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Dx Urinary Tract Infection Treatment:

Urinary Tract Infection

The Merck Manual Home Edition
"Cystitis is infection of the bladder.
*Usually, bacteria are the cause of cystitis.
*A frequent need to urinate and pain or burning while urinating are the most common symptoms.
*Doctors can base the diagnosis on the symptoms, but they usually examine a urine specimen.
*Drugs are needed to treat the infection and often the symptoms.

Causes in Women:
Cystitis is common among women, particularly during the reproductive years. Some women have recurring episodes of cystitis. There are a number of reasons why women are susceptible, including the short length of the urethra and the closeness of the urethra to the vagina and anus, where bacteria are commonly found. Sexual intercourse can contribute, too, because the motion can cause a tendency for bacteria to reach the urethra, from which they ascend to the bladder. Pregnant women are especially likely to develop cystitis because the pregnancy itself can interfere with emptying of the bladder.

Use of a diaphragm increases the risk of developing cystitis, possibly because spermicide used with the diaphragm suppresses the normal vaginal bacteria and allows bacteria that cause cystitis to flourish in the vagina.

The decrease in estrogen production that occurs after menopause can thin the vaginal and vulvar tissues around the urethra (atrophic vaginitis and atrophic urethritis), which can predispose a woman to repeated episodes of cystitis. In addition, a drooping (prolapsed) uterus or bladder may cause poor emptying of the bladder and predispose to cystitis. A prolapsed uterus or bladder is more common among women who have had many children.

Rarely, cystitis recurs because of an abnormal connection between the bladder and the vagina (vesicovaginal fistula).

Cystitis is less common among men. In men, cystitis generally starts with an infection in the urethra that moves into the prostate, then into the bladder. The most common cause of recurring cystitis in men is a persistent bacterial infection of the prostate. Although antibiotics quickly clear bacteria from the urine in the bladder, most of these drugs cannot penetrate well enough into the prostate to quickly cure an infection there. Usually antibiotics must be taken for weeks at a time. Consequently, if drug therapy is stopped prematurely, bacteria that remain in the prostate tend to reinfect the bladder.
A frequent cause of infection is an indwelling catheter. The Double-J catheter that is used to flush out the bladder after prostate surgery (T.U.R.P.) is always found to infect the bladder. Appropriate measures include intra-operative and post-operative antibiotics and repeat culture to make sure the infection has cleared.

Both Sexes:
If the flow of urine becomes partly obstructed because of a stone in the bladder or urethra, an enlarged prostate (in men), or a stricture in the urethra, bacteria that enter the urinary tract are less likely to be flushed out with urine. Bacteria that are left in the bladder after voiding can multiply rapidly. The more bacteria in the bladder, the more likely is infection. People with longstanding or repeated obstruction of urine flow may develop a bladder outpouching (diverticulum). This pocket retains urine after voiding, further increasing the risk of infection.

Cystitis can also be caused by a catheter or any instrument inserted into the urinary tract that introduces bacteria into the bladder. In men and women, an abnormal connection between the bladder and the intestine (vesicoenteric fistula) can develop, allowing fecal material to pass from the intestine into the bladder, causing bladder infection.

Sometimes the bladder can become inflamed without an infection being present, a disorder called interstitial cystitis (see see Interstitial Cystitis).

Cystitis usually causes a frequent, urgent need to urinate and a burning or painful sensation while urinating. These symptoms usually develop over several hours or a day. The urgent need to urinate may cause an uncontrollable loss of urine (urge incontinence), especially in older people. Fever is rarely present. Pain is usually felt above the pubic bone and often in the lower back as well. Frequent urination during the night (nocturia) may be another symptom. The urine is often cloudy and contains visible blood in about 30% of people. Air can be passed in the urine (pneumaturia) when infection results from an abnormal connection between the bladder and the intestine or the vagina (fistula).

Symptoms of cystitis may disappear without treatment. Sometimes cystitis causes no symptoms, particularly in older people, and is discovered when urine tests are performed for other reasons. A person whose bladder is malfunctioning because of nerve damage (neurogenic bladder—see see Neurogenic Bladder) or a person who has a permanently placed catheter may have cystitis with no symptoms until a kidney infection or an unexplained fever develops.

Doctors can usually diagnose cystitis based on its typical symptoms. A midstream (clean-catch) urine specimen is collected so that the urine is not contaminated with bacteria from the vagina or the tip of the penis. A strip of test paper is sometimes dipped into the urine to perform two quick and simple tests for substances that are normally not found in the urine. The testing strip can detect nitrites that are released by bacteria. The testing strip can also detect leukocyte esterase (an enzyme found in certain white blood cells), which may indicate that the body is trying to clear the urine of bacteria. In adult women, these may be the only tests necessary.

In addition, the urine specimen can be examined under a microscope to see whether it contains red or white blood cells or other substances. Bacteria are counted, and the sample can be cultured to identify the numbers and type of bacteria. If the person has an infection, one type of bacteria is usually present in large numbers.

In men, a midstream urine specimen is usually sufficient for a urine culture. In women, a specimen is more likely to be contaminated with bacteria from the vagina or vulva. When the urine contains only small numbers of bacteria, or several different types of bacteria simultaneously, the urine has likely been contaminated during the collection process. To ensure that the urine is not contaminated, doctors sometimes must obtain a specimen directly from the bladder with a catheter.

