Andrew Siegel, MD 9/12/2015
Bladder infections (a.k.a., cystitis) are common among women. Acute cystitis is a bladder infection that typically causes the following symptoms: pain/burning, frequent urination, and urinary urgency (“gotta go”). Additional symptoms that may occur are the following: urinating small volumes, bleeding and urinary incontinence (leakage). Microscopic inspection of urine usually shows bacteria, white blood cells and red blood cells. 80-90% of cystitis is caused by Escherichia coli, 5-15% by Staphylococcus and the remainder by less common bacteria including Klebsiella, Proteus, and Enterococcus.
The occasional occurrence of cystitis is a nuisance and oftentimes uncomfortable, but is usually easily treated with a short course of oral antibiotics. When bladder infections recur time and again, it becomes a major source of inconvenience and suffering for the patient and it becomes important to fully investigate the source of the recurrence.
Bladder infections occur when bacteria gain access to the urinary bladder, which normally does not have bacteria present. The short female urethra and the proximity of the urethra to the vagina and anus are factors that predispose to cystitis.
For an infection to develop, the vagina and urethra usually have to be colonized with the type of bacteria that can cause an infection (not the normal healthy bacteria that reside in the vagina), these bacteria must ascend into the bladder, and these bacterial must latch onto bladder cells.
Offense and Defense
Whether or not an infection develops is based upon the interaction of protective mechanisms (“defense”) and bacterial factors (“offense”). “Defense” factors include the following:
- An acidic vagina, which inhibits the growth of infection-causing bacteria while promoting the growth of “good” bacteria such as lactobacilli
- The unique layer that protects the bladder lining
- Immune cells in the urine that prevent bacteria from sticking to the bladder cells
- The dilution action of urine production and the flushing effect of urinating
Bacterial “offense” factors include in following:
- Tentacle-like structures that promote the attachment of bacteria to bladder cells
- The capability of bacteria to evolve and develop resistance to antibiotics
Bladder Infections in Young Women
Women aged 18-24 years old have the greatest prevalence of bladder infections and sex is usually a key factor, hence the term “honeymoon cystitis.”
The following are risk factors for bladder infections:
- A new sexual partner
- Recent sexual intercourse
- Frequent sexual intercourse
- Spermicides, diaphragms and spermicide-coated condoms (which can increase vaginal and urethral colonization with E. Coli)
Bladder Infections in Older Women
Cystitis is common after menopause, based upon the following factors:
- Female hormone (estrogen) deficiency, which causes a change in the bacterial flora of the vagina such that E. Coli replaces Lactobacilli
- Age-related decline in immunity
- Incomplete bladder emptying
- Urinary and fecal leakage (incontinence), often managed with pads, which remain moist and contaminated and can promote movement of bacteria from the anal area towards the urethra
- Diabetes (particularly when poorly controlled, with high levels of glucose in the urine that can be thought of as “fertilizer” for bacteria)
- Neurological diseases that impair emptying or cause incontinence
- Pelvic organ prolapse
- Poor hygiene
A urinary infection is considered complicated if:
- It involves the upper urinary tracts (kidneys)
- You are pregnant
- Bacteria are resistant to antibiotics
- There is a structural abnormality of the urinary tract
- It occurs in immune-compromised patients including diabetics
- It occurs in the presence of a foreign body such as a urinary catheter or stone
If It’s Not an Infection, What Is It?
It is important to distinguish a symptomatic urinary infection from asymptomatic bacteriuria, urethritis, vaginitis, and Painful Bladder Syndrome (PBS)/Interstitial Cystitis (IC).
- Asymptomatic bacteriuria, common in elderly and diabetics, is the presence of bacteria within the bladder without causing an infection. This does not require treatment, which is futile and promotes selection of resistant bacteria. It should be treated only in pregnant women, in patients undergoing urological-gynecological surgical procedures, and in those undergoing prosthetic surgery (total knee replacement, etc.).
