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UTI Suppressive and Prophylactic Therapy

Recurrent urinary tract infection (rUTI), defined as ≥2 symptomatic, culture-confirmed UTIs in 6 months or ≥3 in 12 months, is one of the most common chronic problems in functional urology and urogynecology. The overarching goal of prophylaxis is to improve quality of life while minimizing antimicrobial exposure.[1][2] The AUA/CUA/SUFU 2025 guideline supports shared selection of antibiotic and non-antibiotic prevention; methenamine is now a conditional option for eligible women with rUTI.[21] It does not require every patient to complete a fixed sequence before antibiotic prophylaxis. These AUA recommendations concern recurrent localized cystitis in women without complicating factors; pregnancy, catheterization, neurogenic dysfunction and reconstructed urinary tracts require population-specific guidance.[21]

Treat an active symptomatic infection before beginning methenamine prophylaxis. In an otherwise uncomplicated, nonpregnant woman whose symptoms resolve, do not require a routine negative test-of-cure culture. Reassess and culture persistent or recurrent symptoms.[21][22]

For adjacent topics, see UTI treatment antibiotics, Non-antibiotic UTI prevention, and Recurrent UTI (clinical).

Prevention framework​

Consider non-antibiotic options and stewardship while matching therapy to recurrence pattern, eligibility, tolerability, and preferences.[4][5][6][21]

StrategyInterventions
Behavioral / non-pharmacologicConsider increased water for low-volume drinkers; review spermicide use and relevant voiding/bowel dysfunction
Non-antibiotic prophylaxisVaginal estrogen (AUA 2025: recommend for peri- and postmenopausal women with rUTI and no contraindication; Moderate Recommendation, Grade B)[21], methenamine hippurate, cranberry proanthocyanidins
Self-start / symptomatic therapyPre-prescribed treatment course for patients who can reliably self-diagnose
Antibiotic prophylaxisPost-coital single dose or continuous low dose, selected by recurrence pattern
Immunoprophylaxis (where available)OM-89, MV140, Urovac — not FDA-approved in the US

Non-antibiotic prophylaxis​

Vaginal estrogen — first-line in postmenopausal women​

Vaginal estrogen restores Lactobacillus colonization, lowers vaginal pH, and reduces uropathogen colonization, which is the mechanistic basis of GSM-driven rUTI. Available as vaginal cream, tablets or inserts (e.g., estradiol 10 µg vaginal inserts), and the estradiol ring.[33] In postmenopausal women, a meta-analysis of five vaginal-estrogen trials (n = 1,936) found fewer rUTIs than placebo (RR 0.42; 95% CI 0.30–0.59).[36] An earlier two-trial estimate (n = 201) was imprecise (RR 0.42; 95% CI 0.16–1.10).[7] The AUA/CUA/SUFU 2025 guideline recommends vaginal estrogen for eligible peri- and postmenopausal women with rUTI .[21] Use the estrogen hub for contemporary evidence and product-specific safety.

Systemic estrogen should not be used for UTI prevention.[4] See GSM for the full treatment framework.

Methenamine hippurate — AUA-endorsed alternative to daily antibiotics​

Methenamine is an option for women seeking to reduce daily antibiotic exposure . The US label limits use to prophylaxis after the infection has been eradicated with other antimicrobials, dosed at 1 g twice daily in adults, and contraindicates it in renal insufficiency, severe hepatic insufficiency, severe dehydration and concurrent sulfonamide therapy.[29] Do not routinely pair it with vitamin C. Use the methenamine prescribing section for the regimen, urine-pH and label distinction, and contraindication check.[21][29]

The ALTAR trial (Harding 2022, BMJ, multicenter open-label non-inferiority RCT) randomized 240 women with rUTI; the primary modified intention-to-treat analysis included 205 (103 methenamine, 102 antibiotic) with at least 6 months of data.[8][9]

  • Methenamine hippurate 1 g BID versus daily low-dose antibiotics (nitrofurantoin 50–100 mg, trimethoprim 100 mg, or cefalexin 250 mg) over 12 months[8]
  • During treatment, symptomatic, antibiotic-treated UTIs occurred at 1.38 versus 0.89 episodes/person-year (absolute difference 0.49; 90% CI 0.15–0.84), within the predefined non-inferiority margin of 1 UTI/person-year[8]
  • During treatment, resistance to at least one antibiotic in perineal-swab E. coli was found in 46/64 (72%) tested antibiotic-arm participants versus 39/70 (56%) tested methenamine-arm participants (p = 0.05).[9] -After treatment, multidrug-resistant E. coli in perineal swabs was found in 9/45 (20%) tested methenamine-arm participants versus 2/39 (5%) tested antibiotic-arm participants (p = 0.06).[9]

