A 29-year-old woman comes to the office and says, "my interstitial cystitis is getting worse." Six months ago, the patient developed chronic urinary frequency and suprapubic pain relieved with voiding. She was diagnosed with interstitial cystitis and prescribed amitriptyline, which initially improved her symptoms. However, for the past week, the patient has had worsening urinary urgency and pain with voiding. She has no other chronic medical conditions and has no medication allergies. The patient recently started a relationship with a male partner and uses oral contraceptives. Temperature is 37.2 C (99 F), blood pressure is 126/74 mm Hg, and pulse is 88/min. The abdomen is soft with diffuse lower abdominal discomfort to deep palpation. A clean-catch urinalysis shows: Urine culture and pregnancy testing are negative. Which of the following is best next step in management of this patient?

Question

A 29-year-old woman comes to the office and says, "my interstitial cystitis is getting worse."  Six months ago, the patient developed chronic urinary frequency and suprapubic pain relieved with voiding.  She was diagnosed with interstitial cystitis and prescribed amitriptyline, which initially improved her symptoms.  However, for the past week, the patient has had worsening urinary urgency and pain with voiding.  She has no other chronic medical conditions and has no medication allergies.  The patient recently started a relationship with a male partner and uses oral contraceptives.  Temperature is 37.2 C (99 F), blood pressure is 126/74 mm Hg, and pulse is 88/min.  The abdomen is soft with diffuse lower abdominal discomfort to deep palpation.  A clean-catch urinalysis shows:  Urine culture and pregnancy testing are negative.  Which of the following is best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d9dc_dd48_bc81_638f26814c23_MD0003_00 This patient has interstitial cystitis (ie, painful bladder syndrome), a chronic pain disorder classically characterized by suprapubic pain that worsens with bladder filling and is relieved with voiding, resulting in increased urinary frequency. Interstitial cystitis is often treated with amitriptyline, and those with worsening symptoms may require an increased dose (Choice A). However, this patient's new-onset pain with urination (ie, dysuria) is atypical for interstitial cystitis and requires evaluation for other disorders (Choice B). The most common causes of dysuria in young sexually active women are cystitis and urethritis, and initial evaluation is with urinalysis and urine culture. This patient's urinalysis reveals sterile pyuria (positive leukocytes but no bacteria), and she has a negative urine culture. This combination of dysuria and sterile pyuria is a common presentation of Chlamydia trachomatis-associated urethritis in women (up to 25% of patients). Therefore, the best next step in management is nucleic acid amplification testing for chlamydia; testing for gonorrhea is typically added because co-infection is common. A first-catch urine sample can be used in women; however, because most women have concomitant cervical infection, a vaginal or cervical swab may also be performed. (Choice C) CT scan of the abdomen and pelvis can be used to evaluate for renal pathology. However, an acute onset of sterile pyuria alone (ie, no associated casts or red blood cells) is an uncommon presentation for renal disease. (Choice E) Nitrofurantoin is used to treat acute cystitis, which has symptoms (eg, urinary frequency, urgency, dysuria) similar to acute urethritis. Although this patient's urinalysis reveals pyuria (ie, urine leukocytes, leukocyte esterase), her urine culture is negative, making cystitis unlikely. Educational objective: The combination of dysuria and sterile pyuria is a common presentation for Chlamydia trachomatis urethritis in sexually active women. Patients with this clinical presentation require nucleic acid amplification testing for chlamydia and gonorrhea. References: Dysuria: evaluation and differential diagnosis in adults. (http://www.ncbi.nlm.nih.gov/pubmed/26554471) Recommendations for the laboratory-based detection of Chlamydia trachomatis and Neisseria gonorrhoeae-2014. (http://www.ncbi.nlm.nih.gov/pubmed/24622331) Update to CDC's treatment guidelines for gonococcal infection, 2020. (http://www.ncbi.nlm.nih.gov/pubmed/33332296)

A 29-Year-Old Woman Comes to the Office and Says, "My