Cystitis

Marian Grosser studied human medicine in Munich. In addition, the doctor, who was interested in many things, dared to make some exciting detours: studying philosophy and art history, working on the radio and, finally, also for a Netdoctor.

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Inflammation of the bladder (also known as cystitis or cystitis) is uncomfortable: Burning sensation when urinating and the frequent need to urinate are typical symptoms that afflict those affected. In the vast majority of cases, cystitis is harmless and clears up quickly. Read here which symptoms also indicate a cystitis, who is particularly at risk and what treatment can be used to get rid of it!

ICD codes for this disease: ICD codes are internationally recognized codes for medical diagnoses. They can be found, for example, in doctor's letters or on certificates of incapacity for work. N30

Cystitis: Quick Reference

Symptoms: frequent, painful urination in small amounts of urine, cramp-like pain in the bladder, often unpleasant smelling, cloudy urine, rarely with blood, sometimes fever
Treatment: especially in pregnant women and in the case of recurring bacterial inflammation antibiotics, if necessary after previous germ determination
Home remedies: drink a lot (> 2l / day), special tarpaulin and kidney teas, hot water bottle (relieves cramps), warm foot baths, cranberry, nasturtium, hackle or horseradish root.
Who is affected? Especially girls and women (shorter urethra!), Risk increases during pregnancy and after menopause; in boys / men seldom, then often a complicated course (research into the cause is important!).
Causes: mostly bacteria, sometimes fungi, parasites or viruses, rarely drugs or other external factors
Trigger: spread of bacteria from the anal region, frequent sexual intercourse (in women), flow obstacles in the urethra, frequently used or long-lying urinary catheters, metabolic (diabetes) and immune diseases
Possible complications: ascending urinary tract infection, inflammation of the kidneys (pelvis), blood poisoning (urosepsis), inflammation of the epididymis (in men), scarring in the bladder / shrunken bladder
Attention: During pregnancy there is probably an increased risk of miscarriages, pregnancy poisoning and reduced birth weight, therefore always treat!

Cystitis - Symptoms

Mild bladder infections are sometimes only slightly noticeable. The classic signs of a common (uncomplicated) cystitis are pain when urinating (alguria), which can usually be felt as a burning sensation, and a frequent urge to urinate, whereby only small amounts of urine are given (pollakiuria).

Often these are the only complaints. But there are more symptoms that indicate a bladder infection and which, due to various factors (concomitant diseases, type of pathogen), can be more or less pronounced or not at all. The most common symptoms, but never all of them together, include:

Painful urination
difficulty urinating (dysuria)
frequent need to urinate
increased need to urinate at night (nocturia)
Pain in the bladder area (suprapubic pain)
Spasmodic, painful contraction of the bladder with a strong urge to urinate (tenesmus)

There are also other signs that could suggest a bladder infection:

Occasionally the urine appears cloudy and / or has an unpleasant smell.
Women may experience increased discharge (fluorine) if an infection spreads to the vagina.
Back pain can occur if the inflammation spreads to the kidneys or, in men, the prostate.
Sometimes there is also a fever (rarely with a simple cystitis.
The urge to urinate can be so sudden and compelling (imperative to urinate) that the patient cannot make it to the toilet in time (urge incontinence).
Visible blood in the urine can occur in rare cases. On the other hand, blood that cannot be seen with the naked eye is more common (microhematuria).

"If you have a bladder infection, drink a lot!"

Three questions for

Dr. med. Massimo Lombardo,
Gynecological and Obstetric Specialist
1
How can I quickly counteract a cystitis?

Dr. med. Massimo Lombardo
The most important rule: drink a lot! Preferably water or tea. Cranberries in a highly concentrated form can also be helpful. Such substances, which acidify the urine, deprive the bacteria of their habitat. Together with a good supply of fluids, this can often be enough to slow down a cystitis.
2
When do you have to start taking antibiotics?

