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Cystitis is caused by bacterial growth in the bladder. It is one of the most common bacterial infections that occur in humans. Up to a third of all women suffer at least one urinary tract infection at some point in their lives. As a result, this disease is of great medical and economic importance.
Urinary tract infections are classified as either simple or complicated, depending on the cause and course. Simple (uncomplicated) cystitis only affects healthy women with a normal urinary system. Due to the anatomy of the female urinary system, women suffer more frequently of this disease than men. In women, the mouth of the urethra is near the vagina and anus. Therefore, bacteria from the rectum, where the number of bacteria is high, can migrate into the area around the vagina and urethra. From there, it is only a short distance (about 4 centimeters) through the urethra to the bladder. Sexual intercourse can force the bacteria into the bladder. Consequently, sexually active women are at higher risk for cystitis.
All urinary tract infections, other than those referred to in point 2, fall into the category of complicated urinary tract infections. A complicated version of the infection can happen, for example, if the inflammation rises in the direction of the kidneys or if there is an organic disease or malformation of the urinary tract, making the treatment of these infections more difficult.
In men, cystitis is generally considered complicated, since the long male urethra should reliably prevent bacteria from entering the bladder. However, if the normal flow of urine is obstructed and urine remains in the bladder, bacteria multiply there, increasing the risk of infection. Causes of such residual urination are, for example, nerve damage due to spinal cord injuries.
Causes of such residual urination are, for example, nerve damage due to spinal cord injuries (such as herniated discs) or a disease such as diabetes mellitus (diabetes). However, the most common reason for obstruction of bladder emptying in men over 50 is an enlarged prostate.
A distinction is also made between acute and chronic inflammation. Chronic urinary tract infections are defined as at least three episodes per year or two per half-year. They are a very common disease with a prevalence of 1-5 percent in women.
In women, the main cause is generally the menopause and the associated decrease in estrogen levels that make the mucosa of the urethra thinner and weaken the local defense system, allowing the germs to penetrate more easily. Also, women in pregnancy or after birth suffer more frequently from cystitis.
The risk factors, especially in young women, include sexual intercourse and the use of chemical contraceptives. Another cause may be the side effects of drugs such as cortisone, as well as previous radiation therapies in the pelvic area. Patients with urinary catheters (a tube that is inserted into the urethra to drain the urine) also have a very high rate of bladder infections, as the bacteria reach the bladder along the wall of the catheter. There are other possible bacterial retreats such as urinary stones, tumors, or scarring. In addition, a weakened immune system, an unhealthy lifestyle such as smoking, little exercise, and little sleep contribute to the susceptibility to develop the infection.
The most common cause of cystitis is the intestinal bacterium Escherichia coli (E.coli). This bacterium triggers about 80 to 90% of acute cystitis. Other pathogens include Proteus mirabilis, staphylococci, streptococci, or Klebsiellen; also, very rarely, fungi. Unfortunately, the level of resistance of many bacteria to the most commonly used antibiotics has increased in recent years.
An uncomplicated urinary tract infection causes irritation and swelling of the bladder mucosa and urethra. This leads to the sudden development of one or more of the following symptoms:
The need to urinate more often than normal (even at night), although each time only small amounts of urine can be released, a sudden need to urinate (imperative urination), burning while urinating, and pain in the lower abdomen. The urine is often cloudy and has an unpleasant or intense smell.
Sometimes the urine is even reddish because blood is a very powerful dye. Even small blood admixtures can lead to an intense red coloration of the urine.
Many women who have had cystitis in the past can easily recognize these symptoms if a new infection is indicated.
People with complicated cystitis usually have similar symptoms to people with simple infections. However, they can also develop additional general symptoms of the disease such as fever, chills, nausea, vomiting, flank pain, back pain, or confusion when the bacteria spread from the urinary system into the bloodstream or kidney.
Complicated cystitis requires more tests and treatment than simple infections.
If you suspect cystitis, you should contact a doctor as soon as possible. This can be the family doctor but also an urologist or gynaecologist. It is important to get treatment soon. Also, this can initially be done by remote diagnosis.
The doctor will ask you about the above-mentioned symptoms, which are typical for cystitis. He will rule out that you have fever, chills, nausea, vomiting, flank pain or other symptoms that may indicate a more serious infection. If you have had cystitis before, your doctor may be able to diagnose the problem by phone. Based on the validated questionnaire ACSS (Acute Cystitis Symptom Score), the diagnosis of acute, uncomplicated cystitis can be made with certainty based on clinical criteria. If the symptoms do not exactly match those of the previous cystitis, you will probably need to pay a visit to the outpatient clinic or doctor’s office.
Women with first-time cystitis, as well as all men, children, and people with potentially complicated cystitis must see a doctor. The doctor will perform a urinalysis to look for signs of an active infection. Before releasing a urine sample, you should clean your urethra opening. The urine sample must be taken during urination (so-called middle jet urine) in order to avoid contamination with bacteria living around the urethra entrance. The urine is then examined for white and red blood cells, as well as bacteria and cell residues. A culture can also be created from the sample in the laboratory, to identify the exact type of bacteria.
As a rule, the so-called sensitivity tests are also carried out to determine which antibiotics can effectively combat the infection.
In ultrasound, the bladder is examined for residual urine after urination and in case of a complicated infection the kidneys for drainage obstructions.
In the case of chronic or repeated cystitis, a bladder reflection is also carried out.
