The American Urological Association (AUA) periodically updates their guidance on the evaluation and management of recurrent uncomplicated urinary tract infection (rUTI). The goal is to improve outcomes in women with rUTI by preventing inappropriate antibiotic use, decreasing the risk of antibiotic resistance, reducing antibiotic adverse effects, and providing strategies that can be used to prevent UTIs.
In this article we will take a look at what has changed between the 2019 guideline and the 2025 guideline.
Guidelines Referenced:
- Recurrent Uncomplicated Urinary Tract Infections in Women: AUA/CUA/SUFU Guideline
- Published: April 2019
- Recurrent Uncomplicated Urinary Tract Infections in Women: AUA/CUA/SUFU Guideline (2025) - American Urological Association
- Published: September 2025
Major Changes and Key Takeaways (2019-2025)
Some of the major changes and key takeaways in the 2025 clinical practice guidelines for recurrent uncomplicated UTI in women are reviewed below.
Evaluation:
- There were changes to two out of the six evaluation recommendations.
- Recommendation 3 was updated regarding making the diagnosis of rUTI: Evidence should be documented of inflammation (pyuria) and the presence of uropathogenic bacteria in association with symptomatic episodes to diagnose rUTI.
- Recommendation 6 for patient initiated/self-start treatment was changed to a conditional recommendation.
Asymptomatic Bacteriuria:
- The two recommendations for asymptomatic bacteriuria were unchanged from the previous guideline.
Antibiotic Treatment:
- The three recommendations for antibiotic treatment of rUTI remain unchanged.
Antibiotic Prophylaxis:
- The recommendation on antibiotic prophylaxis remains unchanged.
Non-Antibiotic Prophylaxis:
- Recommendation 13 was changed from clinicians “may” offer cranberry to clinicians “should” offer cranberry for UTI prophylaxis.
- Three new recommendations were added:
- Recommendation 14, supplements containing only D-mannose may not be an effective prophylaxis for women with rUTI.
- Recommendation 15, methenamine hippurate may be offered for prophylaxis in women with rUTI.
- Recommendation 16, women with rUTIs who drink less than 1.5 L/day (50 oz) of water may be offered increased water intake for prophylaxis.
Follow-Up Evaluation:
- A new recommendation was added. Recommendation 19: Clinicians should evaluate for an alternative cause of symptoms in women with persistent UTI symptoms after microbiological cure.
Estrogen:
- The recommendation for vaginal estrogen to prevent rUTIs in perimenopausal and postmenopausal women remains unchanged.
Comparison of Recommendations
| Recommendation | 2019 | 2025 |
|---|---|---|
| Evaluation | Clinicians should obtain a complete patient history and perform a pelvic examination in women presenting with rUTIs. (Clinical Principle) | Clinicians should obtain a complete patient history and perform a pelvic examination in women presenting with rUTIs. (Clinical Principle) |
| Clinicians should obtain urinalysis, urine culture and sensitivity with each symptomatic acute cystitis episode prior to initiating treatment in patients with rUTIs. (Moderate Recommendation; Evidence Level: Grade C) | Clinicians should obtain urinalysis, urine culture and sensitivity with each symptomatic acute cystitis episode prior to initiating treatment in patients with rUTIs. (Moderate Recommendation; Evidence Level: Grade C) | |
| To make a diagnosis of rUTI, clinicians must document positive urine cultures associated with prior symptomatic episodes (Clinical Principle) | To make a diagnosis of rUTI, clinicians should document evidence of inflammation (pyuria) and the presence of uropathogenic bacteria in association with symptomatic episodes. (Clinical Principle) | |
| Clinicians should obtain repeat urine studies when an initial urine specimen is suspect for contamination, with consideration for obtaining a catheterized specimen. (Clinical Principle) | Clinicians should obtain repeat urine studies when an initial urine specimen is suspect for contamination, with consideration for obtaining a catheterized specimen. (Clinical Principle) | |
| Cystoscopy and upper tract imaging should not be routinely obtained in the index patient presenting with rUTI. (Expert opinion) | Cystoscopy and upper tract imaging should not be routinely obtained in the index patient presenting with rUTI. (Expert Opinion) | |
| Clinicians may offer patient-initiated treatment (self-start treatment) to select rUTI patients with acute episodes while awaiting urine cultures. (Moderate Recommendation; Evidence Level: Grade C) | Clinicians may offer patient-initiated treatment (self-start treatment) to select rUTI patients with acute episodes while awaiting urine cultures. (Conditional Recommendation; Evidence Level: Grade C) | |
