Key information from history

Age: The England NHS Pharmacy First service includes women aged between 16-64 years old. The reason for the lower age limit is that UTIs in children may result in damage to the kidneys or bladder, or may be caused by an abnormality of the urinary tract (cases need investigating). Older women are more likely to have incidental bacteria and also comorbidities that may complicate a UTI, and may present with confusion and weakness in addition to typical symptoms. 

Female/male: Cystitis is more common in women than in men because bacteria need to pass up the urethra to enter the bladder. The urethra is much shorter in females than in males, so the passage of bacteria is much easier and the process may also be facilitated by sexual intercourse. There is also some evidence that prostatic fluid has antibacterial properties, which provides an additional defence against bacterial infection in males. Any man who presents with symptoms of cystitis requires medical referral because of the possibility of more serious conditions, such as kidney or bladder stones or prostate problems.

Pregnancy: Any pregnant woman who presents with symptoms of cystitis needs referral because bacteriuria (presence of bacteria in the urine) in pregnancy can lead to kidney infection and other problems.

Development of symptoms: Cystitis sufferers often report that the first sign of an impending attack is an itching or pricking sensation in the urethra. The desire to pass urine becomes frequent; women may feel the need to urinate urgently, but pass only a few burning, painful drops. This frequency occurs throughout the day and night (nocturia). Dysuria (pain on passing urine) is a classical symptom of cystitis. After urination, the bladder may not feel completely empty and even straining produces no further flow. The urine may be cloudy and strong smelling.

Blood in urine: Macroscopic haematuria (visible presence of blood in the urine) is an indication for referral to the GP. It occurs in UTIs when the bladder lining and urethra are so inflamed that they bleed. This is not usually serious in UTIs and responds quickly to antibiotic treatment but sometimes blood in the urine may indicate other problems. These include a kidney stone, where pain in the loin or between the loin and groin is the predominant symptom. Blood in the urine without pain needs exclusion of the possibility of a tumour in the bladder or kidney. Any person reporting painless haematuria should be advised to see their GP urgently.

Cloudy urine: Urine that is cloudy to the naked eye is an important diagnostic feature that may indicate antibiotic treatment. It is mainly caused by an excess of white blood cells in reaction to infection. Women may report that their urine appears cloudy; they may notice a change in appearance or odour on using the toilet. Ideally, all patients should be asked to provide a sample of urine, if practicable, so that it can be assessed for cloudiness. The Pharmacy First clinical pathway states the necessity of “visual inspection by [the] pharmacist if practicable”.