Cystitis: Diagnosis and Management

by John Fisher, MD

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    00:02 Let's talk about the relative frequencies of causes of the acute onset of frequency dysuria or both in young women.

    00:12 The first thing a physician needs to do in a woman who complains of dysuria is to exclude vaginitis and Herpes genitalis.

    00:22 That accounts for perhaps 10% of these symptoms.

    00:28 They would then get a urine culture.

    00:30 Most cystitis is associated with greater than or equal to 10 to the 5th bacteria per mL of urine.

    00:40 But some women have these symptoms and have less than 10 to the 5th bacteria per mL.

    00:47 So what we call them is having the acute urethral syndrome, and that happens in a sizeable minority of women.

    00:56 So some of them actually do have bacterial urinary tract infection -- about 18%.

    01:03 Others have a sexually transmitted chlamydial infection -- 8%.

    01:08 And the rest, we're just not sure what causes those symptoms.

    01:14 But to make a presumptive diagnosis of cystitis, you need to demonstrate the presence of pyuria.

    01:24 That means greater than 10 white cells per microlitre of mid-stream urine in a counting chamber.

    01:32 Now counting chamber is not available to all the physicians, so more than 5-10 white cells per high power microscopic field in centrifuged urine.

    01:44 There are sort of automated test like the urine dipstick test which test for the presence of leukocyte esterase, one of the enzymes that's present inside of neutrophils.

    01:56 If that's positive, it has a sensitivity of 75-96%, and a specifity of 94-98%.

    02:05 So we often use that.

    02:07 Then there's the microscope, and I want to emphasize the first one -- microscopic hematuria.

    02:16 Now think about the bladder in cystitis, it's going be inflamed.

    02:22 There's inflammation there with evidence of the white cells and so it's probably going to be red on the inside and some red cells are going to get into infected urine.

    02:35 The point I'm trying to make is that if a woman has symptoms of cystitis but no microscopic hematuria, it might be another diagnosis.

    02:46 It might be vaginitis, urethritis.

    02:49 It could be something else.

    02:52 The urine culture most of the patients have, more than 10 to the 5th bacteria per mL but some have fewer than 10 to the 5th.

    03:05 The other thing is that the Gram stain of uncentrifuged mid-stream urine can give you kind of a poor man's result of culture.

    03:15 What I mean by that is if you see 1 microorganism in every microscopic field because of the magnification that equals about 10 to the 5th organisms per mL which would be in keeping with the diagnosis of a urinary tract infection.

    03:37 So what would we try to do about with patients with cystitis? One of the time-honored therapies is to hydrate them.

    03:43 That does rapidly decrease the counts of bacteria, but after the hydration is over, those counts return to the baseline.

    03:52 What about urinary analgesics? They've really not been shown to have much benefit at all.

    04:02 So our antibiotic choices should have good activity against the offending pathogen, but the least effect on vaginal and intestinal flora.

    04:12 Remember clostridium difficile and antibiotic colitis, we don't want any part of that.

    04:19 So we want to choose fairly narrow spectrum agents like nitrofurantoin, fosfomycin, trim/sulfa or pivmecillinam.

    04:29 Fluoroquinolones should be held in reserve because there's increasing incidence to those valuable drugs all over the world.

    04:42 Now for women who have recurrent cystitis and remember a sizable minority do, what we generally recommend is TMP/SMX, nitrofurantoin or fluoroquinolones after intercourse.

    04:56 Another thing that can be done is have the woman void after intercourse.

    05:02 For a long-term prophylaxis in women who have several episodes a year that interfere with her employment or activities of daily living, we sometimes recommend nitrofurantoin or TMP/SMX or a fluoroquinolone, if necessary.

    05:20 And that brings me to the end of my discussion of cystitis.

    05:24 Thank you very much for your attention.

    About the Lecture

    The lecture Cystitis: Diagnosis and Management by John Fisher, MD is from the course Urinary Tract Infections. It contains the following chapters:

    • Cysitis – Diagnosis
    • Cysitis – Management

    Included Quiz Questions

    1. Vaginitis
    2. Pyelonephritits
    3. Interstitial cystitis
    4. Human papilloma virus
    5. Anatomical urethral abnormalities
    1. It can be a typical finding in uncomplicated cystitis.
    2. It means there must be pyelonephritis complicating the urinary tract infection
    3. It strongly suggests interstitial cystitis
    4. It suggests chlamydia infection
    5. It is typically only seen in cystitis caused by Proteus pathogens
    1. Greater than 10 white blood cells per microliter of midstream urine
    2. Greater than 10 white blood cells per milliliter of midstream urine
    3. At least 5 white blood cells per microliter of midstream urine
    4. At least 1 white blood cell seen on high power microscopic field of a centrifuged midstream urine sample
    5. At least 20 white blood cells seen on high power microscopic field uncentrifuged midstream urine sample
    1. Nitrofurantoin nightly
    2. Fosfomycin daily
    3. Trimethoprim/Sulfamethoxazole twice a day
    4. Pivmecillinam three times a day
    5. Metronidazole after intercourse

    Author of lecture Cystitis: Diagnosis and Management

     John Fisher, MD

    John Fisher, MD

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