Dr. med. Massimo Lombardo
I think it's wrong to give antibiotics too quickly. Even so, there are circumstances where the medication is urgently needed. For example, when the pain affects the flanks and the patient's kidneys are in danger. Even if the cystitis cannot be contained with natural means, antibiotics can help. And immunocompromised and elderly patients can benefit from the early administration of antibiotics.
3
Can I prevent the next cystitis?

Dr. med. Massimo Lombardo
Yes: by drinking a lot! The more fluids you drink, the less chance bacteria have of settling in the urinary tract. In general, people who drink a lot have been shown to have less inflammation. Also make sure that there is a good environment for the lactic acid bacteria in the genital area. A vaccination against cystitis can also be helpful. Let your doctor advise you here.
Dr. med. Massimo Lombardo,
Gynecological and Obstetric Specialist
The gynecologist Dr. med. Massimo Lambardo has been running his CentroGyn practice in Munich since 2007.

Cystitis: treatment

The main aim of the cystitis treatment is to let the annoying symptoms subside more quickly and prevent possible complications. In fact, uncomplicated bladder infections often heal on their own and without the use of medication. However, it is better to support and accelerate recovery with the right therapy.

As with almost all bacterial infections, antibiotics are also the drug of choice for bacterial infections. They are usually taken in capsule or tablet form. In more severe cases of inflammation of the renal pelvis (pyelonephritis), the active ingredients are sometimes given directly into the veins.

If fungi are the cause of cystitis, antibiotics won't help. Instead, so-called antimycotics are used.

In principle, one tries to keep antibiotic therapy as effective and short as possible in order to reduce the risk of developing so-called resistance to antibiotics. Resistance is the insensitivity of bacteria to certain active substances.

The duration of use varies depending on the active ingredient. Sometimes a single dose (fosfomycin trometamol) is sufficient. This will alleviate the side effects, but surviving bacteria could cause a relapse in this case. This is why antibiotics are usually taken for three to seven days (nitrofurantoin, pivotmecillinam) in the case of a bladder infection.

"Calculated" antibiotic therapy

In uncomplicated, acute cystitis - if there are no additional aggravating factors - the antibiotics are used empirically or calculated. This means that you use active ingredients that are known to help against the classic pathogens of common cystitis and cause as few side effects as possible.

The triggering bacteria are therefore not determined more precisely, but rather it is assumed that they are typical representatives such as Escherichia coli (E. coli).

So if you notice the typical symptoms of a bladder infection, it is best to see a doctor as quickly as possible so that he can initiate the right therapy. Because even if a common cystitis is relatively harmless, the risk of complications increases if you just wait and see. For example, you can significantly reduce the occurrence of recurring (= recurrent) bladder infections if you take antibiotics in good time.

If the therapy works, the symptoms should improve noticeably after just one day.

Preventive administration of antibiotics

In women who repeatedly suffer from cystitis, antibiotics in low doses may even be given preventively (prophylactically). Before doing this, you should try drugs that stimulate the immune system for several months.

Determination of bacterial species and antibiotic effectiveness

Sometimes a bladder infection can also be severe or chronic. Or there are special circumstances such as pregnancy or certain concomitant diseases. In such cases, it makes sense to use a urine sample from the patient to cultivate the bacteria in a culture for closer examination.

In this way you can determine them precisely and also test which antibiotics they respond particularly well to. These are then used specifically in the treatment of cystitis. Testing for resistance is also called an antibiogram.

If antibiotic therapy does not work, there can be various reasons. Sometimes it is due to application errors by the patient, or unrecognized risk factors prevent success. Of course, possible resistances of the pathogens to the antibiotics used must also be mentioned.

If all of these factors have been considered and there is still no sign of improvement, then a switch is made to another antibiotic.

Cystitis: Treatment for Pregnancy

Since cystitis can lead to serious complications during pregnancy, it is important to start appropriate treatment as early as possible. Women who notice typical symptoms of cystitis should therefore consult a doctor immediately.

