Take home messages in the management of cystitis

Cystitis may sometimes be dismissed as little more than a nuisance but given the wide range of possible causes, this condition warrants careful attention. Updated guidance from SIGN provides a template for best practice

Cystitis, or bladder inflammation, describes a wide range of conditions caused by different aetiologies and pathologies but with a broadly similar presentation. Key symptoms are dysuria, frequency, urgency and occasionally suprapubic pain. Symptoms are generally non-specific and although commonly associated with bacterial infection of the lower urinary tract, can also be caused by non-infectious conditions such as radiation treatment, calculi and carcinoma.¹ Returning travellers who present with cystitis should have a detailed travel history taken to ascertain their exposure to schistosomiasis (bilharzia) and a urine check and blood test for infection.² This article, however, will focus primarily on bacterial urinary tract infections (UTIs) in adults.

SCALE OF THE PROBLEM

UTIs are one of the most commonly acquired bacterial infections in ambulatory and hospitalised populations. Data from the UK is scant but it is estimated that in the United States, UTIs account for more than 7 million physician visits, including more than 2 million for cystitis, along with an additional 1 million visits to A&E and resulting in 100,000 hospital admissions, mainly for pyelonephritis. Approximately 15% of all community prescribed antibiotics in the US are for UTIs at an estimated annual cost of $1 billion and the total estimated annual cost of community-acquired UTIs to the US is approximately $1.6 billion. Importantly, UTIs accounted for around 40% of hospital-acquired infections, mainly associated with catheter use. In addition, the pathogens involved are fully exposed to the healthcare environment and it is no surprise therefore that hospital acquired UTIs comprise the largest reservoir of antibiotic resistant pathogens.³

Take home message 1

Recent guidelines published by the Scottish Intercollegiate Guidelines Network (SIGN) attempt to standardise the management of suspected bacterial urinary tract infections in adults,4 and provide useful algorithms relating to the treatment of adult women, pregnant women, adult men and patients with catheters.

PRACTICE NURSE ROLE

Cystitis is more common in adult women due to the anatomical position of the urethra and anus thereby making it easier for bacteria from the rectum to be transferred to the urethra. It is estimated that almost all women will have an episode of cystitis in their lifetime, and around one in five women who have had cystitis will have recurrent episodes. Risk factors for recurrence include sexual activity, the menopause and antibacterial resistance. It is therefore very common for symptomatic women to present to the practice nurse. Practice nurses who undertake telephone triage will undoubtedly have calls relating to symptoms and may be encouraged to prescribe antibiotic treatment without seeing the patient in an attempt to save valuable appointments and consultation time. The SIGN guidelines quote data indicating that a telephone consultation with a nurse practitioner was as safe and effective as a standard face-to-face medical consultation and was the preferred option for the majority of women and potentially cost effective. However, SIGN also emphasises the Department of Health's recommendation to primary care, 'to limit antibiotic prescribing over the telephone'. The guideline also cites studies that found a marked increase in return visits for sexually transmitted diseases (STDs) among patients managed over the phone.⁴

Take home message 2

The guidelines recommend that in order to exclude an STD, e.g. chlamydia, as a cause of the symptoms, a telephone consultation cannot be recommended as an alternative to a standard (face-to-face) consultation. If vaginal discharge is present, the probability of UTI falls and a PV examination should be conducted to rule out other causes such as STDs or candida.

URINE TESTING

The quality of evidence for the use of urine reagent test strips (urine dipsticks) to determine treatment of symptoms, is poor. A meta analysis of urine dipsticks found that a positive leucocyte AND postitive nitrite was more likely to confirm a UTI, than either a positive leucocyte OR positive nitrite, which was less likely to predict UTI than a combination of signs and symptoms, particularly dysuria and frequency. Where only one sign or symptom is present, a positive dipstick (for either leucocytes or nitrites) is associated with a high probability of infection (around 80%) and a negative test with a much lower probability (around 20%). However, negative tests do not exclude UTI. Studies have shown that symptomatic women with a negative dipstick, who were treated with a 3-day course of antibiotics, showed an improvement in symptoms.^4,5

Take home message 3

Symptoms are key: the guidelines suggest that in otherwise healthy women under the age of 65, who present with mild or less than 2 symptoms (dysuria, nocturia, frequency, cloudy or smell urine) urine dipsticks may be helpful in guiding whether to treat or not. If dysuria and frequency are both present, then the probability of UTI is >90% and an antibiotic should be prescribed.

