How should I manage a patient with recurrent urinary tract infections and associated haematuria?

Management of a patient with recurrent urinary tract infections (UTIs) and associated haematuria involves the following steps:

• Assessment and investigation: Ensure a urine sample for culture and susceptibility testing is sent before starting antibiotic treatment to guide therapy appropriately.
• Antibiotic treatment: Manage acute UTI symptoms based on the patient's clinical situation. Consider self-initiated short-course antibiotics if the patient can self-diagnose and self-treat appropriately. Avoid routine antibiotic treatment for asymptomatic bacteriuria in non-pregnant patients.
• Referral criteria: Arrange urgent urological referral via a 2-week wait pathway if the patient is aged 45 years or over with visible haematuria that persists or recurs after successful UTI treatment, or aged 60 years or over with unexplained non-visible haematuria plus dysuria or raised white cell count. For recurrent or persistent unexplained UTI in women aged 60 years and over, consider non-urgent urological referral for bladder cancer assessment.
• Specialist advice: Seek specialist advice if the underlying cause of recurrent UTI is unknown or if there is suspicion of renal or ureteric stones, interstitial cystitis, or urogynaecological cancer.
• Prevention and self-care: Advise on behavioural measures to reduce recurrence risk, including maintaining adequate hydration (aim for 1.5 L/day if no contraindications), avoiding douching and occlusive underwear, wiping front to back, and avoiding delayed urination post-coitus. Do not recommend cranberry products, urine alkalinising agents, or D-mannose for prevention.

Summary: Manage acute infections with appropriate antibiotics guided by culture, investigate haematuria with urgent referral if indicated by age and haematuria type, seek specialist input for unknown causes, and support prevention through behavioural advice.

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