A 20-year-old woman comes to the office due to dysuria for the past 2 days. She also has had urinary frequency but no fevers, chills, nausea, or hematuria. The patient became sexually active with her boyfriend 6 months ago. Since then, she has had 3 episodes of cystitis. The patient has no other medical conditions and no prior surgery. She takes no medications and does not use tobacco, alcohol, or illicit drugs. The patient uses condoms for contraception, and her last menstrual period was 2 weeks ago. Temperature is 37.2 C (99 F). On abdominal examination, there is mild suprapubic tenderness. No costovertebral or flank tenderness is present. Antibiotic therapy is prescribed. A urine culture grows Escherichia coli. When the patient is called with the results, she reports complete resolution of her symptoms. Repeat urine culture 2 weeks later is negative. Which of the following is the best next step in management of this patient's recurrent cystitis?

Question

A 20-year-old woman comes to the office due to dysuria for the past 2 days.  She also has had urinary frequency but no fevers, chills, nausea, or hematuria.  The patient became sexually active with her boyfriend 6 months ago.  Since then, she has had 3 episodes of cystitis.  The patient has no other medical conditions and no prior surgery.  She takes no medications and does not use tobacco, alcohol, or illicit drugs.  The patient uses condoms for contraception, and her last menstrual period was 2 weeks ago.  Temperature is 37.2 C (99 F).  On abdominal examination, there is mild suprapubic tenderness.  No costovertebral or flank tenderness is present.  Antibiotic therapy is prescribed.  A urine culture grows Escherichia coli.  When the patient is called with the results, she reports complete resolution of her symptoms.  Repeat urine culture 2 weeks later is negative.  Which of the following is the best next step in management of this patient's recurrent cystitis?

Quizplus · Accepted Answer

11ec25c8_d98e_488f_bc81_e53ceeea19a2_MD0003_00 Women are at increased risk for cystitis, a lower urinary tract infection, due to the proximity of the rectum to the vagina and urethra. A significant risk factor is sexual intercourse, as in this patient. During intercourse, enteric bacteria (most commonly Escherichia coli) is introduced to the vagina and periurethral area. Due to the short length of the female urethra, these bacteria can readily ascend to the bladder to cause cystitis and associated symptoms (eg, dysuria, urinary frequency). Other risk factors include conditions that alter the normal urogenital flora (eg, recent antibiotic use, spermicide use). This patient has recurrent cystitis, defined as ≥2 episodes in 6 months (or ≥3 episodes in a year). Patients with recurrent cystitis are at increased risk of repeat episodes, which may be preventable with antibiotic prophylaxis (eg, nitrofurantoin, trimethoprim-sulfamethoxazole). In women with cystitis episodes clearly linked to intercourse, postcoital antibiotics are preferred because they can prevent recurrence while minimizing the risk of chronic antibiotic use (eg, antibiotic resistance). (Choice A) Cystoscopy is typically performed for suspected bladder cancer (eg, persistent or unexplained hematuria) or urinary tract injury (eg, postoperative). Recurrent cystitis that responds appropriately to antibiotic therapy (eg, negative repeat urine culture, as in this patient) does not require cystoscopy. Cystoscopy (Choice B) Although increased daily fluid intake (eg, 2-3 L) is recommended for recurrent cystitis, cranberry juice has not been demonstrated to decrease the incidence of UTIs. (Choice D) Renal ultrasound is indicated in patients with recurrent cystitis when repeat urine cultures are persistently positive or demonstrate atypical pathogens (eg, Proteus), which may indicate an underlying structural anomaly or nephrolithiasis. In contrast, this patient has a negative repeat urine culture and a common pathogen (ie, E coli). (Choice E) Urodynamic testing, which assesses bladder function (eg, storage, evacuation), is used to evaluate urinary incontinence, not recurrent cystitis. Educational objective: A significant risk factor for recurrent cystitis (ie, ≥2 episodes in 6 months or ≥3 episodes in a year) in women is sexual intercourse. Postcoital antibiotic prophylaxis (eg, nitrofurantoin, trimethoprim-sulfamethoxazole) can reduce the rate of recurrence. References: Recurrent urinary tract infections in women. (http://www.ncbi.nlm.nih.gov/pubmed/25410372)

A 20-Year-Old Woman Comes to the Office Due to Dysuria