraindications to estrogen use, vaginal local administration (creams, suppositories, soft capsules; options include promestriene, estriol, conjugated estrogens) is recommended over systemic oral estrogen. Endometrial status should be monitored regularly if continuous use exceeds 6 months.
[Recommendation]
Vaginal local estrogen is recommended to prevent infection recurrence in perimenopausal and postmenopausal rUTI patients with urogenital atrophy (High-quality evidence; Strong recommendation).
Cranberry Preparations
The soluble proanthocyanidins contained in cranberries inhibit the adhesion of pathogens to the bladder mucosa and can effectively reduce the risk of rUTI recurrence in susceptible populations, making them useful for disease prevention.
[Recommendation]
Cranberry preparations are recommended for the prevention of rUTIs, particularly as a priority for female patients without underlying diseases (High-quality evidence; Strong recommendation).
Methenamine Hippurate
This drug dissociates to generate formaldehyde in an acidic urine environment, exerting a bacteriostatic effect without easily inducing bacterial resistance, making it suitable for long-term prophylactic use. Urine acidification should be maintained during administration. It should be used with caution in gout patients to prevent acute gout attacks.
[Recommendation]
Methenamine hippurate may be selectively used for long-term prevention of rUTIs; urine acidification management and screening for medication contraindications should be emphasized during treatment (Moderate-quality evidence; Weak recommendation).
Pseudomonas aeruginosa Injection
The Pseudomonas aeruginosa mannose-sensitive hemagglutinin piliated strain biological preparation effectively improves the body's immune status and demonstrates efficacy comparable to oral antimicrobials for preventing rUTIs.
[Recommendation]
Pseudomonas aeruginosa injection can be used as a novel and effective option for non-antimicrobial prevention of rUTIs (High-quality evidence; Strong recommendation).
Traditional Chinese Medicine (TCM) Therapy
rUTIs fall under the category of "Lin Syndrome" in TCM. Various Chinese herbs contain multiple antibacterial active ingredients and can synergize with antimicrobials to regulate immune function. However, there is insufficient evidence to support that TCM formulas or proprietary Chinese medicines alone can effectively prevent rUTI recurrence.
[Recommendation]
The sole application of TCM methods is not recommended for preventing rUTIs; TCM may serve as an auxiliary intervention in prevention (High-quality evidence; Strong recommendation).
Other Non-antimicrobial Preventive Interventions
Probiotics and D-mannose are emerging preventive methods for rUTIs that avoid bacterial resistance caused by long-term antimicrobial use and show promising clinical application prospects.
[Recommendation]
Individualized selection of probiotics or D-mannose for recurrence prevention should be considered based on the patient's specific condition (Moderate-quality evidence; Weak recommendation).
03 Antimicrobial Prophylaxis
If non-pharmacological preventive measures prove ineffective, antimicrobial prophylaxis may be initiated, with regimens individualized based on predisposing triggers and population stratification.
Young Women of Reproductive Age
Single-dose post-coital regimen. Preferred options: Fosfomycin trometamol 3 g, nitrofurantoin 100 mg, or co-trimoxazole (400 mg/80 mg). Alternatives: Ciprofloxacin 500 mg, levofloxacin 500 mg, or cephalexin 250 mg.
Postmenopausal Women
Long-term low-dose regimen for 3–6 months. Preferred: Fosfomycin trometamol 3 g every 7–10 days; OR bedtime oral nitrofurantoin 50–100 mg (monitor for pulmonary fibrosis); OR co-trimoxazole (400 mg/80 mg). Alternatives: Cephalexin 125–250 mg nightly or cefaclor 250 mg nightly.
Pregnant Women
For infections related to sexual activity, single-dose post-coital administration is used. For non-sexually induced infections, low-dose long-term prophylaxis is given until the puerperium. Options: Fosfomycin trometamol 3 g (every 7–10 days), cephalexin 125–250 mg once daily, or cefaclor 250 mg once daily.
[Recommendation]
For rUTI patients failing non-antimicrobial interventions, individualized antimicrobial prophylaxis should be selected based on age and pregnancy status. Regular monitoring for bacterial resistance and adverse drug reactions is required during long-term prophylactic use (High-quality evidence; Strong recommendation).
04 Bladder Instillation Therapy
Antimicrobial Instillation
Commonly used preparations include amikacin, neomycin combined with polymyxin, etc. These can increase local drug concentration in the bladder and reduce systemic drug load but are prone to causing local urinary tract irritation and systemic adverse reactions. They should only be selected for refractory infections caused by resistant strains.
Polysaccharide Preparation Instillation
Instillation of chondroitin sulfate or sodium hyaluronate can repair and supplement the glycosaminoglycan (GAG) protective layer of the bladder mucosa, offering better overall safety and efficacy than local antimicrobial instillation.
[Recommendation]
Bladder instillation is not a routine preventive regimen for rUTIs; it should only be selected when multiple preventive measures fail or in cases of multidrug-resistant bacterial infection, with priority given to polysaccharide preparations (Moderate-quality evidence; Weak recommendation).
VII. Follow-up
During follow-up, asymptomatic rUTI patients do not require routine urine culture. Urine culture should only be submitted for patients with persistent urinary tract symptoms to guide subsequent diagnosis and treatment based on etiological results. During follow-up, risk factors must be identified one by one, and individualized interventions implemented, alongside standardized implementation of behavioral prevention measures.
[Recommendation]
Follow-up for rUTI patients should prioritize the assessment and intervention of risk factors. Routine urine culture screening is not recommended for asymptomatic populations; early urine culture should be completed for those with persistent discomfort to optimize prevention and treatment plans based on the results (High-quality evidence; Strong recommendation).
VIII. Future Perspectives
The clinical incidence of female rUTIs remains persistently high, compounded by increasingly severe bacterial resistance issues, which significantly heightens the difficulty of clinical diagnosis and treatment. Future efforts should focus on further elucidating the mechanisms underlying rUTIs, developing novel precise diagnostic tools, efficient preventive strategies, and safe therapeutic interventions. The goal is to gradually reduce clinical reliance on antimicrobial agents, continuously optimize the entire workflow of diagnosis and treatment, and improve the long-term prognosis of patients.
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Source: Female Urology Group, Chinese Urological Association; Infection and Inflammation Group, Chinese Urological Association. Chinese expert consensus on the diagnosis and treatment of recurrent uncomplicated lower urinary tract infections in women[J]. Chinese Journal of Urology, 2026, 47(2): 81-86.
DOI: 10.3760/cma.j.cn112330-20251010-00409
Editor: Lily