History
The classic symptoms of urinary tract infection (UTI) in the adult are primarily dysuria with accompanying urinary urgency and frequency along with a sensation of bladder fullness or lower abdominal discomfort.
Because of the referred pain pathways, even simple lower UTI may be accompanied by flank pain and costovertebral angle tenderness. However, assume that the presence of these symptoms represents upper UTI until proven otherwise.
Gross hematuria, hemorrhagic cystitis, develops in up to 10% of heathy women. Fevers, chills, and malaise may be noted in such patients but 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 and necessitate an examination of the pelvis.
Important additional information includes a history of prior sexually transmitted disease (STD) and multiple current sexual partners.
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. [15]
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, whereas 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 infrequent and quite 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 generally are 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
-
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.
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. [10]
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% to 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% to 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.
-
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
Tables
First-line therapy |
|
Second-line therapy |
|
Alternative therapy |
*Should generally be avoided in elderly patients because of the risk of affecting renal function. |
First-line therapy |
Oral: Patients with complicated cystitis who can tolerate oral therapy may be treated with the following options:
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:
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 |
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. |
What would you like to print?
- Overview
- Presentation
- DDx
- Workup
- Treatment
- Approach Considerations
- Uncomplicated Cystitis in Nonpregnant Patients
- Complicated Cystitis in Nonpregnant Women
- Antimicrobial Therapy
- Adjunctive Therapy
- Fungal Infection
- Treatment in Patients with Spinal Cord Injury
- Pregnant Patients
- Renal Transplantation Patients
- Asymptomatic Bacteriuria
- Diet
- Consultations
- Prevention and Long-Term Monitoring
- Show All
- Guidelines
- Medication
- Questions & Answers
- Media Gallery
- Tables
- References
