Cystitis

• Key HPI questions: Onset, duration, and severity of dysuria, urinary frequency, urgency, suprapubic pain, and hematuria [1-2]
• Symptom characterization: Burning/pain with urination (internal vs. external), sense of incomplete emptying, nocturia, gross hematuria, urine cloudiness or odor
• Timing/triggers: Relationship to sexual intercourse, new sexual partner, spermicide/diaphragm use, recent antibiotic use, recent catheterization or instrumentation [3]
• Associated symptoms: Vaginal discharge or irritation (suggests vaginitis/STI rather than cystitis), back/flank pain, fever, nausea/vomiting (suggests pyelonephritis) [1]
• Important negatives: Absence of vaginal discharge raises probability of cystitis to >90% in women with dysuria and frequency. Absence of fever, chills, and flank pain helps exclude upper tract involvement [1][4]

• Fever (>38°C), chills, rigors, or hemodynamic instability → suspect pyelonephritis or urosepsis [1][4]
• Flank pain or costovertebral angle (CVA) tenderness → upper tract infection [4-5]
• Nausea/vomiting with urinary symptoms → pyelonephritis [1]
• Urinary retention or inability to void → urinary obstruction requiring same-day in-person evaluation [6]
• Pregnancy → all UTIs require culture-confirmed diagnosis and treatment; risk of ascending infection and preterm labor [5]
• Immunocompromised patients, recent urologic procedures, or indwelling catheters → complicated UTI pathway [4]

First-line empiric treatment (per IDSA/ACP guidelines): [7-8]

• Nitrofurantoin 100 mg BID × 5 days (most effective in recent head-to-head data) [9]
• TMP-SMX 160/800 mg BID × 3 days (if local resistance <20%) [8]
• Fosfomycin 3 g single dose (inferior efficacy vs. nitrofurantoin per SCOUT trial) [9]
• Pivmecillinam 400 mg TID × 3 days (FDA-approved in the US for uncomplicated UTI in women) [9-10]

Contraindicated/avoid

• Fluoroquinolones: Not recommended empirically for uncomplicated cystitis due to adverse effect profile (tendinopathy, QTc prolongation, aortic dissection risk, C. difficile); reserve for resistant organisms [11-12]
• Nitrofurantoin: Avoid if CrCl <30 mL/min; not effective for upper tract infections (poor renal parenchymal penetration)
• TMP-SMX: Avoid if local E. coli resistance >20% [8]

Medication cautions

• Nitrofurantoin: Pulmonary toxicity with prolonged use; avoid in G6PD deficiency
• Fosfomycin: Not recommended for non-E. coli ESBL infections (e.g., K. pneumoniae carries fosA gene) [12]

• Increased fluid intake: ≥1.5 L/day recommended for symptom relief and prevention of recurrence [2]
• Cranberry products: Evidence supports a role in prevention of recurrent UTI, not treatment of acute episodes [2]
• Avoid bladder irritants during acute episode: caffeine, alcohol, spicy foods, artificial sweeteners
• Long-term: Adequate hydration is the most evidence-supported dietary intervention for recurrence prevention

• GU: Dysuria, frequency, urgency, hematuria, suprapubic pain, nocturia, vaginal discharge/irritation, urethral discharge (men)
• Constitutional: Fever, chills, rigors, malaise, fatigue
• GI: Nausea, vomiting, diarrhea (may suggest alternative diagnosis or systemic illness) [6]
• MSK/Back: Flank pain, CVA tenderness (pyelonephritis)
• GYN: Vaginal discharge, dyspareunia, vulvar lesions (vaginitis, STI)
• Neuro (elderly): New confusion or altered mental status may be the only presenting symptom in frail elderly patients

• Prior UTI history: Number of episodes, prior organisms and sensitivities, prior treatment failures
• Sexual history: New partners, contraceptive method (spermicide/diaphragm increase risk), STI risk factors [1]
• Menopausal status: Genitourinary syndrome of menopause (GSM) can mimic and predispose to UTI [6]
• Family history: Recurrent UTI in first-degree relatives may indicate genetic susceptibility
• Social context: Access to timely urine testing, barriers to follow-up (relevant for triage decisions) [6]

• Female sex: 50× more common than in males; 40–50% of women experience ≥1 UTI in their lifetime [3]
• Sexual intercourse (strongest modifiable risk factor in premenopausal women) [1]
• Spermicide/diaphragm use [1]
• Prior UTI history [2]
• Postmenopausal status: Vaginal atrophy, loss of lactobacilli [6]
• Diabetes mellitus [13]
• Urinary catheterization or recent instrumentation [4]
• Urologic abnormalities: Obstruction, neurogenic bladder, vesicoureteral reflux
• Antibiotic use: Recent antibiotics increase risk of resistant organisms [6]
• Immunosuppression [14]

The following table from the AAFP summarizes key differentiating features: [2]

