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Urinary Tract Infection (Cystitis)

Background

Medical Management Considerations

References

Resources for Families

Advisory Committee

Publication Information

BACKGROUND

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Description

Cystitis, a type of urinary tract infection (UTI), refers to inflammation of the bladder mucosa caused by bacterial infection. (UTI also includes pyelonephritis, but this document will focus on cystitis only.) Escherichia coli is the cause in 80% of cases; other possible causes include klebsiella, enterobacter, proteus, pseudomonas, serratia, streptococcus faecalis, and staphylococcus. UTI is a common secondary condition of many developmental disabilities.

Prevalence

  • 3-8% of women; 0.5% of men
  • The lifetime risk of urinary tract infection may approach 100% in some individuals with spina bifida, meningomyelocele or spastic quariparetic cerebral palsy.

Influencing Factors

  • Central nervous system dysfunction
  • Underlying abnormalities of the urinary tract (tumors, calculi, strictures, etc.)
  • Incomplete bladder emptying
  • Backward flow of urine
  • Urinary outlet obstruction
  • Indwelling urinary catheter
  • Infection of the kidney
  • Medications
  • Immobility
  • Cognitive impairment
  • Diabetes mellitus
  • More frequent or vigorous sexual activity than usual
  • Previous urinary tract infection
  • Recent urologic surgery
  • Fecal incontinence
  • Immunocompromised host
  • Females only: pregnancy, use of spermicides or diaphragm, recent sexual intercourse
  • Males only: benign prostatic hypertrophy, infection of the prostate, anal intercourse

Signs and Symptoms

  • Painful urination (burning sensation)
  • Urgency (sensation of need to urinate frequently)
  • Sensation of incomplete bladder emptying
  • Dysuria
  • Hesitancy
  • Slow urinary stream
  • Dribbling of urine
  • Blood in urine
  • Foul urine odor
  • Lower abdominal pain or cramping
  • Lower back pain
  • Nocturia
  • Systemic symptoms (fever, chills)

Possible Complications

  • Kidney failure
  • Pyelonephritis
  • Renal abscess
  • Ascending infection
  • Recurrent infection
  • High blood pressure

MEDICAL MANAGEMENT CONSIDERATIONS

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Note: These considerations are in addition to the normal medical care provided to an individual without urinary tract infection. All recommendations can be addressed through clinical examination by the primary care provider, unless otherwise noted; however, a good nursing consultation to give individualized patient training to a female with recurrent bladder infections may be helpful.

Cystitis heals in almost all patients within 2-3 days of starting medical treatment. However, these treatments may not address the underlying mechanical cause. To prevent symptoms from recurring, it is important to address the underlying cause in addition to symptoms of pain or discomfort.

Note: Patients with indwelling urinary catheters are likely to be colonized with bacteria rather than infected. As a result, patients with indwelling catheters should demonstrate symptoms of infection (pain, fever, sepsis, etc.) before treatment is warranted. In these individuals, removal of the catheter and intermittent catherization during antibiotic therapy may be necessary to eliminate the infection.

Diagnosis

Classic symptoms may not require urine culture for diagnosis, but it is required to identify the causative agent and treatment sensitivity. Perform the following test(s) if the patient is an infant or child, if it is a repeat episode, if the patient is pregnant, if symptoms are not classic, or if there is risk for complicated infection.

  • Urinalysis to detect pyuria (more than 10 neutrophils per high power field on microscopic exam) or bacteruria (any amount of unspun urine, or 10 rod-shaped bacteria per high power field on centrifuged urine)
  • Nitrite dipsticks to detect bacteruria
  • Leukocyte count in uncentrifuged urine in counting chamber to detect pyuria
  • Urine culture to detect single species of bacteria
  • Radiographic, ultrasound, and/or endoscopic imaging of upper and lower urinary tracts for infants only

Ongoing Treatment

  • Maintain record of urination frequency and characteristics
  • Obtain urinalysis and culture regularly if patients present recurrent UTI
  • Treat influencing factors (above) promptly
  • Avoid use of urinary catheters whenever possible; if catheter must be used, use aseptic technique and closed system, with removal as soon as possible

Lifestyle and Diet Modifications (if applicable)

  • Recommend adequate hydration
  • Advise to take showers instead of tub baths
  • Recommend no sexual activity until cured
  • Advise females to avoid feminine hygiene sprays and scented douches
  • Advise females to wipe urethra from front to back after urinating
  • Advise females to empty bladder immediately before and immediately following sexual intercourse

Medications

Note: Obtain post-treatment urine culture to document eradication of infection.

