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Acutecystitis:Clinicalfeaturesanddiagnosisinchildrenolderthantwoyearsandadolescents
Authors
DebraLPalazzi,MD,MEd
JudithRCampbell,MD

SectionEditors
TejKMattoo,MD,DCH,FRCP
SheldonLKaplan,MD

DeputyEditor
MaryMTorchia,MD

Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:Jul2016.|Thistopiclastupdated:Jul14,2016.
INTRODUCTIONCystitisisinflammationoftheurinarybladder,usuallycausedbyinfection,whichcanoccur
aloneorinconjunctionwithpyelonephritis.
Theclinicalfeaturesanddiagnosisofacutecystitisinchildrenolderthantwoyearsandadolescentswillbereviewed
here.Themanagementandprognosisofacutecystitisinchildrenolderthantwoyearsandadolescentsisdiscussed
separately.(See"Acutecystitis:Managementandprognosisinchildrenolderthantwoyearsandadolescents".)
Urinarytractinfection(UTI)innewbornsandchildrenyoungerthantwoyears(inwhomitisdifficulttodistinguish
cystitisfrompyelonephritisonclinicalgrounds)alsoisdiscussedseparately.

(See"Urinarytractinfectionsinneonates".)
(See"Urinarytractinfectionsinchildren:Epidemiologyandriskfactors".)
(See"Urinarytractinfectionsininfantsandchildrenolderthanonemonth:Clinicalfeaturesanddiagnosis".)
(See"Urinarytractinfectionsininfantsolderthanonemonthandyoungchildren:Acutemanagement,imaging,
andprognosis".)

TERMINOLOGY
UncomplicatedcystitisUncomplicatedcystitisislimitedtothelowerurinarytractandtypicallyoccursinchildren
olderthantwoyearswithnounderlyingmedicalproblemsoranatomicorphysiologicabnormalities.Although
uncomplicatedcystitismayoccurinchildrenyoungerthantwoyears,itisdifficulttodifferentiateupperfromlower
urinarytractinfection(UTI)insuchchildren,andtheyareusuallyassumedtohaveupperUTI.Uncomplicatedcystitis
usuallyiscausedbypathogensthataresusceptibletocommonlyusedantimicrobialagents.
ComplicatedcystitisComplicatedcystitisisdefinedbycoexistingupperUTI,multipledrugresistant
uropathogens,orhostswithspecialconsiderations(eg,anatomicorphysiologicabnormalityoftheurinarytract,
indwellingbladdercatheter,malignancy,diabetes).(See"Etiologyandclinicalfeaturesofbladderdysfunctionin
children"and"Evaluationanddiagnosisofbladderdysfunctioninchildren".)
PATHOGENESISInthenormalhost,mosturopathogensoriginateinthegastrointestinaltract,migratetothe
periurethralareaandtheurethra,andascendtothebladder,wheretheystimulateahostresponse.Bacterialadhesins
(pili)andothervirulencefactors,suchashemolysinandflagellae,provideaselectiveadvantage.Patientswhohave
urodynamicdysfunction,neurogenicbladder,orincompletebladderemptyingmayharborpathogensinresidualurine,
creatingasourceforpersistentorrecurrentinfection.(See"Bacterialadherenceandothervirulencefactorsforurinary
tractinfection".)
Thepathogenesisofcatheterassociatedurinarytractinfections(UTIs)involvesascensionoforganismsalonga
biofilmonintraluminalorextraluminalsurfaceofthecatheter.Failuretomaintaintheintegrityofaclosedurinary
cathetersystemprovidesaccessfororganismstoenterthebladder.
EPIDEMIOLOGYTheprevalenceofacutecystitisinchildrenisdifficulttodeterminebecausemostepidemiologic
studiesincludechildrenwithbothupperandlowerurinarytractinfection(UTI).Inpooledanalysisoffourstudiesthat
includedchildrenyoungerthan19years(mostofwhomwereolderthantwoyears)andhadurinarysymptomsand/or
fever,theprevalenceofUTIwas7.8percent(95%CI6.68.9)[1]nodistinctionwasmadebetweenupperandlower
tractdisease,andsexualactivitywasnotassessed.
RISKFACTORSRiskfactorsforacutecystitisinchildrenandadolescentsinclude:
FemalesexUrinarytractinfections(UTI),includingacutecystitis,aremorecommonamonggirlsthanboys[2].
Thecombinationofvirulencefactorsandthepropensityofbacteriatoadheretothefemaleperiurethralmucosa
mayexplaintheincreasedincidenceofacutecystitisinfemalescomparedtomales[3].Otherfactorsthatmay

contributetothelowerincidenceofacutecystitisinmalesincludetheantibacterialpropertiesofprostaticfluid,
drierperiurethralenvironment,andlongerurethra.
LackofcircumcisionisariskfactorforUTIinmales,butismostimportantininfants.(See"Urinarytract
infectionsinchildren:Epidemiologyandriskfactors"and"Urinarytractinfectionsinchildren:Epidemiologyand
riskfactors",sectionon'Lackofcircumcision'.)
