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  1. 1. Cystitis
  2. 2. Incidence <ul><li>1-3% of all GP consultations </li></ul><ul><li>5% of women each year with symptoms. Up to 50% of women will suffer from a symptomatic UTI during their lifetime. </li></ul><ul><li>UTI in men is much rarer </li></ul><ul><li>A proportion of patients may be symptomatic in the absence of infection - called 'urethral syndrome' </li></ul>
  3. 3. Symptoms <ul><li>Dysuria </li></ul><ul><li>Frequency </li></ul><ul><li>Nocturia </li></ul><ul><li>Urgency of micturition. </li></ul><ul><li>Other symptoms include suprapubic pain, cloudy or foul smelling urine and haematuria. </li></ul>
  4. 4. Causes <ul><li>The most common cause is bacterial infection </li></ul><ul><ul><li>Eschericia coli is the pathogen in 70% of uncomplicated case of lower urinary tract infections. </li></ul></ul><ul><ul><li>Other organisms include Proteus mirabilis, Klebsiella pneumoniae, Staphylococcus saprophyticus, Staphylococcus aureus and Pseudomonas species. </li></ul></ul><ul><li>Urethral Syndrome -not associated with any infection </li></ul><ul><li>Rarely kidney or bladder stones, prostatism, diabetes </li></ul>
  5. 5. Prevention <ul><li>Drinking plenty of fluids helps prevent cystitis in the first place. </li></ul><ul><li>If cystitis follows sexual intercourse, some advise passing urine soon after to try and prevent it. </li></ul><ul><li>There is no evidence to suggest a link between lower urinary tract infection and use of bath preparations </li></ul>
  6. 6. Beware! <ul><li>Pregnant </li></ul><ul><li>Under age 12 </li></ul><ul><li>Males </li></ul><ul><li>Systemically ill (fever, sickness, backache) </li></ul><ul><li>Catheterised patients </li></ul><ul><li>Kidney or bladder stones </li></ul>
  7. 7. Investigation <ul><li>Urine dipstick </li></ul><ul><ul><li>can be done in the surgery and will be positive for nitrates and leucocytes (leukocyte esterase test). This helps to differentiate those with UTI from the 50% with urethral syndrome. </li></ul></ul><ul><li>Urine microscopy and culture reveals significant bacteruria (usually >105 /ml). </li></ul><ul><li>Asymptomatic bacteruria </li></ul><ul><ul><li>is present in 12-20% of women aged 65-70 years and does not impair renal function or shorten life so no treatment </li></ul></ul><ul><ul><li>in 4-7% of pregnant women and associated with premature delivery and low birth weight and always requires treatment. </li></ul></ul>
  8. 8. Differential Diagnosis <ul><li>Urethral syndrome </li></ul><ul><li>Bladder lesion e.g. calculi, tumour. </li></ul><ul><li>Candidal infection </li></ul><ul><li>Chlamydia or other sexually transmitted disease. </li></ul><ul><li>Urethritis </li></ul><ul><li>Drug induced cystitis (e.g. with cyclophosphamide, allopurinol, danazol, tiaprofenic acid and possibly other NSAIDs) </li></ul>
  9. 9. Complications and Prognosis <ul><li>Ascending infection can occur, leading to development of pyelonephritis, renal failure and sepsis. </li></ul><ul><li>In children, the combination of vesicoureteric reflux and urinary tract infection can lead to permanent renal scarring, which may ultimately lead to the development of hypertension or renal failure. 12-20% of children already have radiological evidence of scarring on their first investigation for UTI. </li></ul><ul><li>Urinary tract infection during pregnancy is associated with prematurity, low birth weight of the baby and a high incidence of pyelonephritis in women. </li></ul><ul><li>Recurrent infection occurs in up to 20% of young women with acute cystitis. </li></ul>
  10. 10. Management Issues - General <ul><li>50% will resolve in 3 days without treatment </li></ul><ul><li>No evidence to support “drink plenty” </li></ul><ul><li>It is reasonable to start treatment without culture if the dipstick is positive for nitrates or leucocytes. </li></ul><ul><li>MSU if dipstick negative but suspicion </li></ul>
  11. 11. Management Issues - General <ul><li>Culture is always indicated in </li></ul><ul><ul><li>Men </li></ul></ul><ul><ul><li>Pregnant women </li></ul></ul><ul><ul><li>Children </li></ul></ul><ul><ul><li>Those with failure of empirical treatment </li></ul></ul><ul><ul><li>Those with complicated infection </li></ul></ul>
  12. 12. Self care <ul><li>Drink slightly acid drinks such as cranberry juice, lemon squash or pure orange juice (poor trial evidence for this) </li></ul><ul><li>Try a mixture of potassium citrate available from your pharmacist (little evidence but widely recommended) </li></ul>
  13. 13. Antibiotics <ul><li>Trimethoprim is an effective first line treatment. </li></ul><ul><li>Cephalosporins are as effective as trimethoprim but more expensive and more likely to disrupt gut flora. </li></ul><ul><li>Nitrofurantoin is as effective as trimethoprim but more expensive and frequently causes nausea and vomiting </li></ul><ul><li>The 4-quinolones (ciprofloxacin, norfloxacin, ofloxacin) are effective in the treatment of cystitis. To preserve their efficacy, they should not usually be used as first line therapy </li></ul>
  14. 14. Antibiotics <ul><li>3 days of antibiotic is as effective as 5 or 7 days </li></ul><ul><li>Single dose antibiotic results in lower cure rates and more recurrences overall than longer courses. </li></ul><ul><li>In relapse of infection (i.e. reinfection with the same bacteria), treatment with antibiotic for up to 6 weeks is recommended. </li></ul>
  15. 15. Antibiotics for UTI in Pregnancy <ul><li>Cephalosporins and penicillins are recommended in pregnancy because of their long term safety record </li></ul><ul><li>Nitrofurantoin is also likely to be safe during pregnancy </li></ul><ul><li>Quinolones, Trimethoprim and Tetracyclines are not recommended for use during pregnancy </li></ul><ul><li>Seven days of treatment is required. </li></ul><ul><li>Urine should be tested regularly throughout pregnancy following initial infection. </li></ul>