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S: Subjective
Chief complaint: "It burns when I pee."
History of present illness: A 27-year-old woman reports 2 days of burning on urination, urgency and frequency, and lower abdominal discomfort. No fever, chills, flank pain, nausea or vomiting. No vaginal discharge, itching or odor. She is sexually active with one male partner and uses condoms inconsistently. Last menstrual period 2 weeks ago, normal. One similar episode 2 years ago.
Past medical history: None. No kidney or urinary tract abnormalities. Medications: None. Allergies: No known drug allergies.
O: Objective
- Vital signs: temperature 36.9 °C, heart rate 78, blood pressure 114/70.
- Abdomen: mild suprapubic tenderness; no costovertebral angle tenderness.
- Urine dipstick: positive for leukocyte esterase and nitrites; trace blood.
- Urine pregnancy test: negative.
A: Assessment
Acute uncomplicated cystitis. She has typical symptoms, no vaginal symptoms, no signs of upper tract infection, and is not pregnant. The Infectious Diseases Society of America (IDSA) and European Society for Microbiology and Infectious Diseases guideline limits "uncomplicated" to premenopausal, nonpregnant women with no known urological abnormalities or comorbidities (Gupta et al., 2011), which describes her.
Differential diagnoses:
- Acute pyelonephritis: no fever, flank pain or costovertebral angle tenderness.
- Vaginitis or cervicitis (including chlamydia or gonorrhea): no discharge or vaginal symptoms, but with inconsistent condom use, offer screening.
- Interstitial cystitis: would cause chronic symptoms, not an acute episode.
P: Plan
- Antibiotic. First-line options in the guideline are nitrofurantoin monohydrate/macrocrystals 100 mg twice daily for 5 days; trimethoprim–sulfamethoxazole 160/800 mg twice daily for 3 days if local resistance is below 20% and she hasn't used it for a UTI in the past 3 months; or fosfomycin 3 g as a single dose. Fluoroquinolones are reserved for other situations because of resistance and their wider effects (Gupta et al., 2011). Prescribe nitrofurantoin 100 mg twice daily for 5 days.
- Urine culture: not routinely needed for a typical first presentation; obtain one if symptoms don't improve or recur within weeks.
- Symptom relief: fluids; phenazopyridine for up to 2 days if needed, with the warning that it turns urine orange.
- Sexual health: offer chlamydia and gonorrhea testing; discuss condom use.
- Return precautions: fever, flank pain, vomiting, or no improvement within 48 hours, which could signal pyelonephritis.
- Prevention: urinating after intercourse and staying well hydrated are reasonable, low-risk measures.
Reference
Gupta, K., Hooton, T. M., Naber, K. G., Wullt, B., Colgan, R., Miller, L. G., Moran, G. J., Nicolle, L. E., Raz, R., Schaeffer, A. J., & Soper, D. E. (2011). International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clinical Infectious Diseases, 52(5), e103–e120. https://doi.org/10.1093/cid/ciq257
