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Cystitis & Lower Urinary Tract Infections

Cystitis means an inflammation of the bladder. The bladder is the muscular bag which stores urine after it has been produced by the kidneys before it is released by the water passage (the urethra). With cystitis it is often the case that the bladder and the urethra are both inflamed. Cystitis most commonly affects women, but it can also affect men and children although this is quite rare. Cases of men or children suffering cystitis should always be referred to a doctor.

Urinary tract infections are a serious health problem affecting millions of people each year. Infections of the urinary tract are common—only respiratory infections occur more often. Each year, urinary tract infections (UTIs) account for about 9.6 million doctor visits. Women are especially prone to UTIs for reasons that are poorly understood. One woman in five develops a UTI during her lifetime.

If you have any of the following symptoms you may be suffering from cystitis. The severity of the symptoms vary from person to person

• a frequent urge to pass urine, but when you do so you pass only small amounts
• pain or burning/stinging feeling when you pass urine
• needing to get up several times during the night to pass small amounts of urine
• dark or clouding looking urine which may contain blood
• strong or even fishy smelling urine
• the urge to pass urine is so strong that you can't get to the lavatory in time
• a dull ache or pain in the lower back or abdomen
• generally feeling unwell, sick or feverish.

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At the first sign of an attack it is worth taking immediate action:

• Drink as much fluid as you can to flush out the system, dilute the urine and reduce any stinging. For the first four hours try to drink a pint of water every hour even if the attack starts in the middle of the night. Then drink half a pint every two hours for the next eight hours. Drink bland fluids such as water, weak tea or fruit squash (avoid orange juice and carbonated drinks).
• Making the urine less acid will reduce any discomfort—try a teaspoon of bicarbonate of soda dissolved in a glass of water or preparations containing citrate (your local chemist will be pleased to help you). But women with high blood pressure or heart trouble should not take either bicarbonate of soda or citrate without first consulting their doctor.
• Go to the lavatory as much as you need to, don't try to 'hold on'.
• Keep warm and place a well-covered hot water bottle over your tummy or between your thighs. A second one at your lower back may also help.
• Take one or two aspirin or paracetamol tablets for the pain.
• Avoid alcohol and sexual intercourse until you feel better.
• Rest as much as possible.

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Normal urine is sterile. It contains fluids, salts, and waste products, but it is free of bacteria, viruses, and fungi. An infection occurs when microorganisms, usually bacteria from the digestive tract, cling to the opening of the urethra and begin to multiply. Most infections arise from one type of bacteria, Escherichia coli (E. coli), which normally live in the colon. In most cases, bacteria first begin growing in the urethra. An infection limited to the urethra is called urethritis. From there bacteria often move on to the bladder, causing a bladder infection (cystitis). If the infection is not treated promptly, bacteria may then go up the ureters to infect the kidneys (pyelonephritis). Microorganisms called Chlamydia and Mycoplasma may also cause UTIs in both men and women, but these infections tend to remain limited to the urethra and reproductive system. Unlike E. coli, Chlamydia and Mycoplasma may be sexually transmitted, and infections require treatment of both partners. The urinary system is structured in a way that helps ward off infection. The ureters and bladder normally prevent urine from backing up toward the kidneys, and the flow of urine from the bladder helps wash bacteria out of the body. In men, the prostate gland produces secretions that slow bacterial growth. In both sexes, immune defenses also prevent infection. Despite these safeguards, though, infections still occur.

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Some people are more prone to getting a UTI than others. Any abnormality of the urinary tract that obstructs the flow of urine (a kidney stone, for example) sets the stage for an infection. An enlarged prostate gland also can slow the flow of urine, thus raising the risk of infection. A common source of infection is catheters, or tubes, placed in the bladder. A person who cannot void or who is unconscious or critically ill often needs a catheter that stays in place for a long time. Some people, especially the elderly or those with nervous system disorders who lose bladder control, may need a catheter for life. Bacteria on the catheter can infect the bladder, so hospital staff take special care to keep the catheter sterile and remove it as soon as possible. People with high blood sugar levels have a higher risk of a UTI because of changes in the immune system. Any disorder that suppresses the immune system raises the risk of a urinary infection. UTIs may occur in infants who are born with abnormalities of the urinary tract, which sometimes need to be corrected with surgery. UTIs are rarely seen in boys and young men. In women, though, the rate of UTIs gradually increases with age. Scientists are not sure why women have more urinary infections than men. One factor may be that a woman's urethra is short, allowing bacteria quick access to the bladder. Also, a woman's urethral opening is near sources of bacteria from the anus and vagina. For many women, sexual intercourse seems to trigger an infection, although the reasons for this linkage are unclear. According to several studies, women who use a diaphragm are more likely to develop a UTI than women who use other forms of birth control. Recently, researchers found that women whose partners use a condom with spermicidal foam also tend to have growth of E. coli bacteria in the vagina.

Many women suffer from frequent UTIs. Nearly 20 percent of women who have a UTI will have another, and 30 percent of those will have yet another. Of the last group, 80 percent will have recurrences. Usually, the latest infection stems from a strain or type of bacteria that is different from the infection before it, indicating a separate infection. (Even when several UTIs in a row are due to E. coli, slight differences in the bacteria indicate distinct infections.) Research funded by the National Institutes of Health (NIH) suggests that one factor behind recurrent UTIs may be the ability of bacteria to attach to cells lining the urinary tract. A recent NIH-funded study has also shown that women with recurrent UTIs tend to have certain blood types. Some scientists speculate that women with these blood types are more prone to UTIs because the cells lining the vagina and urethra may allow bacteria to attach more easily. Further research will show whether this association is sound and proves useful in identifying women at high risk for UTIs.

