What is the diagnosis and treatment for a 25-year-old female with one day of urinary frequency and urgency, normal vital signs, and no other symptoms?

Diagnosis: Acute Uncomplicated Cystitis

This 25-year-old woman with one day of urinary frequency and urgency, normal vital signs, and no other symptoms most likely has acute uncomplicated cystitis, and she can be diagnosed and treated based on symptoms alone without requiring urinalysis or urine culture. 1

Clinical Diagnosis Without Testing

• In women presenting with typical acute-onset urinary symptoms (frequency, urgency) without vaginal discharge or fever, the diagnosis of uncomplicated cystitis can be made with over 90% accuracy based on symptoms alone. 1, 2

• Dysuria is the most specific symptom for UTI, but this patient's presentation of frequency and urgency without dysuria still supports the diagnosis when these symptoms are acute-onset and bothersome. 1, 3

• The absence of fever, flank pain, or systemic symptoms excludes pyelonephritis. 1, 2

• Normal vital signs and lack of vaginal discharge make alternative diagnoses (vaginitis, sexually transmitted infections) less likely. 1

When Laboratory Testing IS Required

Urine culture should be obtained only in specific circumstances, which do NOT apply to this patient: 1

• Suspected pyelonephritis (fever, flank pain)
• Symptoms that do not resolve or recur within 4 weeks after treatment
• Atypical symptoms
• Pregnancy
• Recurrent UTIs (≥3 UTIs per year or 2 in 6 months)
• History of resistant organisms

Since this patient has none of these features, empiric treatment without urinalysis or culture is appropriate. 1, 2

First-Line Treatment Options

Choose ONE of the following regimens based on local resistance patterns and patient factors: 1, 2, 4

• Nitrofurantoin 100 mg twice daily for 5 days (preferred due to minimal resistance) 1, 2, 4
• Fosfomycin 3 grams single dose 1, 2, 4
• Trimethoprim-sulfamethoxazole DS twice daily for 3 days (only if local E. coli resistance <20%) 1, 2, 4
• Trimethoprim 200 mg twice daily for 3 days 1, 2

Avoid fluoroquinolones as first-line therapy due to increasing resistance and collateral damage to normal flora. 1, 2

Alternative: Symptomatic Treatment

For patients with mild symptoms who prefer to avoid antibiotics, symptomatic treatment with NSAIDs (ibuprofen) can be offered with delayed antibiotic prescription if symptoms worsen or persist beyond 48 hours. 1, 2

• This approach has low risk of complications in young, healthy women with uncomplicated cystitis. 1, 2
• Patients must be counseled to start antibiotics if symptoms worsen, fever develops, or flank pain occurs. 1, 2

Critical Differential Diagnosis to Exclude

Before diagnosing uncomplicated cystitis, ensure this patient does NOT have: 1, 5

• Overactive bladder (OAB): Would present with chronic (not acute one-day onset) urgency and frequency as bothersome symptoms over weeks to months. 1, 5
• Interstitial cystitis/bladder pain syndrome: Requires symptoms >6 weeks duration with pain/pressure as the hallmark symptom. 1
• Asymptomatic bacteriuria: Requires absence of symptoms, which this patient clearly has. 1

The acute one-day onset of symptoms is the key distinguishing feature that confirms acute cystitis rather than chronic bladder conditions. 1

Common Pitfalls to Avoid

• Do not obtain routine urinalysis or culture in young women with typical acute cystitis symptoms—this leads to overdiagnosis of asymptomatic bacteriuria and unnecessary treatment. 1, 2

• Do not treat asymptomatic bacteriuria if discovered incidentally—it does not require treatment in non-pregnant, healthy women. 1

• Do not use fluoroquinolones as first-line therapy—reserve these for complicated UTIs or pyelonephritis due to resistance concerns. 1, 2

• Do not confuse chronic urgency/frequency (OAB) with acute-onset symptoms (cystitis)—the timeline is critical for diagnosis. 1, 5

Follow-Up

• No routine post-treatment testing is needed if symptoms resolve. 1

• Obtain urine culture only if symptoms persist after treatment completion or recur within 2-4 weeks, suggesting treatment failure or resistant organism. 1

• If symptoms recur, consider this a new infection if it occurs >2 weeks after treatment; consider it treatment failure if <2 weeks. 1