SexualactivitySexualintercourseisoneofthemostimportantriskfactorsforacutecystitisinfemales.
Sexuallyactiveyoungfemaleshaveapproximately0.5episodesofacutecystitisperpersonyear[4].(See
"Acuteuncomplicatedcystitisandpyelonephritisinwomen",sectionon'Epidemiology'.)
Unprotectedinsertiveanalintercoursealsomayincreasetheriskofacutecystitisinmales[5].
Abnormalitiesoftheurinarysystem,including:
Bladderstones(see"Clinicalfeaturesanddiagnosisofnephrolithiasisinchildren",sectionon'Dysuriaand
urgency')
Bowelandbladderdysfunction(see"Etiologyandclinicalfeaturesofbladderdysfunctioninchildren",
sectionon'Urinarytractinfection')
Neurogenicbladder(prolongedstasisofurineinthebladderpredisposestoinfection)[6,7](see
'Pathogenesis'above)
Indwellingbladdercatheterorrecentinstrumentationoftheurinarysystem[811]theriskofcatheterassociated
UTI(CAUTI)increaseswithdurationofurinarycatheteruse,femalesex,severityofillness,cardiovascular
surgery,multipletrauma,diabetes,andmultipleorganfailure[9,12].
Sicklecelldisease.(See"Renalmanifestationsofsicklecelldisease",sectionon'Urinarytractinfection'.)
Diabetesmellitus.(See"Susceptibilitytoinfectionsinpersonswithdiabetesmellitus"and"Emphysematous
urinarytractinfections".)
Immunodeficiency.
MICROBIOLOGYMostcasesofcystitisinchildrenandadolescentsarecausedbyentericbacteria.However,
cystitismaybecausedbyanypathogenthatcolonizestheperiurethralareaandurinarytract,includingnonenteric
bacteria,fungi,viruses,andparasites(table1)[13,14].
Thepotentialpathogensvaryaccordingtohostcharacteristics:
NormalhostEscherichiacoliandothergramnegativeorganismsaccountfornearly90percentofcasesof
uncomplicatedcystitisinolderchildren,adolescents,andyoungadults.Ina2009nationalsurveillancestudy,E.
coliaccountedfor79percentofoutpatienturinaryisolatesobtainedfromchildrenyoungerthan18years[2].E.
coliwasmorefrequentlyisolatedfromgirlsthanboys(83versus50percent).Otherpathogensweremore
frequentlyisolatedfromboysthangirls:Enterococcus(17versus5percent),P.mirabilis(11versus4percent),P.
aeruginosa(7versus2percent),andEnterobacter(5versus1percent).
Adenovirusisanuncommoncauseofacutecystitis(usuallyhemorrhagic)inchildrenwithoutunderlyingmedical
problems[15,16].(See"Epidemiologyandclinicalmanifestationsofadenovirusinfection",sectionon
'Genitourinarytract'.)
InAfricaandtheMiddleEast,hematuriaandcystitisinotherwisehealthychildrenmaybeduetoSchistosoma
haematobium[17].(See"Epidemiology,pathogenesis,andclinicalmanifestationsofschistosomiasis",sectionon
'Genitourinaryschistosomiasis'.)
UnderlyinggenitourinaryabnormalityAmongchildrenwithbladderdysfunction,E.coliisthemostfrequently
isolatedorganism,unlessthereisahistoryofrecentinfectionorcolonizationwithagramnegativerodotherthan
E.colioranotherpathogen.
Entericpathogensthatareincreasinglyisolatedfromchildrenwithotherunderlyinggenitourinaryabnormalities
includeKlebsiellaspp,Enterobacterspp,andPseudomonasaeruginosa[14].
IndwellingbladdercatheterP.aeruginosaandCandidaalbicansarethemostcommonpathogensincatheter
associatedcystitis.Cystitiscausedbycoagulasenegativestaphylococcalspecies,suchasStaphylococcus

epidermidis,alsoalmostexclusivelyoccursinpatientswithindwellingdevices.Funguriaisparticularlycommon
inpatientswithindwellingurinarycatheterswhoaretakingantibioticsorareimmunocompromised[18].
SexuallyactivefemalesInadditiontoE.coliandothergramnegativeorganisms,uropathogensthatmustbe
consideredinsexuallyactivefemaleadolescentsandyoungadultsincludeStaphylococcussaprophyticus[19]
andTrichomonasvaginalis.(See"Bacterialadherenceandothervirulencefactorsforurinarytractinfection",
sectionon'Staphylococcussaprophyticus'and"Trichomoniasis",sectionon'Consequences'.)
ImmunecompromisedchildDuringprolongedhospitalizationorurinarycatheterization,immunocompromised
patientsaresusceptibletohealthcareassociatedinfection,includingcystitiscausedbyentericpathogens,gram
positiveorganisms(eg,Enterococcus),viruses,andyeast(table1).
