Acute cystitis

This page is for adult patients; see urinary tract infection (peds) for pediatric patients.

Background

Anatomy of the bladder (male)

Genitourinary infection

(1) Human urinary system: (2) kidney; (3) renal pelvis; (4) ureter; (5) urinary bladder (6) urethra.
Additional structures: (7) adrenal gland; (8) renal artery and vein; (9) inferior vena cava; (10) abdominal aorta; (11) common iliac artery and vein; (12) liver; (13) large intestine; (14) pelvis.

"UTI" frequently refers specifically to acute cystitis, but may also be used as a general term for all urinary infections; use location-specific diagnosis.

• Renal/perirenal
  • Pyelonephritis
    • Emphysematous pyelonephritis
  • Renal abscess
  • Perinephric abscess
• Ureteral
  • Infected urolithiasis
• Bladder
  • Acute cystitis ("UTI")
  • Chronic cystitis
• Urethra/periurethra
  • Urethritis
  • Prostatitis

Definitions

• Relapse
  • Recurrence of symptoms within month despite treatment
    • Caused by same organism and represents treatment failure
• Reinfection
  • Development of symptoms 1-6mo after treatment
  • Usually due to a different organism
  • If patient has >3 recurrences in 1 yr consider tumor, calculi, diabetes
  • For menopausal or postmenopausal women with recurrent infection consider empiric treatment for genitourinary syndrome of menopause (GSM)

Risk Factors

• Anatomic abnormality of urinary tract or external drainage system
  • Indwelling urinary catheter, stent
  • Nephrolithiasis, neurogenic bladder, polycystic renal disease, recent instrumentation
• Recurrent acute cystitis
• Advanced age in men (BPH, recent instrumentation, recent prostatic biopsy)
• Nursing home residency
• Neonatal
• Comorbidities (DM, sickle cell disease)
• Pregnancy
• Immunosuppression (AIDS, immunosuppressive drugs)
• Advanced neurologic disease (CVA with disability, Spinal Cord Injuries)

Microbiology

• Most common pathogen is E. coli
• Anaerobic organisms are rarely pathogenic (do not grow well in urine)
• Complicated acute cystitis is more likely to be caused by pseudomonas or enterococcus

Clinical Features

Uncomplicated

• Dysuria
• hematuria
• Frequency
• Urgency
• Suprapubic pain

Complicated

Suspect pyelonephritis, infected kidney stone, or other disease process in patients who have inadequate or atypical response to treatment

• May not have classic symptoms
  • Weakness
  • Fever
  • Abdominal pain
  • Altered mental status

Differential Diagnosis

Major

• Pyelonephritis
• Infected kidney stone

Acute Pelvic Pain

Differential diagnosis of acute pelvic pain

Gynecologic/Obstetric

• Normal variants may be noted on exam but generally do not cause pain or other symptoms
  • Nabothian cysts: Epithelial cells within mucous glans that appear as yellow inclusions on the cervix
  • Cervial Ectropion: Edothelial cells on the exterior of the cervix
  • Parous cervix: The is no longer round but may have multiple shapes after birth
• Pregnancy-related
  • Ectopic Pregnancy
  • Spontaneous abortion, threatened or incomplete
  • Septic abortion
• Pelvic organ prolapse
• Acute Infections
  • Herpes
  • Cervicitis
  • Endometritis
  • Bartholin gland abscess
  • Pelvic inflammatory disease (PID)
  • Tubo-ovarian abscess
• Vulvovaginitis
  • Bacterial Vaginosis
  • Candida Vaginitis
  • Trichomonas
  • Contact Vulvovaginitis
  • Atrophic vaginitis
• Adnexal Disorders
  • Hemorrhage/rupture of ovarian cyst
  • Ovarian torsion
  • Twisted paraovarian cyst
• Other
  • Myoma (degenerating)
  • Genitourinary trauma
  • Ovarian hyperstimulation syndrome
  • Sexual assault
• Recurrent
  • Mittelschmerz
  • Primary/Secondary Dysmenorrhea
  • Pelvic Congestion Syndrome
  • Endometriosis

Genitourinary

• Cystitis
• Pyelonephritis
• Urethritis (e.g. N. gonorrhoeae/Chlamydia)
• Urolithiasis

Gastrointestinal

• Gastroenteritis
• Appendicitis
• Bowel obstruction
• Perirectal abscess
• Diverticulitis
• Inflammatory bowel disease
• Irritable bowel syndrome
• Mesenteric adenitis

Musculoskeletal

• Abdominal wall hematoma
• Psoas hematoma, psoas abscess
• Hernia

Vascular

• Pelvic thrombophlebitis
• Abdominal aortic aneurysm
• Ischemic bowel (Mesenteric Ischemia)

