Pragmatic approaches to problem cystitis in women
ystitis means different things to different people. For most sufferers it represents a set of annoying symptoms (urgency to pass urine, frequent visits to the toilet, difficulty in passing urine, painful passage of urine and occasionally a foul smell, or blood in the urine). Most patients and many doctors attribute these symptoms to 'an infection' and in most cases they are correct. Antibiotics are often prescribed empirically and symptoms resolve in the majority of cases.
However, cystitis is really a histopathological term for an inflammation of the bladder lining with many causes. A host of other conditions can give rise to cystitis symptoms without necessarily causing inflammation (see page 43).
When a patient presents with cystitis, a basic history will determine whether there are any long-term urological symptoms (hesitancy, poor flow, dribbling, incontinence, haematuria, loin pain) or whether this episode is a one-off.
Around 10-20 per cent of females get a UTI at some point in their lives. In pre-menopausal women you should ascertain whether there is a relationship between the symptoms and sexual intercourse or their menstrual cycle. Pre-menopausal women who get repeated UTIs often have a history of UTIs in childhood and there may be a maternal history.
If there is a relationship between symptoms (particularly if pain or discomfort is a feature) and the menstrual cycle, consider endometriosis. Post-menopausal women are at risk from urinary infection by enterococci due to the loss of oestrogen-dependent lactobacillus in the vagina and perineum.
Urine dipstick testing
Urine dipstick testing will determine the presence or absence of nitrites and leucocytes. Nitrites are produced by many (but not all) bacteria in urine. A positive nitrite test is strongly suggestive of a UTI, but a negative does not exclude one. In a patient with typical symptoms a positive leucocyte test is a necessary but insufficient basis for diagnosing a UTI.
In combination these tests have a 20 per cent false-negative rate for diagnosing a urinary infection, hence the importance of sending the specimen for culture. I recommend the following:
lboth negative: observe
lboth positive: treat, but send MSU for culture and sensitivity tests if second episode
lonly one positive: treat, but send MSU.
When a patient presents with cystitis symptoms for the first time and you suspect an uncomplicated UTI, treat with a three-day course of a broad-spectrum antibiotic. Cephradine or nitrofurantoin are ideal; resistance to trimethoprim is now widespread. It is good practice to send off a urine specimen. Most cases resolve on this basis, but up to 70 per cent of urine infections resolve spontaneously.
Recurrent cystitis symptoms
Patients with frequently recurring symptoms should have samples sent for culture whenever symptoms occur. It is important to know for certain whether the patient is getting genuine urinary infections. Logistical problems often prevent patients providing a sample in the middle of an attack.
The problem can be overcome by providing the patient with specimen bottles and request forms so the sample can be dispatched without her having to wait to see a professional.
In spite of this, many patients with recurrent cystitis find their symptoms are relieved by empirical antibiotic treatment, despite the MSU being sterile. The reason for this is unclear.
Patients with mild symptoms (urgency, frequency, nocturia and urethral discomfort) with no haematuria may have a trial of an anticholinergic agent (tolterodine, oxybutynin, trospium or propiverine).
A majority tend to be referred to a urologist for further evaluation, investigation or reassurance. In practice, only patients with complicated UTIs or associated haematuria require further investigation.
Recurrent (uncomplicated) UTIs
Premenopausal women If there is a definite relationship between sexual intercourse and their UTIs and they are asymptomatic at other times, a post-coital antibiotic is recommended as well as voiding immediately after intercourse.
Post-menopausal women These patients are prone to recurrent UTIs due to loss of oestrogen-dependent lactobacillus in the perineum. It is worth a trial of periurethral oestrogen cream twice weekly. A long-term low-dose prophylactic antibiotic is also advisable.
In both age groups, there is evidence that drinking cranberry juice prevents infection.
Who to refer
The following patients ought to be referred for a urological opinion and possible investigation:
lpatients with recurrent (refractory) UTIs
lall patients with complicated UTIs (pyrexia, loin pain, frank haematuria, significant lower urinary tract symptoms)
lany male with a proven UTI
lchildren with recurrent UTIs
lpatients with persistent cystitis symptoms which fail to respond to antibiotics or where the urine is always sterile
lany patient with frank haematuria or persistent microscopic haematuria.