PatientswithimpairedTcellimmunefunctioncandevelopprimaryorreactivatedadenoviralinfection,which
oftenpresentsashemorrhagiccystitis.(See"Epidemiologyandclinicalmanifestationsofadenovirusinfection",
sectionon'Genitourinarytract'.)
Hematopoieticcelltransplantandsolidorgantransplantrecipientsareatriskofdevelopinghemorrhagiccystitis
duetoreactivationoflatentadenovirusorpolyomaviruses(BKandJC)[2023].(See"Epidemiologyandclinical
manifestationsofadenovirusinfection",sectionon'Genitourinarytract'and"OverviewofJCpolyomavirus,BK
polyomavirus,andotherpolyomavirusinfections".)
CLINICALPRESENTATIONPatientswithacutecystitisusuallypresentwithlowerurinarytractsymptoms(eg,
dysuria,frequency,urgency,newonsetincontinence[intoilettrainedchild],abdominalorsuprapubicpain)and/or
hematuria[24].However,lowerurinarytractsymptomsarenotalwayscausedbyacutecystitis.(See'Differential
diagnosis'below.)
Childrenwithacuteuncomplicatedcystitisusuallydonothavefeverorsystemiccomplaints.Fever>38C(100.4F),
chills,orflankpainsuggestuppertractinfectionratherthanacutecystitis[25],butcannotreliablymakethis
distinction.(See"Urinarytractinfectionsininfantsandchildrenolderthanonemonth:Clinicalfeaturesanddiagnosis",
sectionon'Clinicalpresentation'.)
Theclinicalmanifestationsofhemorrhagiccystitisrangefrommicroscopichematuriatoextensivebladderhemorrhage
withclotformationandobstruction.Adenoviruscystitisischaracterizedbytheacuteonsetofdysuriaandfrequency
followedbyhematuria12to24hourslater[16]upperrespiratorytractinfectionmayprecedeurinarysymptoms.(See
"Epidemiologyandclinicalmanifestationsofadenovirusinfection",sectionon'Clinicalpresentation'.)
Symptomsofdysuriaorfrequencyoftenareabsentinpatientswithneurogenicbladder.Inpatientswithbladder
dysfunctionandurinarystasis,cloudinessofurine,achangeintheurinarysedimentand/orodor,andpathogencolony
count100,000colonyformingunits(CFU)/mLmayhelptodifferentiatebetweenacutecystitisandchronicbacteriuria
duetocolonization.(See'Diagnosis'belowand"Urinarytractcomplicationsofmyelomeningocele(spinabifida)",
sectionon'Urinarytractinfections'.)
EVALUATION
HistoryThehistoryoftheacuteillnessshouldinclude:
Fever(temperature38C[100.4F]suggestsupperurinarytractinfection[UTI]ratherthanacutecystitis,but
cannotreliablymakethisdistinction).(See"Urinarytractinfectionsininfantsandchildrenolderthanonemonth:
Clinicalfeaturesanddiagnosis",sectionon'Clinicalpresentation'.)
Vomiting(suggestiveofupperUTI).
Recentillnesses(maysuggestadenovirusinfectionoracuteinterstitialnephritis,bothofwhichmaybe
associatedwithhematuria).
Recentantibiotics(maybeassociatedwithresistantpathogens[26]oracuteinterstitialnephritis).
SexualactivitySexualactivityincreasestheriskofacutecystitisandexpandsthelistofpathogenstobe
considered(eg,S.saprophyticus,T.vaginalis)sexuallyactivegirlsshouldbeaskedaboutuseofbarrier
contraceptionwithspermicidalagents(whichpredisposetoUTIbyalteringthenormalvaginalflora[27],andmay
contributetochemicalcystitis[28]).(See'Microbiology'above.)
Informationfromthepastmedicalhistoryshouldinclude(see"Urinarytractinfectionsinchildren:Epidemiologyand
riskfactors",sectionon'Hostfactors'):

Chronicurinarysymptoms(eg,incontinence,poorstream,frequency,urgency,withholdingmaneuvers)Maybe
associatedwithanatomicorphysiologicabnormalitiesoftheurinarytract(eg,bladderdysfunction,posterior
urethralvalves),increasingtheriskofresistantpathogensorrecurrentUTI.(See"Evaluationanddiagnosisof
bladderdysfunctioninchildren",sectionon'Whentosuspectbladderdysfunction'and"Clinicalpresentationand
diagnosisofposteriorurethralvalves",sectionon'Presentation'.)
ChronicconstipationMaybeassociatedwithurinarystasisandrecurrentUTI.(See"Constipationininfantsand
children:Evaluation",sectionon'Constipationandbladderdysfunction'.)
PreviousUTIorundiagnosedfebrileillnesses(whichmayhavebeenUTI)RecurrentUTIisassociatedwith
progressionofrenalscarring.(See"Urinarytractinfectionsinchildren:Longtermmanagementandprevention",
sectionon'Recurrentsymptoms'.)