For complicated or repeated cystitis, an extended examination program is necessary, which includes urethral swabs and an analysis of the semen and prostate fluid in men. A functional assessment of the storage and emptying function of the urinary bladder is carried out by measuring the urine jet on a special toilet (uroflowmetry) and measuring the pressure of the bladder (urodynamics). For the morphological assessment of the urinary system, contrast agent examinations are used as urinary bladder function chromatography (mication cystourethrography - MCU), computed tomography (CT), or magnetic resonance imaging (MRI).
A drug therapy experiment can be undertaken without antibiotics. For example, Ibuprofen 3 x 400 mg over 3-5 days or Diclofenac 2 x 75 mg can be used in this case. In the absence of improvement, simple cystitis in women is usually treated with one of the following antibiotics:nitrofurantoin twice daily for 5 days, fosfomycin as a single oral dose before bedtime, Nitroxoline 250 mg three times daily for 5 days, or pivmecillinam 400 mg three times daily for 3 days.
According to the current guidelines, the following preparations are no longer to be used as the first choice for uncomplicated urinary tract infections: trimethoprim, cotrimoxazole, cefpodoxime, and ciprofloxacin. Unfortunately, one-fifth of those affected do not take the prescribed antibiotics at all and only one-third take them correctly! The health risk of inadequate or improper treatment is almost always higher than the risk of possible side effects. If intolerances or allergies are known, you should inform the treating doctor.
Women with recurrent cystitis (more than two per year) may benefit from preventative antibiotics taken either as a regular dose or after sexual intercourse.
Complicated cystitis is more difficult to treat. The choice of antibiotic, the strength of the drug, and the duration of treatment vary according to the circumstances. In most cases, antibiotics must be taken for 7 to 10 days.
The first-choice remedies are ciprofloxacin, levofloxacin, cefpodoxim, ceftriaxone, and cefotaxim. Ideally, the antibiotic therapy takes place specifically after the presence of bacterial culture and resistance testing. Patients with severe symptoms (fever, confusion, nausea, and vomiting) indicating that the bacteria have spread to the kidney or blood should normally be treated in the hospital.
In women with simple cystitis, the symptoms often improve within hours of taking the first dose of antibiotics. All symptoms should disappear within three days after the end of the antibiotic treatment. Without antibiotics, cystitis can take much longer to heal. If despite antibiotics there are still symptoms, it may be necessary to re-examine the urine in order to find out whether the pathogens are resistant to the antibiotics and to prescribe an antibiotic specifically directed against this bacterial strain.
People with complicated infections, such as men with enlarged prostate glands, may have longer-lasting symptoms. If patients have an in-patient catheter, it is difficult to clean the urinary system of bacteria as long as the catheter cannot be removed.
One-third of all patients can become infection-free with the help of behavioural recommendations. Here are some tips:
If you do not have a heart disease, drink at least 2.5 liters of fluid a day. About 1.5 to 2 liters of urine per day should be excreted. You should avoid coffee, black tea, and alcohol. Protect yourself from hypothermia and moisture.
If you feel the urge to urinate, you should go to the toilet as soon as possible. You should not press your abdominal muscles and do not leave water in a tight crouching position. Avoid constipation, preferably by eating plenty of fruits and vegetables. After each bowel movement, clean yourself by wiping with toilet paper from the front (vagina) to the back (anus). Do not use vaginal or chemical substances for contraception. After each intimate encounter, urinate within 15 minutes and drink plenty of liquid. Do not wash your intimate area excessively, especially not with soap, disinfectants, or intimate sprays, to avoid damaging the acid mantle of the skin.
If you feel the urge to urinate, you should go to the toilet as soon as possible, you should not press your abdominal muscles and do not leave water in a tight crouching position. Avoid constipation, preferably by eating plenty of fruits and vegetables. After each bowel movement, clean yourself by wiping with toilet paper from the front (vagina) to the back (anus). Do not use vaginal or chemical substances for contraception. After each intimate encounter, urinate within 15 minutes and drink plenty of liquid. Do not wash your intimate area excessively, especially not with soap, disinfectants or intimate sprays, to avoid damaging the acid mantle of the skin.
The best cleaning routine for the intimate area is a sitting or bath in warm water. An effective prevention method is drinking cranberry juice (cranberry), approx. 1 glass daily, available in drugstores and health food stores. Cranberry is also available in preparation forms such as granules or capsules. Other supporting herbal remedies such as capuchin press, horseradish, rosemary, millet, lovage root, or bear grape leaves help in the fight against infections via several mechanisms. D-mannose 1 x 2 g in 200 ml of water daily binds the bacteria and flushes them out.
After the consultation with your treating doctor, a low-dose, long-term antibiotic therapy can be useful for about 50 days. However, this can affect the effectiveness of contraception through the pill.
Vaginal administration of oestrogen-containing suppositories can have a preventive effect on patients after menopause. However, this must also be prescribed and checked by a treating doctor. Vaccination methods offer the opportunity to strengthen the immune system against the most common urinary tract bacteria. There is an "oral vaccination" for 90 days (urovaxoma) or vaccination by three injections at weekly intervals (strovac). However, the costs incurred are not covered by statutory health insurance.
Dr. med. Christoph Pies, born in 1970, studied medicine in Bochum and Düsseldorf before he found his true calling as an urologist in a Cologne clinic. Staying abroad has taken him to clinics in Switzerland and the USA (Houston, New York, and Los Angeles). After training as a specialist and senior physician, he became an urologist in 2004, near Aachen. He has additional qualifications in Andrology and Medicinal Tumor Therapy. Dr. med. Christoph Pies has been with Apomeds since 2020.