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Cystitis - Health Information

Health Information

What is it

Cystitis is an acute infection or inflammation of the urinary bladder.

Who gets it

Cystitis is common, and can occur at any age in both sexes. It is fifty times more common in women than in men(1), and is commonest amongst sexually active women. One in five women will get an attack of it during their lifetime(2).

What are the causes

The usual cause is infection due to germs entering the urinary system from outside, via the urethra (the tube that drains the bladder). This is about 20 centimetres long in men, and only 4 centimetres long in women, so the germs have much less far to travel and cause infection more easily. The bowel germ E. Coli is responsible for 80% of infective cystitis(1). Sexual intercourse can cause germs to enter the urethra in spite of good personal hygiene, though poor personal hygiene increases the risk. Many women experience increased bouts of cystitis at the start of the menopause, when the drop in natural oestrogen alters the defence mechanisms in the vagina, increasing risk of infection.

Some children are born with abnormalities of the urinary system which cause germs to enter more easily, or cause urine to stagnate in the bladder or flow back up to the kidneys, making infection of the whole urinary system possible.

Infection elsewhere in the body can occasionally spread to the bladder.

Stress and general illness lower resistance to infection and increase the risk of getting cystitis.

A kidney stone can act as a reservoir for infection. Antibiotics do not penetrate a stone, so the germs survive. A urinary catheter (a tube to drain urine from the bladder) can introduce infection.

Rare causes of cystitis include parasitic infection (schistosomiasis), chronic immunological reactions (3), and as a result of treatment for other conditions (eg radiotherapy).

Interstitial cystitis is a recently recognised variant which is difficult to diagnose and treat, but is probably far commoner than previously thought. It is estimated that up to half a million people are affected by this in the USA, 90% of them women(1). It is not fully understood at present, and there is no set way to treat it. More conclusive research is awaited.

What are the symptoms

Cystitis has a very characteristic set of symptoms, so that it is generally possible to diagnose it from the description alone:

  • burning and stinging on passing urine (dysuria)
  • passing urine often (frequency)
  • experiencing an intense need to pass urine (urgency)
  • passing only small amounts at a time
  • having to pass urine frequently at night (nocturia)
  • bad-smelling urine
  • pain in the lower abdomen over the bladder
  • low back pain
  • passing blood in the urine (sometimes)
  • lack of control over passing urine (incontinence, sometimes)
  • low fever
  • feeling generally unwell or 'fluey'
  • painful sexual intercourse

Sometimes the infection spreads up the ureter (the tube leading from the kidney to the bladder) to the kidney causing a condition called pyelonephritis. This usually causes pain in the area of the kidney and is often associated with a fever and intense shivering called 'rigors'. The treatment of pyelonephritis is the same as for cystitis although in severe cases hospital admission may be necessary in order to give antibiotics intravenously (directly into the bloodstream).

In children the usual symptoms of cystitis are not always present so diagnosis of a urine infection can be difficult to make. In children a urinary infection can cause the symptoms listed above but may only result in the child being generally unwell with a temperature. A clue may be provided if the child in question starts to wet the bed or become incontinent when they have previously had good bladder control or the parent may notice that the child's urine smells offensive.

Diagnosing urine infections in babies is even more difficult since the only symptoms may be a persistent temperature and the baby being generally unwell and off its feeds. For this reason, although urine infections in babies are unusual, parents and doctors need to be alert to the possibility that an unwell child with no obvious cause for its illness may have an infection in the urine. Sending a sample of urine to the laboratory for analysis will enable the doctor to exclude this as a possibility. It is particularly important for urine infections to be diagnosed in children as early as possible to prevent recurrent or chronic infections from causing kidney damage.

What are the risks

The major risk is of recurring (chronic) infection. This usually is no more than a repeat bout of misery, but in a small number of cases, it leads to kidney infection with scarring and permanent damage. The ultimate rare result is a kidney that doesn't work.

The importance of this is to ensure that repeated infection is thoroughly treated. Sometimes a prolonged course of antibiotics for months is needed. This complication is especially important in children who suffer from backwards flow of the urine from the bladder to the kidney (reflux). Inadequate treatment can lead to kidney failure.

What tests are useful

Whilst straightforward urine infections can safely be treated without much or any investigation(4), it is sometimes necessary to do tests to find out the type of germ causing the infection, and occasionally to monitor the kidney function itself and check for underlying causes.

