What is the initial approach to treating a patient with cystitis and hematuria?

Initial Approach to Treating Cystitis with Hematuria

The initial approach to treating cystitis with hematuria should include a thorough urinalysis with microscopic examination, urine culture to rule out infection, and empiric antibiotic therapy with trimethoprim-sulfamethoxazole for uncomplicated cases while awaiting culture results. 1, 2

Diagnostic Evaluation

Laboratory Assessment

• Complete urinalysis with microscopic examination
• Urine culture to identify causative organism
• Complete blood count to assess for systemic disease
• Renal function tests (BUN, creatinine)
• Assess for dysmorphic RBCs (>80% suggests glomerular origin)
• Check for RBC casts (pathognomonic for glomerular bleeding)

Risk Stratification

Patients with hematuria should be categorized into risk groups:

• High-risk factors requiring prompt evaluation:
  • Age (women ≥50 years, men ≥40 years)
  • Smoking history >30 pack-years
  • Gross hematuria or >25 RBC/HPF
  • History of pelvic radiation
  • Chronic urinary infections
  • Occupational exposures (dyes, chemicals) 1

Imaging Considerations

• For uncomplicated cystitis with hematuria, imaging is generally not required initially
• Consider cystoscopy if Hunner lesions are suspected in patients with chronic symptoms 3
• For painful hematuria with suspected urolithiasis, ultrasound is appropriate as first-line imaging 3

Treatment Algorithm

Step 1: Empiric Antibiotic Therapy

• For uncomplicated cases, initiate empiric treatment with trimethoprim-sulfamethoxazole 2
• Alternative options include fluoroquinolones or nitrofurantoin based on local resistance patterns
• Adjust therapy based on culture results and antibiotic sensitivities

Step 2: Supportive Care

• Ensure adequate hydration
• Analgesics for pain management
• Consider phenazopyridine for symptomatic relief of dysuria

Step 3: Follow-up and Further Evaluation

• If symptoms resolve and urine culture confirms bacterial infection, complete antibiotic course
• If hematuria persists after treatment or culture is negative:
  • For patients with risk factors, refer for urologic evaluation including cystoscopy 1
  • Consider renal ultrasound to evaluate for structural abnormalities 3

Special Considerations

Severe Hemorrhagic Cystitis

For patients with severe bleeding:

• Consider hospital admission for monitoring
• Continuous bladder irrigation with normal saline may be necessary 4
• Urologic consultation for potential cystoscopy with fulguration 5

Emphysematous Cystitis

• Rare but serious complication requiring prompt recognition
• Risk factors include diabetes mellitus and immunosuppression
• CT scan is diagnostic, showing gas within bladder wall
• Requires hospitalization, IV antibiotics, and close monitoring 6, 7

Common Pitfalls to Avoid

• Assuming benign cause without complete evaluation in high-risk patients 1
• Inadequate imaging in high-risk patients 1
• Dismissing microscopic hematuria in patients with overactive bladder symptoms 1
• Delays >9 months in evaluation of hematuria in patients with bladder cancer are associated with decreased survival 1
• Failing to perform proper hematuria workup in patients with tobacco exposure, given high risk of bladder cancer 3

Follow-up Recommendations

• If asymptomatic microhematuria persists after negative urologic workup, conduct yearly urinalyses
• If a patient with persistent asymptomatic microhematuria has two consecutive negative annual urinalyses, no further evaluation is necessary 1
• For persistent or recurrent hematuria after initial negative workup, consider repeat evaluation within 3-5 years 1