cystitis
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Introduction
Inflammation/infection of the urinary bladder.
Etiology
- urinary tract infection
- colonic bacteria ascending through the urethra
- fungal cystitis
- protozoa, Schistosoma haematobium
- interstitial cystitis
- pharmaceutical agents
- radiation
Epidemiology
- particularly common in women
Pathology
- frequency of infection in women is mainly because of the much shorter urethra, which provides less of a barrier to bacteria
- in men, infection is usually associated with obstruction to the flow of urine, such as prostate gland enlargement
Clinical manifestations
- dysuria
- urinary frequency
- nocturia
- suprapubic pain/tenderness
- hematuria
- malodorous & cloudy urine*
- urinary urgency
- urinary incontinence
- 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
- also see urinary tract infection
- urine dipstick
- positive leukocyte esterase & nitrite consistent with cystitis[3]
- urinalysis with urine microscopy:
- > 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
- do not schedule routine followup urinalysis for uncomplicated cystitis[3]
- > 10 WBC/HPF & bacteriuria consistent with cystitis[3]
- 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
- see urinary tract infection
- empiric treatment of bacteriuria & pyruria associated with symptoms of cystitis
- nonpregnant young women with uncomplicated cystitis[3][5]
- culture not recommended
- prescription of antibiotic over the telephone acceptable[3]
- trimethoprim/sulfamethoxazole (TMP/SMX, Bactrim) for 3 days[12]
- do not use if used within 3 months[3]
- 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
- fosfomycin 3 grams PO single dose
- less effective & more expensive than nitrofurantoin or TMP/SMX (Bactrim)[4][10]
- fluoroquinolone for 7-10 days for complicated UTI
- avoid fluoroquinolones for uncomplicated cystitis[9]
- ciprofloxacin clearly superior to cefpodoxime[4]
- 3 days of treatment
- ciprofloxacin plus urine culture indicated for recurrent UTI or suspected antibiotic-resistant organism[3]
- nonpregnant young women with uncomplicated cystitis[3][5]
- pregnant women with cystitis
- 3-7 days with amoxicillin clavulanate, cefpodoxime or cefixime
- 5-7 days of nitrofurantoin
- fosfomycin may be an option, especially if compliance is an issue (single dose)
- obtain urine culture after treatment[3]
- pyuria with asymptomatic bacteriuria does not need urine culture or treatment
- recurrent cystitis (see recurrent urinary tract infection)
- 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]
More general terms
More specific terms
Additional terms
References
- ↑ Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 552-553
- ↑ UCLA Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 12-15, 2001 a) Ouslander et al, Ann Intern Med 122:749, 1995 b) Ouslander et al J Am Geriatr Soc 44:420, 1996
- ↑ 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 3.11 3.12 3.13 3.14 3.15 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 - ↑ 4.0 4.1 4.2 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: https://www.ncbi.nlm.nih.gov/pubmed/22318279
- ↑ 5.0 5.1 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: https://www.ncbi.nlm.nih.gov/pubmed/21292654 (corresponding NGC guideline withdrawn Jan 2017)
- ↑ 6.0 6.1 Hooton TM et al. Voided midstream urine culture and acute cystitis in premenopausal women. N Engl J Med 2013 Nov 14; 369:1883 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/24224622 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMoa1302186
- ↑ Hooton TM. Clinical practice. Uncomplicated urinary tract infection. N Engl J Med 2012 Mar 16; 366:1028. PMID: https://www.ncbi.nlm.nih.gov/pubmed/22417256
- ↑ 8.0 8.1 8.2 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. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25918178 Free PMC Article <Internet> http://www.cmaj.ca/content/187/9/648
- ↑ 9.0 9.1 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/
- ↑ 10.0 10.1 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: https://www.ncbi.nlm.nih.gov/pubmed/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: https://www.ncbi.nlm.nih.gov/pubmed/29710273 https://jamanetwork.com/journals/jama/fullarticle/2679130 - ↑ 11.0 11.1 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: https://www.ncbi.nlm.nih.gov/pubmed/32391862 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2764860
- ↑ 12.0 12.1 12.2 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: https://www.ncbi.nlm.nih.gov/pubmed/33819054 https://www.acpjournals.org/doi/10.7326/M20-7355
- ↑ 13.0 13.1 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: https://www.ncbi.nlm.nih.gov/pubmed/31548730 Review.