ImpresU trial (Heltveit-Olsen 2025, CMI, triple-blind placebo-controlled phase IV RCT, 289 recruited / 281 analyzed women ≥70 y):[10]

  • During the 6-month course, methenamine reduced antibiotic-treated UTIs versus placebo by approximately 25% (IRR 0.75; 95% CI 0.57–1.0; p = 0.049).[10]
  • After discontinuation: During the 6-month follow-up, antibiotic-treated UTI incidence was higher in the former methenamine group than in the placebo group (IRR 1.7; 95% CI 1.3–2.3).[10]

Emerging caveat: the frmRAB operon can confer formaldehyde resistance in some E. coli strains; the clinical impact is under investigation.[11]

Cranberry products​

The AUA/CUA/SUFU 2025 guideline recommends offering cranberry for prophylaxis to women with recurrent UTIs .[21] Declared PAC content helps product selection; WikiGuidelines cites cranberry products containing 36 mg PAC.[6] WikiGuidelines also discusses selected populations.[6] In women with rUTI, the 2023 Cochrane review found fewer symptomatic, culture-verified UTIs across eight trials (n = 1,555; RR 0.74; 95% CI 0.55–0.99).[34] An earlier two-trial meta-analysis (n = 250) found RR 0.53 (95% CI 0.33–0.83).[7] Evidence is insufficient in older adults, patients with bladder-emptying problems, and pregnancy.[6]

D-mannose — negative in a placebo-controlled RCT​

D-mannose binds type-1 fimbriae and theoretically blocks E. coli adherence to the urothelium. Small trials suggested benefit, but the MERIT RCT (Hayward 2024, JAMA Intern Med) randomized 598 women in primary care with rUTI and was negative: among 583 with primary-outcome data, 150/294 (51.0%) assigned D-mannose versus 161/289 (55.7%) assigned placebo contacted ambulatory care for a clinically suspected UTI over 6 months.[12] The authors explicitly concluded D-mannose should not be recommended to prevent future UTIs in this population.

Increased water intake​

One RCT showed benefit from an additional 1.5 L of water daily in healthy premenopausal women who initially drank less than 1.5 L/day.[6] Offer increased intake to low-volume drinkers when appropriate; do not prescribe the same extra volume to every patient or override fluid restrictions.

Probiotics​

Evidence for vaginal or oral Lactobacillus products is heterogeneous across strains, routes, and populations, with uncertain preventive benefit.[5][6]

Antibiotic prophylaxis​

For women meeting rUTI criteria, antibiotic prophylaxis may be chosen after discussing benefits, harms, and alternatives; prior failure of every non-antibiotic option is not an AUA requirement.[21] In Jent’s meta-analysis of 11 placebo-controlled trials in patients with recurrent lower UTI (746 evaluable participants), antibiotic prophylaxis lowered pooled clinical or microbiological recurrence during treatment (RR 0.15; 95% CI 0.08–0.29); the clinical-recurrence subanalysis also favored prophylaxis (RR 0.11; 95% CI 0.07–0.17).[13] Nine head-to-head trials found no significant differences for nitrofurantoin, trimethoprim with or without sulfamethoxazole, or norfloxacin versus their comparator antibiotics.[13] Study quality was low, and most placebo-controlled trials predate 1995, so present-day resistance may make prophylaxis less effective.[13][21] EAU 2026 reserves continuous or post-coital prophylaxis for women in whom non-antimicrobial measures have failed , a narrower sequence than AUA 2025. After counseling, EAU says to offer either continuous low-dose or post-coital prophylaxis once behavioral and non-antimicrobial measures have failed, choosing by whether episodes follow intercourse and by patient preference.[24] It found no difference in efficacy between the two approaches, no evidence on the best duration (trials ran 3 to 12 months), and recurrence after stopping, especially with three or more infections a year. EAU regimens are nitrofurantoin 50 or 100 mg daily, fosfomycin trometamol 3 g weekly and trimethoprim 100 mg daily, with cephalexin 125 or 250 mg or cefaclor 250 mg daily in pregnancy; agent choice follows local resistance.[24] EAU also strongly supports self-administered short-course therapy for compliant patients.[21][24]

