Cystitis in Practice: Case 1

Mrs Anne Lawson, a young woman in her twenties, asks to have a quiet word with you. She tells you that she thinks she has cystitis. On questioning, you find that she is not passing urine more frequently than normal, but that her urine looks dark and smells unpleasant. Mrs Lawson has back pain and has been feeling feverish during today. She is not taking any medicine from the doctor and has not tried anything to treat her symptoms.

The pharmacist’s view

This woman has described symptoms that are not of a minor nature. In particular, the presence of fever and back pain indicates an infection higher in the urinary tract. Mrs Lawson should see her doctor as soon as possible.

The doctor’s view

Referral is advisable. She may have a UTI, possibly in the kidney. However, there is insufficient information to make a definite diagnosis. It would be useful to know if she has pain on passing urine and the site and nature of her back pain. Her symptoms could in fact be accounted for by a flulike viral infection in which the backache is caused by muscular inflammation and the urine altered because of dehydration. The GP is likely to check the urine in the surgery with a multistix test and also sends a sample (midstream specimen of urine) to the laboratory for miscroscopy and culture. If the multistix test were positive for leucocytes and nitrites, an urinary infection would be likely, and the patient would be started on antibiotics awaiting laboratory confirmation of the bacteria responsible. She may subsequently require further investigations of her renal tract, e.g. an ultrasound of her kidneys and possibly an intravenous urogram. Severe cases of kidney infection require emergency hospital admission for intravenous antibiotics.

Cystitis in Practice: Case 2

A young man asks if you can recommend a good treatment for cystitis. In response to your questions, he tells you that the medicine is for him: he has been having pain when passing urine since yesterday. He otherwise feels well and does not have any other symptoms. No treatments have been tried already and he is not currently taking any medicines.

The pharmacist’s view

This man should be referred to the doctor because the symptoms of cystitis are uncommon in men and may be the result of a more serious condition.

The doctor’s view

Referral is necessary for accurate diagnosis. A urine sample will need to be collected for appropriate analysis. If it shows that he has a urinary infection, then treatment with a suitable antibiotic can be given and a referral to a specialist for further investigation made. The reason for referral is that urinary infection is relatively uncommon in men compared to women and may be caused by some structural problem within the urinary tract.

If in addition to discomfort on passing urine he develops a urethral discharge, he is most likely to be suffering from a sexually transmitted infection, such as Chlamydia (previously called non-specific urethritis) or gonorrhoea. Chlamydia is the more prevalent of the two and can be treated using azithromycin or doxycycline. Chlamydia can be complicated by an infection around the testis which becomes very painful swollen and red. It may also lead to reduced fertility. Another complication of Chlamydia is the development of a reactive arthritis (Reiters), which often affects the knees and feet often associated with a conjunctivitis.

Cystitis in Practice: Case 3

It is Saturday afternoon and a young woman whom you do not recognise as a regular customer asks for something to treat cystitis. On questioning, you find out that she has had the problem several times before and that her symptoms are frequency and pain on passing urine. She is otherwise well and tells you that her doctor has occasionally prescribed antibiotics to treat the problem in the past. She is not taking any medicines.

The pharmacist’s view

This woman represents a common situation in community pharmacy. She has had these symptoms before and is unlikely to be able to see her doctor before Monday. Since only half of all cases of cystitis are caused by an infection, antibiotic treatment without a urine culture is now discouraged. She should see her doctor on Monday if the symptoms have not improved and the pharmacist could suggest that she take a urine sample with her, although in practice the GP may prescribe without test results. In the meantime, she is experiencing considerable discomfort. It would be reasonable to recommend the use of an alkalinising agent, such as sodium or potassium citrate, over the weekend. Proprietary formulations are more pleasant tasting than is the potassium citrate mixture and they are very acceptable to patients. You could advise her to drink plenty of fluids but with minimum consumption of tea, coffee and alcohol, all of which may cause dehydration and make the problem worse.

The doctor’s view

The story is suggestive of cystitis. Symptomatic treatment with potassium citrate may help until after the weekend. It would be interesting to know how her infections usually resolve. If her symptoms did not ease with an alkalinising agent, she could be advised to speak to the on-call general practitioner (GP). If she had severe symptoms, it would be reasonable to start treatment with an antibiotic. If she brought a urine sample, the GP could test it immediately with a multistix dip test, which would determine the presence or not of protein, red blood cells, leucocytes and nitrite. Positive results for the latter two would be very suggestive of a bacterial infection. It would be important to check whether she is pregnant or on the combined oral contraceptive pill before prescribing antibiotics. Changing patterns of resistance mean that first line antibiotics vary according to local protocols.

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