Cystitis in Females Clinical Presentation
- Author: John L Brusch, MD, FACP; Chief Editor: Michael Stuart Bronze, MD more...
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.
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.
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).
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.
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
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.
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.
For more information on this topic, see the Medscape Reference article Catheter-Related Urinary Tract Infection.
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.
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.
[Guideline] Gupta K, Hooton TM, Naber KG, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis. 2011 Mar. 52(5):e103-20. [Medline]. [Full Text].
[Guideline] Wagenlehner FM, Schmiemann G, Hoyme U, Fünfstück R, Hummers-Pradier E, Kaase M, et al. [National S3 guideline on uncomplicated urinary tract infection: recommendations for treatment and management of uncomplicated community-acquired bacterial urinary tract infections in adult patients]. Urologe A. 2011 Feb. 50(2):153-69. [Medline]. [Full Text].
Abrahamian FM, Moran GJ, Talan DA. Urinary tract infections in the emergency department. Infect Dis Clin North Am. 2008 Mar. 22(1):73-87, vi. [Medline].
Little P, Turner S, Rumsby K, Warner G, Moore M, Lowes JA, et al. Dipsticks and diagnostic algorithms in urinary tract infection: development and validation, randomised trial, economic analysis, observational cohort and qualitative study. Health Technol Assess. 2009 Mar. 13(19):iii-iv, ix-xi, 1-73. [Medline].
Lane DR, Takhar SS. Diagnosis and management of urinary tract infection and pyelonephritis. Emerg Med Clin North Am. 2011 Aug. 29(3):539-52. [Medline].
Czaja CA, Stamm WE, Stapleton AE, et al. Prospective cohort study of microbial and inflammatory events immediately preceding Escherichia coli recurrent urinary tract infection in women. J Infect Dis. 2009 Aug 15. 200(4):528-36. [Medline].
Kanj SS, Kanafani ZA. Current concepts in antimicrobial therapy against resistant gram-negative organisms: extended-spectrum beta-lactamase-producing Enterobacteriaceae, carbapenem-resistant Enterobacteriaceae, and multidrug-resistant Pseudomonas aeruginosa. Mayo Clin Proc. 2011 Mar. 86(3):250-9. [Medline]. [Full Text].
[Guideline] Hooton TM, Bradley SF, Cardenas DD, et al. Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Clin Infect Dis. 2010 Mar 1. 50(5):625-63. [Medline]. [Full Text].
Tiemstra JD, Chico PD, Pela E. Genitourinary infections after a routine pelvic exam. J Am Board Fam Med. 2011 May-Jun. 24(3):296-303. [Medline].
Hsiao CJ, Cherry DK, Beatty PC, Rechtsteiner EA. National Ambulatory Medical Care Survey: 2007 summary. Natl Health Stat Report. 2010 Nov 3. 1-32. [Medline].
Naber KG, Schito G, Botto H, Palou J, Mazzei T. Surveillance study in Europe and Brazil on clinical aspects and Antimicrobial Resistance Epidemiology in Females with Cystitis (ARESC): implications for empiric therapy. Eur Urol. 2008 Nov. 54(5):1164-75. [Medline].
Little P, Merriman R, Turner S, Rumsby K, Warner G, Lowes JA, et al. Presentation, pattern, and natural course of severe symptoms, and role of antibiotics and antibiotic resistance among patients presenting with suspected uncomplicated urinary tract infection in primary care: observational study. BMJ. 2010 Feb 5. 340:b5633. [Medline]. [Full Text].
Molander U, Arvidsson L, Milsom I, Sandberg T. A longitudinal cohort study of elderly women with urinary tract infections. Maturitas. 2000 Feb 15. 34(2):127-31. [Medline].
Johnson L, Sabel A, Burman WJ, Everhart RM, Rome M, MacKenzie TD, et al. Emergence of fluoroquinolone resistance in outpatient urinary Escherichia coli isolates. Am J Med. 2008 Oct. 121(10):876-84. [Medline].
