Recurrent UTI / cystitis

Symptoms of cystitis may include:

• bladder/lower abdominal pain
• burning or stinging sensation when passing urine
• needing to pass urine frequently and urgently
• cloudy and smelly urine
• blood in urine

If bladder infections have led to kidney infections, then this may lead to lower back pain, fever and feeling of nausea and being unwell.

This is most likely related to women’s anatomy as they have a much shorter urethra (the water pipe coming out of bladder). Also, the opening of the bladder is close to the anus, so there is a higher chance of bacteria travelling to the bladder from the bowel.

Almost all women will get at least one episode of cystitis in their lifetime. Around one in five women who have had cystitis will get it again (recurrent cystitis). Cystitis can occur at any age, but it is more common in:

• pregnant women
• sexually active women (“honeymoon cystitis”)
• post-menopausal women

Bacterial infection

Bacterial infection is the most common cause of cystitis. The infection irritates the bladder lining and causes the symptoms described above. The travel of bacteria into the bladder can be a result of intercourse and poor hygiene. It is important to wipe from front to back to reduce the risk of introducing bacteria from the back passage to the bladder.

Changes in the genital area due to menopause can also increase the risk of a bladder infection. This may be related to changes in the bio-bacterium and mucus of the vagina as result of oestrogen deficiency. These changes increase the risk of harbouring bacteria which causes infection.

Other causes

Cystitis symptoms can also occur as a result of damage to or irritation of the urethra and bladder by causes such as:

• damage caused by the insertion of a catheter after surgery
• injury caused by vigorous or frequent sex, sometimes called honeymoon cystitis
• wearing tight clothing
• chemical irritants, such as perfumed soap or talcum powder
• other bladder or kidney problems, such as a kidney infection or stones

Most women self-diagnose cystitis from the recognisable symptoms they get. However, in some cases, a misdiagnosis can occur. A urine dipstick (urinalysis) can be a guide for doctors for diagnosing infection, but this can also be inaccurate in elderly women. The best diagnosis methods are:

Urine culture

Sending a urine sample to a microbiology laboratory can be very important, as this can help to confirm if an infection is present and what type of bacteria is causing the infection. The laboratory can also give information about the type of antibiotics the infection is sensitive to, so the most appropriate treatment can be offered.

Hospital tests

In cases of recurrent UTI when the patient does not respond to treatment, then referral to a specialist will be necessary for further management. Other tests may be offered such as:

• an ultrasound scan of the pelvis and renal tract
• a cystoscopy
• a urodynamic study

Symptoms can settle within 4–9 days with some of the conservative treatments below, or your GP can give you a course of antibiotics.

Conservative treatment options

• These can be of benefit for mild cystitis without the need to see a GP:
• Simple painkillers, such as Paracetamol or Ibuprofen, to reduce discomfort
• Adequate intake of water, over 1.5 litres (8 glasses)
• Avoidance of alcohol and caffeinated drinks
• Avoidance of intercourse until the cystitis has cleared up

There is some more useful advice for avoiding cystitis in the prevention section, below.

Antibiotics

In cases of moderate to severe cystitis, a short course of antibiotics is recommended. This can shorten the duration of the symptoms.

Women with recurring cystitis may benefit from post-coital antibiotics, stand-by antibiotics or continuous antibiotics as described below:

• If the cystitis usually occurs after having sex, the woman may be given a prescription for antibiotics to take within two hours of having sex.
• A stand-by antibiotic is a prescription that can be kept by a patient in the case of a recurrent infection, without her needing to visit her GP again.
• Continuous low-dose antibiotics are medicines that are taken continuously for several months, to prevent further episodes of cystitis.

There is no treatment that can guarantee that cystitis will not reoccur, but the advice below can help to reduce the occurrence of infections:

• Drink adequate amounts of fluid, especially water. The average sized person should be drinking about 1.5 litres (8 glasses) per day. It is also better to avoid alcohol and caffeinated drinks.
• Avoid using chemicals such as bubble bath or soap near the genital area.
• Empty the bladder fully. You can also try emptying your bladder twice (double voiding) to help with complete emptying.
• Wear cotton underwear and loose trousers.
• Maintain good personal hygiene. Wipe from front to back after going to the toilet.
• Avoid food or drinks that can trigger cystitis symptoms such as caffeinated and acidic drinks or spicy foods.

In sex-related cystitis, the following advice may be of benefit:

• wash your genital area and your hands before and after sex
• use a lubricant when having sex
• after having sex, make sure that you empty your bladder as soon as possible to get rid of any germs

Cranberry products

Although cranberry products are not effective at treating cystitis, they may help to prevent recurrent attacks. Cranberry capsules may be a more effective treatment than drinking cranberry juice, as a lot of juice must be drunk for it to have any benefit, and not everyone likes the taste. High-strength capsules, which contain 200mg of cranberry extract, are available in shops.

Vaginal topical oestrogen

The menopause and the related lack of oestrogen can cause thinning of the urogenital skin and changes in vaginal condition. This is called vaginal atrophy which can be treated with topical oestrogen preparations as a pessary (Vagifem) or cream (Ovestin) which is inserted with an applicator.

There is good evidence that this treatment, taken on a longer basis, can prevent recurrent cystitis. This is a prescription-only treatment, so you may need to see your GP for this.