For nonpregnant women, NICE NG112 (UK; updated December 2024) begins with behavioral and hygiene advice, considers vaginal estrogen in peri- or postmenopause, single-dose antibiotic prophylaxis after an identifiable trigger, methenamine hippurate as an alternative to daily antibiotics when applicable earlier measures have not helped, and daily prophylaxis after applicable options have failed.[28] It advises reviewing daily prophylaxis at least every 6 months and choosing the agent from recent culture results and local resistance data, rotating agents by local policy and using a different antibiotic from the one used to treat the acute infection.[28] NICE lists trimethoprim and nitrofurantoin (when eGFR is 45 mL/min or higher) as first-choice oral agents and amoxicillin or cefalexin as second choice.[28]

Continuous prophylaxis​

An initial time-limited course with planned reassessment is appropriate. Most trial evidence covers 6–12 months; continuing prophylaxis for years is not established by that evidence.[21]

AgentTypical continuous dosePractical notes
Nitrofurantoin50–100 mg nightlyUse only when organism and patient are suitable; avoid in chronic lung disease and monitor pulmonary, hepatic and neuropathic toxicity. The historically reported 0.001% pulmonary and 0.0003% hepatic estimates do not establish risk during prolonged prophylaxis. In an audit of 3,400 older users, 5 (0.15%) had highly suspicious serious lung or liver reactions; long-term exposure was more common among these cases. Monitor throughout suppression because lung injury can occur early or after many months.[21] Modern guidance often uses CrCl 30, while US labeling remains more restrictive; see treatment hub[1][2]
TMP-SMX40/200 mg nightly or 3×/weekUse prior culture susceptibility; check hyperkalemia, renal function and interactions. The 20% threshold concerns empirical acute treatment, not a rule overriding an individual susceptible isolate[1][2]
Trimethoprim (monotherapy)100 mg nightlyMay avoid the sulfonamide component, but trimethoprim-related hyperkalemia / renal effects remain. NICE also warns of first-trimester teratogenic risk (folate antagonist)[3][28]
Cephalexin125–250 mg nightlyALTAR comparator (250 mg); NICE lists 125 mg at night as a second-choice option[8][28]
Fosfomycin3 g PO every 10 days (AUA 2025)[21]; EAU 2026 lists 3 g once weekly[24]Limited prophylaxis trial data; guideline intervals differ

Post-coital prophylaxis​

For women whose UTIs are temporally related to intercourse, a single dose taken before or after intercourse is an effective option that may reduce total exposure; comparative studies have not shown a significant difference from continuous dosing.[2][3][13]

AgentPost-coital dose
TMP-SMX40/200 mg or 80/400 mg single dose[21]
Nitrofurantoin50–100 mg single dose[21]
Cephalexin250 mg single dose[21]

For nonpregnant women, trans men, and non-binary people with a female urinary system aged 16 years or older, NICE lists single doses when exposed to a trigger: trimethoprim 200 mg, nitrofurantoin 100 mg when eGFR is at least 45 mL/minute, and second-choice amoxicillin 500 mg or cefalexin 500 mg; it advises returning for review within 6 months.[28]

Self-start (patient-initiated) therapy​

AUA 2025 allows patient-initiated treatment for select patients with rUTI . Selected reliable patients may use a pre-agreed short treatment course while awaiting urine-culture results; obtain a specimen before treatment when feasible and adjust to results. Eligibility is not defined by a ≤2-UTI/year cutoff. Include instructions for fever, flank pain, pregnancy, persistent symptoms and other reasons for reassessment. In one small crossover trial (n = 38), intermittent self-administered TMP-SMX was followed by more UTIs than daily TMP-SMX.[2][3][21]

Immunoprophylaxis​

These products are not FDA-approved in the US.[24] Current EAU guidance limits immunomodulatory prophylaxis to a well-regulated clinical trial .[24]