It is important for doctors to find the cause of cystitis in several different groups. The cause should be found in children, in men of any age, and in some women with frequently recurring infections (3 or more per year), especially when accompanied by symptoms of obstruction, an upper urinary tract infection, or infection with the Proteus bacteria. In these types of people, there is a greater likelihood of finding a cause that requires treatment other than simply giving drugs to treat the infection (for example, a large kidney stone). Doctors may perform an x-ray study in which a radiopaque dye, visible on x-rays, is injected into a vein, then excreted into the urine by the kidneys (intravenous urogram, or IVU). The x-rays then provide images of the kidneys, ureters, and bladder. Ultrasonography or computed tomography (CT) may be done instead of IVU. Performing voiding cystourethrography, which involves injecting a radiopaque dye into the bladder and filming its exit, is a good way to investigate the backflow (reflux) of urine from the bladder, up the ureters, particularly in children, and may also identify any narrowing (stricture) of the urethra. Retrograde urethrography, in which the radiopaque dye is injected directly into the urethra, is useful for detecting stricture, outpouching, or an abnormal connection (fistula) of the urethra in both men and women. Looking directly into the bladder with a flexible viewing tube (cystoscopy) may help diagnose the problem when cystitis does not resolve with treatment.

It is not clear whether wiping from front to back or avoiding the use of tight, nonporous underwear helps women prevent bladder infections. In contrast, cranberry juice does seem to help prevent infections.

People who have frequent bladder infections may continuously take low doses of antibiotics. The antibiotic can be taken daily, 3 times a week, or immediately after sexual intercourse. Postmenopausal women with frequent bladder infections and atrophic vaginitis or atrophic urethritis may benefit from estrogen creams applied to the vulva or estrogen suppositories inserted into the vagina.

Drinking plenty of fluids may help to prevent cystitis. The flushing action of the urine washes many bacteria out of the bladder. The body's natural defenses eliminate the remainder of the bacteria. It is commonly believed that wiping from front to back, urinating soon after sexual intercourse, and avoiding the use of tight, nonporous underwear helps women prevent bladder infections. However, it is not clear whether any of these strategies is effective.

Cystitis is usually treated with antibiotics. Before prescribing antibiotics, the doctor determines whether the person has a condition that would make cystitis more severe, such as diabetes or a weakened immune system (which reduces the person's ability to fight infection), or more difficult to eliminate, such as a structural abnormality. Such conditions may require more potent antibiotics taken for a longer period of time, particularly because the infection is likely to return as soon as the person stops taking antibiotics.

For women, taking an antibiotic by mouth for 3 days is usually effective if the infection has not led to any complications, although some doctors prefer to give a single dose. For more stubborn infections, an antibiotic is usually taken for 7 to 10 days. For men, cystitis usually is caused by prostatitis, and antibiotic treatment is usually required for weeks.

A variety of drugs can relieve symptoms, especially the frequent, insistent urge to urinate and painful urination. Drugs that have anticholinergic effects (such as oxybutynin and tolterodine) may relieve bladder spasms that cause the sense of urgency. These drugs should be used with caution in men with a large prostate gland because the drugs may cause urinary retention. Other drugs, such as phenazopyridine, reduce the pain by soothing the inflamed tissues.

Surgery may be necessary to relieve any physical obstruction to the flow of urine or to correct a structural abnormality that makes infection more likely, such as a drooping uterus or bladder. Until surgery can occur, draining urine from an obstructed area through a catheter helps control the infection. Usually, an antibiotic is given before surgery to reduce the risk of the infection spreading throughout the body."

[Editor] The most recent Journal of the American Medical Association stated:
1. Treatment of uncomplicated cystitis starts with Bactrim® DS/ trimethoprim/sulfamethoxazole one tablet twice daily for 3 days. Due to resistance, ciprofloxin and the fluroquinones are to be avoided.
2. Second drug of choice is nitrofurantoin 100mg twice daily for 5 days 3. Choice for Acute Uncomplicated Pyelonephritisand complicated cystitis reamins ciprofloxin 500mg twice faily for 7 days and then Bactrim DS twice daily for 14 days.
4. When all oral agenets have been exhausted, outpatient parenteral antibiotic thearpy is another viable alternative to hospitalization; Rocephin®/ ceftriaxone 1gm IV followed by 10-14 days of antibiotics with an antibiotic to which the bacteria is susceptible.
They make a point that women need to use vaginal estrogen, especially if sexually active and to not discount the possibility of sexually transmitted diseases in those who do not respond to simple interventions.

Medications Used in Treatment:
1. Penicillin: Amoxil®/amoxicillin; Augmentin®/amoxicillin/clavulanate; see list
2. Cephalosporin: Keflex®/cephalexin; cefadroxil; see list
3. Antifolate/Sulfa: Bactrim®/sulfamethoxazole/trimethoprim; see list
4. Quinolone: Cipro®/ciprofloxacin; see list
5. Tetracycline: Vibramycin®/doxycycline hydlate; see list
6. Nitrofurantoin: Macrobid®/nitrofurantoin; seelist
7. Macrolide: erythromycin
8. Antifolate: trimethoprim in Bactrim®
9. Urinary Analgesics: Pyridium®/phenazopyridine,, Azo®/azogantinol, Uroqid Acid®#2/methenamine, Visqid®A/A/ methenamine
10. Urease Inhibitors: Lithostat®/acetohydroxamic acid (Struvite kidney stones)
12. Monobactam Antibiotics: Azactam®/aztreonam

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*N.H.S. Choices (with Video)

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