What are the signs, symptoms, and treatment options for a urinary tract infection (UTI) in an otherwise healthy adult woman with uncomplicated cystitis?

Urinary Tract Infection: Signs and Symptoms

Cardinal Symptom

Dysuria (painful urination) is the central diagnostic symptom of UTI, with over 90% accuracy in young women when not accompanied by vaginal irritation or discharge. 1, 2

Primary Lower Urinary Tract Symptoms

• Increased urinary frequency is a hallmark symptom where patients need to urinate more often than usual 2
• Urinary urgency presents as a sudden, intense need to urinate 1, 2
• Suprapubic pain or discomfort in the lower abdomen commonly accompanies cystitis 2
• New or worsening urinary incontinence including loss of bladder control may occur 1, 2
• Hematuria (blood in urine) can be present, particularly visible as cloudy or discolored urine 1, 2

Urine Characteristic Changes

• Cloudy urine, changes in urine color, and changes in urine odor are associated with UTI, though these alone should not be relied upon for diagnosis as they can occur with asymptomatic bacteriuria 2

Upper Urinary Tract Symptoms (Pyelonephritis)

• High fever, malaise, vomiting, and flank pain indicate progression to pyelonephritis and represent systemic infection 2
• Costovertebral angle tenderness on physical examination suggests upper tract involvement 2, 3
• Back pain or flank pain distinguishes pyelonephritis from simple cystitis 2

Atypical Presentations in Older Adults

• Mental status changes including new-onset confusion or delirium can be the primary presentation in elderly patients 2
• Functional decline with decreased mobility or impaired activities of daily living may signal UTI 2
• Behavioral changes such as agitation or worsening aggression should prompt consideration of UTI 2
• General symptoms including new or worsening fatigue, weakness, malaise, and dizziness are common in older adults 2
• Gastrointestinal symptoms including decreased fluid or dietary intake, nausea with or without vomiting may be present 2

Treatment for Uncomplicated Cystitis in Adult Women

First-Line Antibiotic Options

For acute uncomplicated cystitis, use nitrofurantoin 100 mg twice daily for 5 days, fosfomycin 3g single dose, or trimethoprim-sulfamethoxazole 160/800 mg twice daily for 3 days (only if local E. coli resistance is <20%). 4, 5, 3, 6

• Nitrofurantoin for 5 days is a preferred first-line agent 4, 3, 7, 6
• Fosfomycin as a single 3g dose offers convenience and effectiveness 4, 3, 7, 6
• Trimethoprim-sulfamethoxazole for 3 days should only be used when local resistance rates are below 20% 4, 8, 3, 7, 6
• Fluoroquinolones should be avoided as first-line therapy due to antimicrobial stewardship concerns and increasing resistance rates 4, 5, 9

Diagnostic Approach

• Urine culture is NOT required for initial episodes of uncomplicated cystitis in young women when symptoms are typical 7, 6
• Urine culture with susceptibility testing is mandatory for recurrent UTIs, treatment failures, atypical presentations, or suspected pyelonephritis 1, 4, 5, 6
• Self-diagnosis with typical symptoms (frequency, urgency, dysuria without vaginal discharge) is accurate enough to initiate treatment without testing 6

Critical Pitfalls to Avoid

• Do NOT treat asymptomatic bacteriuria as this promotes antimicrobial resistance without preventing symptomatic episodes 4, 5
• Do NOT use broad-spectrum antibiotics (fluoroquinolones, cephalosporins) when narrower options are available 4, 5
• Do NOT continue antibiotics beyond recommended duration as this increases resistance without improving outcomes 4
• Do NOT perform routine imaging or cystoscopy in women under 40 without risk factors for complicated infection 4, 5

Treatment Duration

• Three-day regimens are more effective than single-dose for most antimicrobials and are preferred for uncomplicated cystitis 10, 11
• Five days for nitrofurantoin is the recommended duration 3, 7, 6
• Seven days or longer is NOT necessary for uncomplicated cystitis and increases adverse effects 1, 11

When to Suspect Complicated UTI

• Pregnancy, male sex, catheterization, anatomical abnormalities, diabetes mellitus, immunosuppression, recent urinary instrumentation, or healthcare-associated infections classify a UTI as complicated and require different management 2