Cystitis in Females Clinical Presentation

  • Author: John L Brusch, MD, FACP; Chief Editor: Michael Stuart Bronze, MD   more...
 
Updated: Feb 1, 2012
 

History

The classic symptoms of urinary tract infection (UTI) in the adult are primarily dysuria with accompanying urinary urgency and frequency. A sensation of bladder fullness or lower abdominal discomfort is often present.

Because of the referred pain pathways, even simple lower UTI may be accompanied by flank pain and costovertebral angle tenderness. In the emergency department, however, assume that the presence of these symptoms represents upper UTI.

Bloody urine is reported in as many as 10% of cases of UTI in otherwise healthy women; this condition is called hemorrhagic cystitis. Fevers, chills, and malaise may be noted in patients with cystitis, though these findings are associated more frequently with upper UTI (ie, pyelonephritis).

A history of vaginal discharge suggests that vaginitis, cervicitis, or pelvic inflammatory disease is responsible for symptoms of dysuria; therefore, a pelvic examination must be performed. Important additional information includes a history of prior sexually transmitted disease (STD) and multiple current sexual partners.

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Physical Examination

The patient appears uncomfortable but not toxic. The presence of toxic fever, chills, nausea, and vomiting suggests pyelonephritis rather than cystitis; however, immunosuppressed and even immunocompetent patients with pyelonephritis may exhibit few, if any, of these symptoms. In elderly women, 50% of cases of cystitis also involve the upper tracts.[11]

The clinician may appreciate signs of dehydration, such as dry mucous membranes and tachycardia. Clammy extremities and symptomatic orthostasis suggest poor vascular tone due to gram-negative bacteremia rather than simple cystitis.

Most adult women with simple lower UTI have suprapubic tenderness. Pelvic examination should be performed to exclude vaginitis, cervicitis, or pelvic tenderness (eg, cervical motion tenderness, which suggests pelvic inflammatory disease).

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Acute Urethritis Versus Cystitis

The symptoms of acute urethritis overlap with those of cystitis, including acute dysuria and urinary hesitancy. Fever may be a component of urethritis-related syndromes (eg, Reiter syndrome, Behçet syndrome) but rarely is observed in acute cystitis. Urethral discharge is much more suggestive of urethritis, while bladder-related symptoms, such as urgency, polyuria, and incomplete voids, are more consistent with cystitis.

The predominant complaints in acute cystitis relate to the inflamed bladder mucosa. Constitutional symptoms, such as fever, nausea, and anorexia, are rare or mild. The symptoms of dysuria, urgency, hesitancy, polyuria, and incomplete voids may be accompanied by urinary incontinence, gross hematuria, and suprapubic or low back pain. Patients may demonstrate some suprapubic tenderness to palpation.

Abnormal physical examination findings are generally lacking in women with acute cystitis. The pelvic examination reveals no abnormalities unless another process, such as vaginitis, is mimicking or occurring simultaneously with cystitis.

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Infection in Patients with Spinal Cord Injury

In patients with spinal cord injury, the following signs and symptoms are suggestive of a UTI:

  • Malodorous and cloudy urine
  • Muscular spasticity
  • Fatigue
  • Fevers
  • Chills
  • Autonomic instability

Patients with lesions above T6 may exhibit autonomic dysreflexia to noxious stimuli, such as an overdistended bladder. The sympathetic response below the level of injury is uninhibited, producing severe vasoconstriction and reflexive bradycardia. If the patient is febrile, this may appear as a pulse-temperature dissociation.

For more information on this topic, see the Medscape Reference article Urinary Tract Infections in Spinal Cord Injury.

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Catheter-Related Infection

Symptoms of catheter-related UTI generally are nonspecific; most patients present with fever and leukocytosis. Significant pyuria generally is represented by more than 50 white blood cells per high-power field (WBC/hpf). Colony counts on a urine culture range from 100-10,000 CFU/mL. Infections may be polymicrobial. Pyuria and elevated bacterial colony counts are seen in all patients in whom a catheter has been in place for more than a few days. In this situation, their presence is not synonymous with a UTI.[6]

For more information on this topic, see the Medscape Reference article Catheter-Related Urinary Tract Infection.

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Infection in Pregnant Patients

Asymptomatic bacteriuria (ASB) occurs in 5-10% of pregnant women. More than 100,000 CFU/mL of a single uropathogen is the classic definition of ASB, but more recent data support 10,000 CFU/mL from a clean-catch specimen as a threshold.

