Website of the week
Female patients who come back time and again with recurrent cystitis have all my sympathy. It must be so disruptive to their lives to suffer in this way. After the first few episodes, you need a well-orchestrated plan of action. This lets the patient know you are taking her problem seriously and not just going to sit there and keep issuing antibiotics, often closely followed by another visit to treat monilia.
This guidance from PRODIGY gives you the steps to follow and the options open to you. We all know from personal experience that sometimes you just don’t come up with an answer, but at least you will have tried and the patient will know it.
It is an awkward page to access as the information is all provided in jumps through a series of links, but it is worth the effort.
Why go there: helps with a difficult problem
Downside: long-winded layout
Information from: PRODIGY
Address: cks.library.nhs.uk/urinary_ tract_infection_lower_women/scenario/recurrent_cystitis
The full SIGN guidelines on urinary tract infection (UTI) run to about 48 pages, but these two pages provide a useful summary. They deal with suspected lower UTI in pregnant and non-pregnant women.
It is not one of their best efforts, as the layout when printed is somewhat confusing, but it is a handy aide-memoir, and there are some helpful reminders, such as that women taking nitrofurantoin should not take alkalinising agents. Because women with a lower UTI may be taking an over-the-counter version of mist pot cit, they need to be warned.
I know the evidence recommends nitrofurantoin as one of the first choices for the uncomplicated case of cystitis, but I have had so many unhappy women return to me with bad side-effects that I have been put off prescribing it.
Why go there: brief and to the point.
Downside: layout could be clearer.
Information from: Scottish Intercollegiate Guidelines Network.
Errors in diagnosis and management
I make no bones about it, this article is one for the enthusiast — and there are no short cuts, you have to read the whole thing to get the best out of it.
It may sound irrelevant to general practice, coming as it does from a specialist journal, but it deals with issues that are relevant to primary care and of interest to GPs.
Asymptomatic bacteriuria, contamination of specimens, the role of commensal flora and the significance of microscopy are all dealt with.
Among the eight pages there are flow charts and diagrams that help explain the process of reaching a diagnosis.
It is pretty heavy going, but for anyone who is not sure how to interpret the details of reports that do not help you come to a definite conclusion, this is worth the effort.
Why go there: if you are really keen.
Downside: takes time.
Information from: Nephrology Dialysis Transplantation
Collecting an MSU
For years I had in my desk drawer a pad of instruction leaflets for patients on how to take a midstream specimen of urine. They were given to me by a rep whose product has now fallen out of use, and I never found another one.
But here, thanks to the internet, you can download an instruction sheet that is even better than the one I used
for so many years.
Print it out, give some copies to your treatment room nurses, and they will save hours of explaining and may result in some more significant urine test results.
Why go there: helpful leaflet.
Information from: EMIS and PIP (PRODIGY validated).
Address: http://cks.library.nhs.uk/ patient_information/pils/ midstream_specimen_of_ urine_msu.pdf
There are thousands of alternative medicine products out there that claim to cure lower UTIs in women, so I just picked this one at random.
D-mannose is a natural monosaccharide isomer of glucose extracted from trees, and is claimed to work by ‘occupying the mannose receptors of E coli and Klebsiella.’
Apparently, it will cure acute, recurrent and interstitial cystitis.
The site rubbishes cranberry juice, one of the few natural remedies to receive professional approval.
Taken in the doses recommended for treatment and prophylaxis, you will soon get through 1,000g of the powder, and that will set you back £260.
This stuff might work, but if so why have I never heard of mannose receptors and why is not in the BNF?
Why go there: you might learn something, but on the other hand, you might not.
Downside: pages of guff.
Information from: Sweet Cures of York.
Address: www.waterfall-d-mannose.com/cystitis- treatment-method.htm
Dr Barnard is a former GP in Fareham, Hampshire
See clinical review, page 28