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Cystitis in Females Differential Diagnoses

  • Author: John L Brusch, MD, FACP; Chief Editor: Michael Stuart Bronze, MD  more...
 
Updated: Aug 19, 2015
 
 

Diagnostic Considerations

Occult pyelonephritis occurs in 15-50% (or more) of all urinary tract infections (UTIs), based on several studies on localization of organisms within the urinary tract. This usually occurs in older women. It appears that these patients are unable to mount a fever or develop an elevated white count or costovertebral angle (CVA) tenderness. These patients may present with an unexplained fall or a change in mental status.

Postmenopausal women may also experience senile urethritis. In addition to urinary burning, frequency, and urgency, these patients may complain of vaginal and vulvar itching and discharge. Physical examination reveals a dry, pale vaginal epithelium and eversion of the urethral mucosa. Senile urethritis responds to topical estrogen therapy.

The differential diagnosis for infectious causes of sterile pyuria includes perinephric abscess, urethral syndrome, renal tuberculosis, and fungal infections of the urinary tract system. Noninfectious causes of pyuria include the following:

  • Uric acid and hypercalcemic nephropathy
  • Lithium and heavy metal toxicity
  • Sarcoidosis and other granulomatous diseases (eg, tuberculosis)
  • Interstitial cystitis
  • Polycystic kidney disease
  • Genitourinary malignancy
  • Renal transplant rejection
  • Any periurethral process

Consider UTI in any condition involving pain the flank and back or pain in the abdomen and pelvis. Also consider cervicitis and Chlamydia infection. Do not assume that a sexually active female with dysuria has a UTI without first excluding the possibility of sexually transmitted disease–related cervicitis, vaginitis, or pelvic inflammatory disease.

UTIs in pregnancy have potentially adverse outcomes for both the mother and the fetus. Obtain a urine culture in all pregnant patients with suspected UTI, as the results may provide the physician or the follow-up physician with valuable information if the patient does not respond as expected to treatment. Pyuria and bacteriuria are always treated during pregnancy, regardless of whether symptoms are present.

Patients with diabetes mellitus are at increased risk for complicated UTIs. Diagnostic considerations include the following:

  • Renal and perirenal abscess
  • Emphysematous pyelonephritis
  • Emphysematous cystitis
  • Fungal infections
  • Xanthogranulomatous pyelonephritis
  • Papillary necrosis

Older patients who appear toxic are more likely to have obstruction complicating their UTI. Obtain a structural study to rule out this possibility.

Differential Diagnoses

 
 
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, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Coauthor(s)

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, 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, MD is a member of the following medical societies: American College of Physicians-American Society of Internal Medicine

Disclosure: Nothing to disclose.

Mary F Bavaro, MD Fellowship Director, 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, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Chief Editor

Michael Stuart Bronze, MD David Ross Boyd Professor and Chairman, Department of Medicine, Stewart G Wolf Endowed Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center; Master of the American College of Physicians; Fellow, Infectious Diseases Society of America

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

Disclosure: Nothing to disclose.

Acknowledgements

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 [1]
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 [15]
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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