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See also separate article on Urinary Tract Infections in Adults.
Lower urinary tract (LUT) symptoms in women are very common after sexual intercourse. Cystitis means inflammation of the bladder. It is usually due to bacterial infection but approximately a third of cases are non-infective. Bacteria are often pushed mechanically up the urethra and into the bladder during coitus. The male urethra, being substantially longer, is not susceptible to the same problem. The term 'honeymoon' was applied because, in the past, this was expected to be the time of first intercourse. Of course, the condition of postcoital female lower urinary tract infection (UTI) occurs at many times beyond the traditional 'honeymoon' - from the onset of sexual activity into old age.
Some agencies dispute the association : the Scottish Intercollegiate Guidelines Network (SIGN) guidelines reject as inconclusive any association between lifestyle factors including sexual activity and susceptibility to UTI in nonpregnant women and do not advise routine advice from healthcare professionals on these matters.
Lower urinary tract (LUT) infection in young women is very common and 'honeymoon cystitis' probably affects most women several times during their lives. There is considerable variation with regard to individual susceptibility. The incidence of UTIs in sexually active women is about 3% per annum and about 4% of all LUT infections in this group are thought to be related to sexual activity and 60% in recurrent cases. Peak age is between 23 to 27 years with a higher incidence in women from low to median social and economic groups.
- Frequency of sexual intercourse.
- Poor vaginal lubrication during coitus predisposes to UTI. This may be due to inadequate or inexpert foreplay or anxiety. Lack of male expertise may also be relevant.
- Use of a diaphragm and spermicide, either together or separately, increases the risk of UTI.
- Asymptomatic bacteriuria is a risk factor for cystitis in sexually active women.
- Postmenopausal vaginal atrophy might be considered to increase risk. Recent sexual intercourse is strongly associated with UTI in postmenopausal women. Recent sexual intercourse is strongly associated with incident UTI in generally healthy postmenopausal women.
The symptoms are typically those of UTI in the context of sexual activity in the preceding few days:
- Urinary frequency and burning dysuria are the cardinal features .
- Urine may be described as cloudy, bloody or smelly. Other possible features include pelvic discomfort or pain.
- Urgency and detrusor instability may even lead to some urinary incontinence.
- There is not usually systemic illness or malaise.
There is usually little or nothing of note. There may possibly be some suprapubic tenderness.
A recent RCT looking at different strategies (empirical immediate antibiotics, empirical delayed antibiotics, targeted antibiotics according to symptom score, antibiotics according to dipstick test results or antibiotics following midstream specimen of urine (MSU) result) for treating women with uncomplicated UTI in primary care. All management strategies achieved similar control of symptoms. There was no apparent advantage to sending urine for testing prior to treatment.
Urinalysis test strips for blood, protein and nitrites may be used. Treating according to dipstick (nitrite or leucocytes and blood) is one strategy to target treatment and reduce unnecessary antibiotic prescribing.
Midstream specimen of urine (MSU)
These tests are not routinely advised for women with uncomplicated cystitis due to the time delay and cost. Send where:
- Risk factors for a complicated UTI, eg recent urological instrumentation, hospital admission, immunocompromise.
- Confirmation of the diagnosis or exclusion of other conditions is required.
- There is failure of response to antibiotic treatment.
- There is previously uninvestigated, recurrent cystitis.
The most common organisms isolated are faecal, of which Escherichia coli is the most frequent.
Not all cystitis in young women results from sexual intercourse. Alternative causes include:
- Interstitial cystitis, which has the symptoms of dysuria, frequency and dyspareunia but the urine is sterile.
- Vaginitis due to causes like candidiasis, which can cause dysuria from urinating through an inflamed area and dyspareunia, but there is usually not frequency.
- Chlamydia, which can affect the urethra and cause dysuria - send a first void urine specimen and vaginal/cervical swabs as appropriate.
- High temperature, systemic illness and vomiting, which can suggest pyelonephritis, a much more serious illness requiring significantly different management.
Communication is important:
- Be positive, explain that cystitis is generally self-limiting.
- Advise the likely duration of symptoms without antibiotics as between 4 and 9 days and that, with antibiotics, this is reduced by a day to between 3 to 8 days.
Many women prefer not to take antibiotics but may not feel validated by a delayed antibiotic strategy, unless the strategy is fully explained and their concerns are addressed.
Prolonged and more severe symptoms are associated with:
- Antibiotic resistance
- Not prescribing antibiotics
- Previous history of cystitis
- High levels of somatisation
A single, isolated event of honeymoon cystitis can be treated as any other isolated UTI in an adult woman but if it is recurrent then prevention needs to be addressed. Current guidance recommends:
- Suggesting symptomatic relief with paracetamol or ibuprofen, but not urine alkalinising agents or cranberry products.
- Acute cystitis usually responds to a short course of antibiotics. A typical regime is trimethoprim 200 mg twice daily for 3 days. Alternatives should be used in pregnant women. Consult local protocols. Even women with dipstick negative urine (which accurately predicts the absence of an infection according to microbiological definitions) improve symptomatically with a three-day course of trimethoprim.
- Concern about the widespread and often inappropriate use of antibiotics (1 in 10 women are thought to receive them annually for cystitis) and increasing resistance have driven attempts to try to prescribe more rationally.
- For mild cystitis symptoms:
- Dipstick urine to guide treatment.