• Prior UTIs: Frequency, organisms, resistance patterns, treatment responses
• Recurrent UTI (≥2 in 6 months or ≥3 in 12 months): Warrants in-person evaluation and culture-guided therapy [2][6]
• Urologic surgery or instrumentation
• Diabetes, immunosuppression, pregnancy
• Neurogenic bladder, urinary retention, structural abnormalities
• Kidney stones
• Allergies: Sulfa allergy (precludes TMP-SMX), nitrofurantoin hypersensitivity

• Vital signs: Temperature (fever >38°C → pyelonephritis), heart rate, blood pressure (tachycardia/hypotension → sepsis)
• Abdominal exam: Suprapubic tenderness (supports cystitis); distended bladder (retention)
• CVA tenderness: The only physical exam finding that increases the probability of UTI — specifically indicates pyelonephritis [1]
• Pelvic exam (if vaginal symptoms present): Evaluate for discharge, cervicitis, vulvar lesions, vaginal atrophy [15]
• DRE (men): Prostatic tenderness/edema suggests prostatitis [17]
• Genital exam (men): Testicular tenderness/swelling (epididymo-orchitis)

• Urinalysis (dipstick):
  • Leukocyte esterase: Sensitivity ~81–83%, specificity ~67–71% [17]
  • Nitrites: Sensitivity ~55–58%, specificity ~90–98% [5][17]
  • Combined LE or nitrite positive: Sensitivity 75%, specificity 82% [1]
  • If both LE and nitrite negative, UTI is unlikely (NPV 78–98%) [5]
• Urine culture: Not required for uncomplicated cystitis in women with classic symptoms. Indicated for: recurrent UTI, treatment failure, resistant organisms, atypical presentation, all men, pregnant patients, elderly [1-2][6]
• CBC, BMP, blood cultures: Only if systemic illness suspected (fever, sepsis, pyelonephritis) [5]
• STI testing: Gonorrhea/chlamydia NAAT if risk factors present [17]

• Not indicated for uncomplicated cystitis [2]
• Renal ultrasound: Consider if urinary obstruction, abscess, or structural abnormality suspected
• CT abdomen/pelvis: If nephrolithiasis, renal abscess, or emphysematous pyelonephritis suspected
• Important: Imaging should be reserved for complicated presentations, recurrent infections without clear cause, or failure to respond to appropriate therapy

• Urine dipstick: Point-of-care test; most useful when clinical picture is ambiguous. Adds little when history is strongly suggestive of UTI [1]
• Post-void residual (bladder scan): If urinary retention suspected [17]
• Cystoscopy: Not indicated acutely; consider for recurrent UTI, persistent hematuria after infection resolves, or suspected structural pathology
• Methenamine hippurate: Effective for recurrent UTI prevention (not a diagnostic test, but a notable preventive intervention) [2]

• Not routinely indicated for cystitis
• Consider if prescribing fluoroquinolones (risk of QTc prolongation) in patients with cardiac risk factors [12]
• Obtain ECG if sepsis or hemodynamic instability is present

Clinical summary: Acute cystitis is a clinical diagnosis in women with classic symptoms (dysuria, frequency, urgency) without vaginal discharge. The probability exceeds 90% when dysuria and frequency are present without vaginal symptoms. [1] Most cases (80%) are caused by E. coli. [3]

Severity stratification

• Uncomplicated: Symptoms confined to the bladder, no systemic signs, in a non-pregnant, non-catheterized adult without urologic abnormalities [4]
• Complicated: Fever, flank pain, CVA tenderness, systemic illness, or presence of complicating factors (catheter, obstruction, pregnancy, immunosuppression) [4]

Atypical presentations: Elderly patients may present with confusion or functional decline without classic urinary symptoms. Men with cystitis symptoms should be evaluated for prostatitis and urethritis. [2][17]

Complications: Pyelonephritis (1–2% of untreated cases), urosepsis, renal abscess (rare)

Initial management — uncomplicated cystitis in women: [7-9]

Men: 7-day course of TMP-SMX or nitrofurantoin; always obtain urine culture [2]

Symptomatic relief: NSAIDs (ibuprofen) for pain; phenazopyridine 200 mg TID × 2 days for dysuria (warn about orange urine discoloration)

Delayed antibiotic strategy: In select low-risk women who prefer to avoid antibiotics, a backup prescription to fill if symptoms do not improve in 48–72 hours is a reasonable option [2]

Recurrence prevention: Adequate hydration (≥1.5 L/day), cranberry products, methenamine hippurate, topical vaginal estrogen in postmenopausal women [2][6]

• Discharge (vast majority): Uncomplicated cystitis is managed entirely as an outpatient [2][13]
• Same-day in-person evaluation: Symptoms of pyelonephritis, complicated cystitis, or urinary obstruction [6]
• Admission criteria: Sepsis, hemodynamic instability, intractable vomiting (unable to tolerate oral antibiotics), severe pyelonephritis, immunocompromised with systemic illness, pregnant with pyelonephritis [5]
• Observation: Consider for borderline cases (e.g., early pyelonephritis responding to IV fluids and parenteral antibiotics)
• Specialist consultation: Urology referral for recurrent UTI (≥3/year), structural abnormalities, persistent hematuria after infection resolution, suspected obstruction [6]