[Guideline] American College of Obstetricians and Gynecologists (ACOG). 2008. Treatment of urinary tract infections in nonpregnant women. Available at http://guideline.gov/content.aspx?id=12628. Accessed: September 22, 2010.
Barclay L. Urinary Tract Infection: 3 Questions Aid Diagnosis in Women. Medscape Medical News. Available at http://www.medscape.com/viewarticle/810667. Accessed: September 16, 2013.
Knottnerus BJ, Geerlings SE, Moll van Charante EP, Ter Riet G. Toward a simple diagnostic index for acute uncomplicated urinary tract infections. Ann Fam Med. 2013 Sep-Oct. 11(5):442-51. [Medline]. [Full Text].
Schaeffer AJ, Schaeffer EM. Infections of the Urinary Tract. In: McDougal WS, Wein AJ, Kavoussi LR, et al, eds. Campbell-Walsh Urology. 10th Ed. Philadelphia, PA: Elsevier Saunders; 2012. 46-55.
Lifshitz E, Kramer L. Outpatient urine culture: does collection technique matter?. Arch Intern Med. 2000 Sep 11. 160(16):2537-40. [Medline].
Propp DA, Weber D, Ciesla ML. Reliability of a urine dipstick in emergency department patients. Ann Emerg Med. 1989 May. 18(5):560-3. [Medline].
Mehnert-Kay SA. Diagnosis and Management of Uncomplicated Urinary Tract Infections. American Family Physician. August 1, 2005. 27/No.3:1-9. [Full Text].
[Guideline] Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA. Guideline for prevention of catheter-associated urinary tract infections 2009. Infect Control Hosp Epidemiol. 2010 Apr. 31(4):319-26. [Medline]. [Full Text].
Kauffman CA, Fisher JF, Sobel JD, Newman CA. Candida urinary tract infections--diagnosis. Clin Infect Dis. 2011 May. 52 Suppl 6:S452-6. [Medline].
Falagas ME, Kotsantis IK, Vouloumanou EK, Rafailidis PI. Antibiotics versus placebo in the treatment of women with uncomplicated cystitis: a meta-analysis of randomized controlled trials. J Infect. 2009 Feb. 58(2):91-102. [Medline].
Foxman B. The epidemiology of urinary tract infection. Nat Rev Urol. 2010 Dec. 7(12):653-60. [Medline].
Little P, Moore MV, Turner S, Rumsby K, Warner G, Lowes JA, et al. Effectiveness of five different approaches in management of urinary tract infection: randomised controlled trial. BMJ. 2010 Feb 5. 340:c199. [Medline]. [Full Text].
Christiaens TC, De Meyere M, Verschraegen G, Peersman W, Heytens S, De Maeseneer JM. Randomised controlled trial of nitrofurantoin versus placebo in the treatment of uncomplicated urinary tract infection in adult women. Br J Gen Pract. 2002 Sep. 52(482):729-34. [Medline]. [Full Text].
Bleidorn J, Gágyor I, Kochen MM, Wegscheider K, Hummers-Pradier E. Symptomatic treatment (ibuprofen) or antibiotics (ciprofloxacin) for uncomplicated urinary tract infection?--results of a randomized controlled pilot trial. BMC Med. 2010 May 26. 8:30. [Medline]. [Full Text].
Olson RP, Harrell LJ, Kaye KS. Antibiotic resistance in urinary isolates of Escherichia coli from college women with urinary tract infections. Antimicrob Agents Chemother. 2009 Mar. 53(3):1285-6. [Medline]. [Full Text].
McKinnell JA, Stollenwerk NS, Jung CW, Miller LG. Nitrofurantoin compares favorably to recommended agents as empirical treatment of uncomplicated urinary tract infections in a decision and cost analysis. Mayo Clin Proc. 2011 Jun. 86(6):480-8. [Medline]. [Full Text].
