The optimal use of diagnostic testing in women with acute uncomplicated cystitis1
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
References (36)
- et al.
Presentation, diagnosis, and treatment of urinary-tract infections in general practice
Lancet
(1965) Measurement of pyuria and its relation to bacteriuria
Am J Med
(1983)- et al.
Diagnosis and treatment of uncomplicated urinary tract infection
Infect Dis Clin North Am
(1997) - et al.
The effectiveness of a clinical practice guideline for the management of presumed uncomplicated urinary tract infection in women
Am J Med
(1999) - et al.
Mechanism of action and impact of a cystitis clinical practice guideline on outcomes and costs of care in an HMO
J Comm J Qual Improv
(1996) - et al.
Management of urinary tract infections in adults
N Engl J Med
(1993) Urinary Tract Infections: Detection, Prevention, and Management
(1997)- et al.
Diagnosis and treatment of acute urinary tract infections
Infect Dis Clin North Am
(1987) Variations among family physicians’ management strategies for lower urinary tract infection in womena report from the Washington Family Physicians Collaborative Research Network
J Am Board Fam Pract
(1991)- et al.
Variation by specialty in the treatment of urinary tract infection in women
J Gen Intern Med
(1999)
Causes of the acute urethral syndrome in women
N Engl J Med
Diagnosis of coliform infection in acutely dysuric women
N Engl J Med
Establishing the cause of genitourinary symptoms in women in a family practice. Comparison of clinical examination and comprehensive microbiology
JAMA
Promoting quality through managed care
Am J Med Qual
Association between use of spermicide-coated condoms and Escherichia coli urinary tract infection in young women
Am J Epidemiol
Association between diaphragm use and urinary tract infection
JAMA
Risk factors for recurrent urinary tract infection in young women
J Infect Dis
Risk factors for urinary tract infection
Am J Epidemiol
Cited by (59)
A cost-minimization analysis of treatment options for postmenopausal women with dysuria
2019, American Journal of Obstetrics and GynecologyThe Emergency Department Diagnosis and Management of Urinary Tract Infection
2018, Emergency Medicine Clinics of North AmericaCitation Excerpt :UTI and STI can overlap with symptoms, including dysuria, although UTI is typically not associated with vaginal discharge as with STI.3,28,29 STI typically presents with more gradual onset of symptoms, vaginal discharge/bleeding, lower abdominal pain, pruritis, dyspareunia, external dysuria, new sexual partner, and no change in frequency or urgency.118 Chlamydia trachomatis and Neisseria gonorrhoeae are the most common causes of cervicitis or PID in women and epididymitis or prostatitis in reproductive-aged men.3,103–105
Glycemic Control and Urinary Tract Infections in Women with Type 1 Diabetes: Results from the DCCT/EDIC
2016, Journal of UrologyCitation Excerpt :Without these data it is not possible to know if recall bias may have affected our findings. However, recent studies suggest that diagnostic tests such as urinalysis and urine cultures are rarely necessary in the setting of uncomplicated cystitis.28 We have no reason to believe that any possible misclassification as a result of recall bias would have differed between specific exposure groups.
Acute health care utilization and outcomes for outpatient-treated urinary tract infections in children
2016, Journal of Pediatric UrologyTop Ten Myths Regarding the Diagnosis and Treatment of Urinary Tract Infections
2016, Journal of Emergency MedicineCitation Excerpt :Medical systems with reflex urine cultures for >5 white blood cells (WBC)/high-power field should be re-evaluated for their utility in the absence of patient symptoms (8–10). A dipstick leukocyte esterase test has high sensitivity and specificity for the presence of quantitative pyuria, 80–90% and 95–98%, respectively; however, a positive leukocyte esterase alone is NOT recommended for diagnosis of UTI (7,11). As in myth #2, symptoms are usually required for the diagnosis of UTI; pyuria or bacteriuria alone is not an indication for antimicrobial therapy and can result in an overtreatment rate of up to 47% (4,12).
Urinary Tract Infections
2014, Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases
- 1
No reprints available.