- Urethritis is an infection in the urethra
- Vaginitis is a vaginal infection
- PBS/IC is a chronic inflammatory condition of the bladder that can mimic the symptoms of cystitis.
Diagnosis and Treatment
The diagnosis of cystitis is by urinalysis and culture. A urine specimen is obtained after cleansing the vaginal area and collection of a mid-stream specimen. At times, catheterization is necessary to obtain a specimen. Dipstick is the fastest and least expensive means of screening for an infection, but it is not very accurate, whereas microscope exam is much more accurate. The definitive test is urine culture and sensitivity, which will demonstrate the type of bacteria, the quantitative count, and those antibiotics that are most likely to be effective.
Treatment is antibiotics to eradicate the bacteria. In the case of recurrent cystitis, it is important to do an evaluation to rule out a structural cause. This generally involves imaging, often an ultrasound (using sound waves to obtain an image of the urinary tract), and a cystoscopy (a visual inspection of the urethra and bladder with a flexible scope). This will check the entire urinary tract, including the kidneys and bladder. Findings may be a dropped bladder, a stone within the urinary tract, a urethral stricture (a narrowing in the channel leading out of the bladder that causes an obstruction), a urethral diverticulum (a pocket connected to the urethra), or a fistula (abnormal connection between the colon and bladder), etc.
Antibiotic Options For Those With Recurrent Urinary Infections
- Patient-initiated treatment: a short course of antibiotics when the symptoms first occur. It is useful to first test your urine using a dipstick (although not perfect, it is great for home screening) when the symptoms of cystitis arise. This has proven to be safe, economical and effective.
- Sexual prophylaxis: A single dose of antibiotic just before or after sexual activity if the infections are clearly sexually related
- Daily antibiotic prophylaxis: A single dose of antibiotic is taken on a prophylactic basis every evening or every other evening to prevent recurrent cystitis.
Pearls To Help Keep Cystitis At Bay
- Stay well hydrated to keep the urine dilute: “The solution to pollution is dilution.”
- Wipe in a top-to-bottom motion after urination or bowel movements. At minimum, urinate every four hours while awake to avoid an over-distended bladder.
- Maintain a healthy weight.
- Urinate after sex.
- If infections are clearly sexual related, an antibiotic taken before or right after sex can usually preempt the cystitis.
- If you are diabetic, maintain the best glucose control possible.
- Seek urological consultation for recurrent infections to check for an underlying and correctable structural cause.
- Methenamine: This chemical is broken down into formaldehyde, which can kill bacteria.
- Cranberry extract: Cranberries contain proanthocyanidins that inhibit bacteria from adhering to the bladder cells. There are formulations of cranberry extract available to avoid the high carbohydrate load of cranberry juice.
- Probiotics such as Lactobacillus: These bacteria promote healthy colonization of the vagina, production of hydrogen peroxide that is toxic to bacteria, maintenance of acidic urine, induction of an anti-inflammatory response in bladder cells, and inhibition of attachment between bacteria and the bladder cells.
- D-Mannose: This sugar can inhibit bacteria from adhering to the bladder cells.
- Estrogen cream: Applied vaginally, this can help restore the normal vaginal flora as well as uro-genital tissue integrity and suppleness.
- Vaccination: Currently in research phases, the concept is an oral vaccine or vaginal suppository capable of providing immunity against the typical strains of bacteria that cause infections.
Wishing you the best of health,
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Author of Male Pelvic Fitness: Optimizing Sexual and Urinary Health: available in e-book (Amazon Kindle, Apple iBooks, Barnes & Noble Nook, Kobo) and paperback: www.MalePelvicFitness.com. In the works is The Kegel Fix: Recharging Female Pelvic, Sexual and Urinary Health.
Co-creator of Private Gym, a comprehensive, interactive, FDA-registered follow-along male pelvic floor muscle training program. Built upon the foundational work of Dr. Arnold Kegel, Private Gym empowers men to increase pelvic floor muscle strength, tone, power, and endurance: www.PrivateGym.com or Amazon.