Treatment of Chronic Cystitis with Gel-Like Urine Output
The gel-like urine output suggests encrusted cystitis or severe chronic inflammation requiring urgent urine culture, cystoscopy evaluation, and treatment with culture-directed antibiotics combined with bladder-specific therapies such as intravesical dimethyl sulfoxide (DMSO) or hydrodistention. 1, 2
Initial Diagnostic Approach
The gel-like appearance of urine is highly concerning for:
- Encrusted cystitis with calcified mucopurulent material, typically associated with alkaline urine pH and urea-splitting bacteria like Corynebacterium urealyticum 2
- Severe chronic inflammation with mucus production and cellular debris 2
- Interstitial cystitis with chronic inflammatory changes 3, 4
Obtain urine culture and sensitivity testing immediately before initiating treatment, as this is essential for all complicated UTI presentations 1. The gel-like material should prompt:
- Urinalysis with microscopy to assess for pyuria, alkaline pH, and crystalline material 5, 2
- Urine culture (even if prior cultures were negative, as chronic infections may require extended culture techniques) 5
- Cystoscopy with hydrodistention to evaluate for encrustation, glomerulations, Hunner's ulcers, or other pathology 1, 3, 2
Treatment Algorithm
Step 1: Antimicrobial Therapy for Complicated UTI
This presentation represents a complicated UTI requiring broader and longer treatment than uncomplicated cystitis 1:
- Empiric therapy: Use combination therapy with amoxicillin plus aminoglycoside, second-generation cephalosporin plus aminoglycoside, or intravenous third-generation cephalosporin 1
- Treatment duration: 7-14 days (14 days if male or if prostatitis cannot be excluded) 1
- Tailor antibiotics based on culture results and susceptibility testing 1
For chronic symptoms with pyuria despite negative cultures, consider extended antibiotic therapy (mean 383 days in one large case series) using first-generation antibiotics like cefalexin, nitrofurantoin, or trimethoprim combined with methenamine hippurate, as chronic UTI may be undetected by routine testing 5.
Step 2: Intravesical Therapies
For encrusted cystitis specifically, intravesical DMSO has shown efficacy as a novel treatment approach 2. Other bladder-directed therapies include:
- Hydrodistention during cystoscopy for both diagnostic and therapeutic purposes 3, 6
- Intravesical DMSO (50% solution) for chronic inflammation and encrustation 2, 6
- Intravesical heparin or combination agents for persistent inflammation 3, 6
Step 3: Adjunctive Oral Therapies
If interstitial cystitis component is identified on cystoscopy:
- Pentosan polysulfate as first-line oral therapy 3, 6
- Tricyclic antidepressants (e.g., amitriptyline) for pain modulation 3, 6
- Antihistamines to reduce mast cell-mediated inflammation 3, 6
Step 4: Address Underlying Complicating Factors
Identify and manage any urological abnormalities, as this is mandatory for complicated UTI resolution 1:
- Obstruction, incomplete voiding, foreign bodies, or vesicoureteral reflux 1
- Recent instrumentation or catheterization 1
- Immunosuppression or diabetes requiring optimization 1
Monitoring and Follow-Up
- Repeat urine culture if symptoms persist beyond 7 days of treatment or recur within 2-4 weeks 1, 7
- Do not routinely retest urine if symptoms resolve completely 7, 8
- Monitor for pyuria reduction as a biomarker of treatment response 5
- Consider imaging if repeated infection with struvite stone-forming bacteria (e.g., Proteus mirabilis) 7
Critical Pitfalls to Avoid
- Do not treat as simple uncomplicated cystitis with 3-5 day courses—this presentation requires complicated UTI management 1
- Do not delay cystoscopy when gel-like material is present, as encrustation can progress to severe bladder damage 2
- Do not assume negative cultures rule out infection—chronic UTI may require extended culture techniques or pyuria-guided treatment 5
- Do not treat asymptomatic bacteriuria if found on follow-up testing after symptom resolution 1, 8