| Asymptomatic Bacteriuria | Clinicians should omit surveillance urine testing, including urine culture, in asymptomatic patients with rUTIs. (Moderate Recommendation; Evidence Level: Grade C) | Clinicians should omit surveillance urine testing, including urine culture, in asymptomatic patients with rUTIs. (Moderate Recommendation; Evidence Level: Grade C) |
| Clinicians should not treat ASB in patients. (Strong Recommendation; Evidence Level: Grade B) | Clinicians should not treat asymptomatic bacteriuria (ASB) in patients. (Strong Recommendation; Evidence Level: Grade B) | |
| Antibiotic Treatment | Clinicians should use first-line therapy (i.e., nitrofurantoin, TMP-SMX, fosfomycin) dependent on the local antibiogram for the treatment of symptomatic UTIs in women. (Strong Recommendation; Evidence Level: Grade B) | Clinicians should use first-line therapy (i.e., nitrofurantoin, trimethoprim-sulfamethoxazole [TMP-SMX], fosfomycin) dependent on the local antibiogram for the treatment of symptomatic UTIs in women. (Strong Recommendation; Evidence Level: Grade B) |
| Clinicians should treat rUTI patients experiencing acute cystitis episodes with as short a duration of antibiotics as reasonable, generally no longer than seven days. (Moderate Recommendation; Evidence Level: Grade B) | Clinicians should treat rUTI patients experiencing acute cystitis episodes with as short a duration of antibiotics as reasonable, generally no longer than seven days. (Moderate Recommendation; Evidence Level: Grade B) | |
| In patients with rUTIs experiencing acute cystitis episodes associated with urine cultures resistant to oral antibiotics, clinicians may treat with culture-directed parenteral antibiotics for as short a course as reasonable, generally no longer than seven days. (Expert Opinion) | In patients with rUTIs experiencing acute cystitis episodes associated with urine cultures resistant to oral antibiotics, clinicians may treat with culture-directed parenteral antibiotics for as short a course as reasonable, generally no longer than seven days. (Expert Opinion) | |
| Antibiotic Prophylaxis | Following discussion of the risks, benefits, and alternatives, clinicians may prescribe antibiotic prophylaxis to decrease the risk of future UTIs in women of all ages previously diagnosed with UTIs. (Moderate Recommendation; Evidence Level: Grade B) | Following discussion of the risks, benefits, and alternatives, clinicians may prescribe antibiotic prophylaxis to decrease the risk of future UTIs in women of all ages previously diagnosed with UTIs. (Conditional Recommendation; Evidence Level: Grade B) |
| Non-antibiotic Prophylaxis | Clinicians may offer cranberry prophylaxis for women with rUTIs. (Conditional Recommendation; Evidence Level: Grade C) | Clinicians should offer cranberry as an option for prophylaxis for women with rUTIs. (Moderate Recommendation; Evidence Level: Grade B) |
| Not Addressed | Clinicians should inform patients with rUTIs that D-mannose alone for prophylaxis may not be effective in UTI prevention. (Moderate Recommendation; Evidence Level: Grade B) | |
| Not Addressed | Clinicians may offer methenamine hippurate for prophylaxis for women with rUTIs. (Conditional Recommendation; Evidence Level: Grade C) | |
| Not Addressed | When women with rUTIs have a water intake below 1.5 L/day (50 oz), clinicians may offer increased water intake for prophylaxis. (Conditional Recommendation; Evidence Level: Grade C) | |
| Follow-Up Evaluation | Clinicians should not perform a post-treatment test of cure urinalysis or urine culture in asymptomatic patients. (Expert Opinion) | Clinicians should not perform a post-treatment test of cure urinalysis or urine culture in asymptomatic patients. (Expert Opinion) |
| Clinicians should repeat urine cultures to guide further management when UTI symptoms persist following antimicrobial therapy. (Expert Opinion) | Clinicians should repeat urine cultures to guide further management when UTI symptoms persist following antimicrobial therapy. (Expert Opinion) | |
| Not Addressed | For patients with persistent UTI symptoms after microbiological cure, clinicians should evaluate for alternative causes to patient symptoms. (Expert Opinion) | |
| Estrogen | In peri- and post-menopausal women with rUTIs, clinicians should recommend vaginal estrogen therapy to reduce the risk of future UTIs if there is no contraindication to estrogen therapy. (Moderate Recommendation; Evidence Level: Grade B) | In perimenopausal and postmenopausal women with rUTIs, clinicians should recommend vaginal estrogen therapy to reduce the risk of future UTIs if there is no contraindication to vaginal estrogen therapy. (Moderate Recommendation; Evidence Level: Grade B) |
Sign up for alerts and stay informed on the latest published clinical guidelines and guideline updates.
Copyright ® 2025 Guideline Central, all rights reserved.