Cystitis

Lawrence PikeLawrence Pike

IncidenceIncidence

• 1-3% of all GP consultations1-3% of all GP consultations• 5% of women each year with 5% of women each year with

symptoms. Up to 50% of women will symptoms. Up to 50% of women will suffer from a symptomatic UTI during suffer from a symptomatic UTI during their lifetime. their lifetime.

• UTI in men is much rarer UTI in men is much rarer • A proportion of patients may be A proportion of patients may be

symptomatic in the absence of symptomatic in the absence of infection - called 'urethral syndrome' infection - called 'urethral syndrome'

SymptomsSymptoms

• DysuriaDysuria

• FrequencyFrequency

• NocturiaNocturia

• Urgency of micturition. Urgency of micturition.

• Other symptoms include suprapubic Other symptoms include suprapubic pain, cloudy or foul smelling urine pain, cloudy or foul smelling urine and haematuria. and haematuria.

CausesCauses

• The most common cause is bacterial infectionThe most common cause is bacterial infection– Eschericia coli is the pathogen in 70% of Eschericia coli is the pathogen in 70% of

uncomplicated case of lower urinary tract infections. uncomplicated case of lower urinary tract infections. – Other organisms include Proteus mirabilis, Klebsiella Other organisms include Proteus mirabilis, Klebsiella

pneumoniae, Staphylococcus saprophyticus, pneumoniae, Staphylococcus saprophyticus, Staphylococcus aureus and Pseudomonas species. Staphylococcus aureus and Pseudomonas species.

• Urethral Syndrome -not associated with any Urethral Syndrome -not associated with any infection infection

• Rarely kidney or bladder stones, prostatism, Rarely kidney or bladder stones, prostatism, diabetesdiabetes

PreventionPrevention

• Drinking plenty of fluids helps Drinking plenty of fluids helps prevent cystitis in the first place.prevent cystitis in the first place.

• If cystitis follows sexual intercourse, If cystitis follows sexual intercourse, some advise passing urine soon after some advise passing urine soon after to try and prevent it.to try and prevent it.

• There is no evidence to suggest a There is no evidence to suggest a link between lower urinary tract link between lower urinary tract infection and use of bath infection and use of bath preparationspreparations

Beware!Beware!

• PregnantPregnant

• Under age 12Under age 12

• MalesMales

• Systemically ill (fever, sickness, Systemically ill (fever, sickness, backache)backache)

• Catheterised patientsCatheterised patients

• Kidney or bladder stonesKidney or bladder stones

InvestigationInvestigation

• Urine dipstickUrine dipstick– can be done in the surgery and will be positive for nitrates can be done in the surgery and will be positive for nitrates

and leucocytes (leukocyte esterase test). This helps to and leucocytes (leukocyte esterase test). This helps to differentiate those with UTI from the 50% with urethral differentiate those with UTI from the 50% with urethral syndrome. syndrome.

• Urine microscopy and culture reveals significant Urine microscopy and culture reveals significant bacteruria (usually >105 /ml). bacteruria (usually >105 /ml).

• Asymptomatic bacteruriaAsymptomatic bacteruria– is present in 12-20% of women aged 65-70 years and does is present in 12-20% of women aged 65-70 years and does

not impair renal function or shorten life so no treatmentnot impair renal function or shorten life so no treatment– in 4-7% of pregnant women and associated with premature in 4-7% of pregnant women and associated with premature

delivery and low birth weight and always requires delivery and low birth weight and always requires treatment. treatment.

Differential DiagnosisDifferential Diagnosis

• Urethral syndrome Urethral syndrome

• Bladder lesion e.g. calculi, tumour. Bladder lesion e.g. calculi, tumour.

• Candidal infectionCandidal infection

• Chlamydia or other sexually transmitted Chlamydia or other sexually transmitted disease. disease.

• Urethritis Urethritis

• Drug induced cystitis (e.g. with Drug induced cystitis (e.g. with cyclophosphamide, allopurinol, danazol, cyclophosphamide, allopurinol, danazol, tiaprofenic acid and possibly other NSAIDs) tiaprofenic acid and possibly other NSAIDs)

Complications and PrognosisComplications and Prognosis

• Ascending infection can occur, leading to development Ascending infection can occur, leading to development of pyelonephritis, renal failure and sepsis. of pyelonephritis, renal failure and sepsis.

