Cystitis

Definition

Cystitis is inflammation of the urinary bladder. Urethritis is an inflammation of the urethra, which is the tube that connects the bladder with the exterior of the body. Sometimes cystitis and urethritis are referred to collectively as a lower urinary tract infection (UTI). Infection of the upper urinary tract involves the spread of bacteria to the kidney and is called pyelonephritis.

Description

Cystitis in women

Cystitis is a common female problem. It is estimated that 50 percent of adult women experience at least one episode of dysuria (painful urination); half of these people have a bacterial UTI. Between 2 percent and 5 percent of women's visits to primary care physicians are for UTI symptoms. About 90 percent of UTIs in women are uncomplicated but recurrent.

Cystitis in men

UTIs are uncommon in younger and middle-aged men but may occur as complications of bacterial infections of the kidney or prostate gland.

Cystitis in children

In children, cystitis often is caused by congenital abnormalities (present at birth) of the urinary tract. Vesicoureteral reflux is a condition in which the child cannot completely empty the bladder. The condition allows urine to remain in or flow backward (reflux) into the partially empty bladder. In addition, cystitis can also be caused by wiping forward instead of backward after a bowel movement, especially in girls that are newly toilet trained.

Demographics

The frequency of bladder infections in humans varies significantly according to age and sex. The male/female ratio of UTIs in children younger than 12 months is four to one because of the high rate of birth defects in the urinary tract of male infants. Urinary tract infections are fairly common in young girls. In adult life, the male/female ratio of UTIs is one to 50. After age 50, however, the incidence among males increases due to prostate disorders.

Causes and symptoms

The causes of cystitis vary according to gender because of the differences in anatomical structure of the urinary tract.

Females

Most bladder infections in women are so-called ascending infections, which means they are caused by disease agents traveling upward through the urethra to the bladder. The relative shortness of the female urethra (1.2 to 2 inches [3-5 cm] in length for adults) facilitates bacteria gaining entry to the bladder and multiplying there. The most common bacteria associated with UTIs in women (including teens) are: Escherichia coli (approximately 80% of cases), Staphylococcus saprophyticus, Klebsiella, Enterobacter , and Proteus species. Risk factors for UTIs in women include:

• sexual intercourse (The risk of infection increases if the woman has multiple partners.)
• use of a diaphragm for contraception
• an abnormally short urethra
• diabetes or chronic dehydration
• the absence of a specific enzyme (fucosyltransferase) in vaginal secretions (The lack of this enzyme makes it easier for the vagina to harbor bacteria that cause UTIs.)
• inadequate personal hygiene (Bacteria from fecal matter or vaginal discharges can enter the female urethra because its opening is very close to the vagina and anus.)
• history of previous UTIs (About 80 percent of women with cystitis develop recurrences within two years.)

The early symptoms of cystitis in women are dysuria ( pain on urination); urgency (a sudden strong desire to urinate); and increased frequency of urination. About 50 percent of females experience fever , pain in the lower back or flanks, nausea and vomiting , or shaking chills. These symptoms indicate pyelonephritis (spread of the infection to the upper urinary tract).

Males

Most UTIs in adult males are complications of kidney or prostate infections. They usually are associated with a tumor or kidney stones that block the flow of urine and often are persistent infections caused by drug-resistant organisms. UTIs in men are most likely to be caused by E. coli or another gram-negative bacterium. Risk factors for UTIs in men include lack of circumcision and urinary catheterization. The longer the period of catheterization, the higher the risk of contracting a UTI.

The symptoms of cystitis and pyelonephritis in men are the same as in women.

Children

In children, cystitis causes pain and tenderness in the lower abdomen, frequent urination, blood in the urine, and fever. However, some foods, including citrus juices, caffeine , and carbonated beverages, can irritate the lower urinary tract and mimic the symptoms of an infection.

Hemorrhagic cystitis

Hemorrhagic cystitis, which is marked by large quantities of blood in the urine, is caused by an acute bacterial infection of the bladder. In some cases, hemorrhagic cystitis is a side effect of radiation therapy or treatment with cyclophosphamide. Hemorrhagic cystitis in children is associated with adenovirus type 11.

When to call the doctor

A doctor or other healthcare provider should be contacted whenever urination becomes painful or the voided urine is cloudy or bloody, or when a child complains of pain when voiding urine.

Diagnosis

When cystitis is suspected, the doctor first examines a person's abdomen and lower back, to evaluate unusual enlargements of the kidneys or swelling of the bladder. In small children, the doctor checks for fever, abdominal masses, and a swollen bladder.

The next step in diagnosis is collection of a urine sample. The procedure involves voiding into a cup, so small children may be catheterized to collect a sample. Laboratory testing of urine samples as of the early 2000s can be performed with dipsticks that indicate immune system responses to infection, as well as with microscopic analysis of samples. Normal human urine is sterile. The presence of bacteria or pus in the urine usually indicates infection. The presence of hematuria (blood in the urine) may indicate acute UTIs, kidney disease, kidney stones, inflammation of the prostate (in men), endometriosis (in women), or cancer of the urinary tract. In some cases, blood in the urine results from athletic training, particularly in runners.

