Recurrent Cystitis About 20% of premenopausal women with an initial episode of cystitis have recurrent infections. More than 90% of these recurrences are caused by exogenous reinfection. Recurrent cystitis should be documented by culture to rule out resistant micro-organisms. Patients may be treated by one of three strategies: (i) continuous prophylaxis, (ii) postcoital prophylaxis, or (iii) therapy initiated by the patient when symptoms are first noted.
Postmenopausal women may have frequent reinfections. Hormonal therapy or topically applied estrogen cream, along with antimicrobial prophylaxis, is helpful in treating these patients.
Urethritis Women with dysuria caused by urethritis have a more gradual onset of mild symptoms, which may be associated with abnormal vaginal discharge or bleeding related to concurrent cervicitis. Patients may have a new sex partner or experience lower abdominal pain. Physical examination may reveal the presence of mucopurulent cervicitis or vulvovaginal herpetic lesions. C. trachomatis, N. gonorrhoeae, or genital herpes may cause acute urethritis. Pyuria is present on urinalysis, but hematuria is rarely seen. Treatment regimens for chlamydia and gonococcal infections are presented in Table 18.3.
Occasionally, vaginitis caused by C. albicans or trichomonas is associated with dysuria. On careful questioning, patients generally describe external dysuria, sometimes associated with vaginal discharge, and pruritus and dyspareunia. They usually do not experience urgency or frequency. Pyuria and hematuria are absent.
Acute Pyelonephritis The clinical spectrum of acute, uncomplicated pyelonephritis in young women ranges from gram-negative septicemia to a cystitislike illness with mild ﬂank pain. E. coli accounts for more than 80% of these cases (58). Microscopy of unspun urine reveals pyuria and gram-negative bacteria. A urine culture should be obtained in all women with suspected pyelonephritis; blood cultures should be performed in those who are hospitalized because results are positive in 15% to 20% of cases. In the absence of nausea and vomiting and severe illness, outpatient oral therapy can be given safely. Patients who have nausea and vomiting, are moderately to severely ill, or are pregnant should be hospitalized. Outpatient treatment regimens include trimethoprim/ sulfamethoxazole (160/800 mg every 12 hours for 14 days) or a quinolone (e.g., levoﬂoxacin, 750 mg daily for 7 days). Inpatient treatment regimens include the use of parenteral levoﬂoxacin (750 mg daily), ceftriaxone (1–2 g daily), ampicillin (1 g every 6 hours), and gentamicin (especially if Enterococcus species are suspected) or aztreonam (1 g every 8–12 hours). Symptoms should resolve after 48 to 72 hours. If fever and ﬂank pain persist after 72 hours of therapy, ultrasound or computed tomography should be considered to rule out a perinephric or intrarenal abscess or ureteral obstruction. A follow-up culture should be obtained 2 weeks after the completion of therapy (60).
1.
Huggins GR, Preti G. Vaginal odors and secretions. Clin Obstet Gynecol 1981;24:355–377.
2.
Larsen B. Microbiology of the female genital tract. In: Pastorek J, ed. Obstetric and gynecologic infectious disease. New York: Raven Press, 1994:11–26.
3.