Cystitis generally refers to inflammation of bladder but its aetiology may include infection. Recurrent urinary tract infection (UTI) is defined as two or more infections in six months or three or more within 12 months.
Most women have at least one attack of UTI during their lifetime and 20% of women will experience repeated attacks. This is more likely in women who are pregnant, sexually active or postmenopausal.
UTI is a leading cause of morbidity in the female population, with high levels of prevalence and recurrence within six months.1 Most common organisms are E. coli, Klebsiella, Proteus and Staphylococci. Majority of these are dealt with in primary care, however, significant numbers are being referred to secondary care with added financial implications.
A diagnosis of cystitis can be made when the patient reports dysuria, increased frequency, pain or discomfort in suprapubic area and/or fever.
- Ask about number of episodes, dietary habits, fluid intake, bowel routine, STDs, haematuria and vaginal discharge or itching.
- Diabetes and conditions leading to immunosuppression may be contributory.
- In patients over 50 years of age, renal tract malignancy should be ruled out in the case of recurrent episodes, which may or may not be associated with haematuria.
- Some women report recurrent episodes and it may be associated with sexual intercourse. 2
- Some recreational drugs such as ketamine can cause cystitis-like symptoms.
General physical examination followed by focussed examination can add to the establishment of diagnosis and treatment.
- The abdomen should be inspected for scars from previous surgery.
- A vaginal examination should be performed in order to exclude pathology including malignancy of vulva and urethra and large pelvic masses, infection, prolapse or atrophic vaginitis in postmenopausal women. Prolapse can cause recurrent infection, or produce symptoms which could be confused with a recurrent infection.
- Urine dipstick and a subsequent MSU in symptomatic patients are helpful in establishing the diagnosis.
- The measurement of post-void residual volume by bladder scan or catheterisation should be performed in women with symptoms suggestive of voiding dysfunction or recurrent UTI.
- A bladder diary will give an insight into daily fluid intake and could be helpful in advising patients on fluid intake modifications.
- In recurrent episodes of severe cystitis and or repeated infection of more than three in six months, ultrasound scan of renal tract and flexible cystoscopy may be indicated.
The aim of the treatment is to control the symptoms and prevent recurrence of cystitis.
Differential diagnosis – including bladder cancer, carcinoma in-situ and overactive bladder – should be considered, especially if MSU is negative. Be aware of persistent haematuria.
The treatment of cystitis should include:
- Lifestyle advice can be helpful (see box) and an increase in fluid intake is recommended.
- In acute cases, treatment with antibiotics is recommended. Antibiotic resistance and not prescribing antibiotics are associated with a greater than 50% increase in the duration of more severe symptoms in women with uncomplicated urinary tract infection. 3
- For an uncomplicated infection, prescribe either trimethoprim 200 mg twice daily, for three days, or nitrofurantoin 50 mg four times daily, or 100 mg as modified-release twice daily, for three days.
- For a complicated infection, prescribe a five to 10 day course of trimethoprim or nitrofurantoin.
- In postmenopausal cohort with atrophic vaginitis, topical oestrogen application is an effective adjunct to the treatment.
- An NSAID can also be considered in severely symptomatic cases.
- In recurrent episodes, long-term prophylactic antibiotics can be considered with specialist advice.
- Cystitis related to sexual intercourse or ‘honeymoon cystitis’ can be prevented by avoiding spermicidal materials and adequate lubrication. Patients are also advised to void following sexual intercourse. For recurrent cystitis associated with sexual intercourse, offer post-coital trimethoprim 100 mg or cefalexin 500mg to be taken within 2 hours.
Lifestyle advice in recurrent cystitits
- Drink at least one to two litres (three or four pints) of water every day.
- Avoid perfumed soaps, shower and bath products, vaginal deodorants etc.
- Wear cotton underwear and avoid wearing tight trousers.
- If cystitis is triggered by sexual intercourse, it can help if both the patient and the partner wash carefully before and after sex.