The tests are:

Urinalysis: a simple surgery test using a sensitive testing stick that can detect pus cells, blood and breakdown products of bacteria in the urine.

Mid Stream Urine (MSU): a sample of urine taken in mid stream (to exclude germs from the urethra which are washed out first) is analysed in a laboratory for the presence and type of bacteria.

A blood test may give an indication of infection or inflammation, and a rough measure of the kidney function.

Ultrasound scan: particularly useful in children because it is simple to undergo. It provides an image of the urinary tract and is useful for looking for structural abnormalities such as an enlarged or shrunken kidney.

Intravenous Urogram (IVU, also known as an Intravenous pyelogram, IVp): a dye is injected into an arm vein. The kidneys filter it out and show up clearly on an x-ray image. They are not otherwise clearly seen. This is useful to see how much of a kidney is scarred, whether it is working or not, to detect a kidney stone, and to look at the state of the ureters.

Micturating Cystogram: a dye is introduced into the bladder through a catheter. X-rays are taken of the bladder and ureters during the passing of urine to check for reflux of urine.

Isotope scan: a very weak radioactive substance is injected into an arm vein. This is filtered by the kidneys. The radioactivity is detected by a gamma ray camera, linked to a computer which then calculates how accurately each kidney is functioning.

What treatments are there

The treatment for infection is antibiotics. Underlying causes are treated as appropriate. For example, reflux of urine or a kidney stone can sometimes be treated by surgery.

What are the treatment side effects

The infection should begin to improve within 48 hours. If not, it could be that the germs are resistant to the prescribed antibiotic, and contacting the doctor is a good idea.

All antibiotics can cause an allergic rash: if this happens, the doctor should be informed for the record. Diarrhoea and tummy upset are also common, and nearly always subside after the course is finished.

There are a whole host of much rarer side effects which will be listed in the information sheet dispensed with the medication. These are very unlikely to occur, but have to be published by law.

A woman on the oral contraceptive pill should take additional contraceptive precautions from the first day of antibiotics until seven days after the last day, as the efficiency of the pill can be affected.

What self-help strategies are there

  • Urinate whenever the urge is felt, and empty the bladder completely. Holding it in gives the bacteria a chance to multiply
  • Wipe genitals from front to back after using the toilet, to prevent sweeping bacteria forward from the anal area
  • Empty the bladder just before and after intercourse. This reduces the risk of introducing bacteria into the urethra during intercourse, and flushes them out afterwards
  • Spermicides can kill the friendly bacteria that live normally in the vagina, keeping unwanted germs at bay. For those prone to cystitis, switching to a different contraceptive may help
  • Cranberry juice appears to prevent bacteria sticking to the bladder wall. It may help prevent an infection from developing further once it has started
  • Some sufferers of interstitial cystitis find their symptoms reduce when they follow a low-acid diet by avoiding spicy foods, citrus fruits, tomatoes, coffee, tea, chocolate and alcohol
  • Drink plenty of water: at least eight glasses a day
  • Bubble baths can cause urethral irritation in some women

Where can I get further information

Apart from contacting your own Gp, the following organisations may be of help:

Cystitis and Candida
Mrs A Kilmartin
75 Mortimer Rd
London
N1 5AR
Telephone: 020 7249 8664

Interstitial Cystitis Support Group
76 High Street
Stony Stratford
Buckinghamshire
MK11 1AH
Tel: 01908 569169

References

  1. HUGHES, R. (1995) Two types of misery (bacterial cystitis and interstitial cystitis) Harvard Health Letter Jan (4) p.3
  2. brUCKENHEIM, A.H. (1993) Urinary infection among women Family Doctor (CD Rom) Oregon, (USA) Tribune Media Services and Creative Multimedia
  3. LADOSCI, L.T. (1995) Eosinophilic granulomatous cystitis in children; Urology Nov 1995 46(5) pp.732-5.
  4. HOOTON, M. (1995) A simplified approach to urinary tract infection; Hospital practice Off. Ed. Feb 15th 30(2) pp.23-30.
  5. BARNETT B J, STEpHENS D S, (1997) Urinary tract infections: an overview. American Journal of Medical Science. 314(4) pp245-9.
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