  • OM-89 (Uro-Vaxom). Oral immunostimulant containing lyophilized E. coli lysate. Meta-analysis of 4 trials (n = 891) showed RR 0.61 (95% CI 0.48–0.78) for experiencing at least one UTI during prophylaxis; the review reported a good safety profile.[7] Grade A recommendation in the Latin American rUTI consensus.[7][14]
  • MV140 (Uromune). Sublingual polybacterial preparation. A frail-elderly cohort is observational. A completed 240-woman placebo-controlled RCT reported a secondary UTI-free outcome in 215 women in its protocol-defined primary analysis population: during the nine-month efficacy period after the first three months of intervention, 39/70 (56%) in the three-month MV140 group and 40/69 (58%) in the six-month MV140 group were UTI-free versus 19/76 (25%) with placebo; it was industry-funded.[23][15]
  • Urovac. Vaginal mucosal vaccine; low-certainty pooled evidence found lower recurrence at 20 weeks (263 participants, RR 0.75; 95% CI 0.63–0.89), with a larger apparent effect after booster dosing.[16]
  • Systematic review (Aziminia 2019, 10 RCTs, 1,537 participants overall; 1,495 contributed to the pooled recurrence outcome): vaccines reduced rUTI versus placebo (RR 0.74; 95% CI 0.67–0.81), with low-quality evidence and substantial heterogeneity.[16]

Special populations​

Pregnancy​

After treatment of a recurrent UTI during pregnancy (at least two UTIs diagnosed in that pregnancy), ACOG 2023 says clinicians may consider suppression for the remainder of pregnancy with a once-daily susceptible agent; evidence is limited. Common regimens are nitrofurantoin 100 mg orally daily or cephalexin 250–500 mg orally daily, selected by culture and pregnancy-specific safety.[17]

Kidney transplant recipients​

TMP-SMX used for Pneumocystis prophylaxis after transplantation can also reduce UTI; coordinate any change with the transplant team.[19] Do not layer methenamine onto TMP-SMX; the US methenamine label excludes concurrent sulfonamides and renal insufficiency. See the methenamine safety section.[22] IDSA 2019 recommends against routine screening or treatment of asymptomatic bacteriuria more than one month after renal transplantation and finds evidence insufficient in the first month.[18] EAU 2026 gives a Strong recommendation against screening or treating asymptomatic bacteriuria in renal transplant recipients without an early-month carveout; reconcile early postoperative decisions with the transplant team.[24]

Spinal cord injury / neurogenic bladder​

Reassess emptying, bladder pressures, stones and catheter practice. AUA/SUFU advises against daily prophylaxis with an indwelling catheter or with CIC without recurrent UTI . For CIC users with recurrent UTI, oral prophylaxis may be offered after discussing antimicrobial resistance ; bladder instillation is an Expert Opinion option.[25] EAU 2026 is more cautious: avoid continuous long-term antibiotics for rUTI , and offer weekly-cycled prophylaxis only to selected patients with SCI who perform intermittent catheterization and have recurrent UTI.[20][25][27]

The AnTIC RCT randomized 404 adults using intermittent self-catheterization (361 in the primary analysis): prophylaxis reduced antibiotic-treated symptomatic UTIs from 2.6 to 1.3/person-year (IRR 0.52), but resistant urinary isolates increased.[26]

Post-reconstruction / diversion patients​

  • Continent cutaneous diversions, neobladder, augmentation cystoplasty. Colonization is expected; do not screen for or treat asymptomatic bacteriuria during routine follow-up. IDSA 2019 recommends screening and treating bacteriuria before endoscopic urologic procedures expected to cause mucosal trauma ; it suggests culture-directed treatment with one or two perioperative doses beginning 30–60 minutes before the procedure .[18][24]
  • Recurrent symptomatic UTI in diversion patients should trigger evaluation for stones, retained mucus, incomplete emptying, or obstructed efferent limb before escalating antibiotic strategy
  • IPP and AUS patients need syndrome- and culture-directed UTI treatment. Assess suspected device infection separately

