Acute Cystitis

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Acute cystitis is an acute inflammation of the bladder. Women are affected 10 times more than men due to the shortness of their urethra compared to that of men. 40%-50% of all women will develop cystitis in their lifetime. 

The ascending faecal-perineal-urethral route is the primary mode of  infection. Occasionally sexually transmitted organisms are involved. Risk factors include urethral catheterization and diabetes.

Cause

  • E.coli (about 80%)
  • Staphylococcus saprophyticus
  • Klebsiella
  • Proteus mirabilis
  • Gonococcus
  • Enterococci 

Symptoms

  • Low grade fever
  • Frequency 
  • Nocturia
  • Urgency 
  • Dysuria
  • Haematuria
  • Cloudy and foul smelling urine
  • Low back and suprapubic pain

Signs

  • Low grade fever
  • Suprapubic tenderness
  • Haematuria 

Investigations

  • Urinalysis
  • Mid-stream urine for culture and sensitivity
  • FBC
  • FBS 
  • Imaging of urinary tract in recurrent or persistent cases to exclude anatomical abnormalities, lower urinary tract obstruction etc. 
  • Urethrocystoscopy in selected cases

TreatmentTreatment Objectives

  • To eradicate infection
  • To prevent recurrence and complications 
  • To relieve pain 

Non-pharmacological treatment

  • Liberal oral fluids to encourage good urinary output
  • Pre-coital and post-coital emptying of the bladder
  • Personal hygiene and proper cleaning after defaecation especially in females

Pharmacological treatment 

Acute uncomplicated cystitis (absence of fever and flank pain)

1st Line Treatment

Evidence Rating: [A]

  • Nitrofurantoin, oral,

Adults

100 mg 6 hourly for 5-7 days

Children 

12-18 years; 50 mg 6 hourly for 7 days

3 months-12 years; 750 micrograms/kg 6 hourly for 7 days

2nd Line Treatment

Evidence Rating: [A]

  • Ciprofloxacin, oral,

Adults 

500 mg 12 hourly for 5-7 days

Children 

12-18 years; 250-750 mg 12 hourly 

1 month-12 years; 7.5 mg /kg 12 hourly (dose doubled in severe cases) 

Neonates

7.5 mg/kg 12 hourly

Or  

  • Cefuroxime, oral, 

Adults

500 mg 12 hourly for 5-7days

Children 

12-18 years; 250 mg 12 hourly (dose reduced to 125 mg  12 hourly in lower urinary tract infections)

2-12 years; 15 mg/kg 12 hourly (max. 250 mg 12 hourly)

3 months-2 years; 10 mg/kg 12 hourly (max. 125 mg 12 hourly)

And

Evidence Rating: [C]

  • Mist Potassium citrate, oral,

10 ml 8 hourly if urine is acidic (pH of 6 or below). To reduce bladder pain and dysuria. 

Note: Monitor potassium levels and avoid in hyperkalaemia. Do not give with ciprofloxacin

Or

Paracetamol, oral, 500 mg-1g 6-8 hourly when required

For symptomatic cystitis and UTI in pregnancy

  • Cefuroxime, oral, 

Adults

500 mg 12 hourly for 5-7days

And

Evidence Rating: [C]

  • Mist Potassium citrate, oral,

10 ml 8 hourly if urine is acidic (pH of 6 or below). To reduce bladder pain and dysuria. 

Note: Monitor potassium levels and avoid in hyperkalaemia. Do not give with ciprofloxacin.

Referral Criteria

  • Refer all cases, which require cystoscopy and all cases of persistent haematuria, recurrent cystitis or bacterial resistance to the specialist