Vesicoureteralreflux(VUR)Maybeamarkerofabnormalrenaldevelopmentandpossiblyassociatedwithrenal
scarring.(See"Clinicalpresentation,diagnosis,andcourseofprimaryvesicoureteralreflux",sectionon'Renal
scarringand/ordysplasia'.)
MedicationsMaybeassociatedwithinterstitialnephritis.(See'Differentialdiagnosis'below.)
FamilyhistoryoffrequentUTI,VUR,andothergenitourinaryabnormalitiesMaybeassociatedwith
undiagnosedanatomicorphysiologicabnormalitiesoftheurinarytractinthepatient.(See"Clinicalpresentation,
diagnosis,andcourseofprimaryvesicoureteralreflux",sectionon'Genetics'and"Overviewofcongenital
anomaliesofthekidneyandurinarytract(CAKUT)",sectionon'Epidemiology'.)
PhysicalexaminationImportantaspectsofthephysicalexaminationinthechildwithsuspectedUTIinclude
[13,24,29]:
Temperature(temperature38C[100.4F]suggestsupperUTIratherthanacutecystitis,butcannotreliably
makethisdistinction)(see"Urinarytractinfectionsininfantsandchildrenolderthanonemonth:Clinicalfeatures
anddiagnosis",sectionon'Clinicalpresentation')
Bloodpressure(hypertensionmaybeanearlysignofchronickidneydisease)(see"Clinicalpresentationand
evaluationofchronickidneydiseaseinchildren",sectionon'Hypertension')
Growthparameters(poorweightgainmaybeanindicationofchronicorrecurrentUTI)(see"Clinicalpresentation
andevaluationofchronickidneydiseaseinchildren",sectionon'Growthimpairment')
Abdominalpalpationformass(eg,enlargedbladderorenlargedkidney,suggestiveofanatomicabnormality)
Assessmentofsuprapubicandcostovertebralangletenderness(suprapubictendernessissuggestiveoflower
UTI,whereascostovertebralangletendernesssuggestsupperUTI)
Evaluationofthelowerbackforsignsofoccultmyelodysplasia(eg,midlinepigmentation,lipoma,vascular
lesion,sinus,tuftofhair),whichmaybeassociatedwithaneurogenicbladder(see"Pathophysiologyandclinical
manifestationsofmyelomeningocele(spinabifida)")
ExaminationoftheexternalgenitaliaforanatomicabnormalitiesthatmaypredisposetoUTI(eg,phimosisor
labialadhesions)andsignsofconsiderationsinthedifferentialdiagnosis(eg,vulvovaginitis,vaginalforeignbody,
sexuallytransmitteddiseases)(see"Careoftheuncircumcisedpenis",sectionon'Pathologicphimosis'and
"Vulvovaginalcomplaintsintheprepubertalchild"and"Sexuallytransmittedinfections:Overviewofissues
specifictoadolescents",sectionon'STIclinicalpatterns')
LaboratoryevaluationThelaboratoryevaluationofthechildoradolescentwithpossiblecystitistypicallyincludes
aurinalysis(dipstickandmicroscopicexamination)andurineculture.(See'Diagnosis'below.)
Sexuallyactiveadolescentswithhistoryorexaminationfindingsofpossibleurethritis(urethraldischarge)vaginitisor
cervicitis(eg,vaginaldischarge,intermenstrualorpostcoitalbleeding,dyspareunia)orepididymitis(urethral
discharge,painfulorswollenepididymis),shouldbetestedforsexuallytransmittedinfections(withnucleicacid
amplificationornucleicacidhybridizationtestsorculture).(See"Sexuallytransmittedinfections:Overviewofissues
specifictoadolescents",sectionon'STIclinicalpatterns'and"ClinicalmanifestationsanddiagnosisofNeisseria
gonorrhoeaeinfectioninadultsandadolescents"and"ClinicalmanifestationsanddiagnosisofChlamydiatrachomatis
infections",sectionon'Nucleicacidamplification'.)
DIAGNOSISAcutebacterialcystitisisdefinedassignificantbacteriuria(ie,100,000colonyformingunits
[CFU]/mLofauropathogenfromacleancatchurinesampleor50,000CFU/mLofauropathogenfromacatheterized

urinesample)inapatientwithaninflammatoryresponseandlowerurinarytractsymptoms(eg,dysuria,frequency,
etc).Quantitativeurinecultureisthestandardtestforsignificantbacteriuria.Pyuriaondipstickormicroscopic
urinalysisconfirmstheinflammatoryresponse.Thecriterionforpyuriaislesslikelytobemetiftheuropathogenisan
Enterococcusspecies,Klebsiellaspecies,orPseudomonasaeruginosathanforE.coli[30].
