Cystitis
Lawrence Pike
Incidence
1-3% of all GP consultations
5% of women each year with symptoms.
Up to 50% of women will suffer from a
symptomatic UTI during their lifetime.
UTI in men is much rarer
A proportion of patients may be
symptomatic in the absence of infection -
called 'urethral syndrome'
Symptoms
Dysuria
Frequency
Nocturia
Urgency of micturition.
Other symptoms include suprapubic pain,
cloudy or foul smelling urine and
haematuria.
Causes
The most common cause is bacterial infection
Eschericia coli is the pathogen in 70% of
uncomplicated case of lower urinary tract infections.
Other organisms include Proteus mirabilis, Klebsiella
pneumoniae, Staphylococcus saprophyticus,
Staphylococcus aureus and Pseudomonas species.
Urethral Syndrome -not associated with any
infection
Rarely kidney or bladder stones, prostatism,
diabetes
Prevention
Drinking plenty of fluids helps prevent
cystitis in the first place.
If cystitis follows sexual intercourse, some
advise passing urine soon after to try and
prevent it.
There is no evidence to suggest a link
between lower urinary tract infection and
use of bath preparations
Beware!
Pregnant
Under age 12
Males
Systemically ill (fever, sickness, backache)
Catheterised patients
Kidney or bladder stones
Investigation
Urine dipstick
can be done in the surgery and will be positive for nitrates and
leucocytes (leukocyte esterase test). This helps to differentiate
those with UTI from the 50% with urethral syndrome.
Urine microscopy and culture reveals significant
bacteruria (usually >105 /ml).
Asymptomatic bacteruria
is present in 12-20% of women aged 65-70 years and does not
impair renal function or shorten life so no treatment
in 4-7% of pregnant women and associated with premature
delivery and low birth weight and always requires treatment.
Differential Diagnosis
Urethral syndrome
Bladder lesion e.g. calculi, tumour.
Candidal infection
Chlamydia or other sexually transmitted disease.
Urethritis
Drug induced cystitis (e.g. with
cyclophosphamide, allopurinol, danazol,
tiaprofenic acid and possibly other NSAIDs)
Complications and Prognosis
Ascending infection can occur, leading to development of
pyelonephritis, renal failure and sepsis.
In children, the combination of vesicoureteric reflux and
urinary tract infection can lead to permanent renal
scarring, which may ultimately lead to the development of
hypertension or renal failure. 12-20% of children already
have radiological evidence of scarring on their first
investigation for UTI.
Urinary tract infection during pregnancy is associated with
prematurity, low birth weight of the baby and a high
incidence of pyelonephritis in women.
Recurrent infection occurs in up to 20% of young women
with acute cystitis.
Management Issues - General
50% will resolve in 3 days without
treatment
No evidence to support drink plenty
It is reasonable to start treatment without
culture if the dipstick is positive for
nitrates or leucocytes.
MSU if dipstick negative but suspicion
Management Issues - General
Culture is always indicated in
Men
Pregnant women
Children
Those with failure of empirical treatment
Those with complicated infection
Self care
Drink slightly acid drinks such as cranberry
juice, lemon squash or pure orange juice
(poor trial evidence for this)
Try a mixture of potassium citrate
available from your pharmacist (little
evidence but widely recommended)
Antibiotics
Trimethoprim is an effective first line treatment.
Cephalosporins are as effective as trimethoprim
but more expensive and more likely to disrupt gut
flora.
Nitrofurantoin is as effective as trimethoprim but
more expensive and frequently causes nausea
and vomiting
The 4-quinolones (ciprofloxacin, norfloxacin,
ofloxacin) are effective in the treatment of cystitis.
To preserve their efficacy, they should not usually
be used as first line therapy
Antibiotics
3 days of antibiotic is as effective as 5 or 7 days
Single dose antibiotic results in lower cure rates
and more recurrences overall than longer
courses.
In relapse of infection (i.e. reinfection with the
same bacteria), treatment with antibiotic for up
to 6 weeks is recommended.
Antibiotics for UTI in Pregnancy
Cephalosporins and penicillins are recommended
in pregnancy because of their long term safety
record
Nitrofurantoin is also likely to be safe during
pregnancy
Quinolones, Trimethoprim and Tetracyclines are
not recommended for use during pregnancy
Seven days of treatment is required.
Urine should be tested regularly throughout
pregnancy following initial infection.
