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cystitis

Inflammation/infection of the urinary bladder. Etiology: 1) urinary tract infection - colonic bacteria ascending through the urethra - fungal cystitis - protozoa, Schistosoma haematobium 2) interstitial cystitis 3) pharmaceutical agents 4) radiation Epidemiology: - particularly common in women Pathology: 1) frequency of infection in women is mainly because of the much shorter urethra, which provides less of a barrier to bacteria 2) in men, infection is usually associated with obstruction to the flow of urine, such as prostate gland enlargement Clinical manifestations: 1) dysuria 2) urinary frequency 3) nocturia 4) suprapubic pain/tenderness 5) hematuria 6) malodorous & cloudy urine* 7) urinary urgency 8) urinary incontinence 9) not associated with fever * according to ref 2, does not constitute evidence of infection, nonetheless malodorous urine may be the symptom that prompts a urinalysis Laboratory: 1) also see urinary tract infection 2) urine dipstick - positive leukocyte esterase & nitrite consistent with cystitis [3] 3) urinalysis with urine microscopy: a) > 10 WBC/HPF & bacteriuria consistent with cystitis [3] - bacteriuria in the absence of pyuria is common if the specimen remains at room temperature for a prolonged time prior to analysis - pyuria & bacteriuria indicates infection only when symptoms of cystitis are present b) do not schedule routine followup urinalysis for uncomplicated cystitis [3] 4) urine culture - Escherichia coli is most common cause in non-pregnant premenopausal females - >= 100 colony-forming units/mL can indicate infection - gram-positive organisms rarely significant [6] - urine culture not routinely indicated in women with uncomplicated cystitis [3] - urine culture indicated for - recurrent cysititis (recurrent UTI) - suspected pyelonephritis - complicated UTI - recent antibiotic treatment - health care-associated UTI - pyuria with negative culture (sterile pyuria) suggests infection by: - Chlamydia - Neisseria gonorrhoeae - tuberculosis - send urine for acid-fast bacilli stain & culture [13] Management: 1) see urinary tract infection 2) empiric treatment of bacteriuria & pyruria associated with symptoms of cystitis a) nonpregnant young women with uncomplicated cystitis [3,5] 1] culture not recommended 2] prescription of antibiotic over the telephone acceptable [3] 3] trimethoprim/sulfamethoxazole (TMP/SMX, Bactrim) for 3 days [12] - do not use if used within 3 months [3] 4] nitrofurantoin; first line all women [3] - contraindicated in 3rd trimester of pregnancy near term (38-42 weeks gestation) - less effective than ciprofloxacin for treatment of cystitis in elderly women regardless of renal function [8] - MKSAP17 recommends nitrofurantoin to treat cystitis in elderly women [3,8] - may not be a good choice for the elderly - sustained-release nitrofurantoin (MacroBid) 100 mg BID for 5 days - pregnant women (except near term) [3] - 5 days of therapy [12] - insufficient levels in renal tissue to treat pyelonephritis 5] fosfomycin 3 grams PO single dose - less effective & more expensive than nitrofurantoin or TMP/SMX (Bactrim) [4,10] b) fluoroquinolone for 7-10 days for complicated UTI - avoid fluoroquinolones for uncomplicated cystitis [9] c) ciprofloxacin clearly superior to cefpodoxime [4] - 3 days of treatment d) ciprofloxacin plus urine culture indicated for recurrent UTI or suspected antibiotic-resistant organism [3] 3) pregnant women with cystitis a) 3-7 days with amoxicillin clavulanate, cefpodoxime or cefixime b) 5-7 days of nitrofurantoin c) fosfomycin may be an option, especially if compliance is an issue (single dose) d) obtain urine culture after treatment [3] 4) pyuria with asymptomatic bacteriuria does not need urine culture or treatment - antibiotic stewardship in nursing home residents [11] 5) recurrent cystitis (see recurrent urinary tract infection) 6) prophylaxis - daily QHS nitrofurantoin or TMP/SMX reduces recurrences of cysititis, but adverse effects are common [3] - a single does of nitrofurantoin or TMP/SMX after sexual intercourse reduces intercourse-related cystitis [3] - self initiated therapy for recurrent infection [3]

Related

bacteriuria urinary tract infection (UTI)

Specific

fungal cystitis interstitial cystitis

General

urinary bladder disease

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 552-553
  2. UCLA Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 12-15, 2001
    1. Ouslander et al, Ann Intern Med 122:749, 1995
    2. Ouslander et al J Am Geriatr Soc 44:420, 1996
  3. Medical Knowledge Self Assessment Program (MKSAP) 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 2009, 2012, 2015, 2018, 2021. - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  4. Hooton TM et al. Cefpodoxime vs ciprofloxacin for short-course treatment of acute uncomplicated cystitis: A randomized trial. JAMA 2012 Feb 8; 307:583. PMID: 22318279
  5. Gupta K, Hooton TM, Naber KG, Wullt B et al International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis. 2011 Mar 1;52(5):e103-20 PMID: 21292654 (corresponding NGC guideline withdrawn Jan 2017)
  6. Hooton TM et al. Voided midstream urine culture and acute cystitis in premenopausal women. N Engl J Med 2013 Nov 14; 369:1883 PMID: 24224622 http://www.nejm.org/doi/full/10.1056/NEJMoa1302186
  7. Hooton TM. Clinical practice. Uncomplicated urinary tract infection. N Engl J Med 2012 Mar 16; 366:1028. PMID: 22417256
  8. Singh N et al. Kidney function and the use of nitrofurantoin to treat urinary tract infections in older women. CMAJ 2015 Jun 16; 187:648. PMID: 25918178 Free PMC Article http://www.cmaj.ca/content/187/9/648
  9. American Urological Association Fifteen Things Physicians and Patients Should Question Released February 21, 2013 (1-5), June 11, 2015 (6-10), May 13, 2017 (11-15); sources for #5 revised May 9, 2016 http://www.choosingwisely.org/societies/american-urological-association/
  10. Huttner A, Kowalczyk A, Turjeman A et al Effect of 5-Day Nitrofurantoin vs Single-Dose Fosfomycin on Clinical Resolution of Uncomplicated Lower Urinary Tract Infection in Women. A Randomized Clinical Trial. JAMA. Published online April 22, 2018 PMID: 29710295 https://jamanetwork.com/journals/jama/fullarticle/2679131 - Datta R, Juthani-Mehta M. Nitrofurantoin vs Fosfomycin. Rendering a Verdict in a Trial of Acute Uncomplicated Cystitis. JAMA. Published online April 22, 2018 PMID: 29710273 https://jamanetwork.com/journals/jama/fullarticle/2679130
  11. Nace DA, Hanlon JT, Crnich CJ et al. A multifaceted antimicrobial stewardship program for the treatment of uncomplicated cystitis in nursing home residents. JAMA Intern Med 2020 May 11; PMID: 32391862 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2764860
  12. Lee RA, Centor RM, Humphrey LL et al. Appropriate use of short-course antibiotics in common infections: Best practice advice from the American College of Physicians. Ann Intern Med 2021 Apr 6; [e-pub]. PMID: 33819054 https://www.acpjournals.org/doi/10.7326/M20-7355
  13. Muneer A, Macrae B, Krishnamoorthy S, Zumla A. Urogenital tuberculosis - epidemiology, pathogenesis and clinical features. Nat Rev Urol. 2019 Oct;16(10):573-598 PMID: 31548730 Review.