What happens at referral?
Recurrent/complicated UTIs Investigation aims to determine whether there is an anatomical abnormality or urinary tract stasis. A urinary tract ultrasound scan will detect underlying hydronephrosis or impaired bladder emptying, while a plain abdominal
X-ray may show radio-opaque stones in the line of the urinary tract. A micturating cystogram is often indicated in children with dilated upper tracts as they may have vesico-ureteric reflux. Adults with haematuria (frank or persistent microscopic haematuria) should have a diagnostic cystoscopy as some will have a bladder tumour.
A vast majority of women patients have anatomically normal urinary tracts. So, why do they get recurrent UTIs? The short answer is we don't know. We do know younger women with recurrent UTIs have an increased tendency to carry virulent strains of E. coli in their perinea than unaffected women. They are often non-secretors of the Lewis blood group antigen and have a high density of E. coli receptors in their urothelium. The relevance of these findings is unclear.
Some patients with recurrent UTIs are found to have poor bladder emptying on post-void ultrasound scanning. In postmenopausal women this may be due to urethral stenosis. Some will benefit from having a urethral dilatation under general anaesthesia and thereafter from applying periurethral oestrogen cream. If chronic retention persists the patient may be taught clean intermittent self-catheterisation.
Patients with evidence of pyelonephritis (loin pain, pyrexia, haematuria) may be very unwell and often warrant acute admission. After obtaining urine and blood samples for culture, intravenous fluid resuscitation and antibiotics may be required. An urgent renal ultrasound scan should be arranged and any hydronephrosis should be drained promptly by percutaneous nephrostomy. Once the patient settles the underlying cause can be dealt with.
Recurrent non-infective cystitis symptoms
It is useful to have the patient complete a frequency-volume diary (over two days at least) before they are seen in the clinic. This gives an indication of the severity of her problem in terms of voiding frequency, nocturia and functional bladder capacity. An assessment of bladder outlet obstruction and bladder emptying can be made by uroflowmetry and post-void bladder scanning respectively. Both can also be performed as pre-clinic investigations.
There is a growing trend to manage patients on the basis of these limited investigations alone, treating predominantly irritative symptoms with anticholinergic agents. Formal urodynamic studies (filling and voiding cystometry) are required if the symptoms persist despite treatment or if there is evidence of incontinence or voiding dysfunction.
Interstitial cystitis should be suspected in women with persistent cystitis symptoms and associated pain (bladder, urethral or pelvic) and who generally have sterile urine. These patients are found to have hypersensitive small-capacity stable bladders on urodynamics.
A cystoscopy under general or spinal anaesthesia is recommended as the next investigation and this may reveal glomerulations (pinpoint haemorrhages), suburothelial haemorrhages, fissures or ulceration. With this exception, all patients with cystitis symptoms and microhaematuria should have a flexible cystoscopy under
local anaesthetic to exclude a bladder malignancy.
Causes of cystitis are not always clear
Mr Paul Irwin outlines
on the grey areas of management
Causes of true (histological) cystitis
· Infection: bacterial, fungal, parasitic
· Trauma/irritation: stones, catheter
· Chemicals: cyclophosphamide, NSAIDs
· Idiopathic: interstitial cystitis
Other causes of cystitis symptoms
· Detrusor over-activity
· Sensory urgency
· Bladder outlet obstruction
· Endometriosis, constipation
· Bladder tumour
Most women have normal urinary tracts, and we don't know why they get cystitis~
Recurrent (documented) UTIs
· Premenopausal Postcoital antibiotic + voiding after intercourse
· Postmenopausal Long-term antibiotic prophylaxis + topical periurethral oestrogen cream
Recurrent cystitis symptoms with sterile urine
· No haematuria /loin pain: Trial of anticholinergic agent
· Bladder/pelvic pain: Possible interstitial cystitis refer to urologist
Referral to urologist advised if
· Persistent symptoms despite the above measures
· Persistent infection despite the above measures
· Frank haematuria or persistent microscopic haematuria
· Complicated UTIs (haematuria, loin pain, pyrexia, obstructive voiding symptoms etc)