clinicalBacterial cystitis in women
AUSTRALIAN FAMILY PHYSICIAN VOL. 39, NO. 5, MAY 2010
urologic abnormalities are uncommon. However,
urinary tract ultrasound is indicated if seemingly
uncomplicated cystitis recurs frequently (two
episodes in 6 months or three or more episodes
in 12 months) or shows a pattern of bacterial
persistence. Urinary tract ultrasound also confirms
the degree of bladder emptying by measurement of
postvoiding residual. Abnormalities on ultrasound
may require specialist evaluation and further
investigation with contrast enhanced computerised
Postmenopausal women with recurrent cystitis
pelvic organ prolapse and vaginal atrophy as these
conditions may mimic the symptoms of cystitis.
Older patients with recurrent UTIs should also be
screened for diabetes.
Microscopic haematuria often occurs with UTI
and, if persistent 6 weeks following resolution
of cystitis, requires further investigation. All
patients with macroscopic haematuria require
urological evaluation if they have risk factors for
to cyclophosphamide, chemicals or radiation). In
the absence of risk factors these patients should
be monitored to ensure the haematuria has
resolved. All patients with persistent haematuria
(macroscopic or microscopic) should be referred to
a urologist with urine cytology (three specimens
on three separate days) and upper tract imaging.
A urinary tract ultrasound is an acceptable
preliminary investigation and if needed, can be
followed by contrast CT urogram or retrograde
pyelography. Cystoscopy is also performed to
evaluate the urothelium of the bladder.
Women with a simple UTI should be treated with
empirical first line antibiotic therapy such as
trimethoprim 300 mg orally at night for 3 days or
clavulanate) is only recommended if the organism
has shown to be susceptible.
should only be used as a second line agent when
resistance has been documented or in the presence
of P. aeruginosa.
Trimethoprim is contraindicated in pregnancy
‘history’ to aid in further treatment. Continuous
twice daily, may also be helpful.
agents can provide symptomatic relief and may
also reduce the incidence of UTI.
In the presence of atrophic vaginitis, the risk
of UTIs may be reduced by improving the vaginal
tissues with oestrogen replacement.
issue and beyond the scope of this article.
A sexually active woman, 25 years of age,
presents with recurrent bacterial cystitis.
This is her third episode of cystitis in 12
months. She is otherwise fit and well.
Urinary tract infection is confirmed initially
on the basis of symptomatology and dipstick
urinalysis followed by formal MCS. She has
a history of E. coli UTI sensitive to standard
antibiotics, and empirical treatment is
initiated with trimethoprim 300 mg orally
at night for 3 days.
A urinary tract
ultrasound was normal.
Case study discussion
If UTIs occur postintercourse, then postintercourse
diaphragms should be replaced with other means
If the episodes are unrelated
to intercourse it would be reasonable to start
treatment for recurrent UTIs. Evidence based
prophylactic regimens may reduce recurrence of
UTIs by up to 95% and are listed in Table 2.
In this young woman, self start intermittent
therapy would be a reasonable option to trial for
12 months, as she has only had three infections
in 1 year. A woman with more frequent infections
may only tolerate a 6 month trial. If this fails,
months would be appropriate. There should be
a low threshold for evaluation with urinary tract
ultrasound. Urological evaluation may be required
if infections persist.
The incidence of UTIs is high. All the evaluation
and treatment measures outlined above may
be undertaken in the general practice setting.
However, referral to a urologist is beneficial
in the setting of recurrent UTIs, persistent
as first line therapy. Alternatives include
A 3 day course of antibiotics is similar to
a prolonged course (5–10 days) in achieving
symptomatic cure, but is not as effective in
achieving complete bacterial eradication.
is appropriate to prescribe a longer course of
antibiotics for women in whom complete bacterial
eradication is important (such as in pregnancy,
urolithiasis and in the immunocompromised) even
though prolonged treatment is associated with a
higher rate of side effects.
Adjuvant therapy with urine alkalinisers can
help alleviate the dysuric symptoms of cystitis.
Sufficient fluid intake (at least 2 L/day) is
thought to have a ‘flushing’ effect on the urinary
tract, avoiding urinary stasis and bacterial
proliferation. Other factors such as good hygiene,
postcoital voiding, anterior to posterior wiping
patterns and the wearing of cotton underwear may
reduce the risk of UTIs. Alternatives to diaphragms
and spermicides should be considered. Cranberry
products may reduce bacterial adherence and may
reduce the incidence of UTIs, however the optimum
is yet to be established.
probiotic yoghurt (either vaginal or oral) to restore
commensal vaginal flora has been proposed
women, but the data remains inconclusive and no
recommendations can be made for its use.
Treating recurrent UTIs
Women with recurrent UTIs being considered for
prophylactic antibiotic therapy may benefit from a
foreign bodies. Prophylactic antibiotic regimens
for women with recurrent cystitis may reduce
recurrence by up to 95%
(see Case study).
• postintercourseprophylaxis(Table 2).
With self start therapy, a urine specimen should be
collected for MCS before the taking first antibiotic
tablet. The most practical method is to give the
patient pathology request forms to obviate the
need for an urgent appointment with a GP. The
patient then presents for review once the MCS
results are available. This ensures appropriate
antibiotic use and provides a microbiologial