Cystitis

1. Cystitis

2. IncidenceIncidence
•1-3% of all GP consultations1-3% of all GP consultations
•5% of women each year with symptoms. 5% of women each year with symptoms.
Up to 50% of women will suffer from a Up to 50% of women will suffer from a
symptomatic UTI during their lifetime. symptomatic UTI during 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 infection - symptomatic in the absence of infection -
called 'urethral syndrome' called 'urethral syndrome'

3. SymptomsSymptoms
•DysuriaDysuria
•FrequencyFrequency
•NocturiaNocturia
•Urgency of micturition. Urgency of micturition.
•Other symptoms include suprapubic pain, Other symptoms include suprapubic pain,
cloudy or foul smelling urine and cloudy or foul smelling urine and
haematuria. haematuria.

4. 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

5. PreventionPrevention
•Drinking plenty of fluids helps prevent Drinking plenty of fluids helps prevent
cystitis in the first place.cystitis in the first place.
•If cystitis follows sexual intercourse, some If cystitis follows sexual intercourse, some
advise passing urine soon after to try and advise passing urine soon after to try and
prevent it.prevent it.
•There is no evidence to suggest a link There is no evidence to suggest a link
between lower urinary tract infection and between lower urinary tract infection and
use of bath preparationsuse of bath preparations

6. Beware!Beware!
•PregnantPregnant
•Under age 12Under age 12
•MalesMales
•Systemically ill (fever, sickness, backache)Systemically ill (fever, sickness, backache)
•Catheterised patientsCatheterised patients
•Kidney or bladder stonesKidney or bladder stones

7. InvestigationInvestigation
•Urine dipstickUrine dipstick
– can be done in the surgery and will be positive for nitrates and can be done in the surgery and will be positive for nitrates and
leucocytes (leukocyte esterase test). This helps to differentiate leucocytes (leukocyte esterase test). This helps to differentiate
those with UTI from the 50% with urethral syndrome. those with UTI from the 50% with urethral 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 not is present in 12-20% of women aged 65-70 years and does not
impair renal function or shorten life so no treatmentimpair 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 treatment. delivery and low birth weight and always requires treatment.

8. 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 disease. Chlamydia or other sexually transmitted 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)

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

10. Management Issues - GeneralManagement Issues - General
•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 without It is reasonable to start treatment without
culture if the dipstick is positive for culture if the dipstick is positive for
nitrates or leucocytes. nitrates or leucocytes.
•MSU if dipstick negative but suspicionMSU if dipstick negative but suspicion

11. Management Issues - GeneralManagement Issues - General
•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

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

13. AntibioticsAntibiotics
•Trimethoprim is an effective first line treatment. Trimethoprim is an effective first line treatment.
•Cephalosporins are as effective as trimethoprim Cephalosporins are as effective as trimethoprim
but more expensive and more likely to disrupt but more expensive and more likely to disrupt
gut flora. gut flora.
•Nitrofurantoin is as effective as trimethoprim but Nitrofurantoin is as effective as trimethoprim but
more expensive and frequently causes nausea more expensive and frequently causes nausea
and vomiting 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

14. Antibiotics Antibiotics
•3 days of antibiotic is as effective as 5 or 7 days 3 days of antibiotic is as effective as 5 or 7 days
•Single dose antibiotic results in lower cure rates Single dose antibiotic results in lower cure rates
and more recurrences overall than longer and more recurrences overall than longer
courses. courses.
•In relapse of infection (i.e. reinfection with the In relapse of infection (i.e. reinfection with the
same bacteria), treatment with antibiotic for up same bacteria), treatment with antibiotic for up
to 6 weeks is recommended. to 6 weeks is recommended.

15. Antibiotics for UTI in PregnancyAntibiotics for UTI in Pregnancy
•Cephalosporins and penicillins are recommended Cephalosporins and penicillins are recommended
in pregnancy because of their long term safety in pregnancy because of their long term safety
recordrecord
•Nitrofurantoin is also likely to be safe during Nitrofurantoin is also likely to be safe during
pregnancy pregnancy
•Quinolones, Trimethoprim and Tetracyclines are Quinolones, Trimethoprim and Tetracyclines are
not recommended for use during pregnancy not recommended for use 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.