ClinicalsuspicionAcutecystitisshouldbesuspectedinchildren2yearsandadolescentswithlowerurinarytract
symptoms(eg,dysuria,frequency,urgency,newonsetincontinence,abdominalorsuprapubicpain)and/orhematuria
[31].
Urinarytractinfection(UTI)(includingcomplicatedcystitis)alsoshouldbesuspectedinchildrenwhohavean
indwellingbladdercatheterorhadbladdercatheterizationintheprevious48hours,areimmunocompromised,have
abnormalitiesoftheurinarytract,familyhistoryofurinarytractdisease,orhistoryofpreviousUTI,iftheyarefebrile
(38C[100.4F]),whetherornottheyhavelowerurinarytractsymptoms.
UrinalysisUrinalysisisnecessarytoassesstheinflammatoryresponse(ie,pyuria).Pyuriacanbeestablishedon
dipstickormicroscopicurinalysis.Dipstickandmicroscopicurinalysisalsocansuggestbacteriuriabeforetheresults
oftheurinecultureareavailable.However,quantitativeurinecultureisnecessarytoconfirmthediagnosis.(See
'Bacterialculture'below.)
Acleanvoidedspecimenisthepreferredmethodofcollectionfortoilettrainedchildren.Forchildrenwhoarenottoilet
trained,weprefercatheterizedurinesamplestosuprapubicaspirationsamplesgiventhatprovidersmaynotbe
proficientinobtainingsuprapubicsamples.(See"Urinecollectiontechniquesininfantsandchildrenwithsuspected
urinarytractinfection".)
Pyuriaisestablishedbyanyofthefollowing:
Positiveleukocyteesteraseondipstickanalysis
5whitebloodcells(WBC)/highpowerfield(hpf)withstandardmicroscopy(centrifugedandunstained)
10WBC/mm3onahemocytometerwithanenhancedurinalysis(whichisperformedatsomecenterson
catheterizedurinesamplesthatareGramstained,butnotcentrifuged)[32]
Pyuriamaybelesslikelywithcertainpathogens(eg,Enterococcusspecies,Klebsiellaspecies,P.aeruginosa)[30].
Bacteriuriaissuggestedbyanyofthefollowing:
PositivenitritesondipstickanalysisnitritesareproducedbyEnterobacteriaceae(eg,E.coli,Klebsiella,and
Proteus)anegativedipsticknitritedoesnotexcludebacteriuriabecauseurinemustremaininthebladderforat
leastfourhourstoaccumulateadetectableamountofnitrite(see"Urinarytractinfectionsininfantsandchildren
olderthanonemonth:Clinicalfeaturesanddiagnosis",sectionon'Dipstickanalysis')
Anybacteriaperhpfonstandardmicroscopicanalysis(centrifugedandunstained)
Anybacteriaper10oilimmersionfieldsonaGramstainedsmearonenhancedurinalysis(whichisperformedat
somecentersoncatheterizedurinesamples)[32]
Instudiescorrelatingurinalysisresultswithurineculture,positiveleukocyteesteraseand/ornitritesondipstick
analysisorwhitebloodcellsorbacteriaonmicroscopicexaminationarehighlysuggestiveofUTI(table2)[33,34].
(See"Urinarytractinfectionsininfantsandchildrenolderthanonemonth:Clinicalfeaturesanddiagnosis",sectionon
'Rapidlyavailabletests'.)
Urineculture
BacterialcultureUrinecultureshouldbeobtainedinchildreninwhomacutecystitisissuspected.Urineculture
isnecessarytodetermineifthebacteriuriaissignificant,whethertheisolateisauropathogen,andforsusceptibility
testingtoguidetherapy.(See"Acutecystitis:Managementandprognosisinchildrenolderthantwoyearsand
adolescents",sectionon'Bacterialcystitis'.)
Thedefinitionofsignificantbacteriuriadependsuponthemethodofcollectionandtheidentificationoftheisolated
organism(see"Urinarytractinfectionsininfantsandchildrenolderthanonemonth:Clinicalfeaturesanddiagnosis",
sectionon'Significantbacteriuria'):
Withmidstream(cleancatch)samples,significantbacteriuriausuallyisdefinedbythegrowthof100,000
CFU/mL[35].However,wesuggestusingathresholdof10,000CFU/mLformales15yearsofageinwhom

thereisanassociationbetweenUTIandunderlyingurologicabnormalities(whichincreasesthepotentialbenefit
ofantibiotictherapy).(See"Acuteuncomplicatedcystitisandpyelonephritisinmen",sectionon'Urineculture'.)
Withcatheterizedsamples,significantbacteriuriausuallyisdefinedbygrowthofatleast50,000CFU/mL[36].
UropathogensinchildrenandadolescentsincludeorganismssuchasE.coli,Klebsiellaspp,Enterobacterspp,
andPseudomonasaeruginosa(table1).
Lactobacillusspp,coagulasenegativestaphylococciotherthanS.saprophyticus,andCorynebacteriumsppare
notconsideredclinicallyrelevanturopathogensinimmunecompetentchildrenwithoutindwellingbladder
catheters.
