Diagnosis, treatment, and

prevention of cystitis
A case report to guide nurse practitioners.
By Myriam Jean Cadet, PhD, APRN, MSN, FNP-C

CASE DESCRIPTION sister; all have been diagnosed with HTN.

Chief complaint Personal and social history

Laura Johnson*, a 42-year-old woman, arrives for her clinic Ms. Johnson is married and has three children—two sons
appointment that she made because of urological (14 and 16 years old) and one daughter (12 years old).
symptoms. She lives in a private house in the suburbs. She denies
any drug use or smoking currently or in the past; she
History of present illness drinks one glass of wine occasionally on the weekends.
Ms. Johnson reports dysuria, which she describes as Her hobbies are quilting, reading, dancing, and
painful, burning, and stinging. In addition, she reports needlepoint.
urinary frequency every 2 to 3 hours, including during the
night, and urgency that began prior to other symptoms. Ms. Pertinent exam findings
Johnson decreased her fluid intake to alleviate her The physical examination reveals that Ms. Johnson is
symptoms, but the dysuria got worse every day and afebrile, weighs 145 pounds, is 5 feet 6 inches tall, and
increased in intensity. She’s taking acetaminophen 650 mg has a body mass index of 23.4 kg/m2. Her vital signs are
for her discomfort, which hasn’t improved her condition. blood pressure 122/78 mmHg, heart rate 67 beats per
minute, respiration rate 14 breaths per min ute, and
Medications oxygen saturation 97% on room air. Ms. John son says
Ms. Johnson’s medications include a daily multivitamin and that her pain on urination ranges between 4 and 6 on a 10-
650 mg of acetaminophen as needed for pain. She’s allergic point pain scale. She complains of urinary frequency and
to nitrofurantoin, trimethoprimsulfamethoxazole, and voids 10 or 14 times daily. Her urine is cloudy, with a
fosfomycin. strong odor. She reports no vaginal discharge, irritation,
sores, lesions, or itching. She also denies any flank pain or
History costovertebral-angle tenderness. She’s sexually active,
Ms. Johnson’s family history includes cataracts, glaucoma, and her last period was the previous week. Her menstrual
hypertension (HTN), and coronary artery disease (CAD). flow is moderate and lasts 5 to 6 days. She doesn’t use
Her mother died from HTN and CAD 3 years ago, and her any contraceptive pills, patches, or rings.
father died from prostate cancer 5 years ago. Ms. Johnson
*Name is fictitious.
has three brothers and one

CYSTITIS (inflammation of the blad- fections such as pyelonephritis, der) is a

lower urinary tract infec-which is an upper UTI that affects tion (UTI)
commonly caused by athe kidneys. As a nurse practitioner uropathogenic agent
such as Es-(NP), you’ll encounter this significherichia coli (E. coli). (See
UTIcant health problem in primary care facts.) Signs and symptoms
includesettings. This article uses a case deurinary urgency and frequency,
asscription to analyze NPs’ role in the well as burning on urination. Un-
diagnosis, treatment, and prevention treated cystitis can lead to renal in-of
uncomplicated cystitis.

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Discussion
Cystitis causes inflammation to the
bladder and can be subclassified as
complicated or uncomplicated. Patients
with uncomplicated cys- titis experience
urinary incontinence, urgency, and
burning on urination, which may persist
for days or weeks. Complicated cystitis
manifests with the same symptoms as
uncomplicated cystitis, but additional
characteristics include urinary
obstruction, male gender, diabetes,
history of drug resistance, recurrent
cystitis, or pregnancy. Complicated
cystitis may need more extensive UTI facts
evaluation and longer antibiotic
treatment.
• Urinary tract infections (UTIs) account for about 10 million healthcare visits per
Adequately assessing cystitis can
year.
be challenging because symptoms overlap with other urologic condi- • UTI prevalence in women is estimated to be 150
million cases worldwide. tions, such as pyelonephritis. As an • The incidence of UTI increases substantially after age 85.
NP, you should be prepared to initi- • Women are more likely than men to get a UTI. ate effective medical treatment to
• Cystitis occurs in 40% to 60% of women during their lifetime.
provide safe, quality care for pa-
tients with cystitis. We’ll use Ms. Sources: American Urological Association 2016; National Institute of Diabetes and Digestive and Kidney Johnson’s
case of uncomplicated Disease, Definition & facts: What is a bladder infection, 2017; National Kidney Foundation 2017; Rowe, cystitis to guide your
diagnosis and Juthani-Mehta 2013. treatments.