ASB most commonly appears between the ninth and 17th weeks of pregnancy. ASB predisposes to preterm labor, intrauterine growth retardation, low-birth-weight infants, anemia, amnionitis, and hypertensive disorders of pregnancy.

Risk factors include sexual activity, increasing age and parity, diabetes, lower socioeconomic class, a history of UTIs, sickle cell disease, and structural/functional abnormalities. Cystitis occurs in 0.3-1.3% of pregnancies but does not appear to be related to ASB.

The recommendation is to screen pregnant women at their first prenatal visit and during the third trimester. Further screening is not indicated unless the initial test result is positive or the patient develops symptoms.

For more information, see the Medscape Reference topic Urinary Tract Infections in Pregnancy.

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Infection in Patients with Diabetes Mellitus

Complicated UTIs in patients who have diabetes include renal and perirenal abscess, emphysematous pyelonephritis, emphysematous cystitis, fungal infections, xanthogranulomatous pyelonephritis, and papillary necrosis. Susceptibility increases with longer duration and greater severity of diabetes.

For more information on this topic, see the Medscape Reference article Urinary Tract Infections in Diabetes Mellitus.

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Contributor Information and Disclosures
Author

John L Brusch, MD, FACP  Assistant Professor of Medicine, Harvard Medical School; Consulting Staff, Department of Medicine and Infectious Disease Service, Cambridge Health Alliance

John L Brusch, MD, FACP is a member of the following medical societies: American College of Physicians and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Coauthor(s)

Mary F Bavaro, MD  Chief, Division of Infectious Disease, Navy Medical Center, San Diego

Mary F Bavaro, MD is a member of the following medical societies: American College of Physicians and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Burke A Cunha, MD  Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital

Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Jeffrey M Tessier  MD, Assistant Professor, Division of Infectious Diseases, Department of Internal Medicine, Virginia Commonwealth University School of Medicine

Jeffrey M Tessier is a member of the following medical societies: American College of Physicians-American Society of Internal Medicine

Disclosure: Nothing to disclose.

Chief Editor

Michael Stuart Bronze, MD  Professor, Stewart G Wolf Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center

Michael Stuart Bronze, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Medical Association, Association of Professors of Medicine, Infectious Diseases Society of America, Oklahoma State Medical Association, and Southern Society for Clinical Investigation

Disclosure: Nothing to disclose.

Additional Contributors

Michael S Beeson, MD, MBA, FACEP Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine and Pharmacy; Attending Faculty, Akron General Medical Center

Michael S Beeson, MD, MBA, FACEP is a member of the following medical societies: American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, National Association of EMS Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Pamela L Dyne, MD Professor of Clinical Medicine/Emergency Medicine, University of California, Los Angeles, David Geffen School of Medicine; Attending Physician, Department of Emergency Medicine, Olive View-UCLA Medical Center

Pamela L Dyne, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

David S Howes, MD Professor of Medicine and Pediatrics, Section Chief and Emergency Medicine Residency Program Director, University of Chicago Division of the Biological Sciences, The Pritzker School of Medicine

David S Howes, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Physicians-American Society of Internal Medicine, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Elicia S Kennedy, MD Clinical Assistant Professor, Department of Emergency Medicine, University of Arkansas for Medical Sciences

Elicia S Kennedy, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Klaus-Dieter Lessnau, MD, FCCP Clinical Associate Professor of Medicine, New York University School of Medicine; Medical Director, Pulmonary Physiology Laboratory; Director of Research in Pulmonary Medicine, Department of Medicine, Section of Pulmonary Medicine, Lenox Hill Hospital

Klaus-Dieter Lessnau, MD, FCCP is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Medical Association, American Thoracic Society, and Society of Critical Care Medicine

Disclosure: Sepracor None None

Allison M Loynd, DO Resident Physician, Department of Emergency Medicine, Wayne State University School of Medicine, Detroit Receiving Hospital

Allison M Loynd, DO is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, and Emergency Medicine Residents Association

Disclosure: Nothing to disclose.

Mark Jeffrey Noble, MD Consulting Staff, Urologic Institute, Cleveland Clinic Foundation

Mark Jeffrey Noble, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, American Urological Association, Kansas Medical Society, Sigma Xi, Society of University Urologists, and Southwest Oncology Group

Disclosure: Nothing to disclose.