- Discuss not using an antibiotic where the the urine dipstick test is negative.
- If the patient is concerned about not taking an antibiotic, offer a delayed antibiotic prescription to use if the symptoms become worse, or last more than 48 hours.
- Have a lower threshold for the use of antibiotic if there are risk factors for persistent or recurrent infection.
- For moderate-to-severe cystitis symptoms:
- Treat empirically with an antibiotic. Do not dipstick test the urine as results will not alter the decision to treat.
- Where a woman prefers not to take an antibiotic, offer a delayed antibiotic prescription to be used if symptoms worsen or last more than 48 hours.
- For mild cystitis symptoms:
- Always 'safety net' and advise women to seek help if they develop a high fever or become systematically unwell, or if symptoms persist for longer than advised.
- Follow-up is not routine for uncomplicated cystitis but, if haematuria has been found, urine should be retested after treatment/resolution of symptoms, to check that the haematuria has also cleared.
For recurrent episodes of cystitis:
- Review the diagnosis and woman's history, particularly for risk factors for recurrent cystitis such as renal stones, papillary necrosis and vesicoureteric reflux.
- Send MSU to confirm an infection.
- Refer urgently if urological cancer is suspected.
- Provide advice on lifestyle measures:
- Bladder voiding shortly after intercourse - this will help flush out any bacteria that have been introduced into the urethra or bladder.
- Consider alternative contraceptive techniques if a diaphragm or spermicide are being used.
- Trauma at sexual intercourse may be contributory and a lubricant may be of value, especially for the postmenopausal.
- High-strength (≥200 mg) cranberry capsules as a preventative measure.
- If there are frequent UTIs related to sexual activity, further preventative options include:
- Patient-initiated ('stand-by') antibiotics for new episodes.
- Single-dose antibiotic prophylaxis taken before or shortly after sex (trimethoprim 100 mg to be taken within 2 hours of intercourse, note unlicensed use).
- Refer or seek specialist advice if these measures are not successful.
- Surgical options are not usually considered in this condition. An approach used in the past is excision of any rough edge of the hymen. If the urethra opens into the vagina rather than slightly further forward the operation of urethroplasty can offer cure or provide significant relief.
Sex, cystitis and contraception in the young
The connection of sexual activity to cystitis can provide health promotion opportunities especially with young women, preventing future unwanted pregnancies or sexually transmitted infections:
- Contraception - check notes for current status. Discuss current or future needs and options.
- Similarly, sexual health education or sexually transmitted infection screening may be addressed.
- Teenagers - where a girl is legally underage, it is probably even more important that the possibility of sexual activity be addressed. Diplomatic skills may be required if the girl is accompanied by a parent. Nonjudgemental approaches are usually most successful, enabling the teenager to be aware of services and confidentiality policies within the practice. Occasionally, abuse may be disclosed or suspected.
Further reading & references
- Embarrassing problems - cystitis; useful, patient-friendly website
- Management of suspected bacterial urinary tract infection in adults, Scottish Intercollegiate Guidelines Network - SIGN (updated guidelines 2012)
- Stamatiou C, Bovis C, Panagopoulos P, et al; Sex-induced cystitis--patient burden and other epidemiological features. Clin Exp Obstet Gynecol. 2005;32(3):180-2.
- Foxman B, Frerichs RR; Epidemiology of urinary tract infection: I. Diaphragm use and sexual intercourse. Am J Public Health. 1985 Nov;75(11):1308-13.
- Hooton TM, Scholes D, Stapleton AE, et al; A prospective study of asymptomatic bacteriuria in sexually active young women. N Engl J Med. 2000 Oct 5;343(14):992-7.
- Moore EE, Hawes SE, Scholes D, et al; Sexual intercourse and risk of symptomatic urinary tract infection in J Gen Intern Med. 2008 May;23(5):595-9. Epub 2008 Feb 12.
- Little P, Moore MV, Turner S, et al; Effectiveness of five different approaches in management of urinary tract BMJ. 2010 Feb 5;340:c199. doi: 10.1136/bmj.c199.
- Urinary tract infection (lower) - women, Clinical Knowledge Summaries (October 2009)
- Leydon GM, Turner S, Smith H, et al; Women's views about management and cause of urinary tract infection: qualitative BMJ. 2010 Feb 5;340:c279. doi: 10.1136/bmj.c279.
- Little P, Merriman R, Turner S, et al; Presentation, pattern, and natural course of severe symptoms, and role of BMJ. 2010 Feb 5;340:b5633. doi: 10.1136/bmj.b5633.
- Richards D, Toop L, Chambers S, et al; Response to antibiotics of women with symptoms of urinary tract infection but negative dipstick urine test results: double blind randomised controlled trial. BMJ. 2005 Jul 16;331(7509):143. Epub 2005 Jun 22.
- Blackledge D; A simple operation for postcoital urethrotrigonitis in women. Aust N Z J Obstet Gynaecol. 1979 May;19(2):123-5.
- Smith PJ, Roberts JB, Ball AJ; "Honeymoon" cystitis: a simple surgical cure. Br J Urol. 1982 Dec;54(6):708-10.
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|Original Author: Dr Chloe Borton||Current Version: Dr Chloe Borton|
|Last Checked: 16/07/2010||Document ID: 2269 Version: 23||© EMIS|