Acute uncomplicated cystitis is a symptomatic infection of the bladder causing one or more of the following symptoms: burning, frequency, urgency, bleeding, urinating small volumes, incontinence, and pain (abdominal, pelvic, lower back). Laboratory studies usually show bacteria, white cells and red blood cells in the urine. Cystitis has predictable bacteriology with 80-90% caused by Escherichia coli, 5-15% by Staphylococcus saprophyticus and the remainder by less common pathogens including Klebsiella pneumoniae, Proteus, and Enterococcus. An occasional bout of cystitis is not an uncommon event in the female population; however, when bladder infections recur time and time again, it becomes a major source of inconvenience and debility for the sufferer, and it becomes important to investigate the source of the recurrence.

Studies indicate that women 18-24 years of age have the greatest incidence of cystitis and that the following are risk factors for recurrent cystitis: a new sexual partner, recent sexual intercourse, and the use of spermicides, a diaphragm or spermicide-coated condoms. It is important to distinguish cystitis from urethritis and vaginitis, which may cause similar symptoms. Cystitis also occurs with increased incidence in the post-menopausal population, based upon changes that occur on the basis of estrogen deficiency. As a result of estrogen deficiency, there is a change in the normal resident bacteria (flora) of the vagina in which E. Coli replaces lactobacilli. Topical estrogen cream has been shown to reverse vaginal colonization with E. Coli and help prevent cystitis. Additionally, abnormalities as a result of childbearing and menopausal changes such as pelvic relaxation are common among the post-menopausal population and contribute to the increased incidence of cystitis in this population. It is important to distinguish a symptomatic urinary infection from asymptomatic bacteruria. Asymptomatic bacteruria is the presence of bacteria within the bladder without causing an infection. Asymptomatic bacteruria does not require treatment, which is often futile, achieving nothing but selection of a resistant organism.

Management of recurrent cystitis is based upon:

• Antibiotic treatment for the current infection.
• Evaluation to rule out a structural cause for the recurrent cystitis. This generally involves urinary tract imaging, cystoscopy, and at times, urodynamic testing.
• Behavioral alterations to minimize recurrences.
• Management of subsequent recurrences including prophylaxis.

Recommendations:

• Hygiene: After urination or a bowel movement, it is important to wipe in a top to bottom direction in order to avoid bringing bacteria towards the urethra.
• Urinate after intercourse: This will help flush out any bacteria that may have been introduced by sexual activity.
• Hydration: Drinking adequate volumes of fluid will dilute the bacterial count in the urine and cause increased urinary frequency.
• Frequent Urinating: Urinate on a regular basis over the course of the day. It is not a good idea to not urinate for extended periods of time.
• Cranberry extract: Cranberries, lingonberries, and blueberries contain condensed tannins that help prevent bacterial adherence to bladder cells. There are formulations of cranberry extract available to avoid the high carbohydrate load of cranberry juice.
• Topical estrogen cream: Estrogen cream applied vaginally can help restore the normal vaginal flora and well as increase the tone of the vagina and urethra.

Management of subsequent recurrences:

• SELF-TREATMENT: You can self-administer a short course of antibiotics when the cystitis symptoms first occur. It is often useful to first test your urine using a dipstick that can be prescribed. This has proved to be safe, economical, and effective.
• SEXUAL PROPHYLAXIS: A single dose of antibiotic can be administered just before or after sexual activity if the infections are clearly sexually related.
• CONTINUOUS LOW DOSE ANTIBIOTIC TREATMENT: A single dose of antibiotic can be administered on a prophylactic basis every evening to prevent recurrent cystitis.

Andrew L. Siegel, M.D.
Revised 11/2009