Urinary tract imaging methods of choice include ultrasound, CT, and IV urography. Occasionally a voiding cystourethrography, retrograde urethrography, or cystoscopy are needed. In women with symptomatic cystitis or with recurrent asymptomatic cystitis, routine urological investigations are not necessary, because these findings do not influence therapy. Children with a urinary tract infection often require imaging techniques.
1. Hooton TM, Roberts PL, Cox ME, et al: Voided midstream urine culture and acute cystitis in premenopausal women. N Engl J Med 369 (20): 1883-1891, 2013. doi: 10.1056 / NEJMoa1302186
Occasionally surgery (eg, to drain abscesses, correct underlying structural abnormalities, or resolve obstruction)
All forms of symptomatic bacterial urinary tract infection require antibiotic therapy. In patients with severe dysuria, phenazopyridine can help control symptoms until antibiotics take effect (usually within 48 hours).
The choice of antibiotics must be based on the patient’s allergies and history, local resistance patterns (if known), the availability and cost of antibiotics, the patient’s tolerance for the risk of therapeutic failure. The ability to induce antibiotic resistance must also be considered. When urine culture is performed, the choice of antibiotic should be changed based on culture results and sensitivity using the drug with the narrowest and most effective spectrum of action against the identified pathogen.
Surgical correction is generally required in cases of obstructive uropathy, anatomical abnormalities and neuropathic lesions of the genitourinary tract such as compressive lesions of the spinal cord. Catheter drainage of a blocked urinary tract helps to control urinary tract infections promptly.
- Sometimes, a renal or perinephritic cortical abscess requires surgical drainage.
- If possible, instrumental investigations of the lower urinary tract should be postponed in the presence of infected urine.
- Urine sterilization before instrumental maneuvers and subsequent antibiotic therapy for 3-7 days can prevent potentially fatal urinary sepsis.
Sexually active symptomatic patients are usually treated for sexually transmitted diseases on a presumptive basis pending test results. A typical protocol consists of ceftriaxone 250 mg IM plus azithromycin 1 g orally once / day or doxycycline 100 mg orally 2 times / day for 7 days. All sexual partners must be evaluated within 60 days.
Men diagnosed with urethritis should be tested for HIV and syphilis in accordance with the Centers for Disease Control and Prevention’s 2015 Sexually Transmitted Diseases Treatment Guidelines.
First-line treatment of uncomplicated cystitis is nitrofurantoin 100 mg orally twice / day for 5 days (contraindicated if creatinine clearance is <60 mL / min), trimethoprim / sulfamethoxazole 160/800 mg orally 2 times / day for 3 days, or phosphomycin 3 g orally 1 time.
Less desirable choices include a fluoroquinolone or a beta-lactam antibiotic. If cystitis recurs within a week or two, a broader-spectrum antibiotic (eg, a fluoroquinolone) can be used and urine culture done.