Dysuria

• Genitourinary infection
  • Acute cystitis ("UTI")
  • Pyelonephritis
  • Urethritis
  • Chronic cystitis
  • Infected nephrolithiasis
  • Prostatitis
  • Epididymitis
  • Renal abscess/perinephric abscess
  • Emphysematous pyelonephritis
• Nephrolithiasis
• Urethral issue
  • Urethritis
  • Urolithiasis
  • Urethral foreign body
  • Urethral diverticulum
  • Allergic reaction (contact dermatitis)
  • Chemical irritation
  • Urethral stricture or obstruction
  • Trauma to vagina, urethra, or bladder
• Gynecologic
  • Vaginitis/cervicitis
  • PID
  • Genital herpes
  • Pelvic organ prolapse
  • Fistula
  • Cystocele
• Other
  • Diverticulitis
  • Interstitial cystitis
  • Behavioral symptom without detectable pathology

Evaluation

Urine with pyuria.

Urine Analysis (UA)

WBC count

• WBC >5 in patient with appropriate symptoms is diagnostic
  • Lower degrees of pyuria may still be clinically significant in presence of symptoms
    • False negative may be due to: dilute urine, systemic leukopenia, obstruction, recent antibiotic use with incomplete treatment
  • WBC 1-2 with bacteriuria can be significant in men
    • More likely represents urethritis or prostatitis from STI
  • High WBCs w/o bacteria, consider TB, Chlamydia, Appendicitis

Leukocyte Esterase

• Found in PMNs
• High sensitivity
• Low specificity

Nitrite

• Very high specificity (>90%) in confirming diagnosis
• Low sensitivity (enterococcus, pseudomonas, acinetobacter are not detected)

Urine Culture

• Indicated for:
  • Complicated acute cystitis
  • Pyelonephritis
  • Pregnant women
  • Children
  • Adult males
  • Relapse/reinfection

Blood Culture

• Not indicated
  • Organisms in blood cultures matched those in urine cultures 97% of time

Management

• Consider local resistance patterns (if >10-20% use a different agent)
• Avoid use of fluoroquinolones for uncomplicated cystitis if possible
• Consider phenazopyridine for dysuria symptoms
  • 100-200mg TID after meals x 2 days for pain control (bladder analgesic)
  • Warn of discoloration of urine and tears. Don’t wear contact lens due to risk of staining.

Complicated if

• Symptoms >7days
• Diabetes mellitus
• Urinary tract infection in previous 4wk
• Men
• >65 years old
• Women who use spermicides or diaphragm
• Relapse
• Pregnancy

Outpatient

Women, Uncomplicated

• Nitrofurantoin ER 100mg BID x 5d, OR
• TMP/SMX DS (160/800mg) 1 tab BID x 3d, OR
• Cephalexin 250mg QID x 5d, OR
• Ciprofloxacin 250mg BID x3d
  • Avoid using fluoroquinolone for the first-line treatment of uncomplicated urinary tract infections (UTIs) in women.
• Fosfomycin 3 g PO once
  • Lower clinical and microbiologic success compared to nitrofurantoin TID for 5 days

Women, Complicated

• Ciprofloxacin 500mg BID x10-14d, OR
• Cefpodoxime 200 mg BID x10-14d

Women, Concern for Urethritis

• Ceftriaxone 250mg IM x1 AND azithromycin 1gm PO x1 AND nitrofurantoin ER 100mg BID x5d, OR
• Levofloxacin 500mg QD x 14d (covers urinary pathogens, GC, and chlamydia)
  • GC resistance to fluoroquinolones is increasing

Men

• Ciprofloxacin 500mg BID x10-14d, OR
• Cefpodoxime 200 mg BID x10-14d

Inpatient Options

• Ciprofloxacin 400mg IV q12hr, OR
• Ceftriaxone 1gm IV QD, OR
• Cefotaxime 1-2gm IV q8hr, OR
• Gentamicin 3mg/kg/day divided q8hr +/- ampicillin 1–2 gm q4hr, OR
• Piperacillin/Tazobactam 3.375 gm IV q6hr, OR
• Cefepime 2gm IV q8hr, OR
• Imipenem 500mg IV q8hr

Disposition

Uncomplicated

• Admit for inability to tolerate PO

Complicated

• Consider admission for period of observation and/or culture results

Special Populations

AIDS

• TMP-SMX resistance is increased due to its use in PCP pneumonia prophylaxis
  • Fluoroquinolones should be initial antibiotic of choice
• Most acute cystitis is caused by typical pathogens or common STI organisms

Pregnant Women

• New ACOG guidelines: If asymptomatic, get a culture and only treat if >100k CFUs

See Also

• Urinary tract infections
• UTI (Peds)