The optimal use of diagnostic testing in women with acute uncomplicated cystitis1

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Abstract

Acute uncomplicated cystitis is a common and costly disorder in women, and there is considerable variation in the diagnostic strategies currently used in clinical practice. Because the diagnosis of cystitis can be established in most patients using the history alone, the clinician’s responsibility is to determine which patients require additional diagnostic testing. Patients with typical symptoms (i.e., dysuria, frequency, urgency, hematuria), without risk factors for complicated infection or pyelonephritis, and without a history of vaginal discharge, have a very high probability of cystitis and are appropriate candidates for empiric treatment. It is more difficult, however, to rule out infection in patients with suspected cystitis. Because the prevalence of culture-proven infection is very high in women who present with ≥1 symptom, and because the treatment threshold for this condition is low, a urine culture is generally required to rule out infection in patients with atypical symptoms, even in the presence of a negative dipstick test. In population-based, before-and-after studies, use of diagnostic algorithms has been shown to significantly decrease the use of urinalysis, urine culture, and office visits while increasing the percentage of patients who receive recommended antibiotics. These strategies have substantially reduced the cost of managing cystitis without an increase in adverse events or a decrease in patient satisfaction. Randomized controlled trials are needed to more closely examine the outcomes, costs of care, and patient satisfaction from different diagnostic and management strategies.

Section snippets

History

The history is critical in evaluating whether a woman has cystitis. Indeed, the diagnosis of cystitis can usually be made based on the history alone. The clinician’s responsibility is carefully considering when additional diagnostic tests are needed. We describe the utility of different historical features below.

Although cystitis is a very common cause of dysuria (pain or difficulty when urinating), other disorders may cause this symptom. Specifically, there are 3 major infectious causes of

Physical examination

Compared with symptoms, specific features on the physical examination have been subjected to less rigorous evaluation. Although a few reports do provide data on the accuracy of certain physical examination signs for the presence of cystitis,21, 22 in general, the physical examination is only marginally useful in the diagnosis of cystitis. In a retrospective chart review of 506 patients presenting to an emergency department with suspected UTI, Wigton et al22 found that the presence of

Urine collection

The midstream clean-catch technique has long been considered the standard method by which to collect urine from women. Several investigators, however, have questioned whether the time and expense associated with this procedure are warranted.2 This technique is somewhat time intensive, because a woman must first clean her perineum with either a bactericidal wash or saline, spread her labia, discard the initial urine sample, and then collect a midstream sample in a sterile container. A recent

Urinalysis

Urinalysis can be used to confirm the presence of bacteriuria or pyuria and is usually the only laboratory test required to establish the diagnosis of acute uncomplicated cystitis in a symptomatic patient. Urinalysis and urine culture (including antimicrobial susceptibility tests) should always be obtained in patients with suspected pyelonephritis. Microscopic methods that may be used for determining the presence of bacteriuria include the Gram stain and microscopy of urinary sediment. The Gram

Urine culture

The gold standard for bacteriuria remains the quantitative urine culture. The amount of bacterial growth required before the urine culture is considered “positive” depends on whether a patient has symptoms of urinary tract infection. Among asymptomatic patients, bacteriuria is designated as significant when there are bacteria ≥105 CFU/mL of voided urine in otherwise healthy patients. In women with clinical symptoms suggesting uncomplicated cystitis, a quantitative urine culture of ≥102 CFU/mL

Treatment threshold

The decision to treat a patient (for any condition) depends in part on the costs and benefits of treatment. Costs include both financial costs incurred by the patient and risks of adverse outcomes or side effects. Benefits include both symptomatic relief and the prevention of more serious diseases. The treatment threshold defines a probability of disease above which treatment is the preferred strategy (benefits of treatment outweigh costs of treatment) and below which no treatment is the

Telephone-based management

Given the above discussion about probabilities of disease and importance of historical features, it is reasonable to consider telephone-based therapy for women with symptoms of acute uncomplicated cystitis. Recently, a small, randomized controlled trial compared telephone management with office evaluation in 72 women with suspected UTI.29 Patients with symptoms suggestive of pyelonephritis, vaginitis, or cervicitis and patients with risk factors for complicated infections were excluded. All

Diagnostic algorithms

Several proposed algorithms exist for the approach to a patient with symptoms of cystitis.30, 32, 34 Most algorithms, like the one evaluated by Group Health Cooperative described in detail above,30 initially attempt to include only those women with presumed acute uncomplicated cystitis. Thus, patients with diabetes mellitus, recent urinary tract manipulation, possible pregnancy, receiving recent treatment for cystitis, or with other predictors for having a complicated infection are excluded

Conclusions

Acute uncomplicated cystitis is an extremely common infection in women. Although diagnostic evaluation of this disorder has been shown to vary considerably, recent data provide important information to guide clinicians when evaluating women with presumed cystitis. It is critically important that health-care providers carefully consider when treatment can be initiated based on historical data alone and when additional diagnostic information is necessary. In women without risk factors for a

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