ADVICE

Practice nurses can play a large role in educating women about the causes of cystitis and simple preventative measures for example, wiping from front to back and micturating post intercourse. Simple pain relief such as paracetamol or ibuprofen can help relieve symptoms, as can a hot water bottle for topical relief. Many women will buy over the counter (OTC) remedies to relieve mild cystitis. These are generally urine-alkalising agents such as sodium bicarbonate or potassium citrate, but the evidence for their effectiveness is limited and they are omitted from the recent guidelines.⁶

Cranberries have long been used as folk remedy to prevent UTI. Researchers in 1984 discovered that cranberries contain a substance called proanthocyanidin (PAC), which interferes with the attachment of bacteria to uroepithelial cells.⁷

A recent meta-anaylsis found that cranberry-containing products are associated with protective effects against UTIs, however there was a large variance between the cranberry products used in the studies, with products varying from 0.838mg of PAC to 224mg per day with no minimum protective amount identified.⁷ The authors conclude that among women who suffer recurrent UTIs, cranberry juice drinkers and those who use cranberry containing supplements more than twice a day, may benefit the most from its protective effects.⁷ It is important to note that a potentially fatal drug interaction with warfarin can occur in those taking cranberry supplements and patients on warfarin should be therefore advised to avoid such products unless the benefit outweighs the risk.^4,8

Take home message 4

The SIGN guidelines suggest that women with recurrent UTI should be advised to consider the benefits of cranberry products, but that cranberry capsules may be more convenient than juice, and that high strength capsules may be most effective. Health care professionals should consider increasing medical supervision and INR monitoring in those patients also being prescribed warfarin.⁴

PREGNANT WOMEN

Symptomatic bacteriuria occurs in 17-20% of pregnancies, and 10-30% of women with bacteriuria in their first trimester will develop a UUTI in their second or third trimester. This has important implications. Bacteriuria has been linked to pre-labour, premature rupture of membranes and pre-term labour. In addition untreated UUTI carries a risk of both morbidity and mortality to the pregnant woman herself. Dipstick testing with urine reagent strips is not sensitive enough to be used as a screening test in an antenatal clinic, therefore a urine culture should be sent from every pregnant woman at their 'booking in' visit. ⁴

Take home message 5

UTI in pregnancy can be problematic for both mother and developing baby. All pregnant women should have a urine sample sent for culture during their first trimester, followed by a second culture to confirm positive results. Urine dipsticks should not be used to detect UTI but simply to determine protein and glucose.⁴

MEN

Urinary tract infections in men are generally regarded as 'complicated' because they result from either an anatomic or functional anomaly i.e. obstruction due to enlarged prostate, or following cystoscopy. The annual incidence of UTI in men under the age of 50 is approximately 5-8 per 10,000, although rates approach those in women over the age of 60.⁹ Conditions such as prostatitis, chlamydial infection and epididymitis should be considered in the differential diagnosis of men over the age of 50 presenting with acute dysuria, as should glycosuria in those presenting with frequency and nocturia. As with young women, sexually transmitted infections (STIs) should be considered in those aged 15-50. NICE has specific guidelines for the management of lower urinary tract symptoms in men.¹⁰

Take home message 6

UTI in young men under the age of 50 is very uncommon, however the incidence of UTI in those aged over 50 years rises considerably. All men presenting with symptoms of a UTI should have a urine sample sent for culture. Consider UUTI in those presenting with a history of pyrexia and/or back pain, and consider other conditions such benign prostatic hyperplasia (BPH) or prostatitis in the differential diagnosis.

HAEMATURIA

When to suspect cancer?

Haematuria often occurs with an episode of UTI, and may be associated with malignancy.

Prostate cancer should be suspected in men presenting with:

• Erectile dysfunction
• Haematuria
• Lower back pain
• Bone pain
• Weight loss

Bladder and renal cancer should be considered in:

• Male and female adult patients of any age who present with painless macroscopic haematuria
• Male and female patients who present with symptoms suggestive of UTI and macroscopic haematuria but whose urine culture is negative
• All adults aged 40 years and over who present with recurrent or persistent UTI associated with haematuria
• Those aged under 50 years with microscopic haematuria who have no proteinuria and a normal serum creatinine
• Those aged over 50 with unexplained microscopic haematuria¹¹

Take home message 7

Practice nurses should be alert to the possibility of cancer when confronted by unusual symptom patterns or when patients who are thought not to have cancer fail to recover as expected.¹¹

TREATMENT

Adult women: treat non-pregnant women of any age with signs or symptoms of acute LUTI with a 3-day course of trimethoprim or nitrofurantoin. Particular care should be taken when prescribing nitrofurantoin to elderly patients who may be at increased risk of toxicity. Treat non-pregnant women with signs or symptoms of acute UUTI with a course of ciprofloxacin (7 days) or co-amoxiclav (14 days).

