Sections View Full Chapter Figures Tables Videos Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 23-03: Genitourinary Tract Infections + Key Features Download Section PDF Listen +++ +++ Essentials of Diagnosis ++ Irritative voiding symptoms Patient usually afebrile Positive urine culture; blood cultures may also be positive +++ General Considerations ++ Most commonly due to the coliform bacteria (especially Escherichia coli) and occasionally gram-positive bacteria (enterococci) The route of infection is typically ascending from the urethra Uncomplicated cystitis in men is rare and implies a pathologic process such as infected stones, prostatitis, or chronic urinary retention requiring further investigation + Clinical Findings Download Section PDF Listen +++ +++ Symptoms and Signs ++ Frequency, urgency, dysuria, suprapubic discomfort, gross hematuria Suprapubic tenderness, no systemic toxicity +++ Differential Diagnosis ++ In women Vulvovaginitis Pelvic inflammatory disease In men Urethritis Prostatitis In both Pelvic irradiation Chemotherapy (cyclophosphamide) Bladder carcinoma Interstitial cystitis Voiding dysfunction disorders Psychosomatic disorders + Diagnosis Download Section PDF Listen +++ +++ Laboratory Tests ++ Urinalysis: pyuria, hematuria, bacteriuria Urine culture: positive, though colony counts > 105/mL not required Urine culture and sensitivity +++ Imaging Studies ++ Abdominal ultrasonography, postvoid residual testing, and cystoscopy help identify any underlying problem Obtain CT scan if pyelonephritis, recurrent infections, or anatomic abnormalities are suspected + Treatment Download Section PDF Listen +++ +++ Medications ++ Uncomplicated cystitis: fosfomycin, nitrofurantoin, and trimethoprim-sulfamethoxazole are the medications of choice Fosfomycin trometamol (3 g single dose) Nitrofurantoin (100 mg twice daily for 5–7 days) Trimethoprim-sulfamethoxazole (160/800 mg twice daily for 3 days) +++ Therapeutic Procedures ++ Symptomatic relief: hot sitz baths or urinary analgesics (phenazopyridine, 200 mg three times daily orally) Uncomplicated cystitis in men warrants elucidation of underlying problem + Outcome Download Section PDF Listen +++ +++ Prognosis ++ Infections typically respond rapidly to treatment Failure to respond suggests resistance to the selected drug or anatomic abnormalities requiring further investigation +++ Prevention ++ Drinking plenty of fluid and emptying the bladder frequently and completely can reduce risk of developing infection Women in whom urinary tract infections tend to develop after intercourse should be advised to void before, and especially after intercourse, and may benefit from a postcoital single dose of antibiotic Postmenopausal women with recurrent urinary tract infections (3 or more episodes per year) may benefit from a topical estrogen cream Women with recurrent episodes of cystitis (3 or more episodes per year) may also benefit, after treatment of the urinary tract infection, from prophylactic antibiotic therapy to prevent recurrences Before starting antibiotic prophylaxis, a thorough urologic evaluation is warranted to exclude any anatomic abnormality (eg, stones, reflux, fistula) An initial course of 6 to 12 months of prophylactic antibiotics can be offered The benefits of prophylactic antibiotics should be weighed against the risks of developing bacterial resistance +++ When to Refer ++ Suspicion or radiographic evidence of anatomic abnormality Evidence of urolithiasis Recurrent cystitis due to bacterial persistence + References Download Section PDF Listen +++ + +Arnold JJ et al. Common questions about recurrent urinary tract infections in women. Am Fam Physician. 2016 Apr 1;93(7):560–9. [PubMed: 27035041] + +Bader MS et al. An update on the management of urinary tract infections in the era of antimicrobial resistance. Postgrad Med. 2017 Mar;129(2):242–58. [PubMed: 27712137] + +Bonkat G, Pickard R et al. EAU Guidelines on Urological Infections. Presented at the EAU Annual Congress Copenhagen, March, 2018. https://uroweb.org/wp-content/uploads/EAU-Guidelines-on-Urological-Infections-2018-large-text.pdf+ +Datta R et al. Nitrofurantoin vs fosfomycin: rendering a verdict in a trial of acute uncomplicated cystitis. JAMA. 2018 May 1;319(17):1771–2. [PubMed: 29710273] + +Dawson-Hahn EE et al. Short-course versus long-course oral antibiotic treatment for infections treated in outpatient settings: a review of systematic reviews. Fam Pract. 2017 Sept 1;34(5):511–9 [PubMed: 28486675] + +Grigoryan L et al. Diagnosis and management of urinary tract infection in the outpatient setting: a review. JAMA. 2014 Oct 22–29;312(16):1677–84. [PubMed: 25335150] + +Huttner 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. 2018 May 1;319(17):1781–9 [PubMed: 29710295] + +Kang CI et al. Clinical practice guidelines for the antibiotic treatment of community-acquired urinary tract infections. Infect Chemother. 2018 Mar;50(1):67–100. [PubMed: 29637759] + +Michels TC et al. Dysuria: evaluation and differential diagnosis in adults. Am Fam Physician. 2015 Nov 1;92(9):778–86. [PubMed: 26554471] + +Mody L et al. JAMA patient page. Urinary tract infections in older women. JAMA. 2014 Feb 26;311(8):874. [PubMed: 24570259] + +U.S. Food & Drug Administration. FDA Drug Safety Communication: FDA updates warnings for oral and injectable fluoroquinolone antibiotics due to disabling side effects. 2016 Jul 26. http://www.fda.gov/Drugs/DrugSafety/ucm511530.htm