SOAP Note: Acute Uncomplicated Cystitis in a Healthy Adult Female
Subjective
Chief Complaint:
Dysuria, urinary frequency, urgency, and suprapubic discomfort for 2–3 days.
History of Present Illness:
A 20–50‑year‑old otherwise healthy woman presents with acute‑onset dysuria, increased urinary frequency, urgency, and suprapubic pain beginning 2–3 days ago. She denies fever, chills, flank pain, nausea, vomiting, vaginal discharge, or vaginal irritation. No recent antibiotic use, no history of recurrent urinary tract infections (< 2 episodes in 6 months), and no known urologic abnormalities. She is not pregnant and has no indwelling catheter or recent instrumentation. 1, 2
Review of Systems:
Negative for fever, back pain, costovertebral angle tenderness, nausea, vomiting, hematuria, or systemic symptoms. 1, 2
Objective
Vital Signs:
Temperature, blood pressure, heart rate, and respiratory rate all within normal limits. Afebrile. 1, 2
Physical Examination:
- General: Alert, comfortable, no acute distress.
- Abdomen: Soft, mild suprapubic tenderness on palpation, no costovertebral angle tenderness, no flank pain. 1, 3
- Genitourinary: No vaginal discharge or irritation noted (if examined).
Laboratory Findings:
- Urine Dipstick: Positive for leukocyte esterase and nitrites. 4
- Microscopic Urinalysis: > 10 white blood cells per high‑power field, bacteria present, no red blood cells or casts. 4, 5
Assessment
Diagnosis:
Acute uncomplicated cystitis in an otherwise healthy, non‑pregnant adult female aged 20–50 years. 1, 3
Rationale:
The combination of acute urinary symptoms (dysuria, frequency, urgency, suprapubic pain) and documented pyuria (> 10 WBC/HPF) with positive leukocyte esterase and nitrites confirms the diagnosis of acute uncomplicated cystitis. 1, 4 The absence of fever, flank pain, nausea, vomiting, or systemic signs excludes pyelonephritis. 1, 2 The patient has no complicating factors (pregnancy, anatomic abnormalities, immunosuppression, catheter, recent instrumentation, or recurrent infections), which classifies this as an uncomplicated infection. 1, 2
Urine Culture:
A urine culture is not required for this straightforward case of acute uncomplicated cystitis in a healthy woman with typical symptoms and no risk factors for resistant organisms. 1, 3 Culture should be reserved for recurrent infections (≥ 2 episodes in 6 months or ≥ 3 in 12 months), treatment failure, atypical presentations, pregnancy, or suspected pyelonephritis. 1, 4
Plan
1. First‑Line Antibiotic Therapy
Nitrofurantoin 100 mg orally twice daily for 5 days is the preferred first‑line agent because local E. coli resistance remains < 5 %, urinary drug concentrations are high, and disruption of gut flora is minimal compared with fluoroquinolones or trimethoprim‑sulfamethoxazole. 1, 4, 3
Alternative First‑Line Options:
- Fosfomycin trometamol 3 g as a single oral dose is an excellent alternative, especially when adherence to a multi‑day regimen is a concern. 1, 6, 3
- Trimethoprim‑sulfamethoxazole 160/800 mg (double‑strength) twice daily for 3 days may be used only if local E. coli resistance is < 20 % and the patient has had no recent exposure to this agent. 1, 3, 7
Agents to Avoid:
- Fluoroquinolones (ciprofloxacin, levofloxacin) should be reserved for second‑line use because of rising resistance, serious adverse effects (tendon rupture, peripheral neuropathy, QT prolongation), and substantial microbiome disruption. 1, 8, 3
- Beta‑lactams (amoxicillin/clavulanate, cephalosporins) are not recommended as first‑line therapy due to lower urinary concentrations and inferior clinical efficacy. 1, 3
2. Patient Education
- Symptom Resolution: Symptoms should improve within 48–72 hours of starting antibiotics. 1, 9
- Red‑Flag Symptoms: Instruct the patient to return immediately if she develops fever > 38.3 °C, flank pain, nausea, vomiting, or inability to tolerate oral intake, as these signs indicate possible pyelonephritis requiring urgent evaluation and possibly parenteral antibiotics. 1, 4, 2
- Hydration: Encourage adequate fluid intake to help flush bacteria from the urinary tract. 2
- Avoid Irritants: Advise avoidance of caffeine, alcohol, and spicy foods during treatment. 2
3. Follow‑Up
- No routine follow‑up urinalysis or urine culture is needed for uncomplicated cystitis that resolves clinically. 1, 4
- Re‑evaluate within 48–72 hours if symptoms persist or worsen; if so, obtain a urine culture and consider imaging (ultrasound or CT) to rule out obstruction, stones, or abscess. 1, 4
- If symptoms recur within 2 weeks, obtain a repeat urine culture and prescribe a 7‑day course of a different antibiotic, assuming resistance to the initial agent. 1, 4
4. Prevention Counseling
- Behavioral Measures: Post‑coital voiding, adequate hydration, and avoidance of spermicidal contraceptives can reduce recurrence risk. 2, 7
- Recurrent UTI Threshold: If the patient experiences ≥ 2 UTIs in 6 months or ≥ 3 in 12 months, consider prophylactic strategies (e.g., post‑coital antibiotics, low‑dose daily prophylaxis, or non‑antibiotic options such as methenamine hippurate or cranberry products). 1, 2, 7
5. Common Pitfalls to Avoid
- Do not treat asymptomatic bacteriuria; it occurs in 15–50 % of older adults and provides no clinical benefit when treated. 1, 4
- Do not prescribe a 3‑day course of nitrofurantoin; the minimum effective duration is 5 days to avoid treatment failure. 1, 4
- Do not delay antibiotic initiation while awaiting culture results in a typical uncomplicated case; empiric treatment is both safe and effective. 1, 3
- Do not use fluoroquinolones empirically when local resistance exceeds 10 % or when the patient has had recent fluoroquinolone exposure. 1, 8
Disposition:
Discharge home with oral antibiotics and clear return precautions. No further testing or follow‑up is required unless symptoms persist, worsen, or recur. 1, 4, 9