What is Cystitis (Urinary Tract Infection)?
Cystitis is an infection that occurs in the lower part of the urinary system, specifically the bladder. This infection falls into two categories: uncomplicated or complicated. Uncomplicated cystitis is a bladder infection in healthy men or non-pregnant women. Complicated cystitis, on the other hand, is linked with risk factors that increase the chances and risks of the infection, as well as the possibility of antibiotics not working against the infection.
What Causes Cystitis (Urinary Tract Infection)?
Acute cystitis, or a bladder infection, is usually caused by bacteria. Women are especially prone to these infections because of their body structure, specifically, how close the rectum is to the opening of the urinary tract and the shorter length of the female urinary tract.
The bacteria Escherichia coli, is involved in about 75% to 95% of bladder infection cases in women. Other organisms that often play parts in bladder infections include bacteria such as Klebsiella, Proteus mirabilis, Staphylococcus saprophyticus and enterococcus. However, some bacteria like Group B streptococci, lactobacillus, and other similar bacteria are rarely the cause of these infections.
Escherichia coli is also the main cause of complicated bladder infections, but various other microorganisms, including certain kinds of bacteria and fungi, could be involved. These complicated infections are harder to treat since the causative bacteria often resist common treatments. This includes bacteria like the E. coli that can resist many types of the usual antibiotics.
Risk Factors and Frequency for Cystitis (Urinary Tract Infection)
Urinary Tract Infections (UTIs) are a common health issue, particularly in women. Roughly one out of three women have had a UTI by the age of 24, and by the age of 32, this increases to half of all women. Approximately 12% of women experience a UTI annually. The UTI occurrence rate is about 0.5 to 0.7 per year in sexually active women. Several factors can increase the risk for a simple bladder infection, or cystitis. These include intercourse, the use of spermicides, having a new sexual partner within the past year, previous UTIs, a family history of UTIs, and menopause. Furthermore, cystitis is more common than kidney infection, or pyelonephritis, with up to 28 times more cystitis cases.
The occurrence of complicated UTIs varies according to the individual’s underlying conditions. For instance, 26% of women with diabetes have asymptomatic bacteriuria (presence of bacteria in the urine), compared to just 6% of non-diabetic women. Also, patients with diabetes have a higher risk of both cystitis and pyelonephritis. UTIs frequently occur in patients who’ve had a kidney transplant, with up to 75% of patients experiencing a UTI. The risk is highest in the first year after transplantation. Around 2.3% of pregnant women suffer from symptomatic UTIs. There are also other risk factors contributing to the development of a complicated UTI, such as having kidney stones, a weakened immune system, the presence of foreign objects like urinary catheters, urinary tract issues, urinary stents, strictures, and other obstructions.
Cystitis is not as common in men and is generally below-in 10 cases per year for every 10,000 men under age 65. Men and women share the same UTI symptoms: a burning sensation when urinating, frequent urges to urinate, and lower belly pain. If the symptoms return after treatment or if there is a fever and discomfort in the pelvic or groin area, it could mean a prostate infection. Fever, chills, pain in the sides, or any sign of illness can indicate a complicated UTI.
Signs and Symptoms of Cystitis (Urinary Tract Infection)
Acute cystitis is a type of urinary tract infection (UTI) which often shows symptoms like painful urination, increased need to urinate, feeling of urgency to urinate, pain or discomfort in the lower abdomen, and sometimes blood in the urine. These symptoms are quite common, but they can be less obvious in certain groups such as very young or very old individuals. A cloudy or strong-smelling urine on its own is usually not enough to diagnose cystitis.
In specific groups, such as those with multiple sclerosis or spinal cord injuries, symptoms may appear differently. For example, a patient with multiple sclerosis might experience a sudden worsening of neurological symptoms while those with a spinal cord injury might notice changes in autonomic body functions or increased muscle stiffness.
To differentiate cystitis from a more severe UTI condition known as pyelonephritis, doctors look for systemic symptoms such as fever, chills, or signs of sepsis. Symptoms like pain in the side, tenderness in the rib area, nausea, and vomiting suggest an upper urinary tract infection or pyelonephritis.
When a patient comes in with symptoms of a UTI, it’s important for doctors to also ask about previous episodes of UTI, recent antibiotic use, and any risk factors that could predispose them to the condition. These risk factors include conditions that compromise the immune system, recent urological procedures, kidney transplant, history of kidney stones, structural or functional abnormalities in the urinary tract, or pregnancy.
In women with cystitis, especially those experiencing recurrent UTIs, a pelvic examination is crucial. A recurrent UTI is defined as having two documented UTIs within six months or three within a year. Positive urine cultures are necessary for a definitive diagnosis of recurrent or relapsing UTIs. It’s worth noting that recurrent infections with the same bacterial species might indicate the presence of urinary stones. In men, recurrent infections can also point to chronic bacterial prostatitis.
