Urinary Tract Infection (Cystitis)

BACKGROUND

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

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

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

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

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

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

Robin L. Hansen, M.D.

PUBLICATION INFORMATION

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.