Adam J Rosh, MD Assistant Professor, Department of Emergency Medicine, Detroit Receiving Hospital, Wayne State University School of Medicine

Adam J Rosh, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Joseph A Salomone III, MD Associate Professor and Attending Staff, Truman Medical Centers, University of Missouri-Kansas City School of Medicine; EMS Medical Director, Kansas City, Missouri

Joseph A Salomone III, MD is a member of the following medical societies: American Academy of Emergency Medicine, National Association of EMS Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Richard H Sinert, DO Associate Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center

Richard H Sinert, DO is a member of the following medical societies: American College of Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Mark Zwanger, MD, MBA Assistant Professor, Department of Emergency Medicine, Jefferson Medical College of Thomas Jefferson University

Mark Zwanger, MD, MBA is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and American Medical Association

Disclosure: Nothing to disclose.

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Nonobstructing distal left ureteral calculus 2 X 1 X 2 cm.
Multiple abscesses, upper pole of left kidney.
Bilateral hydronephrosis.
Plain radiograph in a 63-year-old patient with poorly controlled type 2 diabetes mellitus shows emphysematous cystitis.
Lactobacilli and a squamous epithelial cell are evident on this vaginal smear. The presence of squamous cells and lactobacilli on urinalysis suggests contamination or colonization. Source: Centers for Disease Control and Prevention, Dr. Mike Miller
Table 1. Treatment Regimens for Uncomplicated Cystitis in Nonpregnant Women[23]
First-line therapy
  • trimethoprim/sulfamethoxazole* 160 mg/800 mg (Bactrim DS, Septra DS) 1 tablet PO BID for 3d (use when bacterial resistance is < 20% and patient has no allergy) or
  • nitrofurantoin monohydrate/macrocrystals (Macrobid) 100 mg PO BID for 5-7d or
  • nitrofurantoin macrocrystals (Macrodantin) 50-100 mg PO QID for 7d or
  • fosfomycin (Monurol) 3 g PO as a single dose with 3-4 oz of water
Second-line therapy
  • ciprofloxacin (Cipro) 250 mg PO BID for 3d or
  • ciprofloxacin extended release (Cipro XR) 500 mg PO daily for 3d or
  • levofloxacin (Levaquin) 250 mg PO q24h for 3d or
  • ofloxacin 200 mg PO q12h for 3d
Alternative therapy
  • amoxicillin-clavulanate (Augmentin) 500 mg/125 mg PO BID for 3-7d or
  • amoxicillin-clavulanate (Augmentin) 250 mg/125 mg PO TID for 3-7d or
  • cefdinir 300 mg PO BID for 7d or
  • cefaclor 500 mg PO TID for 7d or
  • cefpodoxime 100 mg PO BID for 7d or
  • cefuroxime 250 mg PO BID for 7-10d
*Should generally be avoided in elderly patients because of the risk of affecting renal function.
Table 2. Treatment Regimens for Complicated Cystitis in Nonpregnant Women[13]
First-line therapy
Oral:



Patients with complicated cystitis who can tolerate oral therapy may be treated with the following options:



  • ciprofloxacin (Cipro) 500 mg PO BID for 7-14d or
  • ciprofloxacin extended release (Cipro XR) 1 g PO daily for 7-14d or
  • levofloxacin (Levaquin) 750 mg PO daily for 5d
Parenteral:



Patients who cannot tolerate oral therapy as outlined above or patients with infection that is suspected to be due to resistant organisms should be treated with parenteral therapy, as follows:



  • ciprofloxacin (Cipro) 400 mg IV q12h for 7-14d or
  • levofloxacin (Levaquin) 750 mg IV daily for 5d or
  • ampicillin 1-2 g IV q6h plus gentamicin 2 mg/kg/dose q8h for 7-14d or
  • piperacillin-tazobactam (Zosyn) 3.375 g IV q6h or
  • doripenem 500 mg (Doribax) IV q8h for 10d or
  • imipenem-cilastatin (Primaxin) 500 mg IV q6h for 7-14d or
  • meropenem (Merrem) 1 g IV q8h for 7-14d
Duration of therapy: shorter courses (7d) are reasonable if patient improves rapidly; longer courses (10-14d) are reasonable if patient has a delayed response or is hospitalized.



Parenteral therapy can be switched to oral therapy once clinical improvement is observed.



Second-line therapy
  • cefepime (Maxipime) 2 g IV q12h for 10d or
  • ceftazidime (Fortaz, Tazicef) 500 mg IV or IM q8-12h for 7-14d
Duration of therapy: shorter courses (7d) are reasonable if patient improves rapidly; longer courses (10-14d) are reasonable if patient has a delayed response or is hospitalized.



Parenteral therapy can be switched to oral therapy once clinical improvement is observed.



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