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Cystitis, urocystitis

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Understanding Cystitis (Urocystitis - Bladder Inflammation)

Cystitis, also referred to as urocystitis, is an inflammation of the wall of the urinary bladder. It is one of the most common urological diseases, particularly affecting women. This higher prevalence in women is primarily attributed to anatomical differences: females have a shorter and wider urethra compared to males, whose urethra is longer and narrower. In men, infections often tend to linger in the urethra, causing urethritis, before potentially ascending to the bladder.

 

Definition and Prevalence

The bladder is a hollow, muscular organ that stores urine. When its lining becomes inflamed, it leads to the characteristic symptoms of cystitis. While it can affect individuals of any age and gender, it is significantly more common in adult women. It is estimated that almost every woman will experience at least one episode of cystitis in her lifetime.

 

Types of Cystitis: Infectious vs. Non-Infectious

Cystitis can be broadly classified based on its duration and underlying cause:

  • Duration:
    • Acute Cystitis: Sudden onset of symptoms, usually resolving within a few days to a week with or without treatment.
    • Chronic Cystitis: Persistent or recurrent inflammation of the bladder, often with milder but more prolonged symptoms, or characterized by frequent exacerbations.
  • Cause:
    • Infectious Cystitis: The most common type, caused by microbial infection, usually bacterial.
    • Non-Infectious Cystitis: Occurs when the bladder mucosa is irritated by non-microbial factors. Examples include:
      • Chemical Cystitis: Irritation from chemicals excreted in the urine, including certain drugs if used long-term in large doses (e.g., historical "phenacetin cystitis" or "urotropinic cystitis" from methenamine). Exposure to chemotherapy drugs like cyclophosphamide can also cause hemorrhagic cystitis.
      • Traumatic/Irritant Cystitis: Caused by physical or thermal injury, such as accidental introduction of concentrated chemical solutions or overly hot solutions (above 45°C) during bladder washing (irrigation), or damage to the mucous membrane by foreign bodies like urinary calculi (bladder stones) or indwelling catheters.
      • Interstitial Cystitis/Bladder Pain Syndrome (IC/BPS): A chronic condition of unknown etiology characterized by bladder pain, urinary urgency, and frequency, without evidence of infection.
      • Radiation Cystitis: Inflammation resulting from radiation therapy to the pelvic region.

 

Pathways of Infection and Common Pathogens in Infectious Cystitis

As a rule, an infection is at the heart of most cases of cystitis. The causative microorganisms can enter the bladder through several routes:

  • Ascending Infection (Most Common): Bacteria from the urethra or the external genital area ascend into the bladder. This is facilitated by the shorter urethra in females.
  • Descending Infection: Less commonly, infection can descend from the kidneys or ureters, for example, in cases of pyelonephritis or kidney tuberculosis.
  • Hematogenous or Lymphogenous Spread: Rarely, bacteria can reach the bladder via the bloodstream or lymphatic system from distant foci of infection in other organs or tissues.
  • Direct Extension: From adjacent inflamed organs (e.g., in pelvic inflammatory disease or diverticulitis with fistula formation).

The most common causative agent of infectious cystitis is Escherichia coli (E. coli), a bacterium normally found in the gastrointestinal tract. Other common pathogens include:

  • Proteus mirabilis
  • Klebsiella pneumoniae
  • Staphylococcus saprophyticus (especially in young, sexually active women)
  • Staphylococcus aureus
  • Various fungi (e.g., Candida species, especially in immunocompromised individuals or those on long-term antibiotics)
  • Trichomonas vaginalis (a protozoan parasite)
  • Viruses (e.g., adenovirus, can cause hemorrhagic cystitis, especially in children)

 

Predisposing Factors for Cystitis

The mucous lining of the bladder possesses robust natural defense mechanisms and is highly resistant to infection. Therefore, the mere presence of bacteria is usually not sufficient to cause cystitis. The development of the disease often requires the presence of one or more predisposing factors that compromise these defenses or facilitate bacterial entry and growth:

  • Female Anatomy: Shorter urethra allows easier bacterial access.
  • Sexual Activity: Can introduce bacteria into the urethra.
  • Use of Certain Contraceptives: Spermicides or diaphragms can alter vaginal flora and increase risk.
  • Menopause: Estrogen deficiency can lead to atrophic changes in the urethra and vagina, making infection more likely.
  • Urinary Tract Obstruction or Incomplete Bladder Emptying:
  • Catheterization: Indwelling urinary catheters or intermittent catheterization can introduce bacteria.
  • Pregnancy: Hormonal changes and pressure from the enlarging uterus can affect bladder emptying.
  • Diabetes Mellitus: Impaired immune function and glucosuria (sugar in urine) can promote bacterial growth.
  • Immunosuppression: Due to conditions like HIV/AIDS, or medications (e.g., chemotherapy, corticosteroids).
  • Hypothermia (Exposure to Cold): May impair local immune responses.
  • Overwork, Exhaustion, Poor General Health: Conditions after serious illness or surgery can lower resistance.
  • Poor Personal Hygiene.
  • Vesicoureteral Reflux (VUR): Abnormal backflow of urine from the bladder into the ureters.
Appropriate perineal hygiene, such as cleaning and wiping the genital area from front to back after urination or defecation, may help reduce the chances of introducing bacteria like E. coli from the rectal area into the urethra. Females are especially vulnerable to this mode of infection due to the close proximity of the urethra to the anus.

 

Acute and Chronic Cystitis: Symptoms and Course

Acute Cystitis

Acute cystitis typically develops suddenly, often a short time after exposure to a provoking factor such as hypothermia, sexual activity, or instrumentation. In acute cystitis, the inflammatory process usually affects only the superficial mucous membrane of the bladder.

The main signs and symptoms of acute cystitis include:

  • Dysuria: Painful urination, often described as burning, stinging, or discomfort during or immediately after voiding.
  • Urinary Frequency: The need to urinate more often than usual, even if only small amounts are passed.
  • Urinary Urgency: A sudden, strong, and compelling need to urinate that is difficult to defer.
  • Suprapubic pain or Discomfort: pain, pressure, or tenderness in the lower abdomen, just above the pubic bone.
  • Nocturia: Waking up during the night to urinate.
  • Hematuria: Blood in the urine, which can be visible (gross hematuria, urine appears pink, red, or cola-colored) or microscopic (detected only on urinalysis).
  • Cloudy or Strong-Smelling Urine.
  • Pyuria: The presence of pus (white blood cells) in the urine, confirmed by laboratory analysis.

The intensity of pain during urination in patients with acute cystitis can increase progressively, sometimes becoming almost constant. Patients, especially children, may experience urinary incontinence or be unable to hold urine due to severe urgency and pain. Sometimes, all these phenomena of acute cystitis may resolve spontaneously within 2-3 days without specific treatment, especially in mild cases. However, more often, acute cystitis, even with timely initiation of appropriate treatment, lasts for about 6-8 days. A longer or more complicated course may suggest the presence of a concomitant underlying disease (e.g., prostate adenoma, bladder stone) or a resistant pathogen.

 

Chronic Cystitis

Chronic cystitis typically occurs as a result of improperly treated or recurrent acute cystitis, or in the presence of persistent underlying predisposing factors. In chronic cystitis, the inflammatory process may involve deeper layers of the bladder wall, not just the mucosa.

The main manifestations of chronic cystitis are generally the same as those of acute cystitis (dysuria, frequency, urgency, suprapubic pain) but are often less severe in intensity, though more persistent. Chronic cystitis can follow one of two main patterns:

  • Continuous Process: Characterized by constant, more or less pronounced signs and symptoms of the disease.
  • Recurrent Course: Involves periods of acute exacerbation of symptoms, alternating with "light intervals" or periods of remission where symptoms are minimal or absent. Three or more episodes of cystitis in a year, or two or more in six months, often define recurrent cystitis.

Long-standing chronic inflammation can lead to changes in the bladder wall, such as fibrosis, decreased bladder capacity, or specific pathological changes like cystitis cystica or cystitis glandularis.

 

Diagnosis of Cystitis

The diagnosis of cystitis is primarily based on the patient's symptoms and confirmed by laboratory tests. A thorough medical history, including urinary symptoms, sexual history, contraceptive use, and previous UTIs, is essential.

