Cystitis

Definition

Cystitis is defined as inflammation of the urinary bladder. Urethritis is an inflammation of the urethra, which is the passageway that connects the bladder with the exterior of the body. Sometimes cystitis and urethritis are referred to collectively as a lower urinary tract infection, or UTI. Infection of the upper urinary tract involves the spread of bacteria to the kidney and is called pyelonephritis.

Description

The frequency of bladder infections in humans varies significantly according to age and sex. The male/female ratio of UTIs in children younger than 12 months is 4:1 because of the high rate of birth defects in the urinary tract of male infants. In adult life, the male/female ratio of UTIs is 1:50. After age 50, however, the incidence among males increases due to prostate disorders.

Cystitis in women

Cystitis is a common female problem. It is estimated that 50% of adult women experience at least one episode of dysuria (painful urination); half of these patients have a bacterial UTI. Between 2-5% of women's visits to primary care doctors are for UTI symptoms. About 90% of UTIs in women are uncomplicated but recurrent.

Cystitis in men

UTIs are uncommon in younger and middle-aged men, but may occur as complications of bacterial infections of the kidney or prostate gland.

Cystitis in children

In children, cystitis often is caused by congenital abnormalities (present at birth) of the urinary tract. Vesicoureteral reflux is a condition in which the child cannot completely empty the bladder. It allows urine to remain in or flow backward (reflux) into the partially empty bladder.

Causes and symptoms

The causes of cystitis vary according to sex because of the differences in anatomical structure of the urinary tract.

Females

Most bladder infections in women are so-called ascending infections, which means they are caused by disease agents traveling upward through the urethra to the bladder. The relative shortness of the female urethra (1.2-2 inches in length) makes it easy for bacteria to gain entry to the bladder and multiply. The most common bacteria associated with UTIs in women include Escherichia coli (about 80% of cases), Staphylococcus saprophyticus, Klebsiella, Enterobacter, and Proteus species. Risk factors for UTIs in women include:

• Sexual intercourse. The risk of infection increases if the woman has multiple partners.
• Use of a diaphragm for contraception
• An abnormally short urethra
• Diabetes or chronic dehydration
• The absence of a specific enzyme (fucosyltransferase) in vaginal secretions. The lack of this enzyme makes it easier for the vagina to harbor bacteria that cause UTIs.
• Inadequate personal hygiene. Bacteria from fecal matter or vaginal discharges can enter the female urethra because its opening is very close to the vagina and anus.
• History of previous UTIs. About 80% of women with cystitis develop recurrences within two years.

The early symptoms of cystitis in women are dysuria, or pain on urination; urgency, or a sudden strong desire to urinate; and increased frequency of urination. About 50% of female patients experience fever, pain in the lower back or flanks, nausea and vomiting, or shaking chills. These symptoms indicate pyelonephritis, or spread of the infection to the upper urinary tract.

Males

Most UTIs in adult males are complications of kidney or prostate infections. They usually are associated with a tumor or kidney stones that block the flow of urine and often are persistent infections caused by drug-resistant organisms. UTIs in men are most likely to be caused by E. coli or another gram-negative bacterium. S. saprophyticus, which is the second most common cause of UTIs in women, rarely causes infections in men. Risk factors for UTIs in men include:

• Lack of circumcision. The foreskin can harbor bacteria that cause UTIs.
• Urinary catheterization. The longer the period of catheterization, the higher the risk of UTIs.

The symptoms of cystitis and pyelonephritis in men are the same as in women.

Hemorrhagic cystitis

Hemorrhagic cystitis, which is marked by large quantities of blood in the urine, is caused by an acute bacterial infection of the bladder. In some cases, hemorrhagic cystitis is a side effect of radiation therapy or treatment with cyclophosphamide. Hemorrhagic cystitis in children is associated with adenovirus type 11.

Diagnosis

When cystitis is suspected, the doctor will first examine the patient's abdomen and lower back, to evaluate unusual enlargements of the kidneys or swelling of the bladder. In small children, the doctor will check for fever, abdominal masses, and a swollen bladder.

The next step in diagnosis is collection of a urine sample. The procedure differs somewhat for women and men. Laboratory testing of urine samples now can be performed with dipsticks that indicate immune system responses to infection, as well as with microscopic analysis of samples. Normal human urine is sterile. The presence of bacteria or pus in the urine usually indicates infection. The presence of hematuria, or blood in the urine, may indicate acute UTIs, kidney disease, kidney stones, inflammation of the prostate (in men), endometriosis (in women), or cancer of the urinary tract. In some cases, blood in the urine results from athletic training, particularly in runners.

Females

Female patients often require a pelvic examination as part of the diagnostic workup for bladder infections. Normally, however, a midstream urine sample of 200 ml is collected to test for infection.

A count of more than 104 bacteria CFU/ml (colony forming units per milliliter) in the midstream sample indicates a bladder or kidney infection. A colony is a large number of microorganisms that grow from a single cell within a substance called a culture. A bacterial count can be given in CFU or (colony forming units).

In recent years, many health providers and insurance companies have adopted telephone treatment of women with presumed cystitis. Trained nurses diagnose uncomplicated bladder infections over the telephone based on the patient's symptoms and a series of questions prepared by physicians. The practice has been found safe and cost-effective.

Males

In male patients, the doctor will cleanse the opening to the urethra with an antiseptic before collecting the urine sample. The first 10 ml of specimen are collected separately. The patient then voids a mid-stream sample of 200 ml. Following the second sample, the doctor will massage the patient's prostate and collect several drops of prostatic fluid. The patient then voids a third urine specimen for prostatic culture.

A high bacterial count in the first urine specimen or the prostatic specimens indicates urethritis or prostate infections respectively. A bacterial count greater than 100,000 bacteria CFU/ml in the midstream sample suggests a bladder or kidney infection.

Other tests

Women with recurrent UTIs can be given ultrasound exams of the kidneys and bladder together with a voiding cystourethrogram to test for structural abnormalities. (A cystourethrogram is an x-ray test in which an iodine dye is used to better view the urinary bladder and urethra.) Voiding cystourethrograms are also used to evaluate children with UTIs. In some cases, computed tomography scans (CT scans) can be used to evaluate patients for possible cancers in the urinary tract.

Treatment

Medications

Uncomplicated cystitis is treated with antibiotics. These include penicillin, ampicillin, and amoxicillin; sulfisoxazole or sulfamethoxazole; trimethoprim; nitrofurantoin; cephalosporins; or fluoroquinolones. (Flouroquinolones generally are not used in children under 18 years of age.) A 2003 study showed that fluoroquinolone was preferred over amoxicillin, however, for uncomplicated cystitis in young women. Treatment for women is short-term; most patients respond within three days. Men do not respond as well to short-term treatment and require seven to 10 days of oral antibiotics for uncomplicated UTIs.

Patients of either sex may be given phenazopyridine or flavoxate to relieve painful urination.

Trimethoprim and nitrofurantoin are preferred for treating recurrent UTIs in women.

Over 50% of older men with UTIs also suffer from infection of the prostate gland. Some antibiotics, including amoxicillin and the cephalosporins, do not affect the prostate gland. Fluoroquinolone antibiotics or trimethoprim are the drugs of choice for these patients.

Patients with pyelonephritis can be treated with oral antibiotics or intramuscular doses of cephalosporins. Medications are given for 10-14 days, and sometimes longer. If the patient requires hospitalization because of high fever and dehydration caused by vomiting, antibiotics can be given intravenously.

Surgery

A minority of women with complicated UTIs may require surgical treatment to prevent recurrent infections. Surgery also is used to treat reflux problems (movement of the urine backward) or other structural abnormalities in children and anatomical abnormalities in adult males.

Alternative treatment

Alternative treatment for cystitis may emphasize eliminating all sugar from the diet and drinking lots of water. Drinking unsweetened cranberry juice not only adds fluid, but also is thought to help prevent cystitis by making it more difficult for bacteria to cling to the bladder wall. A variety of herbal therapies also are recommended. Generally, the recommended herbs are antimicrobials, such as garlic (Allium sativum ), goldenseal (Hydrastis canadensis ), and bearberry (Arctostaphylos uva-ursi ), and/or demulcents that soothe and coat the urinary tract, including corn silk and marsh mallow (Althaea officinalis ).

Homeopathic medicine also can be effective in treating cystitis. Choosing the correct remedy based on the individual's symptoms is always key to the success of this type of treatment. Acupuncture and Chinese traditional herbal medicine can also be helpful in treating acute and chronic cases of cystitis.

Prognosis

Females

The prognosis for recovery from uncomplicated cystitis is excellent.

Males

The prognosis for recovery from uncomplicated UTIs is excellent; however, complicated UTIs in males are difficult to treat because they often involve bacteria that are resistant to commonly used antibiotics.

Prevention

Females

Women with two or more UTIs within a six-month period sometimes are given prophylactic treatment, usually nitrofurantoin or trimethoprim for three to six months. In some cases the patient is advised to take an antibiotic tablet following sexual intercourse.

Other preventive measures for women include:

• drinking large amounts of fluid
• voiding frequently, particularly after intercourse
• proper cleansing of the area around the urethra

In 2003, clinical trials in humans were testing a possible vaccine for recurrent urinary tract infections. The vaccine was administered via a vaginal suppository.

KEY TERMS

Bacteriuria— The presence of bacteria in the urine.

Dysuria— Painful or difficult urination.

Hematuria— The presence of blood in the urine.

Pyelonephritis— Bacterial inflammation of the upper urinary tract.

Urethritis— Inflammation of the urethra, which is the passage through which the urine moves from the bladder to the outside of the body.

Males

The primary preventive measure for males is prompt treatment of prostate infections. Chronic prostatitis may go unnoticed, but can trigger recurrent UTIs. In addition, males who require temporary catheterization following surgery can be given antibiotics to lower the risk of UTIs.

Resources

PERIODICALS

Harrar, Sari. "Bladder Infection Protection." Prevention November 2003: 174.

Jancin, Bruce. "Presumed Cystitis Well Managed Via Telephone: Large Kaiser Experience." Family Practice News November 1, 2003: 41.

Prescott, Lawrence M. "Presumed Quinolone Gets the Nod for Uncomplicated Cystitis." Urology Times November 2003: 11.

Cystitis

Definition

Cystitis is inflammation of the urinary bladder. Urethritis is an inflammation of the urethra, which is the tube that connects the bladder with the exterior of the body. Sometimes cystitis and urethritis are referred to collectively as a lower urinary tract infection (UTI). Infection of the upper urinary tract involves the spread of bacteria to the kidney and is called pyelonephritis.

Description

Cystitis in women

Cystitis is a common female problem. It is estimated that 50 percent of adult women experience at least one episode of dysuria (painful urination); half of these people have a bacterial UTI. Between 2 percent and 5 percent of women's visits to primary care physicians are for UTI symptoms. About 90 percent of UTIs in women are uncomplicated but recurrent.

Cystitis in men

UTIs are uncommon in younger and middle-aged men but may occur as complications of bacterial infections of the kidney or prostate gland.

Cystitis in children

In children, cystitis often is caused by congenital abnormalities (present at birth) of the urinary tract. Vesicoureteral reflux is a condition in which the child cannot completely empty the bladder. The condition allows urine to remain in or flow backward (reflux) into the partially empty bladder. In addition, cystitis can also be caused by wiping forward instead of backward after a bowel movement, especially in girls that are newly toilet trained.

Demographics

The frequency of bladder infections in humans varies significantly according to age and sex. The male/female ratio of UTIs in children younger than 12 months is four to one because of the high rate of birth defects in the urinary tract of male infants. Urinary tract infections are fairly common in young girls. In adult life, the male/female ratio of UTIs is one to 50. After age 50, however, the incidence among males increases due to prostate disorders.

Causes and symptoms

The causes of cystitis vary according to gender because of the differences in anatomical structure of the urinary tract.

Females

Most bladder infections in women are so-called ascending infections, which means they are caused by disease agents traveling upward through the urethra to the bladder. The relative shortness of the female urethra (1.2 to 2 inches [3-5 cm] in length for adults) facilitates bacteria gaining entry to the bladder and multiplying there. The most common bacteria associated with UTIs in women (including teens) are: Escherichia coli (approximately 80% of cases), Staphylococcus saprophyticus, Klebsiella, Enterobacter, and Proteus species. Risk factors for UTIs in women include:

• sexual intercourse (The risk of infection increases if the woman has multiple partners.)
• use of a diaphragm for contraception
• an abnormally short urethra
• diabetes or chronic dehydration
• the absence of a specific enzyme (fucosyltransferase) in vaginal secretions (The lack of this enzyme makes it easier for the vagina to harbor bacteria that cause UTIs.)
• inadequate personal hygiene (Bacteria from fecal matter or vaginal discharges can enter the female urethra because its opening is very close to the vagina and anus.)
• history of previous UTIs (About 80 percent of women with cystitis develop recurrences within two years.)

The early symptoms of cystitis in women are dysuria (pain on urination); urgency (a sudden strong desire to urinate); and increased frequency of urination. About 50 percent of females experience fever , pain in the lower back or flanks, nausea and vomiting , or shaking chills. These symptoms indicate pyelonephritis (spread of the infection to the upper urinary tract).

Males

Most UTIs in adult males are complications of kidney or prostate infections. They usually are associated with a tumor or kidney stones that block the flow of urine and often are persistent infections caused by drug-resistant organisms. UTIs in men are most likely to be caused by E. coli or another gram-negative bacterium. Risk factors for UTIs in men include lack of circumcision and urinary catheterization. The longer the period of catheterization, the higher the risk of contracting a UTI.

The symptoms of cystitis and pyelonephritis in men are the same as in women.

Children

In children, cystitis causes pain and tenderness in the lower abdomen, frequent urination, blood in the urine, and fever. However, some foods, including citrus juices, caffeine , and carbonated beverages, can irritate the lower urinary tract and mimic the symptoms of an infection.

Hemorrhagic cystitis

Hemorrhagic cystitis, which is marked by large quantities of blood in the urine, is caused by an acute bacterial infection of the bladder. In some cases, hemorrhagic cystitis is a side effect of radiation therapy or treatment with cyclophosphamide. Hemorrhagic cystitis in children is associated with adenovirus type 11.

When to call the doctor

A doctor or other healthcare provider should be contacted whenever urination becomes painful or the voided urine is cloudy or bloody, or when a child complains of pain when voiding urine.

Diagnosis

When cystitis is suspected, the doctor first examines a person's abdomen and lower back, to evaluate unusual enlargements of the kidneys or swelling of the bladder. In small children, the doctor checks for fever, abdominal masses, and a swollen bladder.

The next step in diagnosis is collection of a urine sample. The procedure involves voiding into a cup, so small children may be catheterized to collect a sample. Laboratory testing of urine samples as of the early 2000s can be performed with dipsticks that indicate immune system responses to infection, as well as with microscopic analysis of samples. Normal human urine is sterile. The presence of bacteria or pus in the urine usually indicates infection. The presence of hematuria (blood in the urine) may indicate acute UTIs, kidney disease, kidney stones, inflammation of the prostate (in men), endometriosis (in women), or cancer of the urinary tract. In some cases, blood in the urine results from athletic training, particularly in runners.

Other tests

Women and children with recurrent UTIs can be given ultrasound exams of the kidneys and bladder together with a voiding cystourethrogram to test for structural abnormalities. (A cystourethrogram is an x-ray test in which an iodine dye is used to better view the urinary bladder and urethra.) In some cases, computed tomography scans (CT scans) can be used to evaluate people for possible cancers in the urinary tract.

Treatment

Medications

Uncomplicated cystitis is treated with antibiotics . These include penicillin, ampicillin, and amoxicillin; sulfisoxazole or sulfamethoxazole; trimethoprim; nitrofurantoin; cephalosporins; or fluoroquinolones. (Fluoroquinolones generally are not used in children under 18 years of age.) A 2003 study showed that fluoroquinolone was preferred over amoxicillin, however, for uncomplicated cystitis in young women. Treatment for women is short-term; most women respond within three days. Men and children do not respond as well to short-term treatment and require seven to 10 days of oral antibiotics for uncomplicated UTIs.

Persons of either gender may be given phenazopyridine or flavoxate to relieve painful urination.

Trimethoprim and nitrofurantoin are preferred for treating recurrent UTIs in women.

Individuals with pyelonephritis can be treated with oral antibiotics or intramuscular doses of cephalosporins. Medications are given for ten to 14 days and sometimes longer. If the person requires hospitalization because of high fever and dehydration caused by vomiting , antibiotics can be given intravenously.

Surgery

A minority of women with complicated UTIs may require surgical treatment to prevent recurrent infections. Surgery also is used to treat reflux problems (movement of the urine backward) or other structural abnormalities in children and anatomical abnormalities in adult males.

Alternative treatment

Alternative treatment for cystitis may emphasize eliminating all sugar from the diet and drinking lots of water. Drinking unsweetened cranberry juice not only adds fluid but also is thought to help prevent cystitis by making it more difficult for bacteria to cling to the bladder wall. A variety of herbal therapies also are recommended. Generally, the recommended herbs are antimicrobials, such as garlic (Allium sativum ), goldenseal (Hydrastis canadensis ), and bearberry (Arctostaphylos uva-ursi ); and/or demulcents that soothe and coat the urinary tract, including corn silk and marsh mallow (Althaea officinalis ).

Homeopathic medicine also can be effective in treating cystitis. Choosing the correct remedy based on the individual's symptoms is always key to the success of this type of treatment. Acupuncture and Chinese traditional herbal medicine can also be helpful in treating acute and chronic cases of cystitis.

Prognosis

The prognosis for recovery from uncomplicated cystitis is excellent.

Prevention

Females

Women and teens with two or more UTIs within a six-month period sometimes are given prophylactic treatment, usually nitrofurantoin or trimethoprim for three to six months. In some cases the woman is advised to take an antibiotic tablet following sexual intercourse.

Other preventive measures for women include drinking large amounts of fluid; voiding frequently, particularly after intercourse; and proper cleansing of the area around the urethra. Children with UTIs should be encouraged to drink plenty of fluids and wipe themselves properly after a bowel movement.

In 2003, clinical trials in humans tested a possible vaccine for recurrent urinary tract infections. The vaccine was administered via a vaginal suppository.

Nutritional concerns

Many experts recommend that people with a UTI should drink cranberry juice, which contains hippuric acid that tends to lower the pH (acidify) of urine. This change reduces the ability of bacteria to thrive, thus helping to cure a UTI.

Parental concerns

Parents should monitor the urine of their young children. Older children should be encouraged to discuss episodes of painful urination with their parents or other knowledgeable persons.

KEY TERMS

Bacteriuria —The presence of bacteria in the urine.

Dysuria —Painful or difficult urination.

Hematuria —The presence of blood in the urine.

Pyelonephritis —An inflammation of the kidney and upper urinary tract, usually caused by a bacterial infection. In its most serious form, complications can include high blood pressure (hypertension) and renal failure.

Urethritis —Inflammation of the urethra, the tube through which the urine moves from the bladder to the outside of the body.

Resources

BOOKS

Davis, Ira D., and Ellis D. Avner. "Lower Urinary Tract Causes of Hematuria." In Nelson Textbook of Pediatrics, 17th ed. Edited by Richard E. Behrman et al. Philadelphia: Saunders, 2003, pp. 2256–7.

