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Cystitis |
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Cystitis is an inflammation of the bladder, usually caused by a bacterial infection. It is a common condition, with more than 30% of women experiencing at least one episode in their lifetime (1). Cystitis occurs when bacteria enters the urethra and travels to the bladder (see diagram below). The bacteria most commonly associated with cystitis is Escherichia coli (E.coli). E. coli is found naturally in the bowel and, in smaller numbers, in the vagina and on the skin between the anus and the vagina (perineum) (2). Women are much more prone to developing cystitis than men. The shorter urethra allows the bacteria to reach the bladder quickly. In addition, the urethral, vaginal and anal openings are closely located, making it easy for bacteria to be transferred from one to another. 
Symptoms
- Frequent painful urination - often a burning sensation
- Urgent need to urinate, even after just urinating
- Passing only small amounts of urine each time
- Cloudy, smelly urine or blood in the urine
If left untreated, the infection can move from the bladder to the kidneys. Symptoms of a kidney infection include those associated with cystitis as well as fever, chills, back pain, nausea and vomiting. Cystitis and kidney infections are also referred to as urinary tract infections (UTIs). Risk factors Sexual activity – The most common contributing factor for cystitis is sexual activity. This is why the condition is sometimes referred to as ‘honeymoon cystitis’. During sex, bacteria can be spread from the perineum to the urethral opening. In addition, any form of vaginal penetration can cause rubbing or irritation to the urethra (which is adjacent to the interior of the vagina). If a woman’s lubrication is inadequate the vaginal skin can become irritated or suffer from small abrasions, encouraging bacteria to grow. The bacteria in the vagina may then be transferred to the urethral opening. Contraceptive use – Evidence suggests that the use of spermicides increases the risk of cystitis. Spermicides kill the ‘good’ bacteria in the vagina and may also cause an allergic reaction, leading to an increase in ‘bad’ bacterial growth. Diaphragms and condoms have also been linked to an increased risk of cystitis (3). Diaphragms can alter urination patterns leading to bacteria not being flushed out of the bladder as efficiently or the bladder not being completely emptied (4). Unlubricated condoms can result in rubbing and irritation, increasing the chances of infection. Menopause – The drop in oestrogen which occurs at the menopause leads to a reduction in vaginal elasticity and lubrication and an increase in the pH level of the vagina. All of these changes result in an increased risk of bacterial infection (5). The drop in oestrogen can also cause changes in the pelvic floor tone, resulting in a ‘pool’ of urine remaining in the bladder (see below). Urination pattern – Not emptying the bladder frequently enough can cause problems, with the urine becoming concentrated and irritating the lining of the bladder. Not drinking enough fluid will result in concentrated urine being stored in the bladder, helping bacteria to grow. In addition, the incomplete emptying of the bladder can lead to an infection. The flow of urine from the bladder can be affected by:
- a blockage in the urinary tract (cyst, stones, birth defect).
- weight of the foetus during pregnancy. It is important that cystitis during pregnancy is treated as it more likely to ascend to the kidneys and can cause pregnancy complications.
- genital prolapse (the dropping down of pelvic organs).
- use of a diaphragm or an incorrectly placed tampon.
Health conditions – Women with diabetes, spinal cord injury and multiple sclerosis have a higher risk of cystitis and other urinary tract infections. Family history – Women who experience recurrent infections are more likely to have a mother who has had urinary tract infections (6). Other – Exposure to cold appears to increase the risk of cystitis in women with a history of recurrent infection (7). Personal hygiene practices (wiping from back to front when going to the toilet), taking baths and wearing tight pants or pantyhose have all been hypothesised as increasing the risk of cystitis. Although there is little conclusive evidence that these behaviours contribute to cystitis it is plausible. Diagnosis Cystitis can sometimes disappear on its own without the need to see a doctor. Women can try drinking plenty of water to help flush out the bacteria as well as taking a urinary alkaliniser. Urinary alkalinisers help neutralise the acid in the urine, making it more difficult for the bacteria to survive. They can also help relieve symptoms. Dissolve one level teaspoon of baking soda in a glass of water or use one of the preparations available from the chemist (eg. Ural). If a woman is pregnant, her symptoms persist for longer than 24 hours or she has any fever, chills, back pain, nausea and vomiting (symptoms of a kidney infection) she needs to see her doctor. Apart from noting the symptoms, the doctor will ask questions to determine what may have contributed to an infection and ask for a urine sample to test for the presence of bacteria. To be accurate, the urine sample should be what is referred to as ‘mid-stream’. A mid-stream urine sample aims to provide a specimen of urine as it appears in the bladder, without contamination from outside bacteria. It involves allowing some urine to pass into the toilet before collecting the sample of urine. The doctor may perform a dipstick test on the urine sample to see if there are signs that a bacterial infection is present. The sample will then be sent to a laboratory for testing. Treatment Cystitis is treated with a course of antibiotics. As the laboratory testing of the urine sample may take a couple of days, the doctor will often prescribe a broad-spectrum antibiotic in the meantime to bring relief from symptoms and to stop any infection progressing. It is important that the complete antibiotic course be taken, even if the symptoms resolve, as the infection can recur. To get relief from symptoms, women can also:
- Drink plenty of fluids.
