Key information from history (continued)

Vaginal discharge: Absence of vaginal discharge is a key feature of acute uncomplicated cystitis; 80 per cent of women with vaginal discharge and symptoms of cystitis will not have a UTI. The presence of vaginal discharge may indicate local fungal (usually candida or thrush) trichomoniasis or bacterial infection that would require referral. Vaginal pruritus or discharge may suggest vaginitis. 

The sexually transmitted infection chlamydia is most commonly seen in women aged 16-24 years. About one in 10 women under the age of 25 years may have it. Unfortunately, about 80 per cent of women with this infection are asymptomatic. Those with chlamydia can have symptoms of cystitis, an alteration in vaginal discharge or lower abdominal pain. Chlamydia can cause pelvic inflammatory disease (PID) and infertility. It is important that the infection is detected and treated. Screening programmes for chlamydia are now widespread.

Other symptoms: Cystitis may be accompanied by lower abdominal pain and tenderness.

Previous episodes: Women with recurrent UTIs (more than two episodes in the last six months or more than three episodes in the last year) should be referred to their GP. 

Diabetes: Recurrent UTIs can sometimes occur in people with diabetes, so anyone describing a history of increasing thirst, weight loss and a higher frequency of passing urine than normal should be referred. Patients with known diabetes and recent onset of urinary symptoms should be assessed by their GP as UTIs can be more troublesome and difficult to treat.

Post-sex cystitis: Sexual intercourse may precipitate an attack of cystitis due to minor trauma or resulting infection when bacteria are pushed along the urethra. The occurrence of urinary symptoms after starting a new sexual relationship is still sometimes referred to as ‘honeymoon cystitis’...

Postmenopausal women: Oestrogen deficiency in postmenopausal women leads to thinning of the lining of the vagina. Lack of lubrication can mean the vagina and urethra are vulnerable to trauma and irritation, and attacks of cystitis can occur. There may be other symptoms, such as hot flushes and night sweats (see CPD module on Menopause).

Medication: Cystitis can be caused by cytotoxic drugs, such as cyclophosphamide. Other drugs, such as opioids and nifedipine, can also cause urinary tract symptoms.

Irritants: Other precipitating factors may include the irritant effects of toiletries (e.g. bubble baths and vaginal deodorants) and other chemicals (e.g. spermicides and disinfectants). Use of a diaphragm for contraception can also cause symptoms of cystitis. Lack of personal hygiene is not thought to be responsible for this problem, except in extreme cases.

Urine testing: Dipstick testing or sending a urine sample for culture are used only in specific circumstances. In the Pharmacy First clinical pathway in England, this would only apply to women referred to general practice (see TARGET flowchart for women under 65 years with a suspected UTI).