Cystitis is a term that refers to urinary bladder inflammation that results from any one of
a number of distinct syndromes. It is most commonly caused by a bacterial infection in
which case it is referred to as a urinary tract infection.
Signs and symptoms
• Pressure in the lower pelvis
• Painful urination (dysuria)
• Frequent urination (polyuria) or urgent need to urinate (urinary urgency)
• Need to urinate at night (nocturia, similar to prostate cancer or BPH)
• Abnormal urine color (cloudy), similar to a urinary tract infection
• Foul or strong urine odour
• A urinalysis commonly reveals white blood cells (WBCs) or red blood cells
• A urine culture (clean catch) or catheterized urine specimen may be performed to
determine the type of bacteria in the urine and the appropriate antibiotic for
Causes of cystitis
Cystitis is often caused by bacteria that get into your urethra from surrounding skin and
travel up towards your bladder, causing infection and irritation. Most infections are
caused by bacteria that normally live harmlessly in your bowel, usually a type of bacteria
called Escherichia coli (or E. coli for short).
Women get cystitis more than men partly because, in women, the urethra is nearer the
opening of the back passage (anus) where bacteria from your bowel can collect. This
makes it easier for bacteria to get transferred from the surrounding skin into the urethra.
The urethra is also much shorter in women than men, so there is less distance for the
infection to travel to the bladder.
You're more likely to get cystitis if you:
• are sexually active - the risk increases the more often you have sex
• use spermicide-coated condoms or a diaphragm with spermicide
• have been through the menopause - causing changes to the lining of your vagina
and urethra, making you more likely to have bacteria in your urine
• have a urinary catheter - introducing bacteria directly into your bladder
• have diabetes - your urine may contain more sugar, encouraging bacteria to
• have a condition that prevents you from emptying your bladder such as bladder
or kidney stones, an enlarged prostate or if you're pregnant
• use irritants such as certain soaps, which may irritate your urethra or bladder
The most common cause of cystitis is when bacteria, that usually live in the anus, enter
the urethra and travel into the bladder. This can happen during sexual intercourse, when
inserting tampons or by wiping/washing your bottom from back to front. Women who use
the contraceptive diaphragm may also be at risk of cystitis.
If the bladder is not emptied fully this can also cause bacteria to multiply, this is
especially common in pregnant women because of the pressure on the pelvic area.
After the menopause women have a reduction in female sex hormones and so the lining
of the urethra and the bladder become thinner and so are more likely to become infected
and damaged. Women also produce less mucus after the menopause and without the
mucus bacteria are more likely to multiply.
In women physical damage or bruising often caused by vigorous or frequent sex can
also lead to cystitis this is sometimes known as 'honeymoon cystitis'.
Men who have an enlarged prostate gland are more at risk of getting cystitis, this is
because the prostate prevents the bladder from completely emptying. When the bladder
is not completely emptied the small drop that is always left behind may contain bacteria
(a cause of cystitis).
Treatment of cystitis
You can often treat cystitis yourself by doing the following.
• Take an over-the-counter painkiller, such as paracetamol. Always read the
patient information leaflet that comes with the medicine and if you have any
questions, ask your pharmacist for advice.
• Make your urine less acidic by drinking a glass of water with half a teaspoon of
bicarbonate of soda dissolved in it. Products that contain sodium bicarbonate or
potassium citrate have the same effect and are available from your pharmacist.
Always read the patient information that comes with your medicine and ask your
pharmacist for advice if you have any questions.
• Make sure you drink enough fluids to help flush out the infection.
Your GP may prescribe antibiotics, which you will need to take for three to six days. You
should always take the full course of antibiotics to get rid of the bacteria completely,
even if your symptoms clear up before you finish the course. Always ask your doctor or
pharmacist for advice and read the patient information leaflet that comes with your
If your symptoms don't clear up, contact your GP as some infections can be resistant to
the antibiotics normally used.
If antibiotics don't work, it's possible that you have a type of cystitis called interstitial
cystitis. This is chronic (long-lasting) inflammation of your bladder wall that isn't caused
by infection. Your GP will be able to give you more information.
Prevention of cystitis
There's good evidence to show that drinking cranberry juice or taking capsules
containing 200mg of cranberry extract is effective in preventing cystitis from coming
back. However, it's not clear if this works as a treatment. Ask your GP or pharmacist for
advice before taking cranberry capsules or drinks, particularly if you're taking the blood-
thinning medicine warfarin. Avoid cranberry juice containing lots of sugar, as sugar can
encourage bacteria to grow.
If you get cystitis three or more times a year, your GP may give you a course of
antibiotics to keep at home so you can start taking them as soon as you know you're
getting a bout of cystitis. Alternatively, if you get repeated attacks, you may need to take
a low dose of antibiotics for six to 12 months. If you get cystitis after having sex, your GP
may advise you to take a single dose of antibiotics immediately after you have had sex
to prevent an attack.
