Recurrent Cystitis in Women

Background

• Recurrent cystitis episodes are common in women, affecting over 30% of women following initial infection.
• Recurrence may be due to reinfection from extra-urinary sources or may be associated with the establishment of intracellular reservoirs of uropathogenic bacteria, especially Escherichia coli strains within the bladder epithelium.
• Recurrence rate may be higher for E. coli than for other bacteria.
• Risk factors in premenopausal women include being sexually active, young age at first urinary tract infection (UTI), and a family history of UTI.
• Risk factors in postmenopausal women include urinary incontinence and a history of UTI prior to menopause.

Evaluation

• Clinical presentation of recurrent cystitis is the same as acute cystitis and includes symptoms of dysuria, urgency, and frequency.
• Urinalysis and urine culture are recommended for diagnosis but self-diagnosis may also be appropriate in women with a documented history of recurrent UTI.
• Additional work-up such as ultrasound and cystoscopy are typically not needed for recurrence of uncomplicated cystitis unless history or physical is suggestive of an underlying functional or anatomical abnormality.

Management

• Treatment for recurrent cystitis episodes is similar to that for acute UTI.
  • Empiric antibiotic selection should be based on prior response and susceptibility patterns of prior infecting bacteria.
  • Definitive therapy should be tailored to culture and susceptibility results.
  • Longer courses may be considered for women with continual relapse or complicated infection.
• Common empiric options, derived from treatment of acute uncomplicated cystitis, include:
  • nitrofurantoin monohydrate/macrocrystals 100 mg orally twice daily for 5 days
  • fosfomycin trometamol 3 g orally in a single dose
  • trimethoprim-sulfamethoxazole (co-trimoxazole [TMP-SMX]) 160/800 mg (1 double-strength tablet) orally twice daily for 3 days
  • pivmecillinam 400 mg orally twice daily for 3-7 days (not available in the United States)
• Alternatively, self-diagnosis and patient-initiated empiric treatment with short course antibiotics may be considered in selected patients.

Prevention

• Preventive strategies include behavioral modifications, nonantimicrobial pharmacologic therapy, and antimicrobial prophylaxis.
• Limited evidence exists to support most behavioral interventions to reduce recurrent cystitis.
  • It is generally advisable to try these interventions before or along with pharmacologic interventions.
  • Consider counseling premenopasual patients who consume < 1.5 L/day on increasing fluid intake (Weak recommendation).
  • Consider counseling patients on postcoital voiding.
• Nonantimicrobial strategies to avoid antibiotic overuse and development of resistance include:
  • vaginal estrogen replacement in postmenopausal women (Strong recommendation)
  • cranberry products (Weak recommendation)
  • local or oral probiotics (Weak recommendation)
  • D-mannose (Weak recommendation)
  • methenamine hippurate in women without urinary tract abnormalities (Strong recommendation)
  • intravesical administration of hyaluronic acid with or without chondroitin sulphate (Weak recommendation)
  • immunoprophylaxis with OM-89 (Uro-Vaxom) which is available in Europe (Strong recommendation)
• When nonantimicrobial agents have failed, give antimicrobial prophylaxis as postcoital prophylaxis or continuous prophylaxis after counseling patients on possible adverse events (Strong recommendation).