AUA releases amendment to recurrent uncomplicated UTIs in women guideline

On September 4, 2025, the American Urological Association (AUA), in collaboration with the Canadian Urological Association and the Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction (SUFU), released an amendment to the guideline on recurrent uncomplicated urinary tract infections (rUTIs) in women.^1,2

This amendment follows the guideline’s original publication in 2019 and a review and validity confirmation in 2022.

“In updating the 2025 guideline update for Recurrent Uncomplicated Urinary Tract Infections in Women, we hope to take a more patient-centered, risk-based, and microbiome-aware approach to rUTI management,” guideline amendment chair A. Lenore Ackerman, MD, PhD, director of research for the Division of Urogynecology and Reconstructive Pelvic Surgery at UCLA in Los Angeles, California, said in a news release from the AUA.² “The updated guideline tries to balance diagnostic accuracy with clinical judgment, redefining treatment success as symptom resolution rather than microbial eradication and placing a premium on antimicrobial stewardship and patient-centered care. These changes reflect a maturing understanding of the urinary microbiome, the limitations of existing diagnostics, and a public health imperative to reduce unnecessary antibiotic exposure.”

Specifically, the updated guideline includes 20 recommendations for urologists treating rUTIs in women. According to the AUA, changes to the guideline include²:

• Updates to the Introduction section to define new and existing guideline terms used throughout and additional information on emerging diagnostics
• New recommendations on non-antibiotic prophylaxis
• New recommendation on symptom evaluation
• Updates to the Future Directions section that include information on potential new treatment alternatives and new molecular technologies
• Updates to the Guideline algorithm

The guideline amendments are based on a review of the literature that included 87 studies published between June 2021 and November 2024. Of those, 14 met the inclusion criteria for review.

The updated guideline includes an expansion of nonantibiotic options for UTI prophylaxis. Clinicians are now advised to offer cranberry, methenamine hippurate, and increased water intake for patients with a water intake below 1.5 L (50 oz) per day as prophylaxis options for women with rUTIs. Additionally, the guidelines recommend that women be counseled that D-mannose alone for prophylaxis may not be effective in UTI prevention.”

Further, the authors note that the guideline updates reflect a “greater understanding of the value of a negative urinalysis in ruling out UTI and a paradigm shift away from microbial detection to reliance on clinician judgement when weighing the individual risks and benefits of antibiosis.”³

According to the authors, “The answer to improved antimicrobial stewardship lies not in better testing but in better clinical judgement.”

The guideline continues to recommend that vaginal estrogen be offered to perimenopausal and postmenopausal women with rUTIs given that there is no contraindication to vaginal estrogen therapy.

“Recurrent urinary tract infections are a source of great suffering among our patients, and SUFU was thrilled to partner with the AUA on the new rUTI guideline amendment,” Anne Pelletier Cameron, MD, FRCSC, URPS, president of SUFU and professor and vice chair of academic affairs in the Department of Urology at the University of Michigan in Ann Arbor, added in the news release.² “Clear guidance on diagnosis and management of this condition will be used by urology providers and the greater medical community, and this updated document incorporates the most recent scientific evidence in a clear and actionable manner.”

REFERENCES

1. Recurrent Uncomplicated Urinary Tract Infections in Women: AUA/CUA/SUFU Guideline (2025). American Urological Association. Accessed September 4, 2025. https://www.auanet.org/guidelines-and-quality/guidelines/recurrent-uti

2. American Urological Association release Recurrent Uncomplicated Urinary Tract Infections in Women guideline amendment. News release. American Urological Association. September 4, 2025. Accessed September 4, 2025. https://www.auanet.org/about-us/media-center/press-center/american-urological-association-release-recurrent-uncomplicated-urinary-tract-infections-in-women-guideline-amendment

3. Ackerman AL, Bradley M, D'Anci KE, Hickling D, Kim SK, Kirkby E. Updates to Recurrent Uncomplicated Urinary Tract Infections in Women: AUA/CUA/SUFU Guideline (2025). J Urol. 2025;101097JU0000000000004723. doi:10.1097/JU.0000000000004723