Treatment of Chronic Cystitis
For chronic cystitis with recurrent bacterial infections, implement conservative self-care measures first, reserve antibiotic prophylaxis for patients with ≥3 documented infections per year, and use first-line agents (fosfomycin, nitrofurantoin, or pivmecillinam) while avoiding fluoroquinolones for routine treatment. 1, 2
Initial Management: Conservative Measures Before Antibiotics
Before considering antibiotic prophylaxis, implement these evidence-based self-care interventions 1:
- Ensure adequate hydration to promote frequent urination 1
- Encourage urge-initiated voiding and post-coital voiding 1
- Discontinue spermicidal-containing contraceptives 1
- For postmenopausal women with atrophic vaginitis, prescribe topical vaginal estrogens 1
These measures are critical because antibiotic prophylaxis increases resistance risk for both causative organisms and indigenous flora, plus risks adverse effects 1.
Diagnostic Workup: When to Culture
Obtain urine culture in these specific situations 2:
- Atypical symptoms 2
- Symptoms that fail to resolve or recur within 4 weeks after treatment completion 2
- Suspected acute pyelonephritis 2
- Pregnancy 2
- Bacterial cystitis recurring rapidly (within 2 weeks) after initial treatment 1
A clean-catch or catheterized specimen typically reveals >100,000 organisms/mL, with E. coli causing approximately 75% of recurrent UTIs 1.
Acute Treatment: First-Line Empirical Therapy
For symptomatic acute episodes, use these first-line agents 2:
- Fosfomycin trometamol 3g single dose 2
- Nitrofurantoin 100mg twice daily for 5 days 2
- Pivmecillinam 400mg three times daily for 3-5 days 2
Alternative agents if first-line cannot be used 2:
- Trimethoprim-sulfamethoxazole (limited by local E. coli resistance rates) 2, 3
- Cephalosporins (limited by local resistance) 2
Critical Pitfalls to Avoid
Never use amoxicillin or ampicillin empirically due to poor efficacy and high worldwide resistance rates 2.
Reserve fluoroquinolones for important uses other than acute cystitis due to their propensity for collateral damage and ecological effects 2.
Do not dismiss symptoms based solely on negative urinalysis, as bacterial cystitis can occur with minimal or absent pyuria 2. The absence of WBCs has excellent negative predictive value but does not completely rule out bacterial cystitis in symptomatic patients 2.
When to Consider Prophylaxis
Antibiotic prophylaxis is appropriate for women with ≥3 symptomatic infections over 12 months 1.
Postmenopausal women face increased risk with urinary incontinence, cystocele, or high postvoid residuals 1.
When to Image
Imaging is NOT routinely indicated for recurrent UTIs without underlying risk factors, with <2 episodes per year, and prompt response to therapy 1.
Imaging IS indicated when 1:
- Bacterial persistence without symptom resolution 1
- Rapid recurrence (within 2 weeks) after treatment 1
- Suspected anatomic abnormalities (calculi, foreign bodies, urethral/bladder diverticula, infected urachal cyst, postoperative changes) 1
Alternative Diagnosis: Interstitial Cystitis
If symptoms persist despite appropriate antibiotic therapy, consider interstitial cystitis 2, 4, 5.
Interstitial cystitis is a chronic inflammatory bladder condition characterized by 4, 5, 6:
- Urinary urgency and frequency with suprapubic/pelvic pain 4, 5
- Negative urine cultures 5, 6
- No response to antibiotic therapy 4, 6
This condition requires cystoscopy for diagnosis (looking for glomerulations or Hunner's ulcers) and completely different treatment approaches including pentosan polysulfate, tricyclic antidepressants, antihistamines, or intravesical therapies 5, 7.
Symptomatic Management Option
For females with mild-to-moderate symptoms, ibuprofen may be considered as an alternative to antimicrobial treatment in consultation with the patient 2.
Follow-Up Management
If symptoms persist after treatment 2:
- Perform urine culture and antimicrobial susceptibility testing 2
- Consider retreatment with a 7-day regimen using another agent 2
Routine post-treatment urinalysis or cultures are NOT indicated for asymptomatic patients after successful treatment 2.
Special Monitoring Considerations
When using trimethoprim-sulfamethoxazole, monitor for 3: