EAU 2025 Guidelines: Urological Infections

What This Guideline Covers

The EAU 2025 Urological Infections guideline provides evidence-based recommendations across 18 topic areas. The key (Strong-rated) recommendations are summarised below; the complete recommendation tables — including Weak recommendations with their strength ratings — plus classification and evidence tables are in the Full Guidelines tab.

Key Recommendations at a Glance

Every Strong-rated EAU recommendation. Where the guideline labels its sections, they are used as sub-headings.

• Do not screen or treat asymptomatic bacteriuria in the following conditions: • women without risk factors; • patients with well-regulated diabetes mellitus; • post-menopausal women; • elderly institutionalised patients; • patients with dysfunctional and/or reconstructed lower urinary tracts; • patients with renal transplants; • patients prior to arthoplasty surgeries; • patients with recurrent urinary tract infections.
• Screen for and treat asymptomatic bacteriuria prior to urological procedures breaching the mucosa.

Diagnostic evaluation of cystitis

• Diagnose cystitis in women who have no other risk factors for systemic urinary tract infections based on: • a focused history of lower urinary tract symptoms (dysuria, frequency and urgency); • the absence of vaginal discharge or irritation.
• Urine cultures should be done in the following situations: • suspected acute pyelonephritis; • symptoms that do not resolve or recur within four weeks after the completion of treatment; • women who present with atypical symptoms; • pregnant women.

Management of cystitis

• Advise female patients on the possibility of an antibiotic-sparing approach for the treatment and prevention of acute and recurrent cystitis. Patients should be fully informed on the level of evidence for the different approaches.
• Prescribe fosfomycin trometamol, pivmecillinam or nitrofurantoin as first-line treatment for cystitis in women.
• Use non-antibiotic therapy options as an alternative to antibiotic treatment in non- geriatric patients. Shared decision-making with patients is essential.
• Do not use aminopenicillins or fluoroquinolones to treat cystitis.

Diagnostic evaluation and treatment of recurrent cystitis

• Diagnose recurrent cystitis by urine culture.
• Use vaginal oestrogen replacement in post- menopausal women to prevent recurrent cystitis.
• Advise patients on the use of cranberry products, favouring juice, for symptom relief in acute cystitis and to prevent recurrence; however, patients should be informed that the quality of evidence underpinning this is low with contradictory findings.
• Use methenamine hippurate to reduce recurrent cystitis episodes in women without abnormalities of the urinary tract.
• Use continuous or post-coital antimicrobial prophylaxis to prevent recurrent cystitis when non-antimicrobial interventions have failed. Counsel patients regarding possible side effects.
• For patients with good compliance self- administered short-term antimicrobial therapy should be considered.

Diagnostic evaluation and treatment of pyelonephritis

• Perform urinalysis (e.g., using a dipstick method), including the assessment of white and red blood cells and nitrite, for routine diagnosis.
• Perform urine culture and antimicrobial susceptibility testing in patients with pyelonephritis.
• Perform imaging of the urinary tract to exclude urgent urological disorders.
• Treat patients with pyelonephritis not requiring hospitalisation with short course fluoroquinolones as first-line treatment.
• Treat patients with pyelonephritis requiring hospitalisation with an intravenous antimicrobial regimen initially.
• Switch patients initially treated with parenteral therapy, who improve clinically and can tolerate oral fluids, to oral antimicrobial therapy.
• Do not use nitrofurantoin, oral fosfomycin, and pivmecillinam to treat pyelonephritis.

Treatment of systemic UTIs

• Use the combination of: • amoxicillin plus an aminoglycoside; • a second-generation cephalosporin plus an aminoglycoside; • a third generation cephalosporin.
• Only use ciprofloxacin provided: • the local resistance percentages are < 10%; • the patient has contraindications for third generation cephalosporins or aminoglycosides; • the patient has a hypersensitivity for beta-lactam antimicrobials.
• Do not use ciprofloxacin and other fluoroquinolones for the empirical treatment of systemic UTI in patients from urology departments or when patients have used fluoroquinolones in the last six months.
• Manage any urological abnormality and/or underlying complicating factors.

Diagnostic evaluation of CA-UTI

• Do not carry out routine urine culture in asymptomatic catheterised patients.
• Do not use pyuria as sole indicator for catheter-associated UTI (CA-UTI).
• Do not use the presence or absence of odorous or cloudy urine alone to differentiate catheter-associated asymptomatic bacteriuria from CA-UTI.

Recommendations disease management and prevention of CA-UTI

• Treat symptomatic catheter-associated- UTI (CA-UTI) according to the recommendations for localised and systemic UTI.
• Take a urine culture prior to initiating antimicrobial therapy in catheterised patients in whom the catheter has been removed.
• Do not treat catheter-associated asymptomatic bacteriuria in general.
• Treat catheter-associated asymptomatic bacteriuria prior to traumatic urinary tract interventions (e.g., transurethral resection of the prostate).
• Replace or remove the indwelling catheter before starting antimicrobial therapy.
• Do not apply topical antiseptics or antimicrobials to the catheter, urethra or meatus.
• Do not use prophylactic antimicrobials to prevent CA-UTI.
• The duration of catheterisation should be minimal.
• Use hydrophilic coated catheters to reduce CA-UTI.

Diagnosis and treatment of urosepsis

• Perform the quickSOFA score to identify patients with potential sepsis.
• Take a urine culture and two sets of blood cultures before starting antimicrobial treatment.
• Administer parenteral high dose broad spectrum antimicrobials within the first hour after clinical assumption of sepsis.
• Adapt initial empiric antimicrobial therapy on the basis of culture results.
• Initiate source control including removal of foreign bodies, decompression of obstruction and drainage of abscesses in the urinary tract.
• Provide immediate adequate life-support measures.

