Approach

History

Uncomplicated cases can be diagnosed and treated on the basis of the history alone.[30]​ Doing this over the telephone without a clinic visit has been shown to be safe and effective.[31]​ Typical symptoms include dysuria, urgency, and frequency.​ Patients should be screened for factors that would qualify them as having complicated cystitis. Fever, chills, nausea, vomiting, abdominal pain, and flank pain can suggest possible pyelonephritis, and further evaluation with urinalysis and culture is mandatory.[1]​ Vaginal pruritus or discharge may suggest vaginitis.​ See Vaginitis.

Complicated cases include patients with any of the following:[1]​

  • Anatomical or functional abnormalities within the urinary tract

  • Male sex

  • Pregnancy

  • Immunosuppression (e.g., renal transplant)

  • Diabetes

  • Incomplete voiding

  • Indwelling urinary catheter

  • Recent instrumentation

  • Healthcare-associated infection

  • History of infection with extended spectrum beta-lactamase-producing organisms or other multi-drug resistant organisms.

These patients should always have their diagnosis confirmed with urinalysis and culture.[1]

Physical examination

Examination is typically unremarkable, suprapubic tenderness to palpation may be noted in some patients. Fever, tachycardia, vaginal discharge, or significant abdominal pain should raise the possibility of an alternative diagnosis. Costovertebral angle tenderness is highly suggestive of pyelonephritis. Vaginal atrophy may be present in post-menopausal women and can increase the risk of recurrent UTIs.

Laboratory testing

Urinalysis can quickly and easily confirm the diagnosis. The presence of haematuria combined with a positive dipstick test for nitrites has a high diagnostic utility for ruling in the diagnosis of UTI.[32][33] However, for patients with acute uncomplicated cystitis, a urinalysis is not necessary.[34] They can be treated on the basis of the history alone.

In patients with suspected complicated cystitis, the diagnosis should be confirmed with a urinalysis and urine culture. Antibiotics should be started and the treatment strategy can later be modified if necessary based on the culture and sensitivity results.

If there is any possibility that the patient may be pregnant, a pregnancy test should be obtained.

Use of this content is subject to our disclaimer