What is the appropriate treatment and potential diagnosis for a patient with a history of interstitial cystitis and recurrent UTI, presenting with dizziness, vomiting, and trace blood in UA?

Evaluation and Management of Dizziness in a Patient with Interstitial Cystitis and Recurrent UTI History

This patient's dizziness is unlikely to be related to their urinary tract conditions, and the trace hematuria with negative workup suggests a flare of interstitial cystitis rather than active infection. The normal EKG, normal orthostatic vitals, and absence of neurological deficits point away from cardiac, autonomic, or central nervous system causes.

Differential Diagnosis for Dizziness

The 5-day history of dizziness with initial vomiting, in the absence of red flags, most likely represents:

• Benign paroxysmal positional vertigo (BPPV) - most common cause of peripheral vertigo
• Vestibular neuritis - given the vomiting on day one, though typically presents with more severe vertigo
• Migraine-associated dizziness - can present without headache
• Medication side effects - review any recent antibiotic use for UTI treatment
• Dehydration - particularly if vomiting was significant

Addressing the Urinary Findings

The trace blood in the urinalysis without significant bacteriuria does not indicate an active UTI requiring treatment. 1 Key considerations:

• Interstitial cystitis patients frequently experience symptom flares that mimic UTI but are culture-negative - research shows only 9.4% of IC patients with UTI-like symptoms have positive cultures, and recurrent bacteriuria occurs in only 6.6% of IC patients 2
• Hematuria is a common symptom in IC patients and can occur during flares 1
• Given the history of recurrent UTIs, obtain a urine culture before any antibiotic treatment to document actual infection rather than treating presumptively 1

Important Caveat About IC and UTI Symptoms

Patients with IC often receive unnecessary antibiotics because their flares are mistaken for UTIs. 3, 4 Antibiotic therapy provides no benefit for IC and contributes to antimicrobial resistance. 3 The symptoms of IC—urgency, frequency, and pelvic pain—closely resemble UTI symptoms, but standard cultures are negative. 4

Recommended Diagnostic Approach

For the dizziness:

• Perform Dix-Hallpike maneuver to evaluate for BPPV
• Assess for nystagmus and gait abnormalities
• Review medication list for ototoxic or vestibular-affecting drugs
• Consider basic metabolic panel if dehydration suspected

For the urinary symptoms:

• Obtain urine culture via sterile catheterization if UTI symptoms are present 2
• Do not initiate empiric antibiotics without culture confirmation in this IC patient 1, 2
• Cystoscopy and upper tract imaging are not routinely indicated for recurrent UTI evaluation in patients without risk factors 1
• However, cystoscopy should be considered given the hematuria to evaluate for anatomical abnormalities or other pathology 5

Treatment Recommendations

For dizziness (if BPPV confirmed):

• Epley maneuver or other canalith repositioning procedures
• Vestibular rehabilitation if symptoms persist
• Antiemetics if nausea is prominent (meclizine 25mg as needed)

For IC management (if flare suspected):

• Increase fluid intake 1
• Consider methenamine hippurate for prevention of future episodes 1, 5
• Immunoactive prophylaxis may reduce recurrence 1, 5
• Avoid unnecessary antibiotics that worsen antimicrobial resistance 1

For confirmed UTI (only if culture positive):

• Use first-line agents: nitrofurantoin, trimethoprim-sulfamethoxazole, or fosfomycin based on local resistance patterns 1
• Treat for no longer than 7 days 1
• Tailor therapy to culture sensitivities 1

Critical Clinical Pitfall

Do not assume UTI symptoms equal actual infection in IC patients. 2 The vast majority of symptom flares in IC patients are culture-negative and self-limiting. Empiric antibiotic treatment based on symptoms alone leads to unnecessary antibiotic exposure, resistance development, and fails to address the underlying IC pathophysiology. 3, 4, 2

Follow-Up Plan

• If dizziness persists beyond 2 weeks or worsens, refer to ENT or neurology for comprehensive vestibular evaluation
• Schedule follow-up after urine culture results to adjust management 5
• Monitor for resolution of hematuria; persistent hematuria warrants further investigation including cystoscopy 5
• Consider non-antimicrobial prophylaxis strategies for recurrent UTI prevention including vaginal estrogen (if postmenopausal), cranberry products, or D-mannose 1