• In children, the combination of vesicoureteric reflux In children, the combination of vesicoureteric reflux and urinary tract infection can lead to permanent renal and urinary tract infection can lead to permanent renal scarring, which may ultimately lead to the scarring, which may ultimately lead to the development of hypertension or renal failure. 12-20% development of hypertension or renal failure. 12-20% of children already have radiological evidence of of children already have radiological evidence of scarring on their first investigation for UTI.scarring on their first investigation for UTI.

• Urinary tract infection during pregnancy is associated Urinary tract infection during pregnancy is associated with prematurity, low birth weight of the baby and a with prematurity, low birth weight of the baby and a high incidence of pyelonephritis in women. high incidence of pyelonephritis in women.

• Recurrent infection occurs in up to 20% of young Recurrent infection occurs in up to 20% of young women with acute cystitis. women with acute cystitis.

Management Issues - Management Issues - GeneralGeneral• 50% will resolve in 3 days without 50% will resolve in 3 days without

treatmenttreatment

• No evidence to support “drink plenty” No evidence to support “drink plenty”

• It is reasonable to start treatment It is reasonable to start treatment without culture if the dipstick is positive without culture if the dipstick is positive for nitrates or leucocytes. for nitrates or leucocytes.

• MSU if dipstick negative but suspicionMSU if dipstick negative but suspicion

Management Issues - Management Issues - GeneralGeneral

• Culture is always indicated in Culture is always indicated in – MenMen– Pregnant womenPregnant women– ChildrenChildren– Those with failure of empirical treatmentThose with failure of empirical treatment– Those with complicated infectionThose with complicated infection

Self careSelf care

• Drink slightly acid drinks such as Drink slightly acid drinks such as cranberry juice, lemon squash or cranberry juice, lemon squash or pure orange juice (poor trial pure orange juice (poor trial evidence for this)evidence for this)

• Try a mixture of potassium citrate Try a mixture of potassium citrate available from your pharmacist (little available from your pharmacist (little evidence but widely recommended)evidence but widely recommended)

AntibioticsAntibiotics

• Trimethoprim is an effective first line Trimethoprim is an effective first line treatment. treatment.

• Cephalosporins are as effective as Cephalosporins are as effective as trimethoprim but more expensive and more trimethoprim but more expensive and more likely to disrupt gut flora. likely to disrupt gut flora.

• Nitrofurantoin is as effective as trimethoprim Nitrofurantoin is as effective as trimethoprim but more expensive and frequently causes but more expensive and frequently causes nausea and vomiting nausea and vomiting

• The 4-quinolones (ciprofloxacin, norfloxacin, The 4-quinolones (ciprofloxacin, norfloxacin, ofloxacin) are effective in the treatment of ofloxacin) are effective in the treatment of cystitis. To preserve their efficacy, they should cystitis. To preserve their efficacy, they should not usually be used as first line therapynot usually be used as first line therapy

Antibiotics Antibiotics

• 3 days of antibiotic is as effective as 5 or 7 3 days of antibiotic is as effective as 5 or 7 days days

• Single dose antibiotic results in lower cure Single dose antibiotic results in lower cure rates and more recurrences overall than rates and more recurrences overall than longer courses. longer courses.

• In relapse of infection (i.e. reinfection with In relapse of infection (i.e. reinfection with the same bacteria), treatment with the same bacteria), treatment with antibiotic for up to 6 weeks is antibiotic for up to 6 weeks is recommended. recommended.

Antibiotics for UTI in Antibiotics for UTI in PregnancyPregnancy• Cephalosporins and penicillins are Cephalosporins and penicillins are

recommended in pregnancy because of recommended in pregnancy because of their long term safety recordtheir long term safety record

• Nitrofurantoin is also likely to be safe Nitrofurantoin is also likely to be safe during pregnancy during pregnancy

• Quinolones, Trimethoprim and Quinolones, Trimethoprim and Tetracyclines are not recommended for use Tetracyclines are not recommended for use during pregnancy during pregnancy

• Seven days of treatment is required. Seven days of treatment is required. • Urine should be tested regularly throughout Urine should be tested regularly throughout

pregnancy following initial infection.pregnancy following initial infection.