Management of Acute Uncomplicated Cystitis with Hematuria
This patient should receive immediate empiric antibiotic therapy with first-line agents (nitrofurantoin 100 mg twice daily for 5 days, fosfomycin 3 g single dose, or trimethoprim-sulfamethoxazole 160/800 mg twice daily for 3 days), along with symptomatic relief using phenazopyridine for up to 2 days, and the Pristiq prescription can be safely renewed concurrently. 1, 2
Diagnostic Approach
The diagnosis of uncomplicated cystitis can be made with high probability based on the focused history of lower urinary tract symptoms alone. 1
Key diagnostic criteria present in this patient:
- Dysuria (burning sensation after intercourse) 1
- Urinary frequency (constant need to urinate) 1
- Hematuria (bloody tissue) 1
- Absence of vaginal discharge 1
Urine culture is NOT required for typical presentations of uncomplicated cystitis in nonpregnant women without complicating factors. 1 Dipstick testing adds minimal diagnostic accuracy when symptoms are classic. 1
When Urine Culture IS Required:
- Suspected acute pyelonephritis 1
- Symptoms not resolving or recurring within 4 weeks after treatment 1
- Atypical symptom presentation 1
- Pregnancy 1
First-Line Antibiotic Treatment
Recommended regimens (choose one): 1, 3
- Fosfomycin trometamol: 3 g single dose (most convenient) 1
- Nitrofurantoin macrocrystals: 100 mg twice daily for 5 days 1
- Trimethoprim-sulfamethoxazole: 160/800 mg twice daily for 3 days (only if local E. coli resistance <20%) 1, 4
Alternative agents if first-line unavailable:
- Cephalosporins (e.g., cephalexin 500 mg twice daily for 3 days) only if local E. coli resistance <20% 1, 3
Avoid fluoroquinolones for uncomplicated cystitis—reserve for complicated infections or pyelonephritis. 1, 5
Symptomatic Management
Phenazopyridine (urinary analgesic) provides rapid symptomatic relief of burning, urgency, and frequency. 2
- Dosing: Per FDA labeling for symptomatic relief during the interval before antibiotics control infection 2
- Duration: Maximum 2 days—no evidence of benefit beyond this with concurrent antibiotics 2
- Important: Does not treat infection; must be combined with antibiotics 2
NSAIDs (e.g., ibuprofen) may be considered for mild-to-moderate symptoms as adjunctive therapy. 1
Pristiq (Desvenlafaxine) Renewal
The Pristiq prescription can be renewed without concern for drug interactions with standard UTI antibiotics. There are no contraindications to concurrent use of desvenlafaxine with nitrofurantoin, fosfomycin, or trimethoprim-sulfamethoxazole.
Post-Coital UTI Considerations
Sexual intercourse is a recognized risk factor for uncomplicated cystitis in women. 1
If this becomes recurrent (≥2 UTIs in 6 months or ≥3 in 12 months):
- Consider post-coital antibiotic prophylaxis 1
- Increase fluid intake 1
- Cranberry products may provide modest benefit 6
Follow-Up Criteria
Routine post-treatment urinalysis or culture is NOT indicated if symptoms resolve. 1
Obtain urine culture and susceptibility testing if: 1
- Symptoms do not resolve by end of treatment
- Symptoms resolve but recur within 2 weeks
- Assume resistance to initial agent and retreat with 7-day course of different antibiotic 1
Critical Pitfalls to Avoid
Do not treat asymptomatic bacteriuria in nonpregnant women—this leads to unnecessary antibiotic exposure and resistance. 1
Do not obtain urine culture routinely for straightforward uncomplicated cystitis—this increases costs without improving outcomes. 1
Do not use β-lactams (amoxicillin, amoxicillin-clavulanate) as first-line empiric therapy—they are less effective than recommended agents. 7
Hematuria in the setting of acute cystitis does not require imaging or further workup unless symptoms persist after appropriate treatment or the patient is over 40 years old with risk factors. 1