Supportive Treatment for Uncomplicated Cystitis
For otherwise healthy adult women with uncomplicated cystitis, symptomatic treatment with NSAIDs (such as ibuprofen) may be considered as an alternative to immediate antibiotics in patients with mild to moderate symptoms, though this approach results in longer symptom duration and higher rates of progression to pyelonephritis. 1
NSAIDs as Symptomatic Monotherapy
NSAIDs alone (without antibiotics) may be offered to women with mild to moderate symptoms who wish to avoid immediate antibiotic use, after shared decision-making that includes discussion of risks. 1
Compared to antibiotics, NSAIDs probably result in less short-term symptom resolution (days 1-4): only 67% of women achieve resolution versus antibiotics (RR 0.67,95% CI 0.49-0.91). 2
NSAIDs may result in approximately 1 additional day of symptom duration compared to antibiotics (mean difference 1.00 day, 95% CI 0.61-1.39). 2
Three times more women require rescue antibiotic treatment by day 30 when initially treated with NSAIDs versus antibiotics (RR 3.14,95% CI 2.23-4.42). 2
The risk of progression to pyelonephritis is higher with NSAID monotherapy, with studies showing 3.6% progression in the non-antibiotic group versus 0.4% in the immediate antibiotic group. 1
NSAIDs as Adjunctive Symptomatic Treatment
When antibiotics are prescribed, NSAIDs (such as ibuprofen) can be used concurrently for symptomatic relief of dysuria, frequency, and suprapubic discomfort during the first 24-48 hours of antibiotic therapy. 1
NSAIDs provide analgesic and anti-inflammatory effects that may reduce urinary tract discomfort while antibiotics eradicate the infection. 2
Non-Pharmacologic Supportive Measures
Increased fluid intake is commonly recommended, though evidence for efficacy in acute cystitis is limited; one guideline suggests it may reduce recurrence risk in premenopausal women. 1
Urinating after sexual intercourse is a frequently proposed measure, though its effect on acute episodes is unproven. 3
Avoiding spermicides may be beneficial, as spermicide use is a recognized risk factor for cystitis. 1
Critical Safety Considerations
Do not use NSAIDs as monotherapy when pyelonephritis is suspected (fever, flank pain, costovertebral angle tenderness), as this represents a complicated infection requiring immediate antibiotic therapy. 1
Patients choosing NSAID monotherapy must be counseled about the 3-4% risk of progression to pyelonephritis and instructed to seek immediate care if fever or flank pain develops. 1, 2
Close follow-up within 2-3 days is essential for women treated with NSAIDs alone to assess symptom resolution and need for rescue antibiotics. 2
When Supportive Treatment Alone Is Inappropriate
Immediate antibiotic therapy is mandatory for pregnant women, immunocompromised patients, those with diabetes, suspected pyelonephritis, or any anatomic/functional urinary tract abnormalities. 1, 4
Routine post-treatment urinalysis or urine cultures are not indicated for asymptomatic patients who have completed antibiotic therapy successfully. 1