What is the diagnosis and treatment approach for a patient with Cystitis cystica, considering their past medical history of urinary tract infections and potential underlying conditions?

Cystitis Cystica: Diagnosis and Management

Cystitis cystica is a benign, chronic inflammatory bladder condition that requires long-term antimicrobial suppression (6-12 months) to achieve resolution, particularly in patients with recurrent urinary tract infections. 1

Understanding Cystitis Cystica

Cystitis cystica represents the bladder's response to chronic, inadequately treated bacterial lower urinary tract infection. 1 Recent evidence demonstrates these lesions are actually tertiary lymphoid tissues (follicular cystitis) with germinal centers, strongly correlating with recurrent UTI frequency, particularly in postmenopausal women. 2

Key Clinical Associations

• Postmenopausal status (OR: 5.53) is the strongest predictor of cystitis cystica presence 2
• Frequent UTIs (≥4 infections in the past year) significantly increase likelihood (OR: 2.28) 2
• Pelvic floor myofascial pain (OR: 6.82) commonly coexists 2
• Patients with cystitis cystica have shorter time intervals to next UTI (HR: 1.54) 2

Diagnostic Approach

Cystoscopy Findings

Diagnosis is established by cystoscopy showing characteristic cystic bladder mucosal changes. 1, 2 When biopsied, 91% of lesions demonstrate tertiary lymphoid tissue architecture with germinal centers. 2

Critical Distinction from Interstitial Cystitis

While symptoms may overlap (urgency, frequency, bladder pain), cystitis cystica differs fundamentally from interstitial cystitis—the latter has no underlying infection and antibiotic therapy provides no benefit. 3, 4 Cystitis cystica, conversely, is infection-driven and responds to prolonged antimicrobial therapy. 1

Treatment Strategy

Primary Management: Long-Term Antimicrobial Suppression

Administer continuous antimicrobial therapy for 6-12 months using either nitrofurantoin or sulfisoxazole. 1 Both agents demonstrate equal efficacy in controlling infection and promoting lesion resolution. 1

Nitrofurantoin Dosing

• Standard suppressive dosing per FDA labeling for chronic UTI prophylaxis 5
• Monitor for pulmonary reactions (acute, subacute, or chronic) and hepatotoxicity with long-term use 5
• Contraindicated if creatinine clearance <60 mL/min 5

Trimethoprim-Sulfamethoxazole Alternative

• 160/800 mg dosing as per EAU guidelines for complicated UTI management 6
• Appropriate for susceptible organisms 7

Treatment Duration Rationale

Despite adequate infection control, 24% of patients still show cystic changes after standard treatment completion, indicating many months to years of continuous medication may be required for complete healing. 1 However, 82% of patients demonstrate improvement or resolution of lesions with appropriate management. 2

Managing Persistent Symptoms

One-third of patients presenting with urinary frequency, urgency, and urge incontinence require additional interventions beyond infection control alone. 1

Additional measures include:

• Toilet retraining programs 1
• Anticholinergic medications for persistent irritative symptoms 1
• Pelvic floor physical therapy for coexisting myofascial pain 2

When Infection Recurs

Since any UTI in patients with cystitis cystica represents a complicated UTI (due to underlying bladder abnormality), management should follow complicated UTI protocols:

• Obtain urine culture with susceptibility testing before initiating treatment 6
• Treat for 7-14 days depending on clinical severity and gender (14 days for men when prostatitis cannot be excluded) 6
• Tailor therapy based on culture results and local resistance patterns 6

Monitoring and Follow-Up

• Repeat cystoscopy can assess lesion improvement, with 82% showing resolution or improvement over time 2
• Do not perform routine urine cultures in asymptomatic patients, as bacteriuria without symptoms does not require treatment 8
• Culture only when symptomatic (dysuria, frequency, urgency) or before procedures breaching bladder mucosa 8

Common Pitfalls to Avoid

• Insufficient treatment duration: Stopping antibiotics too early (before 6 months) often results in persistent lesions and recurrent infections 1
• Confusing with interstitial cystitis: This leads to inappropriate management, as IC does not respond to antibiotics 3, 4
• Treating asymptomatic bacteriuria: Routine screening and treatment of asymptomatic bacteriuria is not indicated and wastes resources 8
• Ignoring coexisting pelvic floor dysfunction: Infection control alone may be insufficient for symptom resolution 1, 2