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Urinary tract infections (UTIs) are the most common nosocomial
infections. They account for more than 7 million physician visits and
over 1 million hospital admissions in the United States each year.
1,2

They are the most common bacterial infection in older adults and
the most frequent source of bacteremia.
3,4
UTIs are second in serious-
ness only to respiratory infections.
DEFINITION
The term uncomplicated urinary tract infection refers to the invasion
of a structurally and functionally normal urinary tract by a nonresi-
dent infectious organism. Complicated UTI refers to the occurrence
of infection in most men and in patients with an abnormal structural
or functional urinary tract, or both (Box 1).
PREVALENCE AND RISK FACTORS
In 1995, the estimate for the United States put the direct cost of
community-acquired UTIs at $659 million and indirect costs,
through lost productivity, at $936 million.
5-8
The UTI incidence ratio
in middle-aged women to men is 30 : 1; however, during later decades
of life, the ratio of infection in women to men with bacteriuria pro-
gressively decreases.
9
Women are especially susceptible to cystitis for
reasons that are poorly understood. One factor may be that a womans
urethra is short, allowing bacteria quick access to the bladder. Also,
a womans urethral opening is near sources of bacteria from the anus
and vagina. For many women, sexual intercourse seems to trigger an
infection, although the reasons for this linkage are unclear.
10
Esti-
mates have suggested that about one third of women will have at least
one episode of UTI requiring antibiotic therapy by the time they
are 24 years old, and over a lifetime 50% will have had at least one
UTI.
5-7
Hormonally induced changes in the vaginal ora associated
with menopause are responsible for its higher prevalence in older
women.
11
PATHOGENESIS
The infection spreads to the urinary tract through an ascending route
of fecal ora, from the fecal reservoir through the urethra into the
bladder, particularly in patients with intermittent or indwelling cath-
eters; hematogenous dissemination, secondary to Staphylococcus
aureus bacteremia; or by direct extension from adjacent organs via
the lymphatic system, as in the case of retroperitoneal abscesses or
severe bowel obstruction. In women, colonization of the mucosa of
the vaginal introitus is an essential step in the pathogenesis of UTIs.
Some people are more likely to get UTIs than others because of
host factors or urothelial mucosal adherence to the mucopolysac-
charide lining.
12
Any abnormality of the urinary tract that interferes
with the drainage of urine (e.g., kidney stones or an enlarged pros-
tate) sets the stage for an infection, as well as foreign bodies in the
bladder, such as catheters and tubes (see Box 1). Diabetes and other
immunocompromised patients are at higher risk for a UTI and its
complications. Sexual intercourse
10
and womens use of a diaphragm
13

have also been linked to an increased risk of cystitis. Pregnancy does
not increase the risk of cystitis; however, it increases the risk of pyelo-
nephritis if UTI occurs.
URINARY PATHOGENS
Escherichia coli is the most common infecting organism in patients
with uncomplicated UTIs.
14
It causes 85% of community-acquired
infections and approximately 50% of nosocomial infections. Other
gram-negative microorganisms causing UTIs include Proteus, Kleb-
siella, Citrobacter, Enterobacter, and Pseudomonas spp. Gram-positive
pathogens such as Enterococcus fecalis, Staphylococcus saprophyticus,
and group B streptococci can also infect the urinary tract. Anaerobic
microorganisms are frequently encountered in suppurative infec-
tions of the genitourinary tract (e.g., periurethral abscess, Fourniers
gangrene).
SIGNS AND SYMPTOMS
Cystitis may be asymptomatic. However, some patients report incon-
tinence, a general lack of well-being, or both.
15
Cystitis clinically
manifests as irritative voiding symptoms that include frequency,
dysuria, urgency, suprapubic or lower abdominal pain, and inconti-
nence. In men, urinary retention should be ruled out, because it is
frequently associated with cystitis and possible prostatitis. The man-
ifestations of UTIs in older adults may include confusion, lethargy,
anorexia, and incontinence.
DIAGNOSIS
Physical examination, including a pelvic examination, should be
carried out in women with lower urinary tract symptoms to exclude
gynecologic, neurologic, or colorectal disorders. Physicians should
also maintain a high index of suspicion for underlying sexually trans-
mitted disease (STD). Up to 50% of women presenting to an emer-
gency department for symptoms of cystitis were found to have
positive STD cultures.
16
Urine samples are collected for urinalysis in a sterile container
through urethral catheterization, especially in women, or by mid-
stream voided urine after the genital area is washed to avoid con-
tamination. The sample is then tested for bacteriuria, pyuria, and
hematuria. Indirect dipstick tests are informative but less sensitive
than microscopic examination of the urine. About one third of the
women who have acute symptoms of cystitis have sterile urine or
some other cause for the symptom.