Potts, Jeanette M. Essential Urology: A Guide to Clinical Practice. Totowa, NJ: Humana Press, 2004.

Stamm, Walter. "Urinary tract infections and pyelonephritis." In Harrison's Principles of Internal Medicine, 15th ed. Edited by Eugene Braunwald et al. New York: McGraw-Hill, 2001, pp. 1620–6.

Urinary Tract Infections: A Medical Dictionary, Bibliography, and Annotated Research Guide to Internet References. San Diego, CA: ICON Health Publications, 2004.

PERIODICALS

Meria, P., et al. "Encrusted cystitis and pyelitis in children: an unusual condition with potentially severe consequences." Urology 64, no. 3 (2004): 569–73.

Tsakiri, A., et al. "Eosinophilic cystitis induced by penicillin." International Urology and Nephrology 36, no. 2 (2004): 159–61.

ORGANIZATIONS

American Foundation for Urologic Disease. 1128 North Charles St., Baltimore, MD 21201. Web site: <www.afud.org/>.

American Urological Association. 1120 North Charles St., Baltimore, MD 21201. Web site: <www.auanet.org>.

L. Fleming Fallon, Jr., MD, DrPH

Cystitis

Definition

Cystitis is defined as inflammation of the urinary bladder. Urethritis is an inflammation of the urethra, which is the passageway that connects the bladder with the exterior of the body. Sometimes cystitis and urethritis are referred to collectively as a lower urinary tract infection , or UTI. Infection of the upper urinary tract involves the spread of bacteria to the kidney and is called pyelonephritis.

Description

The frequency of bladder infections in humans varies significantly according to age and sex. The male/female ratio of UTIs in children younger than 12 months is 4:1 because of the high rate of birth defects in the urinary tract of male infants. In adult life, the male/female ratio of UTIs is 1:50. After age 50, however, the incidence among males increases due to prostate disorders.

Cystitis in women

Cystitis is a common female problem. It is estimated that 50% of adult women experience at least one episode of dysuria (painful urination); half of these patients have a bacterial UTI. Between 2–5% of women's visits to primary care doctors are for UTI symptoms. About 90% of UTIs in women are uncomplicated but recurrent.

Cystitis in men

UTIs are uncommon in younger and middle-aged men, but may occur as complications of bacterial infections of the kidney or prostate gland.

Cystitis in children

In children, cystitis often is caused by congenital abnormalities (present at birth) of the urinary tract. Vesicoureteral reflux is a condition in which the child cannot completely empty the bladder. It allows urine to remain in or flow backward (reflux) into the partially empty bladder.

Causes and symptoms

The causes of cystitis vary according to sex because of the differences in anatomical structure of the urinary tract.

Females

Most bladder infections in women are so-called ascending infections, which means they are caused by disease agents traveling upward through the urethra to the bladder. The relative shortness of the female urethra (1.2–2 inches in length) makes it easy for bacteria to gain entry to the bladder and multiply. The most common bacteria associated with UTIs in women include Escherichia coli (about 80% of cases), Staphylococcus saprophyticus, Klebsiella, Enterobacter, and Proteus species. Risk factors for UTIs in women include:

• Sexual intercourse. The risk of infection increases if the woman has multiple partners.
• Use of a diaphragm for contraception.
• An abnormally short urethra.
• Diabetes or chronic dehydration.
• The absence of a specific enzyme (fucosyltransferase) in vaginal secretions. The lack of this enzyme makes it easier for the vagina to harbor bacteria that cause UTIs.
• Inadequate personal hygiene. Bacteria from fecal matter or vaginal discharges can enter the female urethra because its opening is very close to the vagina and anus.
• History of previous UTIs. About 80% of women with cystitis develop recurrences within two years.

The early symptoms of cystitis in women are dysuria, or pain on urination; urgency, or a sudden strong desire to urinate; and increased frequency of urination. About 50% of female patients experience fever, pain in the lower back or flanks, nausea and vomiting, or shaking chills. These symptoms indicate pyelonephritis, or spread of the infection to the upper urinary tract.

Males

Most UTIs in adult males are complications of kidney or prostate infections. They usually are associated with a tumor or kidney stones that block the flow of urine and often are persistent infections caused by drug-resistant organisms. UTIs in men are most likely to be caused by E. coli or another gram-negative bacterium. S. saprophyticus, which is the second most common cause of UTIs in women, rarely causes infections in men. Risk factors for UTIs in men include:

• Lack of circumcision. The foreskin can harbor bacteria that cause UTIs.
• Urinary catheterization. The longer the period of catheterization, the higher the risk of UTIs.

The symptoms of cystitis and pyelonephritis in men are the same as in women.

