In times gone by we understood overactive bladder as a condition of mostly older age groups who have detrusor instability causing symptoms of frequency and urgency. However, in recent times this appears to have engulfed a younger age group, with patients as young as 18 labelled as having overactive bladder after having full investigations including a cystoscopy. A vast proportion of them are also being put on bladder muscle relaxing medication.
Cervical motion tenderness on vaginal examination is a very good indicator of infective cause
Interestingly, the same patients had completely normal functioning bladder before they became sexually active.
I have seen many patients, mostly from younger age groups, who came with recurrent cystitis-type symptoms but their MSU report did not show any bacterial growth, although invariably the urine report would show a high WBC count.
Frustrated by my inability to cure these patients, in July 2011 I decided to examine a patient vaginally. To my surprise I found significant tenderness of cervical motion but no other finding like discharge. I treated this patient with a two-week course of Doxycycline and Metronidazole. She was cured and has not come back with cystitis symptoms since. I have treated many such patients in this way since and have found it so successful that I decided to do a small audit.
For six months from September 2015 I systematically sent for an MSU and did a triple swab for patients presenting with recurrent symptoms of frequent and/or dysuria whose MSU did not grow bacteria in the past and I also did full vaginal examination.
As I had previously found, these patients were cured of their symptoms if I treated them with Doxycycline and Metronidazole – I gave them a two week course of these antibiotics along with a one week prescription of Doxycycline for their partners to be taken simultaneously. I arranged to see these patients four weeks after. At the next visit I also repeated the MSU for some of them, mostly to see if their high WBC count in the urine had gone or not.
Results
I had 14 relevant patients in this six month period. All of them had cervical motion tenderness of varying severity. Triple swabs for chlamydia and gonorrhoea were negative in all of them. BV was found in only one of them. MSU showed E. coli in three of them. On review six months later all were cured of the symptoms. None came back with cystitis type symptoms in this period except for one patient who still had urgency and nocturia and was put on Regurin for overactive bladder and one other who still recurrently got cystitis with confirmed E. coli infection every time.
In patients who had repeat MSUs the high WBC count had gone in all of them.
Conclusion
If you see a patient with recurrent cystitis-type symptoms but their MSU does not grow bacteria, they should have a full vaginal examination and if cervical tenderness is found then they should be treated with Doxycycline and possibly Metronidazole and their partner should be treated with Doxycycline simultaneously.
Although triple swab in these patients did not grow any bacteria there is possible another organism present, like mycoplasma, which is sensitive to Doxycycline and the laboratory should consider trying to culture these from the MSU. I am not sure if it is possible but I think more work needs to be done in this.
This can potentially save a lot of money through obviating the need for hospital-based investigation and unnecessary medication to patients as they are currently being given bladder relaxant medication with diagnosis of overactive bladder.
This will also have implications for GUM clinics and STI management and current management of overactive bladder will need to be reconsidered.