Diagnostic evaluation and treatment of urethritis

• Perform a Gram stain of urethral discharge or a urethral smear to preliminarily diagnose gonococcal urethritis.
• Perform a validated nucleic acid amplification test (NAAT) on a first-void urine sample or urethral smear prior to empirical treatment to diagnose chlamydial and gonococcal infections.
• If possible, delay treatment until the results of the NAATs are available to guide treatment choice in patients with mild symptoms.
• Perform a urethral swab culture, prior to initiation of treatment, in patients with a positive NAAT for gonorrhoea to assess the antimicrobial resistance profile of the infective strain.
• Use a pathogen directed treatment based on local resistance data.
• Sexual partners should be treated, while maintaining patient confidentiality.

Diagnosis of bacterial prostatitis

• Do not perform prostatic massage in acute bacterial prostatitis (ABP).
• Perform the Meares and Stamey 2- or 4-glass test in patients with CBP.

Management of bacterial prostatitis

• Treat acute bacterial prostatitis according to the recommendations for systemic UTI.
• Prescribe a fluoroquinolone (e.g., ciprofloxacin, levofloxacin) as first-line treatment for CBP.
• Prescribe a macrolide (e.g., azithromycin) or a tetracycline (e.g., doxycycline) if intracellular bacteria have been identified as the causative agent of CBP.
• Prescribe metronidazole in patients with Trichomonas vaginalis CBP.

Diagnosis and treatment of acute infective epididymitis

• Obtain a mid-stream urine and a first voided urine for pathogen identification by culture and nucleic acid amplification test.
• Initially prescribe a single antibiotic or a combination of two antibiotics active against Chlamydia trachomatis and Enterobacterales in young sexually active men; in older men without sexual risk factors only Enterobacterales have to be considered.
• If gonorrhoeal infection is likely, give single dose ceftriaxone 500 mg intramuscularly or intravenously* in addition to a course of an antibiotic active against C. trachomatis.
• Follow national policies on reporting and tracing/treatment of contacts for sexually transmitted infections.

Management of Fournier’s Gangrene

• Start treatment for Fournier’s gangrene with broad-spectrum antibiotics on presentation, with subsequent refinement according to culture and clinical response.
• Commence repeated surgical debridement for Fournier’s gangrene within 24 hours of presentation.

Treatment of anogenital warts

• Use self-administered imiquimd 5% cream applied to all external warts overnight three times each week for sixteen weeks for the treatment of anogenital warts.

• Use self-administered sinecatechins 15% or 10% applied to all external warts three times daily until complete clearance, or for up to sixteen weeks for the treatment of anogenital warts.

• Use self-administered podophyllotoxin 0.5% self-applied to lesions twice daily for three days, followed by four rest days, for up to four or five weeks for the treatment of anogenital warts.

• Use cryotherapy or surgical treatment (excision, electrosurgery, electrocautery and laser therapy) to treat anogenital warts based on an informed discussion with the patient.

• Discuss male circumcision with patients as an additional one-time preventative intervention for HPV-related diseases.

• Offer early HPV vaccination to boys with the goal of establishing optimal vaccine- induced protection before the onset of sexual activity.

• Apply diverse communication strategies in order to improve HPV vaccination knowledge in young adult males.

• Obtain a comprehensive medical history, including history of previous sexual contacts from all patients presenting with genital ulcers potentially related to HSV.

• Confirm the diagnosis with a clinical swab and type-specific virologic testing, such as PCR or culture, from the lesion.

• Treat the first clinical episode of genital HSV infection.

Diagnosis and treatment of genitourinary tuberculosis

• Take a full medical history including history of previous tuberculosis infection (pulmonary and extrapulmonary) form all patients presenting with persistent non- specific genitourinary symptoms and no identifiable cause.
• Perform acid-fact bacilli culture on three midstream first-void urine samples, on three consecutive days for M. tuberculosis isolation in patients with suspected GUTB.
• Use medical treatment as first-line treatment for GUTB.
• Use a daily six-month regimen for treatment of newly diagnosed GUTB, this should include an intensive phase of two months with isoniazid, rifampicin, pyrazinamide and ethambutol. Followed by a continuation phase of four-months with isoniazid and rifampicin.
• Treat multi-drug resistant TB with an individualised treatment regime including at least five effective tuberculosis medicines during the intensive phase, including pyrazinamide and four core second-line tuberculosis medicines.

Peri-procedural antibiotic prophylaxis

• Do not use antibiotic prophylaxis to reduce the rate of symptomatic urinary infection following: • urodynamics; • cystoscopy; • extracorporeal shockwave lithotripsy.
• Use single dose antibiotic prophylaxis to reduce the rate of clinical urinary infection following percutaneous nephrolithotomy.
• Use antibiotic prophylaxis to reduce infectious complications in men undergoing transurethral resection of the prostate.
• Perform prostate biopsy using the transperineal approach due to the lower risk of infectious complications and better antibiotic stewardship.
• Use rectal cleansing with povidone-iodine in men prior to transrectal prostate biopsy.
• Do not use fluoroquinolones for prostate biopsy in line with the European Commission final decision on EMEA/H/A-31/1452.
• For antibiotic prophylaxis in transrectal biopsy*, and from an antimicrobial stewardship perspective, the following options are recommended**: • First option: Targeted prophylaxis based on rectal swab or stool culture. • Second option: Augmented prophylaxis (using two or more different classes of antibiotics).