17
Many diseases of the urinary
tract produce signicant pyuria without bacteriuria, including stag-
horn calculi, tuberculosis, and infections caused by Chlamydia and
Mycoplasma spp. Microscopic hematuria is found in 40% to 60% of
cystitis patients.
18
Associated gross hematuria should be evaluated
further by imaging studies. Cystoscopy is indicated for those patients
older than 50 years or who have other risk factors for concomitant
diseases, such as nephrolithiasis or transitional cell carcinoma (e.g.,
smoking).
Whereas empirical therapies are acceptable for uncomplicated
cystitis (Box 2), culture and sensitivity testing should be performed
in all other cases. It should be noted that a large percentage of women
with cystitis have been found to have STDs. Additional cultures for
Neisseria gonorrhea, Chlamydia, Mycoplasma hominis, and Urea-
plasma ureolyticus should be considered for women with recurrent
lower urinary tract symptoms.
726
Acute and Chronic
Bacterial Cystitis
Joseph B. Abdelmalak and Jeannette M. Potts
E
Acute and Chronic Bacterial Cystitis 727
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Magnetic resonance imaging may be indicated for patients who
require further evaluation for renal neoplasm, in whom IV con-
trast is contraindicated. It may also be necessary as the most
sensitive modality for the detection of urethral diverticulum.
The urethra and bladder can be inspected quickly and safely by
the use of cystoscopy with a local anesthetic in an ofce setting.
TREATMENT
Cystitis
For the general management of cystitis, the patient is advised to drink
plenty of water, which helps cleanse the urinary tract of bacteria.
Cranberry juice and vitamin C (ascorbic acid) supplements inhibit
the growth of some bacteria by acidifying the urine. Avoiding coffee,
alcohol, and spicy foods is also useful. A heating pad and pain relief
medication are helpful for pain management.
Cystitis is treated with antibacterial drugs. The choice of drug and
length of treatment depend on several factors (Box 3). The sensitiv-
ity test is especially useful for selecting the most effective drug.
Acute Cystitis
Patients who have symptoms of frequency, urgency, pyuria on micro-
scopic examination, and no known functional or anatomic abnor-
mality of the genitourinary tract may be presumed to have acute
uncomplicated cystitis. Empirical therapy with a 3-day regimen of
trimethoprim-sulfamethoxazole (TMP-SMX) or a uoroquinolone
without pretreatment culture and sensitivity testing is usually effec-
tive. Alternative regimens such as a uoroquinolone, an oral third-
generation cephalosporin, or nitrofurantoin (7-day regimen) may
have a better result. Generally, for most female patients, a 3-day
course seems warranted, because this demonstrates similar efcacy
when compared with 7-day therapy, and with lower side effects and
cost.
19
Single-dose therapy usually results in lower rates of cure and
more frequent recurrences.
Recurrent Cystitis
The most common cause of recurrent UTI in women is reinfection
that may occur with varying intervals and different causative organ-
isms. Reinfection in women does not require extensive urologic
evaluation. Recurrent episodes of uncomplicated cystitis can be
managed by several strategies. Behavioral therapy includes increasing
uid intake, urinating as soon as the need is felt, as well as immedi-
ately after intercourse, and changing the method of contraception
(for users of a diaphragm or spermicide), because spermicidal jelly
contains nonoxynol 9, which decreases vaginal lactobacillus coloni-
zation and increases bacterial adherence. Long-term antimicrobial
Radiologic studies are unnecessary for the routine evaluation of
patients with cystitis; however, they may be indicated to nd the
cause of complicated cases, in which UTIs are associated with urinary
calculi, ureteral strictures, ureteral reux, urinary tract tumors, and
urinary tract diversions. The following studies may be useful:
Plain radiography of the abdomen for the detection of radi-
opaque calculi or abnormal renal contour
Intravenous pyelography for radiographic images of the bladder,
kidneys, and ureters. An opaque dye visible on radiographic lm
is injected into the vein and a series of radiographs are taken. The
lms demonstrate the contour of the collecting system, which
may reveal lling defects or obstruction.
Voiding cystourethrography to evaluate neurogenic bladder and
urethral diverticulum and to exclude or dene the extent of vesi-
coureteral reux
Renal ultrasonography, through interpretation of echogenic pat-
terns generated by sound waves, can detect the presence of hydro-
nephrosis, tumors, pyonephrosis, calculi, or abscesses.
Computed tomography (CT), a more sensitive means of dening
renal parenchyma, especially when used with intravenous con-
trast material. CT urograms have replaced intravenous pyelo-
grams in the evaluation of the urinary tract and kidneys,
particularly in the workup of hematuria. Spiral CT scanning
without contrast is the most sensitive means of detecting calculi
within the urinary collecting system and is the standard of care
for the evaluation of acute ank pain.
