Cystitis – symptoms, causes and treatment

Cystitis is inflammation of the lining of the bladder and one of the most common reasons for seeing a urologist. It is almost always bacterial, starts suddenly and is recognised by burning when passing urine and frequent urges that produce only a little urine.

Women are affected far more often, because their urethra is short and lies close to the vagina and anus, where the bacteria come from. Roughly one woman in two has at least one episode in her lifetime. In men cystitis is rare, so an underlying cause is always looked for – an enlarged prostate, a stone or incomplete emptying of the bladder.

What cystitis is

The lining of the bladder has its own defence mechanisms, and regular, complete emptying washes out any microbes that get in. When bacteria stay and multiply, the lining becomes inflamed and the bladder responds with painful urges even when it holds only a little urine.

There are several forms:

• Acute uncomplicated cystitis – in healthy, non-pregnant women with no structural abnormalities of the urinary tract; the most common and mildest form.
• Complicated cystitis – in men, pregnant women, children, and patients with diabetes, stones, a catheter or impaired drainage of urine; it needs more thorough investigation.
• Recurrent cystitis – two or more episodes in six months or three or more in one year.
• Non-infectious cystitis – after radiotherapy, some medicines or chemicals, as well as bladder pain syndrome (interstitial cystitis), with long-term symptoms and sterile urine.

Symptoms

The signs of acute cystitis appear within hours:

• burning and pain when passing urine, especially at the end of the stream;
• frequent, urgent needs to pass urine, with only a little urine each time;
• heaviness or pain low in the abdomen, above the pubic bone;
• cloudy, unpleasant-smelling urine, sometimes with blood in it.

A temperature, shivering, nausea and pain in the lower back are not part of ordinary cystitis – they suggest that the infection has reached the kidney (pyelonephritis), which is described in the article on urinary tract infections. If you have these signs, cannot pass urine or have blood with clots, do not wait for an appointment – go to an emergency department or call 112 (the European emergency number).

Causes and risk factors

In most cases the cause is a gut bacterium, most often Escherichia coli (E. coli), which enters the urethra from the skin around the anus and travels up to the bladder. The risk is higher with:

• sexual activity, a new partner, use of spermicides;
• holding on to urine and not drinking enough fluids;
• the menopause – the fall in oestrogen changes the protective flora of the vagina;
• pregnancy, diabetes, a weakened immune system;
• incomplete emptying of the bladder – in men most often because of an enlarged prostate, in women because of pelvic organ prolapse;
• stones, a catheter, narrowing of the urethra, recent urological procedures.

Diagnosis

Your consultation with Dr Penev begins with a detailed conversation – how long you have had the symptoms, how many episodes you have had, whether you have a temperature, blood in the urine or a link with sex – followed by an examination of the abdomen and, in men, of the prostate.

The main test is a urine test of a midstream sample taken after washing, which in cystitis shows white blood cells, nitrites and often red blood cells. A urine culture with antibiotic sensitivity testing is essential in men, in recurrences, in pregnancy, in complicated cases and when the first treatment has failed – it shows which bacterium is responsible and which antibiotics it responds to.

Ultrasound of the kidneys and bladder is painless, is done during the consultation and shows whether the bladder empties completely and whether there are stones or thickening of the bladder wall. With blood in the urine, in smokers and with frequent recurrences, a cystoscopy – a look inside the bladder – may also be needed.

Treatment

Uncomplicated cystitis in women. Treatment is a short course of antibiotics – under current European guidelines usually one to five days, with a medicine that concentrates in the urine and spares the gut flora. Long “broad-spectrum” treatment for ordinary cystitis is unnecessary and increases bacterial resistance.

Cystitis in men. The course is longer, usually about a week, and is guided by the urine culture, because the prostate is often affected too. The cause must also be treated – prostatitis, an enlarged prostate or a stone – otherwise the infection comes back.

Recurrent cystitis. The first step is changing habits; in women after the menopause local (vaginal) oestrogen therapy helps, and non-antibiotic preventive products are safe, although the evidence for them is moderate. Antibiotic prevention – long-term or a single dose after sex – is prescribed only when other measures have not helped, and under medical supervision.

Do not start an antibiotic left over from a previous time, and do not stop treatment as soon as the burning goes.

When to see a urologist

• You are a man with symptoms of cystitis – in men this is never an “ordinary” infection.
• The episodes come back more than twice a year.
• The symptoms do not settle within two or three days despite treatment.
• There is blood in the urine, even once – read more in the article on blood in the urine.
• The urges continue but the urine is clear – this could be an overactive bladder or another non-infectious cause.
• You have diabetes, stones or a catheter, or you are pregnant.

Dr Penev sees patients with urinary infections at his practice in Plovdiv and at Vita Med Medical Centre, Karlovo, by appointment, and refers complicated cases to the Department of Urology at Kaspela University Hospital (UMBAL Kaspela), Plovdiv.

Prevention

Drink enough fluids to pass urine every three to four hours, and do not put off the urge to go. Pass urine soon after sex and avoid spermicides. Wipe from front to back, avoid harsh intimate hygiene products, treat constipation and keep your blood sugar under control if you have diabetes. You will find detailed advice in the article how to prevent urinary infections.

Cystitis is unpleasant, but it treats well when it is handled correctly from the first episode. Book an appointment with Dr Penev if your symptoms keep coming back or do not settle – an accurate diagnosis saves unnecessary antibiotics and protects your kidneys.