A 20-year-old woman comes to the office due to dysuria for the past 2 days. She also has had urinary frequency but no fever, chills, nausea, or hematuria. The patient became sexually active with her boyfriend 6 months ago. Since then, she has had 3 episodes of cystitis. The patient voids following intercourse and has increased her daily water intake without any improvement. She has no other medical conditions and no prior surgery. She uses a subdermal progestin implant for contraception, and her last menstrual period was 2 weeks ago. Temperature is 37.2 C (99 F). On abdominal examination, there is mild suprapubic tenderness. No costovertebral or flank tenderness is present. Antibiotic therapy is prescribed. A urine culture grows Escherichia coli. When the patient is called with the results, she reports complete resolution of her symptoms. Repeat urine culture 2 weeks later is negative. Which of the following is the best next step in management of this patient's recurrent cystitis?
Recurrent cystitis in women | |
Definition |
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Risk factors |
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Prevention |
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UTI = urinary tract infection. | |
Women are at increased risk for cystitis, a lower urinary tract infection, due to the proximity of the rectum to the vagina and urethra. A significant risk factor is sexual intercourse, as in this patient. During intercourse, enteric bacteria (most commonly Escherichia coli) are introduced into the vagina and periurethral area. Because the female urethra is short, these bacteria can readily ascend to the bladder and cause cystitis and associated symptoms (eg, dysuria, urinary frequency). Other risk factors include conditions that alter the normal urogenital flora (eg, recent antibiotic use, spermicide use).
This patient has recurrent cystitis, defined as ≥2 episodes in 6 months (or ≥3 episodes in a year). Patients with recurrent cystitis are at increased risk for repeat episodes. Prevention is first focused on behavior modifications, which include increasing daily fluid intake, changing contraception method (eg, stop using spermicide or diaphragm), and voiding after sexual intercourse (unproven benefit but possibly helpful). If these measures fail, low-dose antibiotic prophylaxis can be considered, although this has inherent risks related to continuous antibiotic exposure. Therefore, in women with cystitis episodes clearly linked to intercourse, postcoital antibiotics (eg, nitrofurantoin, trimethoprim-sulfamethoxazole) are preferred because they can prevent recurrence while reducing the risks associated with long-term antibiotic use (eg, antibiotic resistance, toxicity).
(Choice A) Cystoscopy is typically performed for suspected bladder cancer (eg, persistent or unexplained hematuria) or urinary tract injury (eg, postoperative). Recurrent cystitis that responds appropriately to antibiotic therapy (eg, negative repeat urine culture, as in this patient) does not require cystoscopy.
(Choice B) Although increased daily fluid intake (eg, 2-3 L) is recommended for patients with recurrent cystitis, cranberry juice has not been demonstrated to decrease the incidence of infection.
(Choice D) Renal ultrasonography is indicated in patients with recurrent cystitis when repeat urine cultures are persistently positive or demonstrate atypical pathogens (eg, Proteus), which may indicate an underlying structural anomaly or nephrolithiasis. In contrast, this patient has a negative repeat urine culture and a common pathogen (ie, E coli).
Educational objective:
A significant risk factor for recurrent cystitis (ie, ≥2 episodes in 6 months or ≥3 episodes in a year) in women is sexual intercourse. Postcoital antibiotic prophylaxis (eg, nitrofurantoin, trimethoprim-sulfamethoxazole) can reduce the rate of recurrence.