• Follow-up timing: Routine follow-up not needed if symptoms resolve. If symptoms persist beyond 48–72 hours of appropriate antibiotics, reassess and obtain urine culture [2]
• Return immediately for: Fever >38°C, rigors, flank pain, vomiting, inability to tolerate oral medications, worsening symptoms, signs of urinary retention
• Patient counseling:
  • Complete the full antibiotic course
  • Increase fluid intake
  • Symptoms typically improve within 24–48 hours of starting antibiotics
  • Phenazopyridine is for symptom relief only, not treatment
• Expected recovery: Most uncomplicated cases resolve within 3–5 days of treatment [2][9]
• Recurrent UTI: If ≥2 episodes in 6 months or ≥3 in 12 months, warrants at least one in-person evaluation with physical exam to assess for treatable underlying conditions (e.g., genitourinary syndrome of menopause) [6]

The following algorithm from the Ann Arbor Guide illustrates the triage approach for nonpregnant women with suspected UTI, including when empiric antibiotics, urine testing, and in-person evaluation are appropriate:

1. Uncomplicated Urinary Tract Infection. — Hooton TM. The New England Journal of Medicine. 2012.

2. Acute Uncomplicated UTIs in Adults: Rapid Evidence Review. — Kurotschka PK, Gágyor I, Ebell MH. American Family Physician. 2024.

3. Reappraisal of the Treatment Duration of Antibiotic Regimens for Acute Uncomplicated Cystitis in Adult Women: A Systematic Review and Network Meta-Analysis of 61 Randomised Clinical Trials. — Kim DK, Kim JH, Lee JY, et al. The Lancet. Infectious Diseases. 2020.

4. Clinical Practice Guideline by Infectious Diseases Society of America (IDSA): 2025 Guideline on Management and Treatment of Complicated Urinary Tract Infections: Introduction and Methods. — Barbara W. Trautner, Nicolás W. Cortés-Penfield, Kalpana Gupta, et al Infectious Diseases Society of America. 2025.

5. Urinary Tract Infections in Pregnant Individuals. — Committee on Clinical Consensus—Obstetrics Obstetrics and Gynecology. 2023.

6. Ann Arbor Guide to Triaging Adults With Suspected Urinary Tract Infection for In-Person and Telehealth Settings. — Meddings J, Chrouser K, Fowler KE, et al. JAMA Network Open. 2026.

7. Appropriate Use of Short-Course Antibiotics in Common Infections: Best Practice Advice From the American College of Physicians. — Lee RA, Centor RM, Humphrey LL, et al. Annals of Internal Medicine. 2021.

8. International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women: A 2010 Update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. — Gupta K, Hooton TM, Naber KG, et al. Clinical Infectious Diseases : An Official Publication of the Infectious Diseases Society of America. 2011.

9. Clinical and Bacteriological Effectiveness of Three Different Short-Course Antibiotic Regimens and Single-Dose Fosfomycin for Uncomplicated Lower Urinary Tract Infections in Women (SCOUT): A Pragmatic, Multicentre, Open-Label, Randomised Clinical Trial. — Llor C, Monfà R, Garcia-Sangenís A, et al. Lancet. 2026.

10. FDA Orange Book. — FDA Orange Book. 2026.

11. Antibiotic Courses for Common Infections: Recommendations From the ACP. — Dakkak M, Sabharwal M. American Family Physician. 2022.

12. Infectious Diseases Society of America 2023 Guidance on the Treatment of Antimicrobial Resistant Gram-Negative Infections. — Tamma PD, Aitken SL, Bonomo RA, et al. Clinical Infectious Diseases : An Official Publication of the Infectious Diseases Society of America. 2023.

13. Diagnosis and Management of Urinary Tract Infections in the Outpatient Setting: A Review. — Grigoryan L, Trautner BW, Gupta K. The Journal of the American Medical Association. 2014.

14. Non-Steroidal Anti-Inflammatory Drugs for Treating Symptomatic Uncomplicated Urinary Tract Infections in Non-Pregnant Adult Women. — Sachdeva A, Rai BP, Veeratterapillay R, Harding C, Nambiar A. The Cochrane Database of Systematic Reviews. 2024.

15. Dysuria: Evaluation and Differential Diagnosis in Adults. — Michels TC, Sands JE. American Family Physician. 2015.

16. Symptoms of Interstitial Cystitis, Painful Bladder Syndrome and Similar Diseases in Women: A Systematic Review. — Bogart LM, Berry SH, Clemens JQ. The Journal of Urology. 2007.

17. Prostatitis. — Borgert BJ, Wallen EM, Pham MN. The Journal of the American Medical Association. 2025.