An 18-year-old woman comes to the office due to pain on urination and "constantly feeling like I have to go to the bathroom even though I go several times every hour." The patient is sexually active with her boyfriend and, since her symptoms began 3 days ago, has felt pain during intercourse but has not had fever, chills, nausea, vomiting, or flank pain. The patient uses condoms consistently during intercourse. Her last menstrual period was 4 weeks ago. She has no chronic medical conditions or surgeries. The patient has no known drug allergies. Temperature is 37.8 C (100 F), blood pressure is 110/70 mm Hg, pulse is 82/min, and respirations are 18/min. Mild suprapubic tenderness is present on abdominal examination. Pelvic examination shows no cervical discharge or cervical motion tenderness. The remainder of the examination is normal. Urinalysis shows positive leukocyte esterase, positive nitrites, and 10 red blood cells/hpf. A decision is made to treat the patient with one week of trimethoprim-sulfamethoxazole.
Prior to initiating treatment, which of the following is the best next step in management of this patient?

Question

An 18-year-old woman comes to the office due to pain on urination and "constantly feeling like I have to go to the bathroom even though I go several times every hour."  The patient is sexually active with her boyfriend and, since her symptoms began 3 days ago, has felt pain during intercourse but has not had fever, chills, nausea, vomiting, or flank pain.  The patient uses condoms consistently during intercourse.  Her last menstrual period was 4 weeks ago.  She has no chronic medical conditions or surgeries.  The patient has no known drug allergies.  Temperature is 37.8 C (100 F), blood pressure is 110/70 mm Hg, pulse is 82/min, and respirations are 18/min.  Mild suprapubic tenderness is present on abdominal examination.  Pelvic examination shows no cervical discharge or cervical motion tenderness.  The remainder of the examination is normal.  Urinalysis shows positive leukocyte esterase, positive nitrites, and 10 red blood cells/hpf.  A decision is made to treat the patient with one week of trimethoprim-sulfamethoxazole. 
Prior to initiating treatment, which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c0a2_fca9_8f63_315250bc0bb7_MD0005_00 This patient has urinary frequency, dysuria, and a positive urinalysis (eg, nitrates, leukocyte esterase, blood), a presentation consistent with acute cystitis. Most patients with acute, uncomplicated cystitis are afebrile and have no flank pain, in contrast to acute pyelonephritis in which fever and flank pain are common. The most common pathogen of acute cystitis is Escherichia coli. Other less common pathogens include Proteus mirabilis and Klebsiella pneumoniae. The diagnosis of acute cystitis is usually clinical; antibiotic treatment is empiric. However, many antibiotics are contraindicated in pregnancy due to the risk of fetal anomalies. Prior to treating a sexually active woman of reproductive age with antibiotics, a urine pregnancy test is indicated to exclude pregnancy and to avoid the possibility of fetal exposure to a teratogenic medication. First-line antibiotics for nonpregnant patients with acute cystitis include nitrofurantoin, fosfomycin, and trimethoprim-sulfamethoxazole. (Choice A) Acute cystitis is a common cause of hematuria. To exclude malignancy, a cystoscopy is indicated in patients with cystitis and hematuria that do not resolve after antibiotic therapy. (Choice B) Nucleic acid amplification testing for Neisseria gonorrhoeae and Chlamydia trachomatis is indicated for the evaluation of acute cervicitis. Acute cervicitis can present with dyspareunia, however, there is typically an associated purulent cervical discharge and cervical friability (not seen in this patient). (Choice C) Patients with glucose-6-phosphate dehydrogenase deficiency may experience dose-related hemolysis when using trimethoprim-sulfamethoxazole. However, a pregnancy test is the priority as pregnancy is a contraindication to trimethoprim-sulfamethoxazole use. (Choice D) In nonpregnant patients, uncomplicated cystitis can be treated empirically. A urine culture is indicated if symptoms do not respond to antibiotics. Educational objective: A pregnancy test is indicated prior to treating sexually active women of childbearing age with antibiotics to avoid potential fetal teratogen exposure. References: Uncomplicated urinary tract infection in adults including uncomplicated pyelonephritis. (http://www.ncbi.nlm.nih.gov/pubmed/18061019) Urinary tract infections in unplanned pregnancies and fetal outcome. (http://www.ncbi.nlm.nih.gov/pubmed/15697103)

An 18-Year-Old Woman Comes to the Office Due to Pain