What is cystitis?

Causes and Symptoms

The term “cystitis” is a combination of two Greek words: kistis, meaning hollow pouch, sac, or bladder, and itis, meaning inflammation. Cystitis is often used generically to refer to any nonspecific inflammation of the lower urinary tract. Specifically, however, it should be used to refer to inflammation and infection of the bladder. Three true symptoms denote cystitis: dysuria, frequent urination, and hematuria.

The symptoms of cystitis may appear abruptly and, often, painfully. One of the trademark symptoms signaling an onset is
dysuria (burning or stinging during urination). It may precede or coincide with an overwhelming urge to urinate, although the amount passed may be extremely small. In addition, some sufferers may experience
nocturia (sleep disturbance because of a need to urinate). In many cases there may be pus in the urine. Origination of
hematuria (blood in the urine), which often occurs with cystitis, may be within the bladder wall, in the urethra, or even in the upper urinary tract. These painful symptoms should be enough to spur one to seek medical attention; if left untreated, the bacteria may progress up the ureters to the kidneys, where a much more serious infection, pyelonephritis, may develop. Pyelonephritis can cause scarring of the kidney tissue and even life-threatening kidney failure. Usually kidney infections are accompanied by chills, high fever, nausea or vomiting, and back pain that may radiate downward.

Acute cystitis can be divided into two groups. One is when infection occurs with irregularity and with no recent history of antibiotic treatments. This type is commonly caused by the bacteria Escherichia coli. Types of bacteria other than E. coli
that can cause cystitis are Proteus, Klebsiella, Pseudomonas, Streptococcus, Enterobacter, and, rarely, Staphylococcus. The second group of sufferers have undergone antibiotic treatment; those bacteria not affected by the antibiotics can cause infection. Most urinary tract infections are precipitated by the patient’s own rectal flora. Once bacteria enter the bladder, whether they will cause infection depends on how many bacteria are present, how well the bacteria can adhere to the bladder wall, and how strongly the bladder can defend itself. The bladder’s inherent defense system is the most important of the factors.

One of the natural defense mechanisms employed by the bladder is the flushing provided by regular urination at frequent intervals. If fluid intake is sufficient—most urologists consider this amount to be sixty-four ounces daily—there will be regular and efficient emptying of the bladder, which can wash away the bacteria that have entered. This large volume of fluid also helps dilute the urine, thereby decreasing bacterial concentration. Another defense mechanism is the low pH of the bladder, which also helps control bacterial multiplication. It may be, too, that the bladder lining employs some means to repel bacteria and to inhibit their adherence to the wall. Some researchers theorize that genetic, hormonal, and immune factors may help determine the defensive capability of the bladder.

Cystitis occurs most frequently in women, in large part because of the length and positioning of the urethra. Many women experience their first episode of cystitis as they become sexually active. So-called honeymoon cystitis, that related to sexual activity, comes about when intercourse (penetrative or nonpenetrative) forces bacteria upward through the urethra. From the urethra, the bacteria travel to the bladder. Unless they are voided through urination upon conclusion of intercourse, they may multiply, causing inflammation and infection. Bathing after intercourse is too late to prevent the E. coli
from being pushed into the urethral opening. Some instances of cystitis may be reduced if there is adequate vaginal lubrication prior to intercourse and vaginal sprays and douches are avoided.

Women who use a
diaphragm as birth control are more likely to develop urinary tract infections than other sexually active women. The reason for this increased likelihood may be linked to the more alkaline vaginal environment in diaphragm users, or perhaps to the spring in the rim of the diaphragm that exerts pressure on the tissue around the urethra. Urine flow may be restricted, and the stagnant urine is a good harbor for bacterial growth.

When urine remains in the bladder for an extended period of time, its stagnation may allow for the rapid growth of bacteria, thereby leading to cystitis. Urine flow may be restricted by an enlarged prostate or pregnancy. Diabetes mellitus may also lead to cystitis, as the body’s resistance to infection is lowered. Infrequent urination for whatever reason is associated with a greater likelihood of cystitis.

Less frequently, cases have been linked to vaginitis as a result of Monilia or Trichomonas. Yeasts such as these change the pH of the vaginal fluid, which will allow and even encourage bacterial growth in the perineal region. Sometimes, it is an endless cycle: A patient takes antibiotics for cystitis, which kills her protective bacteria and allows the overgrowth of yeasts. The yeasts cause vaginitis, which may promote another case of cystitis, and the cycle continues. In fact, recurrent cystitis may be a result of an inappropriate course of antibiotic treatment; the antibiotic is not specific to the bacteria. More rarely, recurrent cases may be a result of constant seeding by the kidneys or a bowel fistula. The most common cause of recurrent cystitis, however, is new organisms from the rectal area that invade the perineal area. This new pool may be inadvertently changed by antibiotic treatment.