Viralculture
ImmunecompromisedchildrenViralculturesshouldbeobtainedinimmunocompromisedchildrenand
adolescentswithhematuria(grossormicroscopic)ifabacterialpathogenhasnotbeenisolatedandifanother
explanationforhematuria(eg,vulvovaginitis)hasnotbeenidentified.
Adenovirus,cytomegalovirus,andpolyomaviruses(BK,JC)maycausecystitisinchildrenwithimpairedTcell
functionandchildrenwhohaveundergonehematopoieticcellorsolidorgantransplant.(See'Microbiology'above
and"Epidemiologyandclinicalmanifestationsofadenovirusinfection",sectionon'Genitourinarytract'and
"Evaluationofgrosshematuriainchildren",sectionon'Symptomatichematuria'.)
Viralcultureandpolymerasechainreactionassaysarehighlysensitiveandspecificmethodsfordetecting
cytomegalovirusandmostadenoviruses.(See"Diagnosis,treatment,andpreventionofadenovirusinfection".)
Thediagnosisofpolyomaviruscystitisisdiscussedseparately.(See"OverviewofJCpolyomavirus,BK
polyomavirus,andotherpolyomavirusinfections",sectionon'Diagnostictests'.)
ImmunecompetentchildrenInimmunecompetentchildren,viralculturesgenerallydonotidentifythecause
ofurinarytractsignsandsymptomsandwedonotobtainthemroutinely[37].
Adenovirusisararecauseofsymptomaticacutecystitisinimmunecompetentchildrenandadolescentswithout
abnormalitiesoftheurinarytract.Mostimmunecompetentchildrenwithadenoviralinfectionpresentwith
incidentalmicroscopichematuriaassociatedwithrespiratorysymptoms[37].Thosewithhemorrhagiccystitis
usuallypresentwithfever.Therefore,ifabacterialpathogenhasnotbeenisolatedandifanotherexplanationfor
hematuria(eg,severethrombocytopenia,vulvovaginitis)hasnotbeenidentified,noninfectiouscausesof
hematuria(eg,autoimmunediseasesuchassystemiclupuserythematosus)shouldbeconsidered.(See
"Evaluationofmicroscopichematuriainchildren"and"Evaluationofgrosshematuriainchildren".)
FungalcultureThevastmajorityoffungalUTIsarecausedbyCandidaspp,whichareeasilyisolatedon
routinebacterialmedia.Specificfungalculturesrarelyarewarrantedinpediatricpatients.
DIFFERENTIALDIAGNOSISThedifferentialdiagnosisofurinarysymptoms(dysuria,frequency,urgency,new
onsetincontinence,abdominalorsuprapubicpain),and/orhematuriainchildren2yearsandadolescentsincludesthe
conditionslistedbelow.Detailedapproachestochildrenwithdysuria,hematuria,andabdominalpainareprovided
separately.(See"Evaluationofdysuriainchildrenandadolescents"and"Evaluationofgrosshematuriainchildren"
and"Causesofacuteabdominalpaininchildrenandadolescents"and"Emergentevaluationofthechildwithacute
abdominalpain".)
Negativeurinecultureusuallydistinguishestheconditionslistedbelowfromacutecystitisinotherwisehealthy
children.However,inimmunocompromisedchildren,viraland/orfungalculturesmaybewarrantedbeforeexcluding
infectiouscystitis.
BladderdysfunctionFrequency,urgency,andincontinencemaybesymptomsofbladderdysfunction,a
diagnosisthatisfrequentlyoverlookedinchildrenwithurinarysymptomsandanegativeurineculture.(See
"Etiologyandclinicalfeaturesofbladderdysfunctioninchildren".)
Vulvovaginitis,chemical/mechanicalcystitis,orvaginalforeignbodyGirlswithnonspecificvulvovaginitis,
chemical/mechanicalcystitisorurethritis(eg,relatedtobathproducts,migrationofpinworms,masturbation),or
vaginalforeignbodymaycomplainofdysuriaand/orbleedingandmayhavewhitebloodcellsintheirurine.(See
"Vulvovaginalcomplaintsintheprepubertalchild".)
EpididymoorchitisClinicalmanifestationsofepididymoorchitismayincludescrotalswelling,pain,and
tendernesswitherythemaandshininessoftheoverlyingskin,aswellasdysuria[38].Mumpsisthemost

commonviraletiology.(See"Causesofscrotalpaininchildrenandadolescents",sectionon'Orchitis'and
"Epidemiology,clinicalmanifestations,diagnosis,andmanagementofmumps",sectionon'Orchitis'.)
NephrolithiasisMostchildrenwithsymptomaticnephrolithiasishaveflankpain/renalcolicinadditiontogrossor
microscopichematuria.(See"Diagnosisandacutemanagementofsuspectednephrolithiasisinadults".)
