Chapter 27 · Acute lower urinary tract conditions
Acute cystitis and complicated lower urinary tract infection
Definition
Acute cystitis is a bladder infection with typical symptoms (dysuria, urinary frequency, urgency, suprapubic pain).
Clinical presentation
- Dysuria, stinging, burning.
- Frequency and urgency.
- Lower abdominal pain.
- Gross hematuria may occur.
- Fever is not typical of uncomplicated cystitis.
Complicated infection
Risk factors:
- an indwelling catheter;
- anatomical abnormalities;
- stones;
- diabetes mellitus;
- immunodeficiency;
- older age.
Features: higher resistance rates and risk of pyelonephritis and sepsis.
Diagnosis
- Urinalysis, culture with susceptibility testing.
- CBC, creatinine.
- Ultrasonography to rule out obstruction and stones.
- Urological evaluation for recurrent disease.
Treatment
- Uncomplicated cystitis in a nonpregnant woman: a short course of a first-line drug according to the local formulary. Do not use nitrofurantoin if pyelonephritis is suspected; consider kidney function when prescribing it. Use trimethoprim/sulfamethoxazole when susceptibility is confirmed or local resistance rates are acceptable.
- Cystitis in a man, a pregnant patient, or a patient with a catheter, anatomical obstruction, or systemic symptoms follows a separate management pathway, including culture and assessment of kidney function, the infection source, and local resistance.
- Symptomatic treatment: antispasmodics, analgesics.
Algorithm
| Step | Action |
|---|---|
| 1 | Establish the patient group: nonpregnant woman, man, pregnancy, catheter, systemic symptoms |
| 2 | Uncomplicated cystitis in a nonpregnant woman: treat according to the local formulary |
| 3 | Male patient, pregnancy, catheter, or risk factors: obtain a culture and follow a separate management pathway |
| 4 | Fever, flank pain, hypotension, or organ dysfunction: rule out systemic infection and obstruction |
| 5 | After culture results, adjust the drug and duration; do not treat asymptomatic bacteriuria without an indication |
Catheter-associated infection and asymptomatic bacteriuria
- Do not prescribe an antibiotic solely for pyuria, bacteriuria, cloudy urine, or odor in the absence of symptoms.
- In symptomatic infection, obtain a culture before antibiotics, provided this does not delay treatment; assess the need for catheter removal or replacement.
- Treat asymptomatic bacteriuria only for established indications, including pregnancy and before a urological procedure involving mucosal injury.
Acute bacterial prostatitis and prostatic abscess
- Consider acute bacterial prostatitis in fever, pelvic pain, dysuria, urinary retention, or sepsis. Do not perform vigorous prostatic massage.
- Obtain a urine culture and, in severe illness, blood cultures. Select the antibiotic according to severity, kidney function, local resistance, and culture results.
- In urinary retention, avoid repeated traumatic catheterization; the urologist selects the drainage method according to urethral condition and infection risk.
- If there is no clinical improvement, fever persists, or an abscess is suspected, perform imaging and assess the need for drainage.