Monitoring and duration​

  • Agree a time-limited course and review date; studies of continuous antimicrobial prophylaxis for recurrent cystitis have lasted 3–12 months, with no established optimal duration.[2][3][24]
  • Continued use requires individualized reassessment.[21]
  • Benefit may diminish after stopping; ImpresU found more antibiotic-treated episodes after discontinuation.[6][10]
  • Periodic reassessment of strategy, including de-escalation to non-antibiotic prophylaxis or symptomatic self-start therapy, is appropriate.[2]
  • Screen for emerging nitrofurantoin pulmonary or hepatic toxicity in patients on long-term suppression; monitor serum potassium, renal function, and complete blood count during prolonged TMP-SMX suppression, with closer review in patients with renal impairment or interacting drugs.[35] In a meta-analysis cited by AUA 2025, antibiotics prescribed for UTI were associated with resistance to the prescribed antibiotic in patients' urinary bacteria (five studies, 14,348 participants; pooled OR 2.5 within two months and 1.33 within 12 months).[21] In a Welsh target-trial emulation of 48,297 women with rUTI (839 initiated prophylaxis), resistance to two or more antibiotics on urine culture by 52 weeks was 22.0% with prophylaxis versus 14.0% without (adjusted RR 1.57; 95% CI 1.37–1.79).[37]

Evidence Summary​

StrategyEvidence levelKey trial / guidelineNotes
rUTI guideline frameworkRecommendations vary by interventionAUA/CUA/SUFU 2025[21]Shared selection; methenamine Conditional / Grade C
Methenamine prophylaxisTwo RCTs with different comparatorsALTAR 2022 BMJ[8][9]; ImpresU 2025 CMI[10]ALTAR met its non-inferiority margin versus daily antibiotics in women with rUTI; ImpresU found fewer antibiotic-treated UTIs versus placebo during treatment in women ≥70 years (mITT IRR 0.75, p = 0.049; complete cases IRR 0.77, p = 0.078), followed by higher incidence in the former methenamine arm during six months after treatment (IRR 1.7)
Antibiotic prophylaxis efficacyLevel 1Jent 2022 meta (11 RCTs)[13]85% lower risk of developing UTI with prophylaxis vs placebo (RR 0.15)
Vaginal estrogen in peri/postmenopausal rUTIAUA Moderate / Grade BAUA 2025[21]Recommend when eligible
CranberryAUA Moderate / Grade BAUA 2025[21]Offer as an option; product variability
D-mannoseLevel 1MERIT RCT 2024[12]Negative in largest primary-care RCT
Hydration + 1.5 L/dayLevel 2WikiGuidelines 2024[6]Reasonable low-risk measure
Immunoprophylaxis (OM-89, Urovac, ExPEC4V; MV140 studied separately)Level 2Aziminia 2019 SR[16]; MV140 RCT[23]RR 0.74 for pooled OM-89/Urovac/ExPEC4V recurrence at trial endpoint; low-quality evidence; not FDA-approved

Clinical Positioning​

  • Discuss eligible non-antibiotic options early and select a prevention strategy together; use the prescribing hub for the methenamine regimen and safety checks.[6][21]
  • Methenamine met ALTAR's prespecified non-inferiority margin in women with rUTI.[8][9]
  • D-mannose evidence no longer supports routine use. The 2024 JAMA Intern Med MERIT trial (598 women, double-blind, placebo-controlled) was negative.[12]
  • For coitus-related rUTI, post-coital prophylaxis may reduce antibiotic exposure while preventing recurrence.[13]
  • Self-start therapy is an option for selected reliable patients with a culture and follow-up plan.[2]
  • Set a review date. Reassess prevention benefit, toxicity, and recurrent episodes; benefit may diminish after treatment ends.[10]
  • Nitrofurantoin and TMP-SMX are common prophylactic options. Avoid fluoroquinolones for routine rUTI prophylaxis because of potential disabling tendon, peripheral-nerve and CNS effects, psychiatric symptoms (anxiety, confusion, hallucinations), QT prolongation, seizures and C. difficile. The US boxed warning covers the tendon, nerve and CNS harms plus exacerbation of myasthenia gravis; aortic aneurysm/dissection risk appears separately under Warnings and Precautions. In patients at increased aortic risk, reserve fluoroquinolones for situations with no alternative antibacterial treatment.[21][30][31][32]
  • Do not treat asymptomatic bacteriuria in transplant recipients more than one month after transplantation, in SCI patients or in catheter patients outside the IDSA 2019 exceptions. Treatment is not shown to prevent symptomatic UTI and promotes antimicrobial resistance.[18][20]
  • In neurogenic patients, investigate correctable causes and match prophylaxis to the catheter and recurrence setting. CIC with recurrent UTI differs from asymptomatic bacteriuria or an indwelling catheter.[20]
  • Immunoprophylaxis remains investigational in the US.[14][15][16]

