| Introduction: Urinary tract infections (UTIs) are common in elderly women, mostly caused by Escherichia coli, and lead to symptoms like burning urination, frequent urination, urgency, and lower abdominal pain. This study aimed to compare the clinical and microbiological effectiveness of oral Fosfomycin, Nitrofurantoin, and Pivmecillinam in treating uncomplicated lower UTIs in women aged 60 years and above.Materials and Methods: A total of 270 patients were enrolled in a prospective, randomized, open-label study, with 90 patients in each treatment group. Group A received a single 3 g dose of Fosfomycin, Group B received Nitrofurantoin 100 mg twice daily for 5 days, and Group C received Pivmecillinam 400 mg twice daily for 3 days. Patients were followed up on days 15, 30, 45, and 60 to assess symptom relief, laboratory parameters, urine culture results, and cure rates.Results: Progressive improvement in symptoms such as dysuria, urinary frequency, urgency, suprapubic pain, nocturia, and malaise was observed in all groups. Proteinuria and hematuria decreased over the treatment period, and blood tests including WBC count, hemoglobin, CRP, and serum creatinine improved significantly. Urine cultures revealed a reduction in bacterial presence, with Fosfomycin showing the highest bacteriological cure (94.4%) by day 60, followed by Pivmecillinam (92.2%) and Nitrofurantoin (91.1%). All three antibiotics were well tolerated without major adverse effects.Conclusion: Fosfomycin, Nitrofurantoin, and Pivmecillinam were effective and safe in treating uncomplicated lower UTIs in elderly women, with Fosfomycin demonstrating the most rapid and highest cure rates.