Cystitis: Inflammation of the Bladder

Symptoms

Acute, uncomplicated bladder infections are among the most common infectious diseases in women. A bladder infection is considered uncomplicated or simple when the urinary tract is functionally and structurally normal and there are no diseases that promote infection, for example, diabetes mellitus or immunosuppression. Symptoms include:

  • Painful, frequent and difficult urination.
  • Strong urge to urinate
  • Pain above the pubic bone (lower abdominal pain).
  • No vaginal itching or discharge

Urine is often cloudy, discolored, foul-smelling and may contain blood. Bacteria and white blood cells are detectable in the urine. The general condition of patients is usually good, there is no fever and the upper urinary tract is rarely affected. The infection heals spontaneously within days to weeks without treatment. About 20% of women who once had a bladder infection will get one again within a few months.

Causes

The cause of acute cystitis is colonization of the otherwise sterile bladder with bacteria. By far the most commonly identified pathogens are the gram-negative uropathogenic . Other possible pathogens include , as well as occasionally , , streptococci and others. Infection usually occurs ascending through the urethra. To do so, the bacteria must attach to the urothelium with pili (Figure 1, click to enlarge). Figure © Lucille Solomon, 2012 http://www.lucille-solomon.com

Risk factors

Risk factors include sexual intercourse, delayed bladder emptying after intercourse, use of diaphragms and spermicides, anatomic features, underlying disease, immunosuppression, diabetes mellitus, urinary stones, catheters, aggressive intimate hygiene, pregnancy, estrogen deficiency, infrequent bladder emptying, history of bladder infections, female sex, and genetic predisposition.

Diagnosis

Diagnosis is made by medical treatment based on symptoms, patient history, with a strip test, or in certain cases with a urine culture. If acute cystitis is clinically suspected in an adult, nonpregnant, and otherwise healthy woman, short-term empiric therapy with antibiotics is given without laboratory testing. If there is a lack of response to empiric treatment, the pathogen can be determined by urine culture and its sensitivity to antibiotics tested. For self-diagnosis, strip tests that detect nitrite and leukocytes in urine are also available at the pharmacy. Nitrite is formed by bacteria from nitrate and leukocytes, the white blood cells, are indicators of acute infection. However, false negative and false positive results are possible (see instructions for use of the tests) and it must be noted that other diseases, even serious ones, cause similar symptoms. Always see a physician:

  • Children, adolescents, men, elderly people
  • Patients with poor general condition, for example, with fever and back pain.
  • Patients in whom the therapy has failed
  • Patients with underlying diseases or frequently recurring infections.
  • Immunocompromised patients
  • Female patients with renal disease (kidney and bladder stones) and previous pyelonephritis (these require prolonged antibiotic therapy)
  • Patients with bladder catheters

Differential diagnoses

Possible differential diagnoses include inflammation of the vagina (additionally with vaginal irritation, discharge), urethra, complicated cystitis, hyperactive bladder, and in men, benign prostatic enlargement and inflammation of the prostate. Fever, back pain, flank pain, nausea and vomiting indicate involvement of the upper urinary tract and kidneys (renal pelvic inflammation, ascending urinary tract infection). If such symptoms are present, medical evaluation is indicated.

Nonpharmacologic treatment

It is recommended to consume plenty of fluids (at least 2 liters daily) to increase water excretion and thus wash out the bacteria. This recommendation is plausible but does not seem to have sufficient scientific support.

Drug treatment

Antibiotics are used for drug treatment.Whereas treatment used to be given over 5-14 days, a short duration of therapy is now considered the standard. Cotrimoxazole and quinolones are given for 3 days and fosfomycin is given as a single dose. However, this does not apply to nitrofurantoin and the beta-lactam antibiotics. Patients undergoing short-term therapy must be made aware that the inflammatory response and symptoms may persist for some time after the bacteria have been cleared. One problem with antibiotic treatment is the increasing resistance to the agents. In addition to antibiotics, analgesics such as ibuprofen or acetaminophen can be used to control pain. For treatment of special patient groups (e.g., pregnant women, children, men, elderly), please refer to the literature. Cotrimoxazole:

  • Cotrimoxazole (Bactrim forte, generics) refers to the fixed combination of trimethoprim and sulfamethoxazole. Both agents inhibit folic acid synthesis, which is essential for bacterial growth. Administration of cotrimoxazole for 3 days is considered the standard treatment for acute uncomplicated cystitis unless there is > 20% resistance. Cotrimoxazole is taken 2 times daily after meals with plenty of fluid and for 3 days. The technical information also mentions the possibility of a single dose or treatment for 5 days.

Fosfomycin:

  • Fosfomycin (Monuril) is the only representative of the group of phosphonic acid derivatives. It inhibits intracellularly the first step of bacterial cell wall synthesis. It is commercially available as granules, which is taken fasting, 2-3 hours before or after meals as a 3 gram single dose in water.

Nitrofurantoin:

  • Nitrofurantoin (Furadantin retard, Uvamin retard) belongs to the nitrofurans and has been used since the 1950s. It is taken during or immediately after meals with sufficient liquid.

Quinolones:

  • Quinolones such as norfloxacin (Noroxin, generic), ciprofloxacin (Ciproxin, generic), or ofloxacin (Tarivid) inhibit bacterial DNA synthesis by inhibiting topoisomerases. They are usually taken 2 times daily fasting 1 hour before or 2 hours after food for 3 days. They are not the 1st choice drug to maintain their effectiveness in complicated infections (reserve drugs).

Beta-lactam antibiotics:

D-mannose:

  • The D-mannose is a sugar that is taken as a medical product mainly for the prevention and also for the treatment of cystitis. The effects are based on the inhibition of the interaction of bacterial pili with the urothelium.

Other options:

  • FimH antagonists are in development
  • Also used are alkalizing agents (e.g., sodium bicarbonate), which is used for short-term symptom relief because acidic urine is responsible for urinary symptoms.

Herbal medicines and alternative medicine

Among the best known herbal medicines for the treatment of cystitis are (Auwahl):

The drugs are used individually as tea or in the form of tea mixtures, so-called kidney and bladder teas. Extracts from such medicinal drugs are also sold in the form of kidney and bladder dragées and other preparations (eg tinctures). Popular for treatment and prevention are also cranberry and cranberry juice. The combination of capuchin cress powder and horseradish root powder (Angocin) is also well-known.

Prevention

Antibiotics (continuous, low-dose, or postcoital), urinary acidifying agents such as methionine, D-mannose (see above), vitamin C, and herbal medicines such as cranberry preparations are used to prevent frequently recurring cystitis with medication. In postmenopausal women, restoration of vaginal flora with estrogens seems to be very effective.For non-drug prevention, there are a number of behavioral recommendations that have limited scientific evidence:

  • Take sufficient liquid to itself
  • After each sexual intercourse quickly empty the bladder
  • Do without spermicide and diaphragm
  • No aggressive intimate hygiene
  • Avoiding hypothermia
  • Clean from front to back
  • Avoid vaginal tampons

In many countries, a vaccine based on is approved for the prophylaxis of recurrent urinary tract infections, taken orally once a day in the form of capsules for 3 months (Uro-Vaxom, Escherichia coli viva).