In patients who are frail or weakened, symptoms associated with UTIs could include changes in mental or physical function, fever, chills, and falls. However, these symptoms may not necessarily indicate a UTI. Recent studies suggest that only changes in urinary features such as urine color, smell, or the presence of blood in urine, and acute painful urination, are reliably associated with UTIs. In such cases, changes in mental status may or may not suggest a UTI as the research findings on this are not conclusive.
Testing for Cystitis (Urinary Tract Infection)
Acute cystitis, often referred to as a lower urinary tract infection (UTI), is commonly diagnosed in patients displaying specific symptoms. These may include pain during urination, frequent urges to urinate, or lower abdominal pain. Laboratory tests that find pyuria (pus in the urine) or nitrites can help confirm the diagnosis.
Doctors often diagnose acute cystitis based on symptoms alone, especially in young, non-pregnant women without signs of vaginal discomfort. Nevertheless, testing a urine sample is highly recommended before starting antibiotic treatment. If the patient doesn’t respond to the initial treatment, these tests can provide valuable information to guide the next steps.
The key lab test for diagnosing a UTI is a urinalysis. This can usually be done with a clean catch urine sample, but in some cases, a quick urethral catheterization might be required. Don’t panic if your urine appears clear or cloudy; this isn’t a surefire way to diagnose a UTI. However, the presence of at least 10 white blood cells (WBCs) per high power field (HPF) in the urine – a condition known as pyuria – is common in UTIs. Conversely, a lack of pyuria suggests something other than UTI may be causing your symptoms.
Another tool often used for UTI diagnosis is a urinary dipstick test, which can detect the presence of two key substances: leukocyte esterase and nitrites. A positive test for either of these, along with typical UTI symptoms, can firmly suggest a diagnosis of acute cystitis. However, a negative result doesn’t mean a UTI is off the cards. Sometimes antibiotics might be prescribed if the test finds positive nitrites, even if leukocyte esterase isn’t present.
A urine culture can help identify the specific bacteria causing infection and their resistance to different antibiotics. High numbers of bacterial colonies in the urine typically indicate a significant infection; however, small numbers don’t necessarily rule out a UTI. These tests are generally only done in certain situations, such as when symptoms persist despite treatment or for patients at high risk of complications. It’s particularly important for all men with UTI symptoms and women at risk of complicated UTIs to have these tests conducted before taking antibiotics.
Some patients, particularly men who repeatedly get cystitis, may need an evaluation for an underlying condition like prostatitis. Cases of severe drug-resistant UTIs, which are caused by bacteria resistant to multiple antibiotic drugs, highlight the importance of performing urine cultures in at-risk individuals. Finally, patients with complicated cystitis who don’t get better after a few days of appropriate treatment may need imaging tests such as a CT scan or ultrasound to check for complications like blockages, stones, or abscesses.
Treatment Options for Cystitis (Urinary Tract Infection)
Acute cystitis, an inflammation of the urinary bladder, is usually treated with antibiotics. The choice of antibiotic depends on the individual’s risk for infection with drug-resistant bacteria. If a patient has a low risk for drug-resistant infection, first-choice antibiotics can be used, such as Nitrofurantoin, Sulfamethoxazole-trimethoprim, Fosfomycin, and Pivmecillinam. Nitrofurantoin is commonly the first antibiotic prescribed because it doesn’t promote resistance or yeast overgrowth, is effective in most patients, and is generally safe, except in people with severe kidney diseases and those with systemic illness.
Sulfamethoxazole-Trimethoprim is recommended when bacterial resistance to this antibiotic is less than 20%. It works well and can penetrate tissues, including the prostate, but resistance can develop quickly. Fosfomycin is not commonly used in the US, but it’s effective against many drug-resistant bacteria. It’s not recommended for initial treatment due to its inadequate concentration in kidney tissues. Pivmecillinam is not available in the United States but is commonly used elsewhere due to its low reported bacterial resistance. It’s useful in the urinary tract but doesn’t effectively penetrate deep tissues.
People with complicated infections usually need antibiotics for 10 to 14 days. Diabetic patients have a higher risk for yeast infections during and after antibiotic treatment, so they need additional care. The choice of an antibiotic takes into account many factors such as potential allergies, side effects, local bacterial resistance, potential drug interactions, costs, and recent use of antibiotics.
If the first-choice antibiotics can’t be used, second-line antibiotics are prescribed. These include amoxicillin-clavulanate, cefpodoxime, cefdinir, cefadroxil, and cephalexin – if other beta-lactam antibiotics can’t be used – as well as doxycycline, or fluoroquinolones such as ciprofloxacin, norfloxacin, or levofloxacin. If the infection doesn’t improve with oral antibiotics, an injection of ceftriaxone, ertapenem, or gentamycin/tobramycin could be given, followed by a course of oral antibiotics.