Hemorrhagic cystitis

Hemorrhagic cystitis, which is marked by large quantities of blood in the urine, is caused by an acute bacterial infection of the bladder. In some cases, hemorrhagic cystitis is a side effect of radiation therapy or treatment with cyclophosphamide. Hemorrhagic cystitis in children is associated with adenovirus type 11.

Diagnosis

When cystitis is suspected, the doctor will first examine the patient's abdomen and lower back, to evaluate unusual enlargements of the kidneys or swelling of the bladder. In small children, the doctor will check for fever, abdominal masses, and a swollen bladder.

The next step in diagnosis is collection of a urine sample. The procedure differs somewhat for women and men. Laboratory testing of urine samples now can be performed with dipsticks that indicate immune system responses to infection, as well as with microscopic analysis of samples. Normal human urine is sterile. The presence of bacteria or pus in the urine usually indicates infection. The presence of hematuria, or blood in the urine, may indicate acute UTIs, kidney disease, kidney stones, inflammation of the prostate (in men), endometriosis (in women), or cancer of the urinary tract. In some cases, blood in the urine results from athletic training, particularly in runners.

Females

Female patients often require a pelvic examination as part of the diagnostic workup for bladder infections. Normally, however, a midstream urine sample of 200 ml is collected to test for infection.

A count of more than 104 bacteria CFU/ml (colony forming units per milliliter) in the midstream sample indicates a bladder or kidney infection. A colony is a large number of microorganisms that grow from a single cell within a substance called a culture. A bacterial count can be given in CFU or (colony forming units).

In recent years, many health providers and insurance companies have adopted telephone treatment of women with presumed cystitis. Trained nurses diagnose uncomplicated bladder infections over the telephone based on the patient's symptoms and a series of questions prepared by physicians. The practice has been found safe and cost-effective.

Males

In male patients, the doctor will cleanse the opening to the urethra with an antiseptic before collecting the urine sample. The first 10 ml of specimen are collected separately. The patient then voids a midstream sample of 200 ml. Following the second sample, the doctor will massage the patient's prostate and collect several drops of prostatic fluid. The patient then voids a third urine specimen for prostatic culture.

A high bacterial count in the first urine specimen or the prostatic specimens indicates urethritis or prostate infections respectively. A bacterial count greater than 100,000 bacteria CFU/ml in the midstream sample suggests a bladder or kidney infection.

Other tests

Women with recurrent UTIs can be given ultra-sound exams of the kidneys and bladder together with a voiding cystourethrogram to test for structural ab-normalities. (A cystourethrogram is an x-ray test in which an iodine dye is used to better view the urinary bladder and urethra.) Voiding cystourethrograms are also used to evaluate children with UTIs. In some cases, computed tomography scans (CT scans ) can be used to evaluate patients for possible cancers in the urinary tract.

Treatment

Medications

Uncomplicated cystitis is treated with antibiotics .

These include penicillin, ampicillin, and amoxicillin; sulfisoxazole or sulfamethoxazole; trimethoprim; nitrofurantoin; cephalosporins ; or fluoroquinolones. (Flouroquinolones generally are not used in children under 18 years of age.) A 2003 study showed that fluoroquinolone was preferred over amoxicillin, however, for uncomplicated cystitis in young women. Treatment for women is short-term; most patients respond within three days. Men do not respond as well to short-term treatment and require seven to 10 days of oral antibiotics for uncomplicated UTIs.

Patients of either sex may be given phenazopyridine or flavoxate to relieve painful urination.

Trimethoprim and nitrofurantoin are preferred for treating recurrent UTIs in women.

Over 50% of older men with UTIs also suffer from infection of the prostate gland. Some antibiotics, including amoxicillin and the cephalosporins, do not affect the prostate gland. Fluoroquinolone antibiotics or trimethoprim are the drugs of choice for these patients.

Patients with pyelonephritis can be treated with oral antibiotics or intramuscular doses of cephalosporins. Medications are given for 10–14 days, and sometimes longer. If the patient requires hospitalization because of high fever and dehydration caused by vomiting, antibiotics can be given intravenously.

Surgery

A minority of women with complicated UTIs may require surgical treatment to prevent recurrent infections. Surgery also is used to treat reflux problems (movement of the urine backward) or other structural abnormalities in children and anatomical abnormalities in adult males.

Alternative treatment

Alternative treatment for cystitis may emphasize eliminating all sugar from the diet and drinking lots of water. Drinking unsweetened cranberry juice not only adds fluid, but also is thought to help prevent cystitis by making it more difficult for bacteria to cling to the bladder wall. A variety of herbal therapies also are recommended. Generally, the recommended herbs are antimicrobials, such as garlic (Allium sativum), goldenseal (Hydrastis canadensis), and bearberry (Arctostaphylos uva-ursi), and/or demulcents that soothe and coat the urinary tract, including corn silk and marsh mallow (Althaea officinalis).

Homeopathic medicine also can be effective in treating cystitis. Choosing the correct remedy based on the individual's symptoms is always key to the success of this type of treatment. Acupuncture and Chinese traditional herbal medicine can also be helpful in treating acute and chronic cases of cystitis.