A less common but often more severe kind of cystitis is interstitial cystitis, an inflammation of the bladder caused by nonbacterial causes, such as an autoimmune or allergic response. With this type of cystitis, there may be inflammation or ulceration of the bladder, which may result in scarring. These problems usually cause frequent and painful urination and possible hematuria. What separates interstitial cystitis from acute cystitis is that it primarily strikes women in their early to mid-forties and that, while urine output is normal, soon after urination, the urge to void again is overwhelming. Delaying urination may cause a pink tinge to appear in the urine. This minimal bleeding is most often a result of an overly small bladder being stretched so that minute tears in the bladder wall bleed into the urine. This form is often hard to diagnose, as the symptoms may be mild or severe and may appear and disappear or be constant.

Treatment and Therapy

Medical students are typically underprepared to deal with the numerous cases of cystitis. The student is told to test urine for the presence of bacteria, prescribe a ten-day course of antibiotics, sometimes take a kidney x-ray or perform a cytoscopy, and then perhaps prescribe more antibiotics. If the patient continues to complain, perhaps a painful dilation of the urethra or cauterizing (burning away) of the inflamed skin is performed. None of these procedures guarantees a cure.

Diagnosis of cystitis should be relatively easy; however, in a number of cases it is misdiagnosed because the doctor has failed to identify the type of bacteria, the patient’s history of past cases, and possible links between cystitis and life factors (sexual activity, contraceptive method, and diet, for example). A more appropriate antibiotic given at this point might lower the risks of frequent recurrences. Diagnosis of urinary tract infection takes into account the medical history, a physical examination of the patient, and performance of special tests. The history begins with the immediate complaints of the patient and is completed with a look back at the same type of infections that the patient has had from childhood to the present. The physician should conduct urinalysis but be cognizant that if the urine is not examined at the right time, the bacteria may not have survived and thus a false-negative reading may occur.

One special test, a cytoscopy, is used to diagnose some of the special characteristics of cystitis. These include redness of the bladder cells, enlarged capillaries with numerous small hemorrhages, and in cases of severe cystitis, swelling of bladder tissues. Swelling may be so pronounced that it partially blocks the urethral opening, making incomplete emptying of the bladder likely to occur. Pus pockets may be visible.

In the case of women who first experience cystitis when they become sexually active, doctors usually instruct the patients to be alert to several details. They should wash or shower before intercourse and be warned that certain contraceptive methods and positions during intercourse may increase their chances of becoming infected. To decrease the chance of introducing the contamination of bowel flora to the urethra, wiping from front to back after urination and defecation is advised.

Children are not immune to attacks of cystitis; in fact, education at an early age may aid children in lowering their chances of developing cystitis. Some of the following may be culprits in causing cystitis and maintaining a hospitable environment for bacteria to grow: soap or detergent that is too strong, too much fruit juice, overuse of creams and ointments, any noncotton underwear, shampoo in the bath water, bubble bath, chlorine from swimming pools, and too little fluid intake. Once children reach the teenage years, many of the above remain causes. Added to them are failure to change underwear daily, irregular periods, use of tampons, and the use of toiletries and deodorants. Careful monitoring of these conditions can greatly reduce the risk of recurrent infections.

The symptoms of cystitis are often urgent and painful enough to alert a sufferer to visit a physician as quickly as possible. Such a visit not only makes the patient feel better but also decreases the chances that the bacteria will travel toward and even into the kidney, causing pyelonephritis. Antibiotic therapy is the typical mode of treating acute or bacterial cystitis. The antibiotics chosen should reach a high concentration in the urine, should not cause the proliferation of drug-resistant bacteria, and should not kill helpful bacteria. Some antibiotics used to treat first-time sufferers of cystitis with a high success rate (80 to 100 percent) are TMP-SMX, sulfisoxazole, amoxicillin, and ampicillin. Typically, a three-day course of therapy not only will see the patient through the few days of symptoms but also will not change bowel flora significantly. When E. coli
cause acute cystitis, there is a significant chance that one dose of an antibiotic such as penicillin will effectively end the bout, and again, the bowel flora will not be upset. Such antibiotics, when chosen carefully by the physician to match the bacteria, are useful in treating cystitis because they act very quickly to kill the bacteria. Sometimes, enough bacteria can be killed in one hour that the symptoms begin to abate immediately.