First UTI: Antibiotics for 3 or more days (trimethoprim-sulfamethoxazole (TMP-SMX) or fluoroquinolone)

Recurrent/chronic UTI: 10-14 day treatment with antibiotic (fluoroquinolone, TMP-SMX, cephalosporin, or other based on culture/sensitivity results)

Pregnant patients: 10-14 day or longer treatment with pregnancy-safe antibiotic (cephalosporin, amoxicillin, or other based on culture/sensitivity results)

Postcoital: postcoital single dose of TMP-SMX or cephalexin for sexually active females

REFERENCES

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Peer-reviewed Journal Articles/Academies

Hooton, T.M. et al. (1996). A Prospective Study of Risk Factors for Symptomatic Urinary Tract Infection in Young Women. New England Journal of Medicine 335(7), 468-474.

Hutton J. et al. (1994). Management of Bacterial Urinary Tract Infections in Adults. Annals of Pharm, 28(11), 1264-1272.

Liptak, G., (1996). Neural Tube Defects. (1996). In ML Batshaw (Ed.), Children with Disabilities (4th ed., pp. 529-552). Baltimore: Paul H. Brookes.

Stamm, W.E Hooton, T.M. (1993). Management of Urinary Tract Infections in Adults. New England Journal of Medicine, 329(18) 1328-1334.

Special Interest Groups/Other Publications

Fields, S.A. (1999). Urinary Tract Infection in Males. In M.R. Dambro (Ed.), Griffith’s 5 Minute Clinical Consult (pp. 1126-1127.) Baltimore: Lippincott Williams & Wilkins.

Smith Consultant Group and McGowan Consultants. (1998). Urine Elimination. In M.L. Snyder (Ed.), Health and Wellness Reference Guide (pp. 145-146). Neri Productions, State of Tennessee Commission on Compliance.

Starrett, A.L. (1991). In: Developmental Disabilities in Infancy and Childhood. (Eds.) A.J. Capute, & P.J. Accardo. Baltimore: Paul H. Brookes., pp. 184-185.

Weiss, Barry D. MD. (1999). Urinary Tract Infection in Females. In M.R. Dambro (Ed.), Griffith’s 5 Minute Clinical Consult (pp. 1124-1125). Baltimore: Lippincott Williams & Wilkins.

RESOURCES FOR FAMILIES

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American College of Obstetricians and Gynecologists,

http://www.acog.com

American Foundation for Urologic Disease, 410-468-1800,

http://www.afud.org

American Urological Assocation,

http://www.auanet.org

California Department of Developmental Services, 916-654-1690,

http://www.dds.ca.gov

California Regional Centers, 916-654-1958,

hhttp://www.dds.ca.gov/rc/RCInfo.cfm

National Kidney Foundation,

http://www.kidney.org

Society of Urologic Nurses and Associates,

http://www.suna.org

ADVISORY COMMITTEE

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Theodore A. Kastner, M.D., M.S.

Felice Weber Parisi, M.D., M.P.H.

Robin L. Hansen, M.D.

PUBLICATION INFORMATION

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Funded by a grant from the California Department of Developmental Services

For more information, contact:

Center for Health Improvement

1330 21st Street, Suite 100

Sacramento, CA 95814

(916) 901-9645

This document does not provide advice regarding medical diagnosis or treatment for any individual case, and any opinions or statements contained in this document are not intended to serve as a standard of medical care. Physicians are encouraged to view the considerations presented in this document in light of evolving scientific information. This document is not intended for use by the layperson. Reproduction of this document may be done with proper credit given to California Department of Developmental Services and the Center for Health Improvement.

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