Pregnant women: treat symptomatic and asymptomatic pregnant women with an antibiotic: usually 7 days is sufficient; refer to local guidelines for advice on the choice of antibiotic.

Adult men: Treat uncomplicated LUTIs with a 7-day course of trimethoprim or nitrofurantoin. Treat bacterical UTIs in men with symptoms suggestive of prostatitis empirically with a quinolone. Refer men for urological investigation if they have symptoms of UUTI, fail to respond to appropriate antibiotics or have recurrent UTI.⁴

Take home message 8

Do not treat non-pregnant women - of any age - with asymptomatic bacteriuria with an antibiotic. Limiting the use of broad spectrum antibiotics such as cephalosporins, quinolones and co-amoxiclav is a key measure in reducing antimicrobial resistance and healthcare associated infections such as methicillin resistant Staphylococcus aureus (MRSA) and Clostridium difficile infection (CDI).

CONCLUSION

Cystitis is often perceived by women as a short-lived, albeit painful, inconvenience, which can be self treated using products bought over the counter; however, the reality for many is that cystitis is caused by a bacterial infection which can, in the case of pregnant women, cause major problems if left untreated. Practice nurses have a key role in the education of patients, discussing treatment options, noting red flags and referring onwards for specialist opinion as necessary.

REFERENCES

1. Szigeti R G. Pathology of cystitis. Medscape Reference. 2012. Available at: http://emedicine.medscape.com/article/2055346-overview [Accessed: 29 July 2012]

2. Field VF, Ford L, Hill DR eds. The Well Returned Traveller: Shistosomiasis screening. Health Information for Overseas Travel. National Travel Health Network and Centre (NaTHNaC). 2010.

3. Grabe M, Bjerklund-Johansen T E, Botto H, Wullt B, Cek M, Naber K G, Pickard R S et al Guidelines on Urological Infections. European Association of Urology. 2011. Available at: http://www.uroweb.org/gls/pdf/15_Urological_Infections.pdf [Accessed: 21 July 2012]

4. SIGN/Health Improvement Scotland. SIGN 88 Management of suspected bacterial urinary tract infections in adults. 2012. Available from: http://www.sign.ac.uk [Accessed: 20July 2012]

5. Little P, Turner S, Rumsby K, Jones R, Warner G, Moore M, Lowes J A et al. Validating the prediction of lower urinary tract infection in primary care: sensitivity and specificity of urinary dipsticks and clinical scores in women. British Journal of General Practice. 2010; 60:495-500. Available at: http://www.rcgp.org.uk/bjgp [Accessed: 14 July 2012]

6. NHS Choices. Cystitis information pages. 2012. http://www.nhs.uk/Conditions/Cystitis/Pages/Introduction.aspx [Accessed: 20 July 2012]

7. Wang C-H, Fang C-C, Chen N-C, Liu S S-H, Yu P-H, Wu T-Y, Chen W-T et al. Cranberry-Containing Products for Prevention of Urinary Tract Infections in Susceptible Populations: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Archives of Internal Medicine. 2012; 172(13): 988-996. Available at: http://www.archinte.jamanetwork.com [17 July 2012]

8. Hisano M, Bruschini H, Nicodemo A C, Srougi M. Cranberries and lower urinary tract infection prevention. Clinics (Sao Paulo). 2012;67(6):661-667. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3370320/pdf/cln-67-06-661.pdf [Accessed: 21 July 2012]

9. Brusch JL. Urinary tract Infections in Males. Medscape Reference. 2012. Available at: http://emedicine.medscape.com/article/231574-overview [Accessed: 30 July 2012]

10. NICE Clinical Guideline 97. The management of lower urinary tract symptoms in men. 2010. Available at: http://www.nice.org.uk/nicemedia/live/12984/48557/48557.pdf [Accessed: 21 July 2012]

11. NICE Clinical Guideline 27. Referral Guidelines for Suspected Cancer. 2005. Available at: http://www.nice.org.uk/nicemedia/pdf/cg027niceguideline.pdf [Accessed: 30 July 2012]