Functional Abnormalities
Vesicoureteral reux
Neurogenic bladder
Obstruction
Congenital Abnormalities
Pelvic-ureteric obstruction
Ureteric and urethral strictures
Urolithiasis
Bladder diverticuli
Tumors
Foreign Bodies
Indwelling catheters
Other
Diabetes mellitus
Renal failure
Urinary diversions
Urinary instrumentation
Box 1 Functional and Structural Abnormalities of the
Genitourinary Tract
Uncomplicated
Acute cystitis in women
Acute pyelonephritis in young healthy women
Complicated
Acute cystitis in men
Acute prostatitis
Chronic prostatitis
Acute pyelonephritis in men
UTI with pregnancy
UTI with gross hematuria
UTI associated with nephrolithiasis
UTI associated with neurogenic bladder
UTI in diabetic or immunocompromised patient
Recurrent UTI (>3 episodes per year)
Box 2 Urinary Tract Infection (UTI) in Adults
Patient Factors
History of drug allergy
Medical history (e.g., renal impairment, liver impairment)
Presence of urologic abnormalities
Drug Factors
Safety prole
Spectrum of activity
Route of administration
Costs
Type of Organism
Results of Gram staining
Results of special culture and sensitivity testing
Box 3 Factors Inuencing Selection of Antimicrobial Agents for
Treating Urinary Tract Infections
E
728 Acute and Chronic Bacterial Cystitis
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of bacteriuria or UTI. Unfortunately, this difference is not associated
with long-term catheterization.
25
Funguria is a common nding in catheterized patients. Whereas
most patients are asymptomatic, interventions should include change
in catheter, elimination of unnecessary antimicrobials, and glycemic
control. Although amphotericin B may be used for bladder irriga-
tions, it is less effective and more expensive than oral uconazole
therapy, although the latter is a concern in patients with hepatic
vulnerability.
Removal of an indwelling catheter should be prompt; whenever
possible, intermittent self catheterization should be used for patients
with transient or long-term urinary retention.
Asymptomatic Bacteriuria
Bacteriuria denotes the presence of bacteria in the urine, which may
be symptomatic or asymptomatic. Treatment of asymptomatic bac-
teriuria is indicated for pregnant women and those requiring
urologic surgery.
26
Preoperative treatment reduces postoperative
complications, including bacteremia.
27
Cystitis and Pregnancy
Although the prevalence of bacteriuria identied by screening is no
higher in pregnant than nonpregnant women, the presence of
asymptomatic bacteriuria in a pregnant woman should be treated
promptly.
28
The gravid uterus causes physiologic alterations that
increase the risk of pyelonephritis. Pyelonephritis has been associated
with infant prematurity, low birth weight, perinatal mortality, and
high blood pressure.
29
The recommended regimen is 7-day treatment
with ampicillin or nitrofurantoin.
Urinary Tract Infection and Renal Failure
When creatinine clearance is signicantly impaired, antibiotic dosage
should be decreased since the renal blood ow is decreased and the
perfusion of antimicrobial agents into the renal tissue and urine is
impaired. Ampicillin, TMP-SMX, and uoroquinolones are all effec-
tive for the treatment of UTIs in uremic patients.
30,31
Nitrofurantoin
and tetracyclines are contraindicated for the treatment of UTIs in
uremic patients.
PROPHYLAXIS
Antimicrobial prophylaxis is recommended to ensure the sterility of
urine for those who appear susceptible to developing infections.
These include immunocompromised patients, patients with heart
disease, people with a prosthetic heart valve, and patients who are
scheduled for a procedure such as cystoscopy. Oral or vaginal estro-
gen administered prophylactically to postmenopausal women also
reduces the incidence of cystitis.
26,31
prophylaxis,
20
postcoital prophylaxes with a single-dose antibiotic,
21

or short-course (1- or 2-day) antibiotics for each symptomatic
episode is recommended. For postmenopausal women, the use of
vaginal estrogen cream may prove an effective preventive measure.
11

Patients with bacterial persistence should be evaluated thoroughly to
exclude potential structural or functional abnormalities.
Prostatitis
Prostate infections are more challenging to cure because of the
altered microenvironment of the inamed tissue, which may affect
antibiotic efcacy. Therefore, men with acute bacterial prostatitis
often need long-term treatment (30 days) with a carefully selected
antibiotic. Severely ill patients need hospitalization and parenteral
antimicrobial agents, such as an aminoglycoside-penicillin combina-
tion, until culture and susceptibility results provide guidance for
alternative, specic antibiotic regimens. In men with urinary reten-
tion, a urethral or suprapubic catheter is necessary. Suprapubic cath-
eterization is preferable to decrease the risk of prostatic abscesses.
Mild and moderate cases respond well to uoroquinolones or TMP-
SMX, both of which have a cure rate of 60% to 90%.