- Empty bladder, before and after sex, as this helps flush out any bacteria which may have entered the urethra.
- Pass urine when feeling the urge, rather than trying to ‘hold on’ until later and make sure the bladder is emptied completely.
- Wipe bottom from front to back to help prevent bacteria spreading.
The management of UTI in pregnancy
For recurrent infections (symptomatic or asymptomatic) in pregnancy, either cephalexin 125-250 mg/day or nitrofurantoin 50 mg/day, may be used for prophylaxis. Nitrofurantoin should be avoided at term because of risk of inducing neonatal haemolytic anaemia.
There is conflicting evidence on use of cranberry juice or tablets in prevention of recurrent cystitis. A recent Cochrane systematic review did not find a significant relation between use of cranberries and reduction in UTIs. 4
Post-menopause recurrent cystitis
The prevalence rate of one episode of UTI in a given year among postmenopausal women varies from 8% to 10%. Of those women who have an episode, 5% will experience a recurrence within the year. Topical oestrogens are effective in postmenopausal women with associated symptoms of atrophic vaginitis, for example, itching, dryness and painful intercourse.5 Topical cream and pessary were equally effective.
Long-term prophylactic antibiotics
Treating an acute uncomplicated cystitis episode reduces duration of symptoms. Non-pregnant women who had two or more UTIs in the past six months have less chance of having a further UTI if given three to six months treatment with prophylactic antibiotics.
For recurrent cystitis not associated with sexual intercourse offer a six-month trial of low-dose continuous antibiotic treatment with trimethoprim 100 mg every night or immediate-release nitrofurantoin 50mg-100mg every night. Modified-release nitrofurantoin is not licensed for prophylaxis. Nitrofurantoin is very rarely associated with pulmonary fibrosis and liver toxicity – liver function testing is advised. Self-start therapy can also be used in patients with recurrent symptoms in specific cases.
Expert advice should be sought for non-infective causes of cystitis such as radiation cystitis or interstitial cystitis (painful bladder syndrome).
While the majority of recurrent UTIs can be managed in primary care, there are red flag signs including recurrent presentations, persistent symptoms, frank haematuria and postmenopausal bleeding that should warrant a referral to secondary care for further assessment and management.
Red flags for urgent referral
• Persistent microscopic haematuria if aged 50 years and older
• Visible/frank haematuria
• Recurrent or persisting UTI associated with haematuria if aged 40years and older
• Suspected malignancy arising from the urinary tract
Referral is required for:
• recurrent UTI not responding to antibiotic treatment.
• non-bacterial cystitis
• clinically benign pelvic mass
• suspected neurological disease
• suspected urogenital fistulae
• previous continence surgery
• previous pelvic cancer surgery
• pelvic radiation
Patient information and support
Mr Zaki Almallah is a consultant urologist with special interest in bladder pain, interstitial cystitis, urinary incontinence and complex bladder dysfunction at Birmingham Bladder Clinic. E mail: email@example.com
Mr Ali Shahzad is a specialist registrar in urology, West Midlands Training Programme.
- Ciani O, Grassi D, Tarricone R. An economic perspective on urinary tract infection: the ‘costs of resignation’. Clin Drug Investig. 2013;33(4):255-61
- Yoon BI, Kim SW, Ha US, et al. Risk factors for recurrent cystitis following acute cystitis in female patients. J Infect Chemother. 2013 10.1007/s10156-013-0556-2
- Little P, Merriman R, Turner S, et al. Presentation, pattern, and natural course of severe symptoms, and role of antibiotics and antibiotic resistance among patients presenting with suspected uncomplicated urinary tract infection in primary care: observational study. BMJ. 2010; 340:b5633.
- Jepson RG, Williams G, Craig JC. Cranberries for preventing urinary tract infections. Cochrane Database Syst Rev. 2012;10:CD001321.
- Perrotta C, Aznar M, Mejia R, et al. Oestrogens for preventing recurrent urinary tract infection in postmenopausal women. Cochrane Database Syst Rev. 2008;(2):CD005131.