Pathogenesis and etiology Adequately assessing Differential diagnoses include

Cystitis usually occurs when fecal urethritis, vaginitis, pelvic
flora colonize in the urethra and then inflammatory disease, nephrolithiasis,
ascend through the urinary tract into and pyelo nephritis. All have been
the bladder. E. coli accounts for about associated with dysuria, but dysuria
80% of all outpatient UTIs. Other cystitis can be usually is caused by urethritis,
vaginitis, cystitis, or pyelonephritis.
uropathogens that cause cystitis are
Staphylococcus, challenging because Dysuria, vaginal discharge, sexually
transmitted infection, irritation, and
Proteus, Candida, Klebsiella, and symptoms overlap with other itching may be related to urethritis or
Enterococcus. Women are
vaginitis (candidiasis or trichomonas
predisposed to cystitis because their urologic vaginitis). A patient who presents with
urethras are short and close to the
anus, which facilitates the entry of
conditions, such as dysuria, flank pain, fever, and chills,
and who looks ill may have pyelo
bacteria into the urinary tract. pyelonephritis. nephritis. (See Differential diagnoses
Behavioral and biologic factors for cystitis.)
may predispose patients to cystitis. pyelonephritis, diabetes, AIDS, and
Behavioral factors include urinary pregnancy.
Diagnosis
catheterization or sexual intercourse; Other potential predisposing factors for
Ms. Johnson’s symptoms of urinary
biologic factors include structural cystitis include age, reduced mobility,
urgency and frequency in addition to
abnormalities and metabolic or changes in acidity in the vagina, and
being premenopausal. dysuria are consistent with a
hormonal conditions. Other biologic
Ms. Johnson’s risk factors for diagnosis of uncomplicated cystitis.
factors include spinal cord injury,
uncomplicated cystitis include being To confirm this diagnosis, a urine
renal calculi, transplant, cysts, urinary
female and sexually active. dipstick, microscopic urine analysis,
incontinence, prostate enlargement,
or urine culture may be ordered. Im-
kidney stones, urinary obstruction, Differential diagnoses

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Consider the following conditions when determining if the patient has cystitis.

Condition Patient presentation Etiology

Nephrolithiasis • Flank pain • Gout

• Renal colic • Hypercalciuria
• Hematuria • Hyperparathyroidism
• Fever • Obesity
• Dysuria • Renal tubular acidosis
• Abdominal pain • History of GI surgery
• Suprapubic pain • Cystic kidney disease
• Medications such as
- calcium-based antacids
- indinavir
- topiramate
- antiseizure agents

Pelvic inflammatory • Endocervical discharge • Intrauterine device disease

• Cervical motion tenderness • Gonorrhea
• Pelvic pain • Chlamydia
• Fever • Abortion
• Dysuria • Miscarriage
• Lower abdominal pain

Pyelonephritis • Urinary urgency • Recurrent infection

• Urinary frequency • Benign prostatic hyperplasia
• Flank pain • Renal stone
• Costovertebral angle • Pregnancy
 tenderness • Diabetes
• Nausea/vomiting
• Dysuria • Fever

Urethritis • Urethral irritation or itching • Gonorrhea

• Dysuria • Chlamydia
• Urethral discharge • Herpes simplex virus
• Yeast infection

Vaginitis • Vaginal discharge or odor • Bacterial vaginosis

• Dysuria • Trichomoniasis
• Pruritus • Yeast infection
• Vaginal dryness • Douching
• Dyspareunia • Tampons
• Urinary urgency or frequency • Contraceptive devices
• E. coli
• HIV
Sources: Giarenis, Robinson 2016; Michels, Sands 2015; National Institute of Diabetes and Digestive and Kidney
Disease 2017; National Kidney Foundation 2017; National Kidney Foundation® 2016; Sharp et al. 2014; Zak
2014.
A 3-day course of antibiotic
therapy, as recommended by the
Infectious Diseases Society of
aging studies aren’t recommended for the simplest tool to screen for cystitis, America 2011 guidelines, usually is
uncomplicated cystitis. but its low specificity and sensitivity sufficient to eradicate uncomplicated
may generate false results. Positive cystitis.
Urine dipstick leukocyte esterase and nitrite tests from (See Treatment options.)
A urine dipstick checks for urine pH, a urine dipstick may indicate cystitis, Based on Ms. Johnson’s diagnosis
glucose, protein, bilirubin, blood, and but they also may indicate bacterial and allergies to nitrofurantoin, tri
white blood cells (WBCs). It’s growth and pyuria. methoprim-sulfamethoxazole, and
Differential diagnoses for cystitis However, negative test results, when
combined with positive clinical presentations, don’t rule out cystitis.
Ms. Johnson’s urine dipstick results are positive for leukocyte esterase and nitrite, so cystitis treatment should be
considered.

Microscopic urinary analysis

A microscopic exam measures red blood cells (RBCs) and WBCs in the urine and detects casts, bacteria, hematuria, and
crystals.
Ms. Johnson’s urinary sediment results are positive for WBCs, RBCs, and bacteria, which may be associated with cystitis.

Urine culture
A urine culture is a definitive diagnostic test to guide drug treatment and provide a cure for UTIs. It helps determine the
source of infection, so that proper antibiotic treatment can be ordered, thereby avoiding unnecessary therapy. A urine culture
of > 105 CFU/mL is diagnostic for UTIs.
A culture was not needed in Ms. Johnson’s case because her cystitis was considered uncomplicated; a urine cultures is
used to diagnose complicated cystitis.