- Reduce their intake of alcohol, tea and coffee as these can all irritate the bladder.
- Take urinary alkalinisers (see diagnosis section above).
- Place a hot water bottle, wrapped in a towel, between the legs. This makes the skin around the urethral opening hotter than the urine and so can bring relief when urinating.
- Take mild painkillers for pain relief.
Recurrent infections Studies indicate that approximately 20% of women with a first urinary tract infection will experience a second within six months (8). Women who experience recurrent infections are encouraged to practice a number of preventive strategies (see below). If the infection appears to recur after sexual activity women may be prescribed a single dose antibiotic to take afterwards (9). Similarly, some women may also be given low dose antibiotics long term as a preventive measure. If infections continue or there are complications, a referral to a urologist may be helpful. Tests may be conducted to ensure there are no abnormalities in the urinary system. Prevention While not all strategies are based on conclusive evidence they are sensible suggestions.
- Drink plenty of water – at least 2-3 litres a day.
- Urinate frequently, avoid ‘holding on’ and ensure the bladder is emptied completely.
- Urinate after sexual activity – this can help wash out bacteria that may have entered the urethra during sex.
- Use a lubricant during sex – if vaginal dryness is a problem a water-based lubricant will reduce the chance of irritation or abrasions.
- If using a diaphragm and/or spermicide have the diaphragm checked to ensure it is the right size and fit. Alternatively, discuss with your doctor the possibility of using another form of contraception.
- Try cranberry products – There is some evidence that cranberry products reduce the number of urinary tract infections in women (10). The tannins found
in cranberries appear to prevent the E.coli bacteria from attaching to the cells which line the urinary tract (11).
- Avoid getting a chill by wearing adequate, dry clothing.
- When going to the toilet, wipe from front to back to minimise the risk of bacteria being transferred to the urethra.
Interstitial cystitis
Interstitial cystitis (IC) is a severe and chronic pain syndrome that affects the bladder (12). It is also referred to as ‘painful bladder syndrome’. The vast majority of IC sufferers are Caucasian women (13). It is thought that many cases of chronic pelvic pain are due to IC. Symptoms include: frequent urination (including having to go to the toilet during the night); an urgent need to urinate; and pain (abdominal, urethral, vaginal or perineal). Other characteristics of IC that may be present are a scarred or stiff bladder, glomerulations (pin point bleeding) and bladder ulcers. The symptoms can be extremely debilitating with many women unable to work full time and/or suffering from related mental and emotional health issues.
Women with IC generally experience pain when their bladder fills and find relief (temporarily) from this pain when they urinate. However, as the pain returns as soon as the bladder begins to fill again, women find themselves urinating very frequently to relieve the pain. Typically, a woman with IC will go to the toilet 16 times a day, but some sufferers go up to 40 times (14). As a consequence, they may suffer the effects of sleep deprivation. Women’s symptoms may be exacerbated with sexual activity and premenstrually. The exact cause of IC is unknown, with a number a theories being investigated.
It is common for IC to be initially diagnosed as bacterial cystitis. However, women with IC do not have bacteria in their urine and so do not respond to antibiotic therapy. Unfortunately, the diagnosis of IC often takes time as other possible causes are usually excluded first. Women may be investigated for a range of other conditions such as endometriosis, irritable bowel syndrome or an overactive bladder.
There is no single diagnostic test for IC. A thorough medical history, pelvic examination and urine studies are all important. Upon a pelvic examination, 95% of IC sufferers will report tenderness at the base of the bladder (15). A cystoscopy with distention may also be performed. Under general anaesthesia a long thin viewing device (cystoscope) is inserted through the urethra into the bladder. The bladder is then filled to high pressure with fluid or gas (distention).
The medical community has differing opinions on the suitability of other diagnostic tools such as urodynamics, potassium sensitivity test (PST), questionnaire based scales (eg. Pelvic Pain and Urgency/Frequency) and biopsy of the bladder wall (to rule out bladder cancer). A number of clinical markers are currently being investigated.
As the cause of IC is uncertain, there are a variety of treatment options available. Treatment recommendations are difficult due to the lack of good quality clinical trials. The general aim of treatment for IC is to help people manage their symptoms. Conservative treatment options are often explored initially, with dietary changes being the most common (16). While diet is not a cause of IC, many women report that particular foods and fluids seem to exacerbate the symptoms. Foods often reported as aggravating symptoms include coffee, chocolate, carbonated drinks, citrus fruits, tomatoes and products containing artificial sweeteners. Women may find it helpful to keep a diary, recording what they eat and drink along with symptoms, to determine if there are particular foods/drinks they should avoid.
Smoking is also thought to exacerbate symptoms so quitting can be helpful. Participating in regular exercise may also assist, with low impact activities such as walking, yoga, swimming and cycling the most suitable. While there is limited research on the use of complementary and alternative therapies in the treatment of IC, women report they are beneficial. Therapies with a focus on pain and stress relief may be most relevant. Women interested in using complementary and/or alternative therapies should consult a qualified practitioner.
