Recurrent Cystitis in Women

What is cystitis?

Cystitis means inflammation of the bladder. It is usually caused by a urine infection. Typical symptoms are pain when you pass urine, and passing urine frequently. You may also have pain in your lower abdomen, blood in your urine and fever (high temperature). Your urine may also become cloudy or smell offensive.

About half of all women have at least one bout of cystitis. For many, only one or two bouts occur in their lifetime. However, recurring bouts of cystitis occur in some women. This most commonly occurs in women in their late 20s and in women over 55.

This leaflet is for women who are prone to recurring cystitis.

Understanding the bladder and genital area

Most urine infections are caused by bacteria (germs) that come from your own bowel. They cause no harm in your bowel but can cause infection if they get into other parts of your body. Some bacteria thrive in urine and multiply quickly to cause infection.

Some bacteria lie around your anus (back passage) after you pass a stool (faeces). These bacteria can sometimes travel to your urethra and into your bladder. Some bacteria thrive in urine and multiply quickly to cause cystitis.

Women are more prone to cystitis than men as their urethra (the tube from the bladder that passes out urine) is shorter and opens nearer the anus.

Why do some women have recurring cystitis?

Your body has defences to prevent bacteria from causing cystitis. The mucus around your vagina and opening of your urethra is slightly acid which prevents bacteria from multiplying. Although bacteria may thrive in urine, you empty your bladder regularly which flushes urine out. Also, the cells that line your urethra and bladder have some resistance against bacteria.

In most cases, there is no apparent reason why cystitis recurs. There is usually no problem with your bladder or defence (immune) system that can be identified. It is possible there may be a slight alteration in the ability of the body to resist bacteria getting into the bladder and causing infection. A slight variation in the body's defence may 'tip the balance' in favour of bacteria to cause infection. (In a similar way, some people seem more prone to colds, sore throats, etc.)

For some women, one of the following may contribute:

• Bladder or kidney problems may lead to infections being more likely. For example, kidney stones, or conditions that cause urine to 'pool' and not drain properly. Your doctor may arrange some tests if a problem is suspected.
• Having sex increases the chance of cystitis in some women (see below).
• Hormones. Your vagina, bladder and urethra respond to the hormone oestrogen. When the levels of oestrogen in the body reduce, the tissues of these organs become thinner, weaker, and dry. These changes can increase the risk of recurrent cystitis if you have gone through the change (menopause). Cystitis is also more common during pregnancy because of changes in the urinary tract.

What can I do to help prevent cystitis?

If you only have the occasional bout of cystitis, you do not need to do anything or change your lifestyle. If you have recurring cystitis, one or more of the following may help:

• Hygiene. There is no evidence that poor hygiene can lead to cystitis. In fact, some women wash their anus and vagina too much, which may do more harm than good. Too much scrubbing and cleaning may slightly damage your genital skin. Bacteria thrive better on damaged skin. Cleaning or 'douching' your vagina may alter the normal balance of protective mucus which may allow bacteria to thrive. A common sense approach is to wash your anus and the nearby skin gently once a day with soap and water. Do not scrub and do not 'douche' your vagina.
• Wiping your anus from front to back after you pass a stool (faeces) is commonly advised. The logic is that bacteria from your anus will be pushed back away from your urethra, and not towards it.
• Drink lots each day to flush out your bladder frequently. This may possibly help to prevent cystitis. (There is no proof, but it seems sensible.) It is also commonly advised to drink lots to treat cystitis if symptoms start. However, the advice to drink lots after symptoms start is controversial. This may do little to clear bacteria from an inflamed bladder, and drinking lots may just cause more (painful) toilet trips.
• Underwear. Wear cotton underwear and change daily. Do not wear tight-fitting trousers or tights. This avoids warm, moist, airless conditions around your genitals which some types of bacteria like. Again, there is no proof that this advice helps, but it seems sensible.

What are the treatment options for recurring cystitis?

Prompt self-treatment of each bout of cystitis

Antibiotics are usually needed for the treatment of bouts of recurrent cystitis. If your symptoms are mild then it is usually advisable to wait for the results of your urine test to see which antibiotics you should be treated with. However, if your symptoms are bad or worsening then you should start antibiotics without any delay.

Some women are prescribed a supply of antibiotics to keep on 'standby'. You can then treat a bout of cystitis as soon as symptoms begin without having to wait to see a doctor. A three-day course of antibiotics is the usual treatment for each bout of cystitis.

Ideally, you should do a midstream specimen of urine (MSU) to send to the laboratory before starting a course of antibiotics. You should see a doctor if your symptoms do not go within a few days, or if they worsen.

Antibiotic prevention is another option

This means taking a low dose of an antibiotic regularly. One dose each night will usually reduce the number of bouts of cystitis. A six-month course of antibiotics is usually given.

You may still have bouts of cystitis if you take antibiotics regularly (but they should be much less often). If a bout does occur, it is usually caused by a bacterium that is resistant to the antibiotic you are taking regularly. A urine sample is needed to check on which bacterium is causing any bout of cystitis. You may then need a temporary change to a different antibiotic.

Cystitis related to having sex

Some women find that they are prone to cystitis within a day or so after having sex. This may be partly due to the movements during sex which may push bacteria up into your bladder. There may also be slight damage to your urethra that encourages bacteria to thrive. This is more likely if your vagina is dry during sex. The normal mucus in and around your vagina may also be upset if you use spermicides or diaphragm contraceptives. The following may reduce the chance of cystitis developing after sex:

• After having sex, go to the toilet to empty your bladder.
• If your vagina is dry, use a lubricating jelly during sex.
• One option is to take a single dose of antibiotic within two hours after having sex.
• Do not use spermicides and/or diaphragm for contraception. See your doctor or practice nurse for advice on other forms of contraception.

Cranberry juice

There is now good evidence that cranberry products can, on average, reduce the number of bouts of cystitis. Cranberry is not an antibiotic and does not kill bacteria. A chemical in the cranberry product is thought to work by preventing certain bacteria from attaching to cells that line the bladder. Therefore, this helps to prevent bacteria from infecting the bladder and so helps to prevent (rather than cure) cystitis.

Some points about cranberry products include:

• You can buy cranberry extracts (capsules, drinks, etc) from supermarkets, pharmacies and health stores. They are not available on the NHS.
• The optimum dose is not yet clear. It is thought that a daily dose of a high-strength capsule (containing at least 200 mg of cranberry extract) is best as this is likely to be more effective than drinking cranberry juice.
• Cranberry can react with certain medicines. In particular, it is unsafe to take with warfarin.

References

• Urinary tract infection (lower) - women, Clinical Knowledge Summaries (October 2009)
• Guay DR; Cranberry and urinary tract infections. Drugs. 2009;69(7):775-807. doi: 10.2165/00003495-200969070-00002. [abstract]
• Jepson RG, Craig JC; Cranberries for preventing urinary tract infections. Cochrane Database Syst Rev. 2008 Jan 23;(1):CD001321. [abstract]
• McMurdo ME, Argo I, Phillips G, et al; Cranberry or trimethoprim for the prevention of recurrent urinary tract J Antimicrob Chemother. 2009 Feb;63(2):389-95. Epub 2008 Nov 28. [abstract]
• Harris N, Teo R, Mayne C, Tincello D. Recurrent urinary tract infection in gynaecological practice. The Obstetrician & Gynaecologist 2008;10:17-21.