Managing uncomplicated cystitis

Antibiotic treatment goals for cystitis include relieving symptoms, preventing bacterial resistance and kidney complications,
and curing the infection. Local resistance rates, bacterial pathogens (if known), patient allergies and comorbidities, drug
costs and adverse effect profiles, and history of medication adherence should guide your choice of antibiotic treatment.

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The Infectious Diseases Society of America’s 2011 guidelines recommend a 3-day

course of antibiotics to treat cystitis. Medication options include nitrofurantoin,
trimethoprim-sulfamethoxazole, fosfomycin, and fluoroquinolone. You can view the
algorithm at academic.oup.com/cid/article/52/5/e103/388285.
Nitrofurantoin
The Infectious Disease Society in America (IDSA) recommends oral nitrofurantoin
as first-line treatment for patients with uncomplicated cystitis who have no urologic
abnormalities, aren’t pregnant, and are premenopausal. Dosage: 100 mg twice daily
for 5 days
Considerations: Avoid if pyelonephritis is suspected, and administer with caution if
creatinine clearance < 30 mL/min.
Trimethoprim-sulfamethoxazole
Trimethoprim-sulfamethoxazole is a bacteriostatic antimicrobial agent that
inhibits folic acid synthesis from bacteria growth. Dosage: 160/800 mg twice
daily for 3 days
Considerations: Possible adverse effects include hemolytic anemia, liver injury, and
bone marrow suppression; it also may cause systemic toxicity when used
concomitantly with methotrexate.
Fosfomycin
Fosfomycin is a bactericidal broad-spectrum antibiotic that inhibits bacterial cell wall
synthesis.
Dosage: Single 3-g dose
Considerations: Fosfomycin is contraindicated in patients with Clostridium difficile–
associated diarrhea, hepatic necrosis, heart failure, or an asthma exacerbation. I.V.
administration can result in hypokalemia.

If none of the recommended antibiotics can be used, consider the following:

Fluoroquinolone
Fluoroquinolone is toxic to the kidneys and liver, so baseline creatinine and liver
function tests are needed before treatment begins. Dosage: 250 mg twice daily for
3 days
Considerations: Contraindications include tendinitis, peripheral neuropathy, tendon
rupture, high bacterial recurrence rates, and increasing antimicrobial resistance.
Fluoroquinolone also potentiates warfarin drug therapy.
Beta-lactams
Use of a beta-lactam requires close follow-up because it’s related to vaginal reservoirs
of infection.
Dosage: Varies by drug
Considerations: Avoid using ampicillin or amoxicillin alone; they have lower efficacy
than other beta-lactams. Adverse effects for both ampicillin and amoxicillin include
oral and vulvovaginal candidiasis, rash, and urticaria.
Source: Gupta et al 2011.
 Treatment options

fosfomycin, you prescribe a 3-day course them to take the full course of
of fluoroquinolone 250 mg twice daily. antibiotics to cure the infection and
prevent antimicrobial resistance. In
Education and prevention addition, review possible medication
Prevention begins with education. Explain adverse effects and when the patient
to patients that treatment adherence will should seek help. Patients with
help prevent reinfection and relapse of complicated cystitis should have a
cystitis. Instruct repeat urine culture to confirm the
infection is cured.
Suggest other steps patients can take at home to prevent cystitis, such as drinking adequate amounts of water to help clear
bacteria from the body. This is especially important for someone who has difficulty emptying his or her bladder because of
conditions such as bladder spasms. Other preventive measures include cleaning the perineal area as needed, wiping from
front to back after urinating, changing underwear every day, and cleaning with soap and water after each bowel movement.
Some patients benefit from cranberry products, which acidify the urine and inhibit bacterial growth in the bladder. In one
study, cranberry juice consumption for 8 weeks (4 ounces daily) significantly reduced UTI symptoms among 24 female
participants. However, another study acknowledged that cranberry products have limited evidence in cystitis prevention.
 For patients with recurrent UTIs, prescribe a bactericidal prophylaxis antibiotic therapy. Methenamine 1 g by mouth four
times daily can be used as a preventive therapy. Refer patients with recurrent UTIs to urology or urogynecology for further
evaluation.
When Ms. Johnson returned for her next office visit for a routine checkup, she reported that she had had no further
episodes of infection.

Role of NP
Through careful assessment, diagnosis, and education, NPs can ensure that patients with cystitis are successfully treated.
Taking the additional step of explaining self-care actions also can promote a positive outcome and lay the groundwork for
preventing recurrence of infection and antibiotic resistance.
Visit americannursetoday.com/?p=47632 to view a list of selected references.

Myriam Jean Cadet is a family nurse practitioner and an adjunct professor at Lehman College in Bronx, New York.
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