Cystitis	Download a PDF of this factsheet

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 enter the urethra and travel to the bladder (see diagram). The bacteria most commonly associated with cystitis are 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. Their shorter urethra allows the bacteria to reach the bladder quickly. In addition, the urethral, vaginal and anal openings are closely located in women, making it easy for bacteria to be transferred.

Recurrent cystitis infections can lead to feelings of exhaustion and anxiety in women.

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. Women with symptoms of a kidney infection should seek immediate medical attention. Cystitis and kidney infections are also referred to as urinary tract infections (UTIs).

Risk factors

Sexual activity—Cystitis 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 next to the entrance 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. This bacteria may then be transferred to the urethral opening.

Contraceptive use—Diaphrams and condoms have been linked to an increased risk of cystitis (3). Diaphragms can change 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 irritation, increasing the chances of infection. 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.

Menopause—The drop in the level of the hormone oestrogen which occurs at menopause leads to a reduction in vaginal elasticity and lubrication and an increase in the pH level of the vagina. 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 next point).

Urination pattern—If the bladder is not emptied adequately bacteria can be left behind which can multiply and cause cystitis. Not emptying the bladder frequently enough can also 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. Incomplete emptying of the bladder can also 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 to promptly treat cystitis during pregnancy as it more likely to move to the kidneys and 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. Other vaginal infections such as candidiasis (thrush) or trichomoniasis can make a woman more susceptible to cystitis.

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

If treated quickly 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. Cystitis during pregnancy can lead to high blood pressure and low birth weight (8). Apart from noting the symptoms, the doctor will ask questions to determine what may have contributed to an infection, including about a woman’s sexual history. The doctor will 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 without contamination from bacteria around the vagina. It involves allowing some urine to pass into the toilet before collecting the sample of urine. Other tests may also be performed to exclude the possibility of any other types of infection.

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. Because the laboratory testing of the urine sample may take several 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, to prevent the infection recurring.

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
• avoid eating foods that can irritate the bladder while infection is present. These include foods with high acid content and amino acids.

Women showing signs of a kidney infection should see a doctor as soon as possible.

Recurrent infections

Approximately 20% of women with a first urinary tract infection will experience a second within six months (9). Recurrent infections can lead to feelings of exhaustion and anxiety in women. Women who experience recurrent infections are encouraged to practice a number of preventive strategies (see below).

If the infection appears to relate to sexual activity women may be prescribed a single dose antibiotic to take after sex. Similarly, some women may also be given low dose antibiotics long term as a preventive measure (10).

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 of recurrent infections

As a number of women will experience a subsequent cystitis infection, preventive strategies play an important role. 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 when you need to, avoid ‘holding on’ and ensure the bladder is emptied completely.
• Urinate after sexual activity—this can help flush 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—cranberries contain a substance that prevents the E.coli bacteria from attaching to the cells which line the urinary tract (11). It is important to note that while cranberry products will help prevent cystitis, they are not effective as a treatment.
• Herbal medicines such as parsley, bearberry and golden seal are used to maintain healthy urinary function. Women seeking to use natural therapies to prevent cystitis recurrence should consult a qualified practitioner.
• Natural therapies such as acupuncture, acupressure, aromatherapy, naturopathy and reflexology are used to promote bladder and urinary tract health.
• Maintain a healthy immune system.
• In post-menopausal women application of vaginal oestrogen cream has been found to reduce the likelihood of recurrent cystitis infection. Possible side affects of vaginal oestrogen creams include breast tenderness, vaginal bleeding or spotting, discharge and irritation (12).
• Maintain a good pH balance in the vagina. A healthy vaginal discharge and balanced perenium environment contain micro-organisms and an acidic pH environment that helps prevent bacteria sticking to the skin. An unhealthy vaginal pH level may lead to bacteria being more able to stick to the skin around the urethra, and therefore more able to travel up the urethra to the bladder (13). Wearing cotton underwear (14), quickly treating any vaginal infections such as thrush or trichomoniasis (15) and keeping soaps and bubble bath away from the vagina may all assist in maintaining a healthy vaginal pH balance.
• When going to the toilet, wipe from front to back to minimise the risk of bacteria being transferred to the urethra.
• Avoid constipation (16).

Further reading

See our Incontinence, bowel and bladder health booklist

References

1. Kurowski, K (1998) ‘The woman with dysuria’ American Family Physician 1998 Vol 57 No 9 p2155-64, 2169-70
2. Syrop, J (1996) ‘Urinary tract infections: prevention is the best medicine’ The Female Patient 1996 S2 pp11-15
3. Foxman, B. ‘Urinary tract infection’ in Goldman MB & Hatch MC (eds). Women and Health London: Academic Press p361-368
4. Foxman ibid. p363
5. Foxman ibid. p364
6. Fihn, S D. Acute uncomplicated urinary tract infection in women New England Journal of Medicine 2003 vol 349 No 3 p259-266
7. Foxman op. cit. p364
8. Kidney Health Australia (2009) Urinary tract infections fact sheet available at www.kidney.org.au accessed 22 July 2010
9. Foxman, B. Recurring lower urinary tract infection: Incidence and risk factors American Journal of Public Health 1990 Vol 80 No 3 pp331-3
10. Chung, A, M Arianayagam & P Rashid (2010) ‘Bacterial cystitis in women’ Australian Family Physician Vol 39 No 5 May 2010 pp298 Available at www.ragp.org.au/afp/201005/201005chung.pdf Accessed 22 July 2010.
11. Jepson, RG & JC Craig (2009) ‘Cranberries for preventing urinary tract infections (Review) The Cochrane Library 2009 Issue 4
12. Perrotta C, M Anzar, R Mejia, X Albert & CW Ning (2008) ‘Oestrogens for preventing recurrent urinary tract infection in postmenopausal women (Review)’ The Cochrane Library 2008, Issue 3.
13. Chung op. cit. p297
14. ibid.
15. Kidney Health Australia op. cit.
16. ibid.

For help understanding this fact sheet or further information on cystitis or interstitial cystitis call the Health Information Line on 3839 9988 (in Brisbane) or 1800 017 676 (toll free outside Brisbane).

This is one of a series of women's health information fact sheets available at www.womhealth.org.au

This factsheet was revised by Lorraine Pacey and the Women's Health Queensland Wide (Women's Health) Editorial Committee in 2011.

Last Modified: March 2011