  1. Clinical Examination by a Doctor: While a physical examination may reveal suprapubic tenderness, its findings are often non-specific for cystitis itself. The exam is important to rule out other conditions and assess for signs of complicated infection (e.g., fever, flank pain suggesting pyelonephritis).
  2. Urinalysis: This is a cornerstone of diagnosis. A midstream clean-catch urine sample is analyzed for:
    • Leukocyte Esterase: An enzyme released by white blood cells, indicating pyuria.
    • Nitrites: Many common UTI-causing bacteria convert nitrates (normally in urine) to nitrites. A positive nitrite test is highly suggestive of bacterial infection.
    • White Blood Cells (WBCs) / Pus Cells: Microscopic examination showing an increased number of WBCs (pyuria).
    • Red Blood Cells (RBCs): Hematuria may be present.
    • Bacteria (Bacteriuria): Presence of bacteria on microscopy.
  3. Urine Culture and Sensitivity: If infection is suspected, especially in recurrent cases, complicated cystitis, or if initial treatment fails, a urine culture is performed to identify the specific causative microorganism and determine its sensitivity to various antibiotics. This guides targeted antibiotic therapy.
  4. Cystoscopy: This procedure involves inserting a thin tube with a camera (cystoscope) into the bladder via the urethra to directly visualize the bladder lining.
    • Contraindication in Acute Cystitis: Cystoscopy is generally **contraindicated** during acute, uncomplicated cystitis because it can be very painful and may risk spreading the infection.
    • Indications in Chronic or Complicated Cases: It is performed in cases of chronic cystitis, recurrent UTIs, hematuria, suspected bladder tumors, stones, fistulas, interstitial cystitis, or to evaluate structural abnormalities. Biopsies can be taken during cystoscopy if needed. The condition of the bladder wall and the degree of its damage can be assessed.
  5. Imaging Studies (Generally Not Needed for Uncomplicated Acute Cystitis):
    • Ultrasound: Can assess bladder wall thickness, residual urine volume, and detect stones or gross abnormalities. Kidney ultrasound may be done if pyelonephritis is suspected.
    • CT Scan or MRI: May be used in complicated cases, suspected tumors, chronic cystitis to evaluate for structural abnormalities, or if other conditions are suspected.
  6. Other Urological Examinations: If necessary, to verify the diagnosis of cystitis or identify underlying causes, other methods such as urodynamic studies (to assess bladder function) or voiding cystourethrography (VCUG) may be employed, especially in recurrent or complex cases.

 

Treatment of Acute and Chronic Cystitis

 

Treatment of Acute Cystitis

For acute, uncomplicated cystitis, especially in women, treatment aims to eradicate the infection and alleviate symptoms:

  • Antibiotics: A short course of oral antibiotics is typically effective. Common first-line choices include nitrofurantoin, trimethoprim-sulfamethoxazole (TMP-SMX), or fosfomycin. Fluoroquinolones are generally reserved for more complicated infections due to potential side effects and resistance concerns. The choice and duration depend on local resistance patterns and patient factors.
  • Supportive Measures:
    • Bed Rest: Patients may benefit from rest, especially if feeling unwell.
    • Increased Fluid Intake (Abundant Drink): Drinking plenty of water helps to flush bacteria from the bladder and dilute urine, making urination less painful.
    • Dietary Modifications: Avoiding spicy and salty foods, as well as alcoholic beverages, is often recommended as these can irritate the bladder.
    • Herbal Remedies: Using a decoction of herbs like kidney tea (Orthosiphon stamineus) or bearberry (Uva-ursi), which are believed to have diuretic and mild antiseptic effects, can be beneficial for some. Cranberry products are also popularly used, though evidence for treatment is mixed (more support for prevention).
    • Pain Relief:
      • Warm baths or applying a heating pad to the lower abdomen can help reduce pain and discomfort.
      • Analgesics like acetaminophen or NSAIDs.
      • Urinary analgesics like phenazopyridine can provide rapid relief from dysuria but do not treat the infection and can turn urine orange/red.
      • Antispasmodic drugs (e.g., drotaverine, papaverine, hyoscyamine) can be used to relieve bladder muscle spasms and severe pain.