If you use spermicidal products for contraception, which can increase your risk of getting
cystitis, ask your GP or family planning adviser about alternative methods.
For women who have been through the menopause, creams containing oestrogen can
be applied to the vagina and may reduce the risk of cystitis.
Although lacking in scientific evidence, the following may help to prevent cystitis:
• passing urine after having sex
• increasing your fluid intake
• wearing loose clothing
• wiping front to back, not back to front after going to the toilet
• passing urine as soon as you feel the need to, instead of 'holding on'
Some people find that certain triggers, such as tea or coffee, can make cystitis worse. If
you notice any such triggers, try to avoid them.
Pyelonephritis: Pyelonephritis is a kidney infection, usually from bacteria that spread
from the bladder. Pyelonephritis is an ascending urinary tract infection that has reached
the pyelum (pelvis) of the kidney
Most cases of "community-acquired" pyelonephritis are due to bowel organisms that
enter the urinary tract. Common organisms are E. coli (70-80%) and Enterococcus
faecalis. Hospital-acquired infections may be due to coliforms and enterococci, as well
as other organisms uncommon in the community (e.g. Klebsiella spp., Pseudomonas
aeruginosa). Most cases of pyelonephritis start off as lower urinary tract infections,
mainly cystitis and prostatitis.
Risk is increased in the following situations:
• Mechanical: any structural abnormalities to the kidneys and the urinary tract,
vesicoureteral reflux (VUR) especially in young children, calculi (kidney stones),
urinary tract catheterisation, urinary tract stents or drainage procedures (e.g.
nephrostomy), pregnancy, neurogenic bladder (e.g. due to spinal cord damage,
spina bifida or multiple sclerosis) and prostate disease (e.g. benign prostatic
hyperplasia) in men
• Constitutional: diabetes mellitus, immunocompromised states
• Behavioural: change in sexual partner within the last year, spermicide use
• Positive family history (close family members with frequent urinary tract
Acute pyelonephritis is an exudative purulent localized inflammation of the renal pelvis
(collecting system) and kidney. The renal parenchyma presents in the interstitium
abscesses (suppurative necrosis), consisting in purulent exudate (pus): neutrophils,
fibrin, cell debris and central germ colonies (hematoxylinophils). Tubules are damaged
by exudate and may contain neutrophil casts. In the early stages, glomeruli and vessels
are normal. Gross pathology often reveals pathognomonic radiations of hemorrhage and
suppuration through the renal pelvis to the renal cortex. Chronic infections can result in
fibrosis and scarring.
Xanthogranulomatous pyelonephritis is a form of chronic pyelonephritis associated with
granulomatous abscess formation and severe kidney destruction.
As practically all cases of pyelonephritis are due to bacterial infections, antibiotics are
the mainstay of treatment. Mild cases may be treated with oral therapy, but generally
intravenous antibiotics are required for the initial stages of treatment. The type of
antibiotic depends on local practice, and may include fluoroquinolones (e.g.
ciprofloxacin), beta-lactam antibiotics (e.g. amoxicillin or a cephalosporin), trimethoprim
(or co-trimoxazole). Aminoglycosides are avoided due to their toxicity, but may be added
for a short duration.
All acute cases with spiking fevers and leukocytosis should be admitted to the hospital
for IV fluids hydration and IV antibiotic treatment immediately. ciprofloxacin IV 400mg
every 12 hours is the first line treatment of choice. Alternatively, ampicillin IV 2g every 6
hours plus gentamicin IV 1mg/kg every 8 hours also provide excellent coverage. If the
patient is pregnant, ampicillin/gentamicin combination is the treatment of choice, as
ciprofloxacin is contraindicated. During the course of antibiotic treatment, serial white
blood count and temperature should be closely monitored. Typically, the IV antibiotics
should be continued till the patient is afebrile for at least 24 to 48 hours, then equivalent
oral antibiotic agents can be given for a total of 2-week duration of treatment.
Intravenous fluids may be administered to compensate for the reduced oral intake,
insensible losses (due to the raised temperature) and vasodilation and to maximize urine
output. If the patient is septic secondary to an obstructing stone, percutaneous
nephrostomy is indicated for source control.
In recurrent infections, additional investigations may identify an underlying abnormality.
Occasionally, surgical intervention is necessary to reduce chances of recurrence. If no
abnormality is identified, some studies suggest long-term preventative (prophylactic)
treatment with antibiotics, either daily or after sexual intercourse. In children at risk of
recurrent UTIs, meta-analysis of the present literature indicates that not enough studies
have been performed to conclude prescription of long-term antibiotics have a net
positive benefit. Ingestion of cranberry juice has been studied as a prophylactic
measure; while studies are heterogeneous, many suggest a benefit.
Some recommend other nutritional approaches to prevent recurrence of UTIs.
Increasing fluid intake, consuming cranberry juice, blueberry juice, and fermented milk
products containing probiotic bacteria, have been shown to inhibit adherence of bacteria
to the epithelial cells of the urinary tract.