22
Chronic
bacterial prostatitis may manifest as episodes of recurrent bacteriuria
with the same organism between asymptomatic periods. Episodic
treatment may be prescribed using the agents mentioned and, in
select patients, may be self administered as needed. Daily suppressive
therapy should be considered in men with frequent cystitis if other
causes are excluded, and the culpable organism is localized to the
prostate, using the Meares-Stamey technique.
23
DIFFERENTIAL DIAGNOSIS
When evaluating patients with LUTS, it is important to consider
gynecologic and colorectal diagnoses as well. STDs in either gender
may manifest as lower urinary tract symptoms (LUTS), with or
without fever. Female patients, especially those presenting with severe
symptoms and pain, should be screened for pregnancy, because com-
plications such as ectopic pregnancy or abortion should be ruled out.
Chronic appendicitis and sigmoid diverticulitis may be confused
with an UTI. We have encountered several patients referred for eval-
uation of persistent or recurrent UTI or prostatitis, in whom diver-
ticulitis (and, even rarer, chronic appendicitis) was proven to be the
cause of their symptoms.
Sexually Transmitted Diseases
Special cultures are needed to diagnose these infections. Antibiotic
therapy should be prescribed accordingly. Longer treatment with tet-
racycline, doxycycline, or any drug appropriate for the treatment of
Mycoplasma hominis and Ureaplasma urealyticum is recommended.
24

The patients sexual partner must be treated simultaneously.
CONSIDERATIONS IN SPECIAL POPULATIONS
Catheter-Related Infections
Catheterization for longer than 2 weeks is usually associated with
bacteriuria. Prophylactic antimicrobial therapy for cystitis during
short-term, indwelling, urethral catheterization is not recommended.
Symptomatic UTIs in older adults should be treated. Careful consid-
eration should be given to antimicrobial choice and meticulous
monitoring of drug levels in this patient population, because the
older patient is more susceptible to harmful side effects of many
antimicrobial agents. Short-term antimicrobial therapy (5-7 days) is
indicated only for symptomatic episodes. In patients requiring long-
term urinary catheterization, suprapubic catheter placement should
be considered. In men, suprapubic catheterization is associated with
decreased risk of meatal erosion or prostatitis. In the short term,
suprapubic catheterization may be associated with a decreased risk
UTI is one of the most common health problems affecting
people of all ages. It is the most common nosocomial
bacterial infection in older adults. Women are especially
prone to UTIs for reasons that are poorly understood.
Although prostatitis syndrome accounts for 25% of male
ofce visits for genitourinary tract infections, only 5% are
attributed to a bacterial cause.
Acute cystitis or pyelonephritis in adult patients should be
considered uncomplicated if there are no known
functional or anatomic abnormalities of the genitourinary
tract. Most of these infections are caused by Escherichia
coli.
Summary
E
Acute and Chronic Bacterial Cystitis 729
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Michota F: Indwelling Urinary Catheters: Infection and Complications. In Potts J (ed):
Genitourinary Pain and Inammation: Diagnosis and Management. Totowa, NJ,
Humana Press, 2008.
Parsons CL, Schmidt JD: Control of recurrent lower urinary tract infection in the post-
menopausal woman. J Urol 1982;128:1224-1226.
Potts JM, Ward AM, Rackley RR: Association of chronic urinary symptoms in women
and Urea plasma urealyticum. Urology 2000;55:486-489.
Raz R, Stamm WE: A controlled trial of intravaginal estriol in postmenopausal women
with recurrent urinary tract infections. N Engl J Med 1993;329:753-756.
Ronald A: The etiology of urinary tract infection: Traditional and emerging pathogens.
Am J Med 2002;113:14S-19S.
Schaeffer AJ, Rajan N, Cao Q, et al: Host pathogenesis in urinary tract infections. Int J
Antimicrob Agents 2001;17:245-251.
Stapleton A, Latham RH, Johnson C, Stamm WE: Postcoital antimicrobial prophylaxis
for recurrent urinary tract infection. A randomized, double-blind, placebo-
controlled trial. JAMA 1990;264:703-706.
References
For a complete list of references, log onto www.expertconsult.com.
Acute uncomplicated cystitis can be effectively treated
with a 3-day course of TMP-SMX, but alternative regimens
such as a uoroquinolone, an oral third-generation
cephalosporin, or nitrofurantoin (7-day regimen) may have
a better result. For acute uncomplicated pyelonephritis, a
10- to 14-day regimen is recommended.
Sexually transmitted diseases, including those caused by
Chlamydia, Mycoplasma hominis, and Ureaplasma
urealyticum, should be considered potential culprits in
sexually active patients.
Complicated UTIs require thorough evaluation and
correction of the underlying abnormality to provide a cure
and prevent recurrence.
Suggested Readings
Foxman B: Epidemiology of urinary tract infections: Incidence, morbidity and economic
costs. Am J Med 2002;113(Suppl. 1A): 5S-13S.