 

Treatment of Chronic Cystitis

Treatment of chronic cystitis is more complex and focuses primarily on:

  • Identifying and Restoring Normal Urine Flow: Addressing any underlying causes of urinary stasis or obstruction, such as treating benign prostatic hyperplasia (BPH), dilating urethral strictures, or removing bladder stones.
  • Eradicating Foci of Infection: Identifying and treating any persistent foci of infection elsewhere in the body (e.g., chronic tonsillitis, dental infections) that might be contributing to recurrent bladder infections.
  • Long-Term or Prophylactic Antibiotics: Antibacterial treatment for chronic cystitis is carried out only after urine culture, precise identification of the causative agent(s) of infection, and determination of their sensitivity to various antibiotics. This may involve longer courses of antibiotics or low-dose prophylactic antibiotics taken daily or post-coitally for recurrent infections.
  • Management of Non-Infectious Causes: If cystitis is non-infectious (e.g., interstitial cystitis, radiation cystitis), treatment is tailored to the specific cause and may include dietary changes, bladder instillations, oral medications (e.g., amitriptyline, pentosan polysulfate sodium for IC/BPS), or other specialized therapies.
  • Bladder Instillations: In some cases of chronic cystitis or IC/BPS, solutions containing medications like heparin, corticosteroids, or local anesthetics may be instilled directly into the bladder.
  • Lifestyle Modifications: Similar to acute cystitis, including adequate hydration and avoidance of bladder irritants.

 

Differential Diagnosis of Dysuria and Lower Abdominal Pain

Symptoms like painful urination (dysuria) and lower abdominal pain can be caused by various conditions other than cystitis. A careful differential diagnosis is important:

Condition Key Differentiating Features
Cystitis (Bladder Infection) Dysuria, frequency, urgency, suprapubic pain. Urinalysis shows pyuria, bacteriuria, +/- hematuria. Positive urine culture.
Urethritis Dysuria (often pain at the start of urination or throughout), urethral discharge. More common in men. Often caused by STIs (gonorrhea, chlamydia) or irritants.
Vaginitis/Vulvovaginitis (e.g., Yeast Infection, Bacterial Vaginosis, Trichomoniasis) Vaginal discharge, itching, irritation, external dysuria (pain as urine passes over inflamed labia). Urinalysis may be normal.
Prostatitis (in men) Dysuria, frequency, urgency, perineal/pelvic pain, painful ejaculation, fever (in acute prostatitis). Prostate tender on examination.
Pyelonephritis (Kidney Infection) Dysuria, frequency, urgency PLUS flank pain, fever, chills, nausea, vomiting, costovertebral angle tenderness. Urinalysis shows pyuria/bacteriuria. Systemically unwell.
Bladder Stones (Urinary Calculi) Intermittent dysuria, frequency, hematuria, suprapubic pain, pain radiating to groin/perineum, interruption of urinary stream. Diagnosed by imaging.
Interstitial Cystitis/Bladder Pain Syndrome (IC/BPS) Chronic pelvic pain, pressure, or discomfort related to the bladder, accompanied by urinary frequency/urgency. Urine cultures are negative. Diagnosis of exclusion.
Urethral Syndrome Symptoms of dysuria and frequency in women, but with sterile urine cultures.
Sexually Transmitted Infections (STIs) Can cause urethritis or cervicitis leading to dysuria. Consider in sexually active individuals.
Bladder Cancer (less common cause of these symptoms) Painless hematuria is more common, but dysuria, frequency can occur. Diagnosed by cystoscopy/biopsy.

 

Potential Complications of Cystitis

While uncomplicated acute cystitis usually resolves without issues, potential complications can arise, especially if untreated, recurrent, or in vulnerable individuals:

  • Recurrent Cystitis: Frequent episodes of bladder infection.
  • Pyelonephritis (Kidney Infection): Infection can ascend from the bladder to the kidneys, causing a more serious illness with fever, flank pain, nausea, and vomiting. This requires prompt and aggressive treatment.
  • Hematuria: While often microscopic, significant gross hematuria can sometimes occur.
  • Chronic Cystitis: Acute episodes may transition into a chronic inflammatory state.
  • Interstitial Cystitis/Bladder Pain Syndrome: Some theories suggest recurrent infections might trigger or exacerbate IC/BPS in susceptible individuals.
  • Complications in Pregnancy: Untreated UTIs during pregnancy can lead to pyelonephritis, preterm labor, and low birth weight infants.
  • Sepsis: Rarely, a severe UTI can lead to urosepsis, a life-threatening systemic infection.

