• Review the diagnosis.
• Culture the urine to confirm infection and exclude other causes.
• Refer urgently if urological cancer is suspected.
• Review the woman's medical and surgical history to assess risk factors for recurrent cystitis such as stones, papillary necrosis, and vesicoureteric reflux — this assessment may require imaging and urological referral.
• Relieve symptoms with paracetamol or ibuprofen.
• If symptoms are moderate or severe, offer an antibiotic immediately.
• If symptoms are mild, suggest delaying antibiotic treatment until culture results are available to guide choice of antibiotic.
• Advise on lifestyle measures such as high-strength cranberry capsules to reduce the risk of recurrent episodes.
• If troublesome cystitis recurs frequently:
• Consider offering a prescription for a 'stand-by' antibiotic to be used for future episodes.
• Consider preventive treatments.
• Refer or seek specialist advice if these measures are not successful.

In depth

• Follow local guidelines when available. Otherwise:
• For empirical treatment, prescribe either:
• Trimethoprim 200 mg twice daily, for 3 days, or
• Nitrofurantoin 50 mg four times daily, or 100 mg (modified-release) twice daily, for 3 days.
• If the woman has been treated with trimethoprim recently (up to a year previously), consider prescribing nitrofurantoin instead of trimethoprim.

In depth

Advise women with recurrent cystitis that:

• Cranberry products reduce the recurrence rate of cystitis, and are available from shops (but not on the NHS).
• Cranberry products should not be taken if warfarin is being used.
• High strength capsules (containing at least 200 mg of cranberry extract) are recommended because they may be more effective and acceptable than cranberry juice.
• If cystitis is related to sexual intercourse, advise:
• Using a different contraceptive method if a diaphragm is being used.
• Voiding soon after intercourse.
• Using a lubricant if symptoms could be due to mild trauma rather than infection.

In depth

• Consider offering a prescription for a 'stand-by' antibiotic to be used for future episodes of cystitis before prescribing prophylactic drug treatment.
• When deciding to offer prophylactic drug treatment, consider the frequency, severity, and impact of recurrent cystitis, and whether referral for urological investigation would be appropriate.
• For recurrent cystitis associated with sexual intercourse, offer trimethoprim 100 mg to be taken within 2 hours of intercourse (off-label use).
• For recurrent cystitis not associated with sexual intercourse offer a 6-month trial of low-dose continuous antibiotic treatment: trimethoprim 100 mg every night, or nitrofurantoin (immediate-release) 50–100 mg every night.

In depth

• If prophylactic antibiotics are prescribed, follow up to review progress after 6 months, or sooner if clinically indicated.
• If haematuria was found, follow up to re-test the urine and check that the infection and haematuria have resolved.

In depth

• Refer urgently, to a team specializing in the management of urological cancer, if urological cancer is suspected (for example if haematuria persists after successful treatment of acute cystitis).
• Refer the woman if:
• Risk factors for recurrent cystitis (such as urinary tract abnormalities, stones, vesicoureteric reflux, papillary necrosis) are present or suspected.
• There is any known abnormality on ultrasound of kidneys, ureters, and bladder.
• The response to preventive treatments and lifestyle measures is ineffective.

In depth