Recurrent urinary tract infection is not one disease: moving from antibiotic suppression to phenotype-guided prevention

Recurrent urinary tract infection (UTI) is commonly defined by episode frequency, but recurrence count alone does not explain why infections recur or which preventive strategy is most appropriate. In everyday practice, patients with postmenopausal hypoestrogenism, post-coital recurrence, low fluid intake, voiding dysfunction, persistent-source relapse, resistant-organism recurrence, or noninfectious urinary symptoms may all receive the same label of recurrent UTI despite having different clinical drivers. This editorial argues that recurrent UTI should be approached as a heterogeneous, phenotype-driven syndrome rather than as a uniform pathway toward repeated antimicrobial treatment or long-term antibiotic suppression. Antibiotics remain essential for acute bacterial infection and selected prophylactic use, but prevention should be preceded by confirmation of recurrent bacterial infection and assessment of the dominant recurrence phenotype. Evidence supporting vaginal estrogen, methenamine hippurate, increased fluid intake in selected patients, and cranberry products illustrates the potential value of targeted non-antibiotic prevention, while negative trial evidence for d-mannose reinforces the need for evidence discipline rather than indiscriminate supplement use. We propose a practical model of recurrent UTI care based on four steps: confirm, phenotype, prevent, and reassess. This approach aligns clinical management with antimicrobial stewardship, improves diagnostic clarity, and encourages prevention strategies matched to individual patient mechanisms rather than recurrence count alone.