 

Prevention Strategies for Cystitis

Several lifestyle measures can help prevent cystitis, particularly recurrent episodes in women:

  • Hydration: Drink plenty of fluids, especially water, to help flush bacteria from the urinary system.
  • Urinary Habits:
    • Urinate frequently and don't hold urine for long periods.
    • Empty the bladder completely when urinating.
    • Urinate shortly after sexual intercourse to help flush away bacteria that may have entered the urethra.
  • Proper Hygiene:
    • Wipe from front to back after urinating and after a bowel movement to prevent bacteria from the anal region from spreading to the vagina and urethra.
    • Cleanse the genital area gently with mild soap and water. Avoid harsh soaps or douches that can irritate the urethra and disrupt normal vaginal flora.
  • Choice of Clothing: Wear cotton underwear and loose-fitting clothes to keep the genital area dry and allow air circulation. Avoid tight pants or nylon underwear.
  • Avoid Bladder Irritants: Some people find that certain foods or drinks (e.g., caffeine, alcohol, spicy foods, acidic fruits/juices, artificial sweeteners) can irritate their bladder and worsen symptoms.
  • Contraception: Women using diaphragms or spermicides may consider alternative birth control methods if they experience recurrent UTIs.
  • Cranberry Products: Some evidence suggests that cranberry (juice or supplements) may help prevent recurrent UTIs in some women by preventing bacteria from adhering to the bladder wall, though its effectiveness for treatment is not established.
  • Probiotics: Certain probiotics (e.g., Lactobacillus strains) may help maintain a healthy vaginal flora and reduce UTI risk, but more research is needed.
  • Topical Estrogen (for postmenopausal women): Low-dose vaginal estrogen can help restore healthy vaginal tissue and reduce UTI recurrence in postmenopausal women with atrophic changes.

 

When to Consult a Urologist or Physician

It is advisable to see a doctor if you experience symptoms of cystitis. Consultation with a urologist (a specialist in urinary tract diseases) or primary care physician is particularly important if:

  • Symptoms are severe (e.g., intense pain, high fever, inability to urinate).
  • Symptoms do not improve within 2-3 days of starting antibiotic treatment (if prescribed).
  • Blood is visible in the urine.
  • Symptoms of a kidney infection develop (flank pain, fever, chills, nausea, vomiting).
  • Cystitis episodes are recurrent (e.g., 2 or more in 6 months, or 3 or more in a year).
  • You are pregnant and develop symptoms of cystitis.
  • You are male and develop symptoms of cystitis (as it is less common and may indicate an underlying issue).
  • You have underlying medical conditions (e.g., diabetes, kidney stones, immunosuppression).

A healthcare professional can provide an accurate diagnosis, prescribe appropriate treatment, and investigate any underlying factors contributing to cystitis, especially if it is chronic or recurrent.

References

  1. Gupta K, Hooton TM, Naber KG, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis. 2011 Mar 1;52(5):e103-20. doi: 10.1093/cid/ciq257.
  2. Bonkat G, Bartoletti R, Bruyère F, et al. EAU Guidelines on Urological Infections. European Association of Urology; 2023. Available from: https://uroweb.org/guidelines/urological-infections.
  3. Medina M, Castillo-Pino E. An introduction to the epidemiology and burden of urinary tract infections. Ther Adv Urol. 2019 May 2;11:1756287219832172. doi: 10.1177/1756287219832172.
  4. Anger J, Lee U, Ackerman AL, et al. Recurrent Uncomplicated Urinary Tract Infections in Women: AUA/CUA/SUFU Guideline. J Urol. 2019 Aug;202(2):282-289. doi: 10.1097/JU.0000000000000296.
  5. National Institute for Health and Care Excellence (NICE). Urinary tract infection (lower): antimicrobial prescribing. NICE guideline [NG109]. Published: 31 October 2018. Available from: https://www.nice.org.uk/guidance/ng109.