Pregnant women seem no more prone to UTIs than other women. However, when a UTI does occur, it is more likely to travel to the kidneys. According to some reports, about 2 to 4 percent of pregnant women develop a urinary infection. Scientists think that hormonal changes and shifts in the position of the urinary tract during pregnancy make it easier for bacteria to travel up the ureters to the kidneys. For this reason, many doctors recommend periodic testing of urine.

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Not everyone with a UTI has symptoms, but most people get at least some. These may include a frequent urge to urinate and a painful, burning feeling in the area of the bladder or urethra during urination. It is not unusual to feel bad all over—tired, shaky, washed out—and to feel pain even when not urinating. Often, women feel an uncomfortable pressure above the pubic bone, and some men experience a fullness in the rectum. It is common for a person with a urinary infection to complain that, despite the urge to urinate, only a small amount of urine is passed. The urine itself may look milky or cloudy, even reddish if blood is present. A fever may mean that the infection has reached the kidneys. Other symptoms of a kidney infection include pain in the back or side below the ribs, nausea, or vomiting. In children, symptoms of a urinary infection may be overlooked or attributed to another disorder. A UTI should be considered when a child or infant seems irritable, is not eating normally, has an unexplained fever that does not go away, has incontinence or loose bowels, or is not thriving. The child should be seen by a doctor if there are any questions about these symptoms, especially if there is a change in the child's urinary pattern.

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To find out whether you have a UTI, your doctor will test a sample of urine for pus and bacteria. You will be asked to give a "clean catch" urine sample by washing the genital area and collecting a "midstream" sample of urine in a sterile container. (This method of collecting urine helps prevent bacteria around the genital area from getting into the sample and confusing the test results.) Usually, the sample is sent to a laboratory, although some doctors' offices are equipped to do the testing. In the urinalysis test, the urine is examined for white and red blood cells and bacteria. Then the bacteria are grown in a culture and tested against different antibiotics to see which drug best destroys the bacteria. This last step is called a sensitivity test. Some microbes, like Chlamydia and Mycoplasma, can be detected only with special bacterial cultures. A doctor suspects one of these infections when a person has symptoms of a UTI and pus in the urine, but a standard culture fails to grow any bacteria. When an infection does not clear up with treatment and is traced to the same strain of bacteria, the doctor will order a test that makes images of the urinary tract. One of these tests is an intravenous pyelogram (IVP), which gives x-ray images of the bladder, kidneys, and ureters. An opaque dye visible on x-ray film is injected into a vein, and a series of x-rays is taken. The film shows an outline of the urinary tract, revealing even small changes in the structure of the tract. If you have recurrent infections, your doctor also may recommend an ultrasound exam, which gives pictures from the echo patterns of soundwaves bounced back from internal organs. Another useful test is cystoscopy. A cystoscope is an instrument made of a hollow tube with several lenses and a light source, which allows the doctor to see inside the bladder from the urethra.

UTIs are treated with antibacterial drugs. The choice of drug and length of treatment depend on the patient's history and the urine tests that identify the offending bacteria. The sensitivity test is especially useful in helping the doctor select the most effective drug. The drugs most often used to treat routine, uncomplicated UTIs are trimethoprim (Trimpex), trimethoprim/ sulfamethoxazole (Bactrim, Septra, Cotrim), amoxicillin (Amoxil, Trimox, Wymox), nitrofurantoin (Macrodantin, Furadantin), and ampicillin. A class of drugs called quinolones includes four drugs approved in recent years for treating UTI. These drugs include ofloxacin (Floxin), norfloxacin (Noroxin), ciprofloxacin (Cipro), and trovafloxin (Trovan). Often, a UTI can be cured with 1 or 2 days of treatment if the infection is not complicated by an obstruction or nervous system disorder. Still, many doctors ask their patients to take antibiotics for a week or two to ensure that the infection has been cured. Single-dose treatment is not recommended for some groups of patients, for example, those who have delayed treatment or have signs of a kidney infection, patients with high blood sugar levels or structural abnormalities, or men who have prostate infections. Longer treatment is also needed by patients with infections caused by Mycoplasma or Chlamydia, which are usually treated with tetracycline, trimethoprim/sulfamethoxazole (TMP/SMZ), or doxycycline. A followup urinalysis helps to confirm that the urinary tract is infection-free. It is important to take the full course of treatment because symptoms may disappear before the infection is fully cleared. Severely ill patients with kidney infections may be hospitalized until they can take fluids and needed drugs on their own. Kidney infections generally require several weeks of antibiotic treatment. Researchers at the University of Washington found that 2-week therapy with TMP/SMZ was as effective as 6 weeks of treatment with the same drug in women with kidney infections that did not involve an obstruction or nervous system disorder. In such cases, kidney infections rarely lead to kidney damage or kidney failure unless they go untreated. Various drugs are available to relieve the pain of a UTI. A heating pad may also help. Most doctors suggest that drinking plenty of water helps cleanse the urinary tract of bacteria. For the time being, it is best to avoid coffee, alcohol, and spicy foods. (And one of the best things a smoker can do for his or her bladder is to quit smoking. Smoking is the major known cause of bladder cancer.)

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Reprinted with Permission - Copyright © 2000 NIDDK.