See Also​

References​

1. Anger JT, Bixler BR, Holmes RS, et al. "Updates to recurrent uncomplicated urinary tract infections in women: AUA/CUA/SUFU guideline." J Urol. 2022;208(3):536–541. doi:10.1097/JU.0000000000002860

2. Hooton TM. "Uncomplicated urinary tract infection." N Engl J Med. 2012;366(11):1028–1037. doi:10.1056/NEJMcp1104429

3. Fihn SD. "Acute uncomplicated urinary tract infection in women." N Engl J Med. 2003;349(3):259–266. doi:10.1056/NEJMcp030027

4. Siddiqui NY, Bradley MS. "Updates in clinical management of recurrent urinary tract infections." Obstet Gynecol. 2025. doi:10.1097/AOG.0000000000006060

5. Smith AL, Brown J, Wyman JF, et al. "Treatment and prevention of recurrent lower urinary tract infections in women: a rapid review with practice recommendations." J Urol. 2018;200(6):1174–1191. doi:10.1016/j.juro.2018.04.088

6. Nelson Z, Aslan AT, Beahm NP, et al. "Guidelines for the prevention, diagnosis, and management of urinary tract infections in pediatrics and adults: a WikiGuidelines group consensus statement." JAMA Netw Open. 2024;7(11):e2444495. doi:10.1001/jamanetworkopen.2024.44495

7. Beerepoot MA, Geerlings SE, van Haarst EP, van Charante NM, ter Riet G. "Nonantibiotic prophylaxis for recurrent urinary tract infections: a systematic review and meta-analysis of randomized controlled trials." J Urol. 2013;190(6):1981–1989. doi:10.1016/j.juro.2013.04.142

8. Harding C, Mossop H, Homer T, et al. "Alternative to prophylactic antibiotics for the treatment of recurrent urinary tract infections in women: multicentre, open-label, randomised, non-inferiority trial (ALTAR)." BMJ. 2022;376:e068229. doi:10.1136/bmj-2021-0068229

9. Harding C, Chadwick T, Homer T, et al. "Methenamine hippurate compared with antibiotic prophylaxis to prevent recurrent urinary tract infections in women: the ALTAR non-inferiority RCT." Health Technol Assess. 2022;26(23):1–172. doi:10.3310/QOIZ6538

10. Heltveit-Olsen SR, Arnljots ES, Sundvall PD, et al. "Methenamine hippurate as prophylaxis for recurrent urinary tract infections in older women — a triple-blind, randomised, placebo-controlled, phase IV trial (ImpresU)." Clin Microbiol Infect. 2025. doi:10.1016/j.cmi.2025.07.006

11. Hodgkinson NC, Al-Rubaye T, Reed TCP, et al. "Implications for methenamine hippurate use in recurrent urinary tract infection management: formaldehyde resistance and altered urinary composition." PLoS Pathog. 2026;22(3):e1014081. doi:10.1371/journal.ppat.1014081

12. Hayward G, Mort S, Hay AD, et al. "D-mannose for prevention of recurrent urinary tract infection among women: a randomized clinical trial." JAMA Intern Med. 2024;184(6):619–628. doi:10.1001/jamainternmed.2024.0264

13. Jent P, Berger J, Kuhn A, et al. "Antibiotics for preventing recurrent urinary tract infection: systematic review and meta-analysis." Open Forum Infect Dis. 2022;9(7):ofac327. doi:10.1093/ofid/ofac327

14. Haddad JM, Ubertazzi E, Cabrera OS, et al. "Latin American consensus on uncomplicated recurrent urinary tract infection — 2018." Int Urogynecol J. 2020;31(1):35–44. doi:10.1007/s00192-019-04079-5

15. Lorenzo-Gómez MF, Padilla-Fernández B, Flores-Fraile J, et al. "Impact of whole-cell bacterial immunoprophylaxis in the management of recurrent urinary tract infections in the frail elderly." Vaccine. 2021;39(42):6308–6314. doi:10.1016/j.vaccine.2021.08.093

16. Aziminia N, Hadjipavlou M, Philippou Y, et al. "Vaccines for the prevention of recurrent urinary tract infections: a systematic review." BJU Int. 2019;123(5):753–768. doi:10.1111/bju.14606

17. American College of Obstetricians and Gynecologists. "Urinary tract infections in pregnant individuals." Obstet Gynecol. 2023;142(2):435–445. doi:10.1097/AOG.0000000000005269

