Treatment of Cystitis with Hematuria
For uncomplicated cystitis presenting with hematuria in women, treat with first-line antimicrobial therapy using nitrofurantoin 100 mg twice daily for 5 days, fosfomycin trometamol 3 g single dose, or pivmecillinam 400 mg three times daily for 3-5 days, as the presence of hematuria does not change the standard treatment approach for acute cystitis. 1, 2
Initial Assessment and Diagnosis
The presence of hematuria in cystitis does not alter the fundamental diagnostic approach:
Diagnosis is clinical based on lower urinary tract symptoms (dysuria, frequency, urgency) without vaginal discharge, and hematuria is a common associated finding that does not require additional workup in typical uncomplicated cystitis 1
Urine culture is NOT routinely needed for typical uncomplicated cystitis with hematuria unless specific red flags are present 1
When to Obtain Urine Culture
Order urine culture only in these specific situations 1:
- Suspected acute pyelonephritis (fever, flank pain, systemic symptoms)
- Symptoms that do not resolve or recur within 4 weeks after treatment completion
- Atypical symptom presentation
- Pregnancy
- Men with UTI symptoms
First-Line Antimicrobial Treatment Options
The 2024 European Association of Urology guidelines recommend these first-line agents 1, 2:
Preferred First-Line Agents
Nitrofurantoin: 100 mg twice daily for 5 days (monohydrate/macrocrystals or macrocrystals prolonged release formulation) 1, 2
Fosfomycin trometamol: 3 g single dose (convenient single-dose therapy, though may have slightly inferior efficacy compared to multi-day regimens) 1, 2
Pivmecillinam: 400 mg three times daily for 3-5 days (where available; limited availability in North America) 1, 2
Alternative Treatment Options
Use these agents when first-line options cannot be used 1, 2:
Trimethoprim-sulfamethoxazole: 160/800 mg twice daily for 3 days, ONLY if local E. coli resistance rates are below 20% 1, 2, 3
Trimethoprim alone: 200 mg twice daily for 5 days (avoid in first trimester of pregnancy) 2
Cephalosporins (e.g., cefadroxil 500 mg twice daily for 3 days): Use only if local E. coli resistance is less than 20% 2
Agents to Avoid or Reserve
Fluoroquinolones (ciprofloxacin, levofloxacin): Highly effective but should be reserved for more invasive infections like pyelonephritis due to concerns about antimicrobial resistance and collateral damage 1, 2, 4
Amoxicillin or ampicillin: Should NOT be used for empirical treatment due to poor efficacy and very high prevalence of resistance worldwide 1, 2
Beta-lactams (amoxicillin-clavulanate, cefdinir, cefpodoxime): Less effective than first-line agents and should only be used when other options cannot be utilized 1
Symptomatic Management Consideration
- For mild to moderate symptoms, symptomatic therapy with ibuprofen may be considered as an alternative to antimicrobial treatment after discussion with the patient 1
- However, immediate antimicrobial therapy is generally recommended rather than delayed treatment or symptom management alone for optimal outcomes 4
Special Populations
Men with Cystitis and Hematuria
- Longer treatment duration required: 7 days minimum 2
- Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 7 days is recommended 2
- Digital rectal examination should be performed to evaluate for prostate disease 1
Pregnant Women
- Avoid trimethoprim in first trimester and trimethoprim-sulfamethoxazole in last trimester 2
- Urine culture is mandatory in pregnant women with cystitis symptoms 1
Treatment Failure Management
If symptoms persist or recur within 2 weeks after treatment completion 1:
- Obtain urine culture and antimicrobial susceptibility testing 1
- Assume the infecting organism is not susceptible to the originally used agent 1
- Retreat with a 7-day regimen using a different antimicrobial agent 1, 2
Follow-Up Recommendations
- Routine post-treatment urinalysis or urine cultures are NOT indicated for asymptomatic patients after successful treatment 1, 2
- Follow-up cultures are only needed if symptoms persist or recur within 2-4 weeks 2, 5
Critical Pitfalls to Avoid
- Do not assume hematuria requires different treatment: Hematuria is a common manifestation of acute cystitis and does not necessitate alternative antimicrobial selection or longer treatment duration in uncomplicated cases 1
- Do not routinely order urine cultures: This leads to unnecessary testing and does not improve outcomes in typical uncomplicated cystitis 1
- Do not use fluoroquinolones as first-line: Reserve these for pyelonephritis and complicated infections to preserve their efficacy 1, 2, 4
- Check local resistance patterns: Trimethoprim-sulfamethoxazole should only be used empirically where E. coli resistance is documented to be below 20% 1, 2