Urinary tract infections are a common issue in the urology outpatient clinic and effective management is key in preventing future hospitalisation and inpatient emergency admission. Unfortunately, it is not uncommon for the information received in a referral for a patient with recurrent urinary tract infections (rUTI) to be less than is required to make a full assessment of the patient. Therefore, history taking is paramount in determining the exact cause of the patient’s complaints and formulating a treatment strategy.

The majority of patients will be referred to your clinic with complaints of cystitis – inflammation of the urothelium and bladder, presumed to be due to infection and invasion of bacteria. It is this scenario that is discussed in this chapter.

History

In addition to a more generalised past medical history that makes note of conditions that may contribute to rUTI (diabetes, menopause, immunosuppression, etc.), it is important to take a full history of the patient’s complaints regarding their cystitis symptoms. A note should be made of symptoms and signs that support the diagnosis of rUTI:

• Recurrent episodes of frequency and urgency/irritative voiding symptoms
  
• Associated supra‐pubic discomfort/pain
  
• Associated dysuria
  
• Offensive and/or purulent urine
  
• General malaise, fever, and associated systemic symptoms
  
• A predictable and recognised trigger for an episode (intercourse, dehydration, etc.)
  
• Positive/confirmatory mid‐stream urine (MSU) culture results
  
• Response to antibiotic therapy

In the absence of supporting evidence from the patient history, consideration should be given to other possible diagnoses. For example, irritative voiding symptoms with recurrent bouts of visible haematuria and bacterial growth on MSU may be a presentation of a bladder tumour (around half of bladder tumours are colonised by bacteria). Alternatively, in the absence of positive microbiology, bouts of irritative voiding symptoms with supra‐pubic pain relieved by voiding is indicative of Bladder Pain Syndrome.

Lastly, a brief history of any lower urinary tract symptoms (LUTS) at other times should be sought.

If a true diagnosis of rUTI is suspected, potential risk factors should be identified as part of history taking (see below).

Definitions

Recurrent urinary tract infection is generally accepted to mean more than two infections in a six‐month period, or more than three episodes in a year.

Significant bacteriuria was originally defined by Kass as >10⁵ cfu/ml. Most hospital laboratories still adhere to this ‘cut‐off.’ However, it is important to be aware that in many patients with frequent proven infections some apparently ‘negative’ MSU samples (which indicate pyuria), may have growth of <10⁵ cfu/ml and, in fact, there may be meaningful bacteriuria. Indeed, the European Urology Association now recognises >10³ cfu/ml as significant.

Re‐Infection is the development of a further infection several months after a previous episode, whereas bacterial persistence can result in more frequent episodes of infection and is likely frequently underestimated as a cause for many presentations of rUTI.

Risk Factors and Patient Discussion

A great deal of ‘common sense’ knowledge regarding potential risk factors for development of rUTI is backed by good evidence. Certainly, no urologist would argue that a male with a chronic urinary retention of 1 litre is at risk of infection, but on a lesser scale there is no evidence to support the idea that a female with a post‐void residual of 150 ml is at any greater risk of developing infection than a female with a 25 ml residual.