UrethralstricturesSymptomsandsignsofurethralstricturemayincludedifficultyurinatingandanabnormal
urinestreaminadditiontolowerurinarytractsymptoms.
Systemicdiseasesthatmaybeassociatedwithurinarysymptomsandsterilepyuriainclude:
KawasakidiseaseadditionalmanifestationsofKawasakidiseasemayincludeconjunctivitis,cervical
lymphadenopathy,rash,orallesions(injectedorfissuredlips,injectedpharynx,strawberrytongue),
extremitychanges(erythemaoredemaofthehandsandfeet,periungualdesquamation).(See"Kawasaki
disease:Clinicalfeaturesanddiagnosis",sectionon'Clinicalmanifestations'.)
Autoimmunediseases(eg,systemiclupuserythematosus,Sjgren'ssyndrome)withinterstitialnephritis
[39].(See"Diagnosisandclassificationofrenaldiseaseinsystemiclupuserythematosus",sectionon
'Tubulointerstitialnephritis'and"RenaldiseaseinSjgren'ssyndrome",sectionon'Interstitialnephritis'.)
Behet'ssyndrome,amultisystemdisorderthatmayincludeurogenitalinvolvement(eg,aphthousulcers,
epididymitis,urethritis,recurrentcystitis)recurrentoralulcersarethecardinalfeature.(See"Clinical
manifestationsanddiagnosisofBehetssyndrome".)
Drugs,suchasnonsteroidalantiinflammatoryagents(eg,ibuprofen),antibiotics(eg,penicillins,cephalosporins,
trimethoprimsulfamethoxazole),andvariouschemotherapeuticagents(eg,cyclophosphamide,doxorubicin,
methotrexate)maycauseinterstitialnephritis,whichmaybeassociatedwithhematuria.(See"Clinical
manifestationsanddiagnosisofacuteinterstitialnephritis",sectionon'Drugs'.)
NeoplasmsNeoplasms,suchasneuroblastoma,pelvicteratoma,orWilmstumormaycauseurinary
symptomssecondarytobladdercompression.Additionalfindingsinpatientswiththesetumorscommonlyinclude
apalpablemassonabdominal/pelvicexamination,hypertension,and/orneurologicsymptomsorsigns.(See
"Clinicalpresentation,diagnosis,andstagingevaluationofneuroblastoma",sectionon'Clinicalpresentation'and
"Presentation,diagnosis,andstagingofWilmstumor",sectionon'Clinicalpresentation'.)
Additionalconsiderationsinsexuallyactivepatientsinclude:
Chemicalcystitis(eg,relatedtospermicides)[28].
VaginitisVaginalodor,discharge,pruritus,ordyspareuniasuggestsvaginitis.Causesofvaginitisincludeyeast
infection,trichomoniasis,andbacterialvaginosis.(See"Approachtowomenwithsymptomsofvaginitis".)
CervicitisSignsandsymptomsofcervicitismayincludepurulentormucopurulentdischargefromthe
endocervix,intermenstrualorpostcoitalbleeding,pruritus,dyspareunia,vulvovaginalirritation,cervicalmotion
tenderness,cervicalfriability,andcervicaledema.(See"Acutecervicitis",sectionon'Diagnosis'.)
PelvicinflammatorydiseaseInadditiontodysuriaandabdominalpain,femaleadolescentswithpelvic
inflammatorydiseasemayhavevaginaldischarge,painwithcoitus,andconstitutionalsymptoms.(See"Pelvic
inflammatorydisease:Clinicalmanifestationsanddiagnosis",sectionon'Clinicalfeatures'.)
UrethritisUrethritisisaconsiderationinsexuallyactivepatientswithdysuria,particularlythosewithpyuriaand
nobacteriuria.CausesofurethritisincludeN.gonorrhoeae,C.trachomatis,Ureaplasmaurealyticum,orT.
vaginalisaswellasroutineuropathogens,suchasE.coli.SymptomsofurethritiscausedbyN.gonorrhoeaeor
C.trachomatistypicallydevelopgraduallyoverseveralweeksinanadolescentwhosesexualpartnermayor
maynothaveurethralsymptoms.(See"Sexuallytransmittedinfections:Overviewofissuesspecificto
adolescents",sectionon'Dischargesyndromes'.)
EVALUATIONFORUNDERLYINGABNORMALITIESRadiologicevaluation(eg,renalultrasonography,renal
scan,voidingcystourethrogram)forunderlyingabnormalitiesisnotroutinelynecessaryinchildrenandadolescents
withuncomplicatedcystitis.
Theimagingindicationsandmodalitiesforchildrenwithcomplicatedcystitisvarydependingupontheclinicalscenario
imagingmaybeindicatedforpatientswith:
Suspectedorconfirmedrecurrentcystitis

Cystitiscausedbyanunusualpathogen
Familyhistoryofrenalorurologicdisease
Poorgrowth
Hypertension
Failuretorespondasexpectedtoantimicrobialtherapy(inchildrenwithconfirmedbacterialinfection)

Theseclinicalfeaturesmayindicateanunderlyinganatomicorfunctionalabnormality(eg,renalcalculus,cyst,
abscess,foreignbody,bladderdysfunction)thatmayrequireadditionalintervention.