Falagas ME, Vouloumanou EK, Togias AG, Karadima M, Kapaskelis AM, Rafailidis PI, et al. Fosfomycin versus other antibiotics for the treatment of cystitis: a meta-analysis of randomized controlled trials. J Antimicrob Chemother. 2010 Sep. 65(9):1862-77. [Medline]. [Full Text].
[Guideline] Nicolle LE, Bradley S, Colgan R, Rice JC, Schaeffer A, Hooton TM. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis. 2005 Mar 1. 40(5):643-54. [Medline]. [Full Text].
Dalal S, Nicolle L, Marrs CF, Zhang L, Harding G, Foxman B. Long-term Escherichia coli asymptomatic bacteriuria among women with diabetes mellitus. Clin Infect Dis. 2009 Aug 15. 49(4):491-7. [Medline]. [Full Text].
Beerepoot MA, ter Riet G, Nys S, et al. Cranberries vs antibiotics to prevent urinary tract infections: a randomized double-blind noninferiority trial in premenopausal women. Arch Intern Med. 2011 Jul 25. 171(14):1270-8. [Medline].
Jepson RG, Craig JC. Cranberries for preventing urinary tract infections. Cochrane Database Syst Rev. 2008 Jan 23. CD001321. [Medline].
Tempera G, Corsello S, Genovese C, Caruso FE, Nicolosi D. Inhibitory activity of cranberry extract on the bacterial adhesiveness in the urine of women: an ex-vivo study. Int J Immunopathol Pharmacol. 2010 Apr-Jun. 23(2):611-8. [Medline].
De Vita D, Giordano S. Effectiveness of intravesical hyaluronic acid/chondroitin sulfate in recurrent bacterial cystitis: a randomized study. Int Urogynecol J. 2012 Dec. 23(12):1707-13. [Medline].
van der Starre WE, van Nieuwkoop C, Paltansing S, et al. Risk factors for fluoroquinolone-resistant Escherichia coli in adults with community-onset febrile urinary tract infection. J Antimicrob Chemother. 2011 Mar. 66(3):650-6. [Medline].
Cunha BA. Prophylaxis for recurrent urinary tract infections: nitrofurantoin, not trimethoprim-sulfamethoxazole or cranberry juice. Arch Intern Med. 2012 Jan 9. 172(1):82; author reply 82-3. [Medline].
Cunha BA, Schoch PE, Hage JR. Nitrofurantoin: preferred empiric therapy for community-acquired lower urinary tract infections. Mayo Clin Proc. 2011 Dec. 86(12):1243-4; author reply 1244. [Medline]. [Full Text].
Fischer HD, Juurlink DN, Mamdani MM, Kopp A, Laupacis A. Hemorrhage during warfarin therapy associated with cotrimoxazole and other urinary tract anti-infective agents: a population-based study. Arch Intern Med. 2010 Apr 12. 170(7):617-21. [Medline].
Hand L. Urinary Infections: Report Offers Long-Needed Clarity. Medscape [serial online]. Available at http://www.medscape.com/viewarticle/814305. Accessed: November 18, 2013.
Hooton TM, Roberts PL, Cox ME, Stapleton AE. Voided midstream urine culture and acute cystitis in premenopausal women. N Engl J Med. 2013 Nov 14. 369(20):1883-91. [Medline].
Pinson AG, Philbrick JT, Lindbeck GH, Schorling JB. ED management of acute pyelonephritis in women: a cohort study. Am J Emerg Med. 1994 May. 12(3):271-8. [Medline].
Turner D, Little P, Raftery J, Turner S, Smith H, Rumsby K, et al. Cost effectiveness of management strategies for urinary tract infections: results from randomised controlled trial. BMJ. 2010 Feb 5. 340:c346. [Medline]. [Full Text].
Patients with complicated cystitis who can tolerate oral therapy may be treated with the following options:
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:
Parenteral therapy can be switched to oral therapy once clinical improvement is observed.
Parenteral therapy can be switched to oral therapy once clinical improvement is observed.