Prognosis

Females

The prognosis for recovery from uncomplicated cystitis is excellent.

Males

The prognosis for recovery from uncomplicated UTIs is excellent; however, complicated UTIs in males are difficult to treat because they often involve bacteria that are resistant to commonly used antibiotics.

Prevention

Females

Women with two or more UTIs within a six-month period sometimes are given prophylactic treatment, usually nitrofurantoin or trimethoprim for three to six months. In some cases the patient is advised to take an antibiotic tablet following sexual intercourse.

KEY TERMS

Bacteriuria —The presence of bacteria in the urine.

Dysuria —Painful or difficult urination.

Hematuria —The presence of blood in the urine.

Pyelonephritis —Bacterial inflammation of the upper urinary tract.

Urethritis —Inflammation of the urethra, which is the passage through which the urine moves from the bladder to the outside of the body.

Other preventive measures for women include:

• drinking large amounts of fluid
• voiding frequently, particularly after intercourse
• proper cleansing of the area around the urethra

In 2003, clinical trials in humans were testing a possible vaccine for recurrent urinary tract infections. The vaccine was administered via a vaginal suppository.

Males

The primary preventive measure for males is prompt treatment of prostate infections. Chronic prostatitis may go unnoticed, but can trigger recurrent UTIs. In addition, males who require temporary catheterization following surgery can be given antibiotics to lower the risk of UTIs.

Resources

PERIODICALS

Harrar, Sari. “Bladder Infection Protection.” Prevention November 2003: 174.

Jancin, Bruce. “Presumed Cystitis Well Managed Via Telephone: Large Kaiser Experience.” Family Practice News November 1, 2003: 41.

Prescott, Lawrence M. “Presumed Quinolone Gets the Nod for Uncomplicated Cystitis.” Urology Times November 2003: 11.

Rebecca J. Frey Ph.D.

Teresa G. Odle

CYSTITIS

DEFINITION

Cystitis (pronounced sis-TIE-tess) is inflammation of the bladder. The condition is often associated with inflammation of other structures adjoining the bladder. For example, cystitis is often accompanied by urethritis (pronounced yur-ih-THRI-tess). Urethritis is inflammation of the urethra. The urethra is the tube through which the bladder empties to the exterior of the body. Cystitis and urethritis together are sometimes called lower urinary tract infections (UTI).

DESCRIPTION

In children under the age of twelve months, cystitis is about four times more common among boys than girls. Among adults, this pattern is very different. The condition is fifty times as common among women as among men. After the age of fifty, the pattern changes again. The rate of cystitis among men increases because of a greater number of prostate problems among men. The prostate is a gland surrounding the male urethra in front of the bladder.

The nature of cystitis varies considerably in men and women. The reason for this variation is the difference between the urinary tract in males and females.

Cystitis is a common female problem. About one-quarter of all adult women are thought to have had at least one episode of cystitis. Between 2 and 5 percent of women's visits to doctors are for UTI symptoms. About 90 percent of these cases are uncomplicated. Many women, however, experience repeated bouts of cystitis.

UTIs are uncommon in younger and middle-aged men. They become more common as men grow older. Older men are more likely to develop bacterial infections of the kidney or prostate gland. These infections may spread and cause cystitis.

Cystitis in children is usually a congenital problem. A congenital problem is one that is present at birth. For example, some children are unable to empty their bladders completely. Urine may remain in or flows backward into the bladder. This condition may lead to cystitis.

CAUSES

The causes of cystitis are somewhat different in women than in men. Most bladder infections in women are so-called ascending (going upward) infections. Ascending infections are caused when disease agents travel upward through the urethra from outside the body. The female urethra is relatively short, about 1 to 2 inches in length. Microorganisms that cause disease can travel this distance very easily. The organism that most commonly causes cystitis in women is Escherichia coli (or E. coli ; pronounced ESH-ur-ickee-uh KO-lie). It is responsible for about 80 percent of all cases of the disease.

Cystitis: Words to Know

Ascending infection:

An infection that begins at the outer edge of a body opening and works its way upward.

Catheterization:

A medical procedure in which a long, thin tube (a catheter) is inserted into some part of the human body.

Circumcision:

The procedure in which the foreskin is removed from the penis.

Congenital problem:

A problem that is present at birth.

Diaphragm:

A thin rubber cap inserted into the vagina as a method of birth control.

Lower urinary tract infection (UTI):

Inflammation of the bladder or urinary tract.

Urethra:

The tube through which the bladder empties to the exterior of the body.

Other organisms that can cause cystitis include Staphylococcus saprophyticus (pronounced STAFF-uh-lo-kock-us SAP-ro-FIT-ick-us), and members of the Klebsiella (pronounced KLEB-see-ell-uh), Enterobacter (pronounced EN-terr-o-BACK-tur), and Proteus (pronounced PRO-tee-us) families of bacteria.

