- The patient complains of urinary frequency, urgency, and suprapubic pain, with no fever, flank pain, or costovertebral angle tenderness. A urinalysis can confirm infection by presence of white blood cells or bacteria. - For uncomplicated lower UTI, prescribe a 3-day course of antibiotics like Bactrim, Cipro, or Noroxin. Extend treatment to 7 days for patients who are pregnant, diabetic, or have other medical issues. - Risk factors for UTI in women include pregnancy, sexual activity, use of diaphragms or spermicides, and history of prior UTI. Recurrent infections suggest inadequate treatment or underlying abnormalities.

1. Lower Urinary Tract Infection (Cystitis)
Presentation
The patient (usually female) complains of urinary frequency and urgency, internal
dysuria, and suprapubic pain. There may have been some antecedent trauma (sexual
intercourse) to inoculate the bladder, and there may be blood in the urine (hemorrhagic
cystitis). Usually, there is no labial irritation, external dysuria or vaginal discharge
(which would suggest vaginitis); and no fever, chills, nausea, flank pain, or
costovertebral angle tenderness (which would suggest an upper urinary tract infection.)
What to do:
• If available in the ED, dip stick for white cells or obtain a urinalysis or Gram stain
a sample of urine. The presence of any white cells or bacteria in a clean
specimen on microscopic examination confirms the infection. A positive nitrite on
dip stick is helpful, but a negative does not rule out infection because many
bacteria do not produce nitrites.
• If the clinical picture is clearly that of an uncomplicated lower UTI, give
trimethoprim 160mg plus sulfamethoxazole 800mg (Bactrim DS or Septra DS)
one tablet bid for three days or a 3 day regimen of a quinolone such as
ciprofloxacin (Cipro) 250mg bid, norfloxacin (Noroxin) 400mg bid or ofloxacin
(Floxin) 200mg bid. Single dose treatment with two TMP/SMX DS tablets is also
effective in the young healthy female, but does have a higher early recurrence
rate. Instruct the patient to drink plenty of liquids (such as cranberry juice) but
do not push fluids when treating children or males.
• Extend therapy to 7 days and obtain cultures when treating a patient who is
unreliable, pregnant, diabetic, symptomatic more than 5 days, older than 50 or
younger than 16. Also extend treatment and obtain cultures on all male patients
and those with an indwelling urinary catheter, renal disease, obstructive urinary
tract lesions, recurrent infection or other significant medical problems.
• If there are no bacteria or few white cells, no hematuria or suprapubic pain,
gradual onset over 7-10 days, and a new sexual partner, the dysuria may be
caused by a chlamydia. Perform a pelvic exam and obtain samples for culture
and microscopic examination. Ask the patient about the use of spermicides or
douches, which may irritate the periurethral tissue and cause dysuria.
• If there is external dysuria, vaginal discharge, odor, itching and no frequency or
urgency, then evaluate for vaginitis with a pelvic examination.
• If the dysuria is severe, you may also prescribe phenazopyradine (Pyridium)
200mg tid for 2 days only, to act as a surface anesthetic in the bladder. Warn
the patient that it will stain her urine (and perhaps clothes) orange.
• Arrange for followup in 2 days if the symptoms have not completely resolved. If
necessary, urine culture and a longer course of antibiotics can be undertaken
then.

2. What not to do:
• Do not undertake expensive urine cultures for every lower urinary tract infection
of recent onset in nonpregnant, normally health women with no history of recent
UTI or antibiotic use.
• Do not follow the single-dose or 3 day regimens for a possible upper urinary
tract infection.
• Do not rely on gross inspection of the urine sample. Cloudiness is usually caused
by crystals and odors result from diet or medication.
• Do not require a follow up visit or culture after therapy unless symptoms persist
or recur.
Discussion
Lower UTI or cystitis is a superficial bacterial infection of the bladder or urethra. The
majority of these infections involve Escherichia coli, Staphylococcus saprophyticus or
enterococci. The urine dip stick is a reasonable screening measure that can direct
therapy if results are positive. Under the microscope, in clean sediment (free of
epithelial cells) one white cell per 400 x fields suggests a significant pyuria, although
clinicians accustomed to imperfect samples usually set a threshold of 3-5 WBCs per
field. In addition, Trichomonas may be appreciated swimming in the urinary sediment,
indicating a different etiology for urinary symptoms or associated vaginitis. In a
straightforward lower UTI, urine culture may be reserved for cases which fail to resolve
with single-dose or 3 day therapy. In complicated or doubtful cases, however, or with
recurrences, a urine culture before initial treatment may be helpful.
Risk factors for UTI in women include pregnancy, sexual activity, use of diaphragms or
spermicides, failure to void post coitally, and history of prior UTI. Healthy women may
be expected to suffer a few episodes of lower urinary tract infection in a lifetime
without indicating any major structural problem, but recurrences at short intervals
suggest inadequate treatment or underlying abnormalities. Young men, however, have
longer urethras and far fewer lower UTIs, and probably should be evaluated urologically
after just one episode unless they have a risk factor such as an uncircumcised foreskin,
HIV infection or homosexual activity and respond to initial treatment. In sexually active
men, consider urethritis or prostatitis as the etiology. In men over 50 years old, there is
a rapid increase in UTI due to prostate hypertrophy, obstruction and instrumentation.