Editing AUA & CUA Recurrent UTI (2019) (section)

== Acute Bacterial Cystitis ==

=== Definition ===
*'''<span style="color:#ff0000">Diagnosis of acute bacterial cystitis requires (2):</span>'''
*# '''<span style="color:#ff0000">Laboratory confirmation of significant bacteriuria AND</span>'''
*# '''<span style="color:#ff0000">Acute-onset symptoms (lower urinary tract symptoms)</span>'''
*In this guideline, the term UTI will refer to culture-proven acute bacterial cystitis and associated symptoms unless otherwise specified.

=== Diagnosis and Evaluation ===

==== History and Physical Exam ====
* '''History'''
** '''<span style="color:#ff0000">Symptoms</span>'''
*** '''<span style="color:#ff0000">Urinary tract infection symptoms include dysuria, central to the diagnosis of UTI, with variable degrees of:</span>'''
***# <span style="color:#ff0000">'''Increased urinary urgency and frequency'''</span>
***# <span style="color:#ff0000">'''Hematuria'''</span>
***# <span style="color:#ff0000">'''Suprapubic pain'''</span>
***# <span style="color:#ff0000">'''New or worsening incontinence'''</span>
*** '''<span style="color:#ff0000">In older adults, the symptoms of UTI may be less clear.</span>'''
**** Given the subjective nature of these symptoms, '''careful evaluation of their chronicity becomes an important consideration.'''
***** Older females frequently have nonspecific symptoms that may be perceived as a UTI, such as dysuria, cloudy urine, vaginal dryness, vaginal/perineal burning, bladder or pelvic discomfort, urinary frequency and urgency, or urinary incontinence, but these tend to be more chronic
***** '''Acute-onset dysuria, particularly when associated with new or worsening storage symptoms, remains a reliable diagnostic criterion in older females''' living both in the community and in long-term care facilities.

==== Labs ====
*'''<span style="color:#ff0000">Urine culture/laboratory confirmation of significant bacteriuria</span>''' 
** '''Urine culture remains the mainstay of diagnosis of an episode of acute cystitis'''
*** '''Clinical judgment is needed to determine when a culture result represents clinically significant bacteriuria''' considering the patient presentation, urine collection method, and the presence of other suggestive factors such as pyuria.
**** '''<span style="color:#ff0000">The definition for clinically significant bacteriuria of >10<sup>5</sup> colony forming units (CFU)/mL represents an arbitrary cut-off.</span>'''
**** '''Although > 10<sup>5</sup> CFU/mL for bacterial growth on midstream voided urine''' '''may help distinguish bladder bacteriuria from contamination in asymptomatic, pre-menopausal women,''' '''<span style="color:#ff0000">a lower 10<sup>2</sup> CFU/mL threshold may be appropriate in symptomatic individuals</span>'''
**'''Obtain repeat urine studies when an initial urine specimen is suspect for contamination, with consideration for obtaining a catheterized specimen'''
*** '''Urine culture contamination should be suspected when (3):'''
***# '''Mixed cultures containing ≥2 organisms'''
***# '''Low quantities (<103 CFU/mL) of a pathogenic organism in an asymptomatic patient'''
***# '''Specimen exhibits growth of normal vaginal flora (e.g. Lactobacilli, Group B Streptococci, Corynebacteria, or non-saprophyticus coagulase-negative Staphylococci)'''
***#* '''Growth of these organisms are thought to be contaminant and generally do not require treatment'''
*** '''Concomitant urinalysis can also be useful (presence of epithelial cells or mucus on microscopic urinalysis may also suggest contaminant).'''
*** When there is high suspicion for contamination, consider obtaining a catheterized specimen for further evaluation prior to treatment.
*** '''Urine specimens should not sit at room temperature for > 30 minutes''' to facilitate lab diagnosis of UTI.
=== Differential Diagnosis ===
*'''<span style="color:#ff0000">Differential Diagnosis of UTI (10):</span>'''
*# '''<span style="color:#ff0000">Interstitial cystitis/bladder pain syndrome</span>'''
*# '''<span style="color:#ff0000">Overactive Bladder</span>'''
*# '''<span style="color:#ff0000">Urinary calculi</span>'''
*# '''<span style="color:#ff0000">Infectious bacterial or fungal vaginitis</span>'''
*# '''<span style="color:#ff0000">Vulvar dermatitis</span>'''
*# '''<span style="color:#ff0000">Non-infectious vulvovestibulitis</span>'''
*# '''<span style="color:#ff0000">Vulvodynia</span>'''
*# '''<span style="color:#ff0000">Hypertonic pelvic floor muscle dysfunction</span>'''
*# '''<span style="color:#ff0000">Genitourinary syndrome of menopause</span>'''
*# '''<span style="color:#ff0000">CIS of the bladder</span>''' (less commonly)
* A lack of correlation between microbiological data and symptomatic episodes should prompt a diligent consideration of alternative/comorbid diagnoses (many females with gross hematuria may be incorrectly treated for a UTI when they should be evaluated for bladder cancer; a negative culture would prompt further investigation of GH)