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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 is often 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 & 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 that 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 are usually associated with a tumor or kidney stones that block the flow of urine and are often 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 can now 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 require a pelvic examination as part of the procedure to obtain urine specimens. The patient lies on an obstetrical table with legs in the stirrups. The doctor first takes a vaginal culture smear. The patient is then asked to void while lying on the table. The first five to 10 ml are collected to test for urethral infection. A midstream urine sample of 200 ml is then collected to test for bladder infection.

In women, a vaginal bacterial count that is higher than those of the two urine samples indicates vaginitis. A high bacterial count in the first urine sample indicates urethritis. 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. Bacterial count can be given in CFU or colony forming units.

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 ultrasound tests 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 are generally not used in children under 18 years of age.) 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 is also used to treat reflux problems (movement of the urine backwards) 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 is also thought to help prevent cystitis by making it more difficult for bacteria to cling to the bladder wall. A variety of herbal therapies are also 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 can also 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 are sometimes 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.

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.

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.

Further Reading

For Your Information

Books

• Anderson, E. Everett. "Dysuria, Pyuria, and Hematuria." In Current Diagnosis 9, edited by Rex B.Conn, et.al. Philadelphia: W. B. Saunders Company, 1997.
• Donovan, James F., and Richard D. Williams. "Urology." In Current Surgical Diagnosis & Treatment, edited by Lawrence W. Way. Stamford, CT: Appleton & Lange, 1994.
• "Genitourinary Disorders: Lower Urinary Tract and Male Genital Tract Infections." In The Merck Manual of Diagnosis and Therapy, vol. II, edited by Robert Berkow, et al. Rahway, NJ: Merck Research Laboratories, 1992.
• King, Lowell R. "Bacterial Infections of the Urinary Tract in Girls." In Conn's Current Therapy, edited by Robert E. Rakel. Philadelphia: W. B. Saunders Company, 1998.
• "Lower Urinary Tract Infection." In Professional Guide to Diseases, edited by Stanley Loeb et al. Springhouse, PA: Springhouse Corporation, 1991.
• Mata, John A. "Bacterial Infections of the Urinary Tract in Females." In Conn's Current Therapy, edited by Robert E. Rakel. Philadelphia: W. B. Saunders Company, 1998.
• Robertson, Jack R., and David B. Hebert. "Gynecologic Urology." In Current Obstetric & Gynecologic Diagnosis & Treatment, edited by Alan H. DeCherney and Martin L. Pernoll. Stamford, CT: Appleton & Lange, 1994.

Gale Encyclopedia of Medicine. Gale Research, 1999.