Other treatments for IC include: bladder distention; bladder instillation; transcutaneous electrical nerve stimulation (TENS); bladder training; medications; and surgery. It was found that following bladder distention for diagnostic purposes some women reported a decrease in symptoms. This has led to bladder distention being used as a treatment option. Bladder instillation involves filling the bladder with a solution and retaining it for a specific length of time before expelling it. The solution most commonly used is dimethyl sulfoxide (DMSO), either alone or with other substances. Other solutions for use in bladder instillation are being investigated. Transcutaneous Electrical Nerve Stimulation (TENS) involves sending small electrical pulses through electrodes placed on the skin and/or through devices inserted into the vagina.
Bladder training may be helpful for those who have found a level of pain relief. It involves urinating to a schedule and gradually increasing the length of time between toilet visits. Techniques like pelvic floor contraction, distraction and breathing exercises are used to resist the urge to urinate before the scheduled time. A bladder diary can assist people to keep a track of their progress. A number of medications are used in the treatment of IC including pentosan polysulfate sodium (PPS), antidepressants, antihistamines and pain management drugs. Other drugs are being investigated.
Surgery is reserved for cases where all other treatment options have failed and in which the symptoms experienced are severe and disabling. Surgical treatments include removal of bladder ulcers, bladder augmentation (plastic or reconstructive procedure on the bladder) and urinary diversion (creation of a new urine storage pouch) with or without the removal of the bladder. Sacral nerve root stimulation, a variation of TENS, involving the surgical implantation of a permanent electrode, is also currently under investigation.
People who suffer from IC may also benefit from joining a support group. A support group can provide people with opportunities to share information and management strategies as well as reduce feelings of isolation (see Further reading section). |
References
- Kurowski K. The woman with dysuria American Family Physician 1998 Vol 57 No 9 p2155-64, 2169-70
- Syrop, J. Urinary tract infections: prevention is the best medicine The Female Patient 1996 S2 p11-15
- Foxman, B. Urinary tract infection. In Goldman MB & Hatch MC (eds). Women and Health London: Academic Press p361-368
- Foxman, B. Urinary tract infection. Ibid p363
- Foxman, B. Urinary tract infection. Ibid p364
- Fihn, S D. Acute uncomplicated urinary tract infection in women New England Journal of Medicine 2003 vol 349 No 3 p259-266
- Foxman, B. Urinary tract infection. Ibid p364
- Foxman, B. Recurring lower urinary tract infections: Incidence and risk factors American Journal of Public Health 1990 Vol 80 No 3 p331-333
- Harvey, M & Versi, E. Urogynecology and pelvic floor dysfunction.
In Ryan, K et al. Kistner’s Gynecology & Women’s Health St Louis: Mosby 1999 p570-609
- Jepson RG, Mihaljevic L & Craig J. Cranberries for preventing urinary
tract infections Cochrane Database Systematic Review 2004 (2): CD001321
- Howell, AB et al. Inhibition of the adherence of P-Fimbriated Escherichia coli to uroepithelial-cell surfaces by proanthocyanidin extracts from cranberries (letter) New England Journal of Medicine 1998 Vol 339 No 15 p1085-1086
- Parsons CL et al. Interstitial cystitis. In Goldman, MB & Hatch MC (eds) Women and Health London: Academic Press 2000 p1110-1119
- Erickson, DR. Interstitial cystitis: Update on etiologies and therapeutic options Journal of Women’s Health 1999 Vol 8 No 6 p745-758
- Parsons CL et al. 1112
- Parsons CL et al. 1113
- Erickson, DR. Ibid 748
Further help and information from Women’s Health Queensland Wide Health Information Line:
Our free statewide line is staffed by women's health nurses and midwives. They provide women with up to date information, support and referral to health practitioners and services. Women can contact the Health Information Line by phone or email via the 'Ask a Health Question' page on the website. All phone calls and emails are confidential.
(07) 3839 9988 or 1800 017 676 (toll free outside Brisbane) Library:
Our free lending library offers a select range of books on major women's health topics. Topic-based booklists are availableon our website, or can be posted out; books can be requested by phone or email and are posted to borrowers.
Contact on administration : (07) 3839 9962 Website:
All our factsheets and booklets are available on our website. The website also features articles on women's health from our newsletter, student factsheets, upcoming events, library services and 'Ask a Health Question' page. A list of reputable links is also available where women can search for further information on health topics.
www.womhealth.org.au Further reading See our Incontinence, bowel and bladder health booklist Australian Interstitial Cystitis Support Group
http://www.users.bigpond.net.au/ICSG/ Interstitial Cystitis Association (US)
http://www.ichelp.com/ Interstitial Cystitis Network ( US )
http://www.ic-network.com/ This factsheet was originally published in October 2001. It was revised by Kirsten Braun and the Editorial Committee in August 2005.
Last Modified:
August 1, 2005
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