18. Nicolle LE, Gupta K, Bradley SF, et al. "Clinical practice guideline for the management of asymptomatic bacteriuria: 2019 update by the Infectious Diseases Society of America." Clin Infect Dis. 2019;68(10):e83–e110. doi:10.1093/cid/ciy1121

19. Apicella L, Vecchione N, Minelli G, et al. "Urinary tract infections in kidney transplant recipients: a narrative review." Transplant Proc. 2026. doi:10.1016/j.transproceed.2026.04.006

20. Milligan J, Goetz LL, Kennelly MJ. "A primary care provider's guide to management of neurogenic lower urinary tract dysfunction and urinary tract infection after spinal cord injury." Top Spinal Cord Inj Rehabil. 2020;26(2):108–115. doi:10.46292/sci2602-108

21. Ackerman AL, Bradley M, D'Anci KE, et al. "Updates to Recurrent Uncomplicated Urinary Tract Infections in Women: AUA/CUA/SUFU Guideline (2025)." J Urol. 2025. doi:10.1097/JU.0000000000004723. Full guideline, statements 12–17.

22. Validus Pharmaceuticals LLC. HIPREX (methenamine hippurate tablets USP): US prescribing information. July 2021; DailyMed record revised February 2022. Prescribing information. Accessed September 11, 2026.

23. Lorenzo-Gómez MF, Foley S, Nickel JC, et al. Sublingual MV140 for prevention of recurrent urinary tract infections. NEJM Evid. 2022. doi:10.1056/EVIDoa2100018.

24. European Association of Urology. EAU Guidelines on Urological Infections. 2026. Full guideline.

25. AUA/SUFU. Adult neurogenic lower urinary tract dysfunction: treatment and follow-up. 2021. Statements 30–31 and 37–39. doi:10.1097/JU.0000000000002239.

26. Fisher H, Oluboyede Y, Chadwick T, et al. Continuous low-dose antibiotic prophylaxis for adults with repeated urinary tract infections (AnTIC): a randomised, open-label trial. Lancet Infect Dis. 2018;18:957–968. doi:10.1016/S1473-3099(18)30279-2.

27. European Association of Urology. EAU Guidelines on Neuro-Urology. Limited update, March 2026. Section 3.5.4, urinary tract infections.

28. NICE. Urinary tract infection (recurrent): antimicrobial prescribing (NG112). Published October 31, 2018; last updated December 12, 2024. Guideline

29. Methenamine hippurate tablets USP. US prescribing information, label effective May 2026. DailyMed.

30. Newton ER, Akerman AW, Strassle PD, et al. "Association of fluoroquinolone use with short-term risk of development of aortic aneurysm." JAMA Surg. 2021;156(3):264–272. doi:10.1001/jamasurg.2020.6165

31. Tennyson LE, Averch TD. "An update on fluoroquinolones: the emergence of a multisystem toxicity syndrome." Urol Pract. 2017;4(5):383–387. doi:10.1016/j.urpr.2016.08.004

32. Bayer HealthCare Pharmaceuticals Inc. CIPRO (ciprofloxacin): US prescribing information. Revised September 2024. DailyMed label.

33. Novo Nordisk Inc. Vagifem (estradiol vaginal inserts) prescribing information. Revised February 2024. DailyMed.

34. Williams G, Stothart CI, Hahn D, Stephens JH, Craig JC, Hodson EM. "Cranberries for preventing urinary tract infections." Cochrane Database Syst Rev. 2023;11(11):CD001321. doi:10.1002/14651858.CD001321.pub7

35. Sun Pharmaceutical Industries, Inc. BACTRIM (sulfamethoxazole and trimethoprim tablets): US prescribing information. DailyMed; updated December 30, 2024. Prescribing information.

36. Chen YY, Su TH, Lau HH. "Estrogen for the prevention of recurrent urinary tract infections in postmenopausal women: a meta-analysis of randomized controlled trials." Int Urogynecol J. 2021;32(1):17–25. doi:10.1007/s00192-020-04397-z

37. Sanyaolu L, Ahmed H, Best V, et al. "Prophylactic antibiotics to prevent recurrent urinary tract infections and risk of antibiotic resistance: target trial emulation with the SAIL Databank." Lancet Obstet Gynaecol Womens Health. 2026;2(3):e209–e217. doi:10.1016/S3050-5038(25)00178-5