Guidelinesforimagingtheurinarytractafterurinarytractinfection(UTI)inyoungchildrenandchildrenwithuppertract
infectionsarediscussedseparately.(See"Urinarytractinfectionsininfantsolderthanonemonthandyoungchildren:
Acutemanagement,imaging,andprognosis",sectionon'Imaging'.)
INFORMATIONFORPATIENTSUpToDateofferstwotypesofpatienteducationmaterials,"TheBasics"and
"BeyondtheBasics."TheBasicspatienteducationpiecesarewritteninplainlanguage,atthe5thto6thgradereading
level,andtheyanswerthefourorfivekeyquestionsapatientmighthaveaboutagivencondition.Thesearticlesare
bestforpatientswhowantageneraloverviewandwhoprefershort,easytoreadmaterials.BeyondtheBasicspatient
educationpiecesarelonger,moresophisticated,andmoredetailed.Thesearticlesarewrittenatthe10thto12thgrade
readinglevelandarebestforpatientswhowantindepthinformationandarecomfortablewithsomemedicaljargon.
Herearethepatienteducationarticlesthatarerelevanttothistopic.Weencourageyoutoprintoremailthesetopics
toyourpatients.(Youcanalsolocatepatienteducationarticlesonavarietyofsubjectsbysearchingon"patientinfo"
andthekeyword(s)ofinterest.)
Basicstopic(see"Patientinformation:Urinarytractinfectionsinchildren(BeyondtheBasics)")
BeyondtheBasicstopic(see"Patientinformation:Urinarytractinfectionsinchildren(BeyondtheBasics)")
SUMMARYANDRECOMMENDATIONS
Riskfactorsforacutecystitisinchildren2yearsandadolescentsincludefemalesex,sexualactivity,
abnormalitiesoftheurinarysystem(eg,vesicoureteralreflux,bowelandbladderdysfunction,neurogenic
bladder),indwellingbladdercatheter,recentinstrumentationoftheurinarysystem,certainchronicdiseases(eg,
sicklecelldisease,diabetesmellitus),andimmunodeficiency.(See'Riskfactors'above.)
AcutecystitisisusuallycausedbyEscherichiacoli,butmaybecausedbyanypathogenthatcolonizesthe
periurethralareaandurinarytract(table1),particularlyinchildrenwithunderlyinggenitourinaryabnormalities,or
immunecompromise.(See'Microbiology'above.)
Childrenwithacutecystitistypicallypresentwithdysuria,frequency,urgency,newonsetincontinence(intoilet
trainedchild),abdominalorsuprapubicpain,and/orhematuria.Fever>38C(100.4F),chills,orflankpain
suggestuppertractinfectionratherthanacutecystitisbutcannotreliablymakethisdistinction.(See'Clinical
presentation'above.)
Thehistory(table3)andexamination(table4)ofchildrenwithsuspectedacutecystitisfocusonriskfactorsfor
urinarytractinfectionandevaluationofotherconditionsinthedifferentialdiagnosis.(See'Evaluation'aboveand
'Riskfactors'aboveand'Differentialdiagnosis'above.)
Acutecystitisshouldbesuspectedinchildren2yearsandadolescentswithlowerurinarytractsymptoms(eg,
dysuria,frequency,urgency,newonsetincontinence,abdominalorsuprapubicpain)and/orhematuria.Urinary
tractinfection(UTI)(includingcomplicatedcystitis)alsoshouldbesuspectedinchildrenwhohaveanindwelling
bladdercatheterorhadbladdercatheterizationintheprevious48hours,areimmunocompromised,have
abnormalitiesoftheurinarytract,familyhistoryofurinarytractdisease,orhistoryofpreviousUTI,iftheyare
febrile(38C[100.4F]),whetherornottheyhavelowerurinarytractsymptoms.(See'Clinicalsuspicion'above.)
Thediagnosisofacutebacterialcystitisrequiresisolationof100,000colonyformingunits(CFU)/mLofa
uropathogenfromacleancatchurinesampleor50,000CFU/mLofauropathogenfromacatheterizedurine
sampleinapatientwithurinarysymptomsandpyuriaondipstickormicroscopicurinalysis.Thecriterionfor
pyuriaislesslikelytobemetiftheuropathogenisanEnterococcusspecies,Klebsiellaspecies,or
Pseudomonasaeruginosa.(See'Diagnosis'aboveand'Urinalysis'aboveand'Bacterialculture'above.)
Theresultsoftheurineculturedifferentiateacutecystitisfromothercausesoflowerurinarytractsymptoms,
hematuria,and/orlowerabdominalpaininchildrenandadolescents.(See'Differentialdiagnosis'above.)

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