Identifying and treating at-risk patients: Many patients fall naturally into groups for whom treatment is fairly straightforward. Those with postcoital cystitis can benefit from prophylactic treatment. Estrogen replacement therapy is often effective in managing cystitis in post-menopausal women. Pregnant women should receive nitrofurantoin for at least 10 days, and a follow-up culture to make sure the organism is eradicated. When a patient’s symptoms include nocturia, be alert for interstitial cystitis. Sexually active women, postmenopausal or pregnant women, those who are diabetic or immunocompromised, and women with a history of childhood urinary tract disease require special cystitis management (and so do children;).
Women susceptible to postcoital cystitis can safely treat it prophylactically. Ask the patient if symptoms begin after intercourse, and if so, how often she has coitus. Someone who has intercourse once a week should take a drug, preferably nitrofurantoin (Furadantin, Macrodantin), just before or after.(*) Those who have coitus more often may be candidates for intermittent self-therapy at the first sign of infection.
Some pragmatic clinicians believe it is helpful to ask the patient if the dysuria starts soon after her menstrual period, and if so, whether she uses tampons. If she does, switching from tampons to pads may effect a cure. Although there are no data to substantiate this solution, some physicians find it works. Diaphragms, too, may encourage a natural predisposition to infection, and switching to another form of contraception may be helpful.
When a postmenopausal woman complains of dysuria, the physical examination may reveal signs of atrophic vaginitis. Estrogen replacement therapy will probably resolve the vaginitis–and the cystitis along with it. The complete solution may not be so simple, however. For older women presenting with signs of upper tract infection–flank pain, fever, asymptomatic hematuria, and particularly nocturia–cystoscopy is essential to look for signs of bladder cancer.
During pregnancy, infection of the lower urinary tract is more likely to ascend to the upper tract than at other times. Thus, when a pregnant patient develops symptoms of cystitis, special precautions are necessary–as they are with diabetic patients and those who are immunocompromised. Do a culture to make sure the organism is eradicated, and follow closely. Trimethoprim/sulfamethoxazole (Bactrim, Cotrim, Septra, etc.) is contraindicated for pregnant women. The usual recommendation is nitrofurantoin, 50-100 mg gid for at least 10 days,(*) although this drug is not recommended for pyelonephritis, whether the patient is pregnant or not. B-Lactams such as ampicillin are also acceptable treatment during pregnancy. Start empiric therapy immediately without waiting for culture results. If a pregnant woman has acute pyelonephritis, hospitalization and parenteral antimicrobial drug therapy are recommended. Posttreatment cultures to assure that urine is sterile are also indicated.
Interstitial cystitis is a problem that is best managed by a urologist. The symptoms are nocturia, frequency of urination, and–sometimes but not always–lower abdominal discomfort. The urine culture will reveal no bacteria, and there is little to offer in the way of a cure. Various courses of treatment have been tried, but without consistent success.