Recurrent Cystitis

1. Epidemiology
   1. Incidence of bacteriuria
      1. School age child: 1.2%
      2. Late Teenage years: 2-5%
      3. Additional 1% per decade of life
   2. Incidence of UTIs for those prone: 2-3 per year
      1. Reduced to <1 per year on prophylaxis
2. Types: Infection Classification
   1. General
      1. Reinfection represents 99% of Recurrent UTI in women
      2. Vaginal colonization is the most common cause
   2. First Infection
   3. Unresolved Bacteriuria (Refractory Infection)
      1. Bacterial resistance to drug selected for treatment
         1. Resistance developed by sensitive bacteria
         2. Bacteriuria with 2 different species
         3. Rapid reinfection with a second resistant organism
      2. Azotemia
      3. Analgesic abuse causing papillary necrosis
      4. Giant staghorn calculi
      5. Noncompliance
   4. Bacterial persistance (Same organism recurs)
      1. Infected Renal Calculi
      2. Chronic Bacterial Prostatitis
      3. Unilateral infected atrophic Pyelonephritis
      4. Infected pericalyceal Diverticulae
      5. Infected nonrefluxing ureteral stumps
         1. Follows Nephrectomy
      6. Medullary sponge Kidneys
      7. Polycystic Kidney Disease
      8. Infected urachal cysts
      9. Analgesic abuse causing infected papillary necrosis
   5. Reinfection (Urine cleared, but new infection occurs)
      1. Colonization of vaginal introitus
      2. Vesicoenteric fistulae
      3. Vesicovaginal fistulae
      4. Vesicoureteral Reflux
      5. Voiding dysfunction
         1. Cystocele
         2. Multiple Sclerosis
         3. Neurogenic Bladder
      6. Immunosuppression
         1. Chronic Renal Insufficiency
         2. Diabetes Mellitus
         3. Immunosuppressant medications
      7. Instrumentation
         1. Ureteral stent
         2. Nephrostomy tube
         3. Intermittent catheterization or indwelling Urinary Catheter
3. Risk Factors: Young women with Recurrent UTI
   1. Intercourse in the past month >9 times: Odds Ratio 10.3
   2. Intercourse in the past month 4-8 times: Odds Ratio 5.8
   3. Age at first UTI >15 years: Odds Ratio 3.9
   4. Mother with Recurrent UTI: Odds Ratio 2.3
   5. New sex partner in the last year: Odds Ratio 1.9
   6. Spermicide use in the last year: Odds Ratio 1.8
   7. Scholes (2000) J Infect Dis 182(4): 1177-82
4. Differential Diagnosis
   1. See Dysuria
5. Management: Urinary Tract Infection Treatment
   1. See Urinary Tract Infection for acute management
6. Management: UTI Prophylaxis in women
   1. Indications
      1. Recurrent Urinary Tract Infections occurring 3 or more times annually
   2. Continuous UTI Prophylaxis (Average Course: Taken daily for 6 months)
      1. Nitrofurantoin 50-100 mg daily
      2. Trimethoprim Sulfamethoxazole 40/200 daily or 3x/week
      3. Trimethoprim 100 mg daily
      4. Cephalexin 125-250 mg daily
      5. Ciprofloxacin 125 mg daily
      6. Norfloxacin 200 mg daily
   3. Postcoital Prophylaxis (one dose taken within 2 hours of intercourse)
      1. Precaution: Recurrence is common after stopping prophylaxis
      2. Nitrofurantoin 50-100 mg once
      3. Trimethoprim Sulfamethoxazole 40/200 to 80/400 once
      4. Trimethoprim 100 mg once
      5. Cephalexin 250 mg once
      6. Ciprofloxacin 125 mg once
      7. Norfloxacin 200 mg once
   4. Self-starting regimen
      1. Emergency prescription available to start after onset of classic Urinary Tract Infection symptoms
      2. Choose a 3 day antibiotic course (see Urinary Tract Infection for antibiotic options and dosing)
      3. Contact provider if symptoms last more than 48 hours despite antibiotics
7. Management: Prophylaxis with Cranberry Juice
   1. Daily cranberry juice prevents Recurrent UTI
      1. Contains proanthocyanidin compounds
      2. Inhibits E. coli from adhering to urinary tract
   2. Recommended daily dosing of cranberry juice
      1. Cranberry extract 300-400 mg tablet bid or
      2. Pure cranberry unsweetened juice 8 ounces tid
   3. References
      1. Kontiokari (2001) BMJ 322:1571-3
      2. Howell (1998) N Engl J Med 339(15): 1085-86
      3. Lynch (2004) Am Fam Physician 70(11): 2175-77
8. Management: Behavior Modification
   1. Women should clean perineum wiping front to back
   2. Women should empty Bladder before, after intercourse
   3. Avoid Contraceptive Diaphragm
   4. Spermicides might also predispose to Urinary Tract Infection
9. References
   1. Kodner (2011) Am Fam Physician 82(6): 638-43
   2. Sen (2006) Clin Evid 15:2558-64