Recurrent Cystitis Is Not Necessarily Bacterial
Maxime Vallée, MD, a urologist at Poitiers University Hospital in Poitiers, France, used a session dedicated to recurrent cystitis (RC) at the French Urology Association’s 2023 conference to set out the correct procedure and basic guidance for the initial diagnostic management of female patients seeking urology services, often for the second or third time, for RC. He reminded attendees that uroflowmetry, post-void residual (PVR) urine and voiding diaries are essential first-step tools in confirming or ruling out an RC diagnosis and in proposing a suitable treatment plan.
Urinary Tract Anomalies
Recurrent episodes of acute cystitis (ie, at least four episodes over a 12-month period) are a common reason why women request an appointment with their physician. But it’s also important not to wrongly “label” patients as having RC, and this is why an appropriate diagnostic approach is essential. As part of the introduction to his presentation, Vallée reiterated that physicians “must remember that regardless of type — lower, upper, simple, or complicated — urinary tract infections are just a sign that some part of the urinary tract is not working as it should, and any such episode should be investigated for a potential anatomical or functional anomaly of the urinary tract. Such an approach will allow doctors to definitively determine the cause of recurrent episodes of cystitis and avoid repeated use of antibiotics, which is harmful for patients and society.”
Differential Diagnosis
“When a patient turns up armed with 15 years of urine microscopy and culture reports, urologists must start by putting these to one side,” joked Vallée. “You can look at these later, should you end up prescribing prophylactic antibiotics — in exceptional cases only. Initially, you need to be focusing on the patient, her case history, and other previous medical history, as well as the testimony given by the patient herself.” To navigate the diagnostic process requires time, patience, empathy, and the ability to listen. Urologists will need to organize themselves and set aside the necessary time to hear the patient’s story from the beginning. “I regularly block out half-hour slots for these patients and often run over,” said Vallée.
It’s all about listening because “the answer will come from the patient and what she tells you, not the results from a urine microscopy and culture. By asking questions, listening to the account and description of their symptoms, you will be able to look for a differential diagnosis,” said Vallée.
This approach is even more imperative because patients often arrive with a ready-made diagnosis of cystitis. This term is often misused. “The problem with bladders is that their only way of expressing that something is wrong is via cystitis,” said Vallée. “And yet recurrent cystitis is not necessarily bacterial. So as not to get it wrong, urologists must go even further in their questioning and rule out any potential differential diagnoses, the most common being overactive bladder and chronic bladder pain syndrome.”
The first thing to look for is a fever. “If the patient has a fever, we’re no longer looking at cystitis,” said Vallée. “Treating the cause and the degree of urgency are then no longer the same. Cystitis is, by definition, a nonserious infection.”
Likewise, physical exams remain worthwhile, even when scan images are available. Although dysfunction caused by an anatomical anomaly is rare, it still must be ruled out.
Urologists’ Key Weapons
The key weapons in a urologist’s armory are basic. Firstly, voiding diaries; these records are indispensable for getting an idea of a patient’s toilet habits on a day-to-day basis. Voiding diaries are especially useful for highlighting a patient’s regularly occurring issues when voiding.
Uroflowmetry and PVR urine are also important because they reveal cases of bladder dysfunction, underactive or overactive bladder, and sometimes even voiding issues.
The advantage of a voiding diary is that it allows urologists to work with patients to reprogram their voiding habits. “When we ask patients not to have a voiding interval of more than 4 hours, not to have a voiding volume of more than 400 mL, and to have a minimum 24-hour urine output of a liter and a half, this manages to resolve a good number of cases,” said Vallée.
But we must be careful when giving advice such as “drink a lot” because for cases of underactive bladder, the cure may be worse than the disease, he warned. This is why voiding diaries are essential.
In terms of the traditional lifestyle and dietary guidelines (eg, wiping front to back, wearing cotton underwear, etc.), doctors must be measured when issuing advice in this area because there is little evidence of their real-world efficacy. “Don’t be dogmatic when it comes to such guidance,” said Vallée.
To sum up, urologists must be prepared to question everything and start from scratch to get the right diagnosis, remembering to make use of the three key tools: Voiding diaries, uroflowmetry, and PVR. This approach will help resolve difficult cases once and for all.
This article was translated from the Medscape French edition.
