Honeymoon Cystitis

Lower urinary tract (LUT) symptoms in women are very common after sexual intercourse. Cystitis means inflammation of the bladder and it is usually, but not invariably due to infection. 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 post-coital female lower urinary tract infection occurs at many times beyond the traditional 'honeymoon' - from the onset of sexual activity into old age.

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.¹ Peak age is between 23 to 27 years with a higher incidence in women from low to median social and economic groups.¹

Risk factors

• Frequency of sexual intercourse.¹
• 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 diaphragm² and spermicide, either together or separately, increases the risk of UTI. Spermicide coated condoms are also a risk.³
• Asymptomatic bacteriuria is a risk factor for cystitis in sexually active women.⁴

Postmenopausal vaginal atrophy might be considered to increase risk - however one study did not find sexual activity predictive of UTI post menopause.⁵

History

The symptoms are typically those of urinary tract infection in the context of sexual activity in the last few days:

• Urinary frequency and burning dysuria are the cardinal features
• Urine may be described as cloudy, bloody or smelly. The bladder is so inflamed that it bleeds. 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.

Examination

There is usually little or nothing of note. There may possibly be some suprapubic tenderness.

The basic investigation is midstream urine for microscopy and culture. It is totally unnecessary to await the results before treatment. Urinalysis test strips for blood, protein and nitrites may be used. The commonest organisms isolated are faecal, of which E. coli is the most frequent.

Current evidence backs the empirical treatment of a young woman presenting with dysuria, frequency and cloudy, bloody or malodorous urine many people, reserving investigation for treatment failure or if complications arose.^6,7 Concerns remain about the potential for over-prescription of unwarranted antibiotics and rise in resistance.
In the past, GPs have tended to favour an individualized approach, treating on the basis of urine dipsticks and midstream urine (MSU) results. However, this approach is less successful than simply treating symptomatic women according to guidelines.⁸ 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.⁹ Recurrent urinary tract infection does require investigation as described.⁸

Not all cystitis in young women results from sexual intercourse. Alternative causes include:

• Interstitial cystitis has the symptoms of dysuria, frequency and dyspareunia but the urine is sterile.
• Vaginitis due to causes like candidiasis can cause dysuria from urinating through an inflamed area and dyspareunia but there is usually not frequency.
• High temperature, systemic illness and vomiting suggest pyelonephritis that is a much more serious illness requiring significantly different management.

• 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.
• Women who has never had cystitis before may require reassurance that she has not acquired a sexually transmitted disease.
• The acute infection usually responds to a short course of antibiotics. A typical regime is trimethoprim 200mg twice daily for 3 days. Note, alternatives should be used in pregnant women.
• Urine volume should be kept high with copious intake of fluids, despite the natural desire to reduce intake so as to make the painful act of micturition less frequent. High urine volume reduces pain and aids recovery.
• Women should be taught always to empty the bladder shortly after intercourse. This will help flush out any bacteria that have been introduced into the urethra or bladder. If a woman goes to sleep without doing this, bacteria have several hours in which to multiply.
• If a diaphragm or spermicide are used, it is worth discussing other techniques.
• Trauma of sexual intercourse may be responsible and a lubricant may be of value, especially for the postmenopausal.
• For those who suffer recurrent UTI a regular intake of cranberry juice has been shown to be beneficial but benefit has not been demonstrated in the acute case.^10,11
• If there are more than 3 events of UTI related to sexual activity per year, then further options include⁶:
  1. Patient-initiated ('stand-by') antibiotics for new episodes.
  2. Continuous low-dose antibiotic prophylaxis for three months.
  3. Single dose antibiotic prophylaxis taken before or shortly after sex.

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 STI screening may be addressed.
• Teenagers - where a girl is legally underage, it is probably even more important that the possibility of sexual activity is addressed. Diplomatic skills may be required if the girl is accompanied by a parent. Non-judgemental 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.