A number of other factors increase a woman's risk for cystitis. These factors include:

• Sexual intercourse. The more sexual partners a woman has, the greater her risk for cystitis.
• Use of a diaphragm for birth control
• An unusually short urethra
• Diabetes (see diabetes entry)
• Poor personal hygiene. Bacteria from vaginal discharges or feces can easily enter the female urethra. The opening to the urethra in women is very close to the vagina and the anus.
• History of previous UTIs. About 80 percent of women who have one case of cystitis will develop another case within two years.

Males

Cystitis in men usually occurs as a complication of kidney or prostate gland infection. The most common cause of cystitis in men, as in women, is the bacterium Escherichia coli. Factors that increase men's risk for cystitis include:

• Lack of circumcision. Circumcision is the procedure in which the foreskin is removed from a man's penis. If the foreskin has not been removed, bacteria can grow beneath it. The bacteria can then travel up the urethra to the bladder.
• Urinary catheterization. Urinary catheterization is a medical procedure in which a long, thin tube (a catheter) is inserted into the urethra. It is pushed up into the bladder. Some men require this procedure if they are unable to urinate normally. The presence of the catheter provides a pathway by which bacteria can travel up into the bladder and cause infection.

SYMPTOMS

The symptoms of cystitis are similar in women and men. The most common symptoms involve changes in urination patterns. Patients may feel pain during urination, may feel a sudden and strong desire to urinate, or may have to urinate more frequently. About half of all patients experience fever, pain in the lower back, nausea and vomiting, or chills.

DIAGNOSIS

The first step in diagnosing cystitis is often a physical examination. A doctor examines the patient's abdomen and lower back. Swelling of the kidneys or bladder can often be felt.

The next step in diagnosis is collection of a urine sample. Normal human urine is sterile. It does not contain bacteria, blood, pus, or other abnormal substances. The presence of any of these substances in urine suggests the presence of an infection.

The patient is asked to urinate into a collecting bottle. The urine can then be tested immediately with a dip stick. A dip stick is a strip of paper that contains one or more testing chemicals. The chemicals change colors if certain abnormal substances are present in the urine. The urine may also be examined using a microscope.

If questions remain about a diagnosis, more advanced tests can also be used. For example, a dye may be injected into the urinary tract and X-ray photographs taken. The dye helps the shape of the urinary tract stand out more clearly. Any abnormal structures present can be seen on the X-ray photograph.

TREATMENT

Since cystitis is a bacterial infection, it can be treated with antibiotics. Some drugs that are commonly used include penicillin, ampicillin (pronounced AMP-ih-SIL-in), amoxicillin (pronounced uh-MOK-sih-SIL-in), sulfisoxazole (pronounced SUL-fuh-SOK-suh-zole), trimethoprim (pronounced tri-METH-o-prim), cephalosporin (pronounced seff-a-lo-SPORE-in), or fluoroquinolone (pronounced FLOOR-o-KWIN-o-lone). Women usually respond to antibiotic treatment in less than three days. Men usually require a longer period of treatment, ranging from seven to ten days.

Alternative Treatment

Some forms of alternative treatment involve changes in one's diet. Practitioners often recommend eliminating all sugar from the diet and drinking lots of water. Some herbal remedies that are suggested include garlic, goldenseal, and bearberry. These herbs are thought to kill bacteria. Acupuncture (the Chinese therapy of inserting fine needles into the skin) and homeopathic medicine may also be effective in treating cystitis.

PROGNOSIS

The prognosis for recovery from uncomplicated cystitis is very good. With proper treatment, the infection usually clears up quickly. In many cases, the condition may reoccur. However, it can be treated in essentially the same way each time it appears. More complicated infections in men may be difficult to treat if antibiotics are not able to clear up the problem.

PREVENTION

Women can reduce their risk for cystitis by becoming aware of risk factors and adjusting their lifestyles accordingly. For example, improving one's personal hygiene is an easy step to help prevent a lower urinary tract infection. In some cases, patients are advised to take an antibiotic tablet following sexual intercourse. Other preventative measures include drinking large amounts of fluid and urinating frequently, especially after intercourse.

The primary method of preventing cystitis in men is to obtain prompt treatment for prostate infections.

FOR MORE INFORMATION

Books

Chalker, Rebecca. Overcoming Bladder Disorders: Compassionate, Authoritative Medical and Self-Help Solutions for Incontinence, Cystitis, Interstitial Cystitis, Prostatitis. New York: HarperCollins, 1991.

Gillespie, Larrian, and Sandra Blakeslee. You Don't Have to Live With Cystitis, revised and updated edition. New York: Avon Books, 1996.

Simone, Catherine M. To Wake In Tears: Understanding Interstitial Cystitis. Cleveland, OH: IC Hope, 1998.

cys·ti·tis / sisˈtītis/ • n. Med. inflammation of the urinary bladder. It is usually accompanied by frequent, painful urination.