In some cases, bladder infections can be treated by injecting an antibiotic solution directly into the bladder, though this typically requires a catheter and is therefore generally reserved for select patients. For recurrent infections, mandelamine, which converts to formaldehyde in acidic urine, can be used as a preventive measure. D-Mannose is a non-antibiotic option for preventing urinary tract infections, though its efficacy needs further research.
If a patient doesn’t respond to treatment within 72 hours or experiences recurrent symptoms, their treatment needs to be reassessed. This might include testing the urine to determine the best antibiotic choice or exploring other potential causes of the symptoms. In men, cystitis is rare and treatment approaches should consider potential complications and prostate involvement. If prostate involvement is suspected, a longer course of antibiotics that can penetrate the prostate is usually given to prevent chronic prostatitis, a long-term inflammation of the prostate.
What else can Cystitis (Urinary Tract Infection) be?
In women who are experiencing pain during urination, doctors might consider whether the patient could have vaginitis (inflammation of the vagina) or urethritis (inflammation of the urethra). Vaginitis often comes with symptoms like vaginal discharge, pain during sex, and itching. It can be caused by a bacterial infection, trichomoniasis, or a yeast infection.
On the other hand, painful bladder syndrome could be a possible cause if there are continuous feelings of discomfort in the bladder but no signs of infection. However, this is usually thought to be the cause only after other conditions have been ruled out.
In men with symptoms of lower urinary tract infection along with fever, feeling unwell, pain around the prostate area, or problems passing urine, the doctor will need to rule out prostatitis (swelling of the prostate gland). Getting repeated urinary tract infections should make doctors consider the possibility of chronic bacterial prostatitis.
Here is a brief rundown of these conditions:
- Painful bladder syndrome – The symptoms include frequent urination, a feeling of urgency to urinate, and discomfort while urinating. However, there are no signs of an infection. This diagnosis is usually made after everything else has been ruled out.
- Pelvic inflammatory disease – Common symptoms include pain in the pelvic and lower abdominal area, fever, and potentially a discharge from the cervix.
- Prostatitis – Symptoms can include pain during ejaculation or unclear pain in the pelvic area and a tender prostate gland on physical examination. Urinalysis is usually negative in this condition.
- Vaginitis – Some symptoms include vaginal discharge, itching, an unpleasant odor, pain during sex (dyspareunia), and potentially painful urination (dysuria). Usually, the patient won’t present urinary urgency or frequency.
- Atrophic vaginitis – This happens primarily in women after menopause and is linked with vaginal dryness, pain during sex, thin watery vaginal discharge, and a loss of color in the labia and vaginal lining.
- Urethritis – There are white cells present in the urine but no bacteria. Women who are sexually active are at high risk.
What to expect with Cystitis (Urinary Tract Infection)
People with simple cystitis, a type of urinary tract infection (UTI), generally see their symptoms improve within three days of starting antibiotics. However, a quarter of women may experience another UTI within six months of their first one, and this likelihood increases if they had more than one UTI previously. With appropriate treatment, complications are rare and severe conditions like bacteremia and sepsis hardly occur.
In rare cases, a lower UTI might lead to emphysematous cystitis, a serious condition with gas formation in the bladder wall. If not properly controlled, this condition could be fatal. Symptoms include abdominal pain and the release of gas or air during urination, both more common than in simple cystitis. Blood tests will also show high levels of bacteria in about half the patients. The best method for diagnosis is a CT scan.
Most people who develop emphysematous cystitis have diabetes, making it the primary risk factor. Other risks include being female, having a weakened immune system or urinary issues, the use of a long-term urinary catheter, being over 60 years old, and having chronic UTIs.
While antibiotics are usually enough for treatment, bladder drainage may be necessary in cases of urinary retention, incomplete bladder emptying, or severe blood in the urine. In rare instances, an infectious disease might destroy part of the bladder wall, requiring surgical removal of the affected part of the bladder.
Possible Complications When Diagnosed with Cystitis (Urinary Tract Infection)
- Kidney infection (Pyelonephritis)
- Formation of abscess, or pus-filled pockets, in the kidney or the surrounding area (Renal or perinephric abscess)
- Clotting of the vein that drains blood from the kidney (Renal vein thrombosis)
- Blood poisoning (Sepsis)
- Sudden failure of kidney function (Acute renal failure)
- A rare, severe kidney infection that causes gas to be produced in the kidney tissue (Emphysematous pyelonephritis)
- Inflammation of the prostate gland (Prostatitis)
Preventing Cystitis (Urinary Tract Infection)
It’s important for individuals diagnosed with cystitis, a type of urinary tract infection, to carefully follow their prescribed course of antibiotics. Drinking plenty of water can also help manage symptoms and clear the infection. For those who are sexually active, peeing after sex can help prevent the infection from coming back. They should also make sure to get in touch with their healthcare provider if their symptoms get worse or don’t get better even after starting antibiotics.