Other tests

Women and children with recurrent UTIs can be given ultrasound exams of the kidneys and bladder together with a voiding cystourethrogram to test for structural abnormalities. (A cystourethrogram is an x-ray test in which an iodine dye is used to better view the urinary bladder and urethra.) In some cases, computed tomography scans (CT scans) can be used to evaluate people for possible cancers in the urinary tract.

Treatment

Medications

Uncomplicated cystitis is treated with antibiotics . These include penicillin, ampicillin, and amoxicillin; sulfisoxazole or sulfamethoxazole; trimethoprim; nitrofurantoin; cephalosporins; or fluoroquinolones. (Fluoroquinolones generally are not used in children under 18 years of age.) A 2003 study showed that fluoroquinolone was preferred over amoxicillin, however, for uncomplicated cystitis in young women. Treatment for women is short-term; most women respond within three days. Men and children do not respond as well to short-term treatment and require seven to 10 days of oral antibiotics for uncomplicated UTIs.

Persons of either gender may be given phenazopyridine or flavoxate to relieve painful urination.

Trimethoprim and nitrofurantoin are preferred for treating recurrent UTIs in women.

Individuals with pyelonephritis can be treated with oral antibiotics or intramuscular doses of cephalosporins. Medications are given for ten to 14 days and sometimes longer. If the person requires hospitalization because of high fever and dehydration caused by vomiting , antibiotics can be given intravenously.

Surgery

A minority of women with complicated UTIs may require surgical treatment to prevent recurrent infections. Surgery also is used to treat reflux problems (movement of the urine backward) or other structural abnormalities in children and anatomical abnormalities in adult males.

Alternative treatment

Alternative treatment for cystitis may emphasize eliminating all sugar from the diet and drinking lots of water. Drinking unsweetened cranberry juice not only adds fluid but also is thought to help prevent cystitis by making it more difficult for bacteria to cling to the bladder wall. A variety of herbal therapies also are recommended. Generally, the recommended herbs are antimicrobials, such as garlic ( Allium sativum ), goldenseal ( Hydrastis canadensis ), and bearberry ( Arctostaphylos uva-ursi ); and/or demulcents that soothe and coat the urinary tract, including corn silk and marsh mallow ( Althaea officinalis ).

Homeopathic medicine also can be effective in treating cystitis. Choosing the correct remedy based on the individual's symptoms is always key to the success of this type of treatment. Acupuncture and Chinese traditional herbal medicine can also be helpful in treating acute and chronic cases of cystitis.

Prognosis

The prognosis for recovery from uncomplicated cystitis is excellent.

Prevention

Females

Women and teens with two or more UTIs within a six-month period sometimes are given prophylactic treatment, usually nitrofurantoin or trimethoprim for three to six months. In some cases the woman is advised to take an antibiotic tablet following sexual intercourse.

Other preventive measures for women include drinking large amounts of fluid; voiding frequently, particularly after intercourse; and proper cleansing of the area around the urethra. Children with UTIs should be encouraged to drink plenty of fluids and wipe themselves properly after a bowel movement.

In 2003, clinical trials in humans tested a possible vaccine for recurrent urinary tract infections. The vaccine was administered via a vaginal suppository.

Nutritional concerns

Many experts recommend that people with a UTI should drink cranberry juice, which contains hippuric acid that tends to lower the pH (acidify) of urine. This change reduces the ability of bacteria to thrive, thus helping to cure a UTI.

Parental concerns

Parents should monitor the urine of their young children. Older children should be encouraged to discuss episodes of painful urination with their parents or other knowledgeable persons.

Resources

BOOKS

Davis, Ira D., and Ellis D. Avner. "Lower Urinary Tract Causes of Hematuria." In Nelson Textbook of Pediatrics , 17th ed. Edited by Richard E. Behrman et al. Philadelphia: Saunders, 2003, pp. 2256–7.

Potts, Jeanette M. Essential Urology: A Guide to Clinical Practice. Totowa, NJ: Humana Press, 2004.

Stamm, Walter. "Urinary tract infections and pyelonephritis." In Harrison's Principles of Internal Medicine , 15th ed. Edited by Eugene Braunwald et al. New York: McGraw-Hill, 2001, pp. 1620–6.

Urinary Tract Infections: A Medical Dictionary, Bibliography, and Annotated Research Guide to Internet References. San Diego, CA: ICON Health Publications, 2004.

PERIODICALS

Meria, P., et al. "Encrusted cystitis and pyelitis in children: an unusual condition with potentially severe consequences." Urology 64, no. 3 (2004): 569–73.

Tsakiri, A., et al. "Eosinophilic cystitis induced by penicillin." International Urology and Nephrology 36, no. 2 (2004): 159–61.

ORGANIZATIONS

American Foundation for Urologic Disease. 1128 North Charles St., Baltimore, MD 21201. Web site: http://www.afud.org/.

American Urological Association. 1120 North Charles St., Baltimore, MD 21201. Web site: http://www.auanet.org.

L. Fleming Fallon, Jr., MD, DrPH