Yet antibiotics are not without their drawbacks: they may cause nausea, loss of appetite, dizziness, diarrhea, and fatigue and may increase the likelihood of yeast infections. The most common problem is the one posed by antibiotics that destroy all bacteria of the body. When the body’s normal bacteria are gone, yeasts may proliferate in the body’s warm, moist places. In one of the areas, the vagina, vaginitis causes a discharge that can seep into the urethra, causing the symptoms of cystitis to begin all over again.

For those suffering from recurrent cystitis, the treatment usually is a seven- to ten-day course of antibiotic treatment that will clear the urine of pus, indicating that the condition should be cured. If another bout recurs fairly soon, it is probably an indication that treatment was ended too quickly, as the infective bacteria were still present. To ensure that treatment has been effective, the urine must be checked and declared sterile.

Because cystitis is so common, and because many are frustrated by the inadequacies of treatment, self-treatment has become very popular. Self-treatment does not cure the infection but certainly makes the patient more comfortable while the doctor cultures a urine specimen, determines the type of bacteria causing the infection, and prescribes the appropriate antibiotic. Monitoring the first signs that a cystitis attack is imminent can save a victim from days of intense pain.

Those advocating home treatment do not all agree, however, on the means and methods that reduce suffering. All agree that once those first sensations are felt, the sufferer should start to drink water or water-based liquids; there is some disagreement on whether this intake should include fruit juice, especially cranberry juice. Some believe that the high acidic content of the juice may act to kill some of the bacteria, while others believe that the acid will only decrease the pH of the urine, causing a more intense burning sensation as the acidic urine passes through the inflamed urethra. An increased fluid intake produces more copious amounts of urine and, by diluting the urine, decreases its normal acidity. The excess urine acts to leach the bacteria from the bladder. More dilute urine will relieve much of the burning discomfort during voiding. If a small amount of sodium bicarbonate is added to the water, it will aid in alkalinizing the urine. The best self-treatment is to drink one cup of water every twenty minutes for three hours; after this period, the amount can be decreased. A teaspoonful of bicarbonate every hour for three or four hours is safe, unless the person suffers from blood pressure problems or a heart condition. Additionally, the patient may wish to take a painkiller such as acetaminophen. If lifestyle permits, resting will enhance the cure, especially if a heating pad is used to soothe the back or stomach. After the frequent visits to the toilet, cleaning the perineal area carefully can reduce continued contamination.

Diagnosis of interstitial cystitis can be made only using a cytoscope. Since the cause is not bacterial, antibiotics are not effective in treating this type of cystitis. To enhance the healing process of an inflamed or ulcerated bladder as a result of interstitial cystitis, the bladder may be distended and the ulcers cauterized; both procedures are done under anesthesia. Corticosteroids may be prescribed to help control the inflammation.

Perspective and Prospects

Infection in males is far less frequent than in females, although it does occur. Unfortunately, most urologists are better versed in male problems. Female specialists, gynecologists, treat the reproductive system but may not have studied female urinary dysfunction. If a man suffers from urinary dysfunction, he should seek the services of a urologist. A woman who has interstitial cystitis should also see a urologist, specifically one who knows about this form of cystitis. If a woman is experiencing recurrent cystitis, she is probably already seeing a gynecologist or an internist; however, if she is not getting relief, she should avail herself of a urologist, especially one specializing in female urology, if possible.

A strong social stigma is associated with bladder dysfunction, which may create an obstacle when treatment is necessary. From the time of infancy, some children are taught that anything to do with bladder or bowel function is shameful or dirty. Therefore, when dysfunction occurs, self-esteem may be decreased. As a result, the sufferer may fail to ask for help. Such a reaction must be overcome if there is to be significant progress in treating and conquering cystitis.

Bibliography

A.D.A.M. Medical Encyclopedia. "Cystitis—Acute." MedlinePlus, September 17, 2010.

A.D.A.M. Medical Encyclopedia. "Cystitis—Noninfectious." MedlinePlus, April 16 2012.

Chalker, Rebecca, and Kristene E. Whitmore. Overcoming Bladder Disorders. New York: HarperCollins, 1990.

Cohen, Barbara J. Memmler’s The Human Body in Health and Disease. 11th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2009.

Gillespie, Larrian, with Sandra Blakeslee. You Don’t Have to Live with Cystitis. Rev. ed. New York: Quill, 2002.

Parker, James N., and Philip M. Parker, eds. The Official Patient’s Sourcebook on Urinary Tract Infection. San Diego, Calif.: Icon Health, 2002.

Riley, Julie. "Acute Cystitis." HealthLibrary, April 12, 2013.

Schrier, Robert W., ed. Diseases of the Kidney and Urinary Tract. 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2007.