Cystitis treatment during pregnancy is also based on antibiotics. However, one uses preparations that are well tolerated during this particular phase of life. These are mainly active ingredients from the groups of penicillins and cephalosporins as well as fosfomycin trometamol.

Antibiotic therapy is usually initiated in pregnant women even if the doctor detects increased bacterial counts in the woman's urine (bacteriuria) - even if there are no symptoms of cystitis.

Cystitis: Home Remedies

There are many home remedies for cystitis. Some of these can actually aid the healing process. Bladder and kidney teas or their herbal ingredients are one example. They have an antispasmodic, anti-inflammatory and diuretic effect. But three to four cups a day are enough.

Certain ingredients (anthocyanidins and proanthocyanidins) in cranberry juice are also said to be helpful in preventing bacteria from attaching to the mucous membrane of the urinary tract and causing cystitis to develop or recur. However, the study situation is not clear here.

In the case of mild, uncomplicated bladder infections, essential and mustard oils such as those found in nasturtiums, grouse or horseradish root can be used as an accompanying phytomedical therapy to provide relief. They have an antibiotic effect and are usually well tolerated.

In general, if you have a bladder infection, you should drink a lot (at least 2 liters per day) - even if it hurts to urinate. Because the pathogens are rinsed out with the urine. Warmth, for example in the form of a hot water bottle, a grain pillow or a foot bath, relaxes the bladder muscles, which often cramp in the event of inflammation, and can alleviate the symptoms.

Coffee, citrus juices, alcohol and sugary drinks should be taboo if you have a cystitis. They irritate the urinary tract or, in the case of soda and co., Promote bacterial growth.

You can find out which home remedies also help and which you should avoid here: Cystitis - home remedies.

Homeopathy - Treating Cystitis Without Antibiotics?

There are numerous homeopathic remedies that are thought to help with different forms of cystitis. However, globules & Co. do not replace antibiotics. A visit to the doctor is therefore advisable in any case, especially for high-risk patients such as pregnant women and diabetics. Homeopathic remedies can then be used in addition to conventional medical cystitis treatment. The concept of homeopathy and its specific effectiveness are, however, controversial in science and not clearly proven by studies.

You can find more information here: Homeopathy for cystitis

What happens if I have a bladder infection?

When a bladder infection occurs, the urothelium - the lining of the urinary bladder - is compromised. On the one hand, this can lead to pain, on the other hand, it often has an impact on the frequency of urination: the damaged bladder wall reacts more sensitively to stretching stimuli and gives the command to empty more quickly, so to speak. This results in the frequent urge to urinate (pollakiuria) in cystitis.

Blood in the urine can also occur as a result of the irritated bladder lining, but it is one of the rarer symptoms. You can find more about this under “Symptoms”.

Since most of the time not only the bladder is affected by an inflammation, but also the urethra, doctors often speak of a urinary tract infection (UTI) in general. In unfavorable cases, the infection can even spread to the ureters and kidneys. Inflammation of the kidney pelvis (pyelonephritis) in particular can then be a serious complication.

Special forms of cystitis

In addition to the classic cystitis, there are a few other, much rarer forms such as hemorrhagic cystitis, in which there is a large amount of blood in the urine. Viruses are often the trigger.

Interstitial cystitis is chronic and has no bacterial or viral cause. In emphysematous cystitis, gas is formed in the bladder, and diabetics are often affected.

Complicated or uncomplicated cystitis?

Depending on the accompanying circumstances of a cystitis, a distinction is made in medicine between a "complicated" and an "uncomplicated" variant. According to this classification, cystitis is uncomplicated as long as there are no functional restrictions or malformations in the urinary tract and no relevant kidney dysfunction or other impairing concomitant diseases.

However, if one of these factors is met, it can promote the development of a cystitis and cause complications, so it is then "complicated".

Who Does Cystitis Affect?

Cystitis in women

Women are far more likely to have cystitis than men. This is mainly due to anatomical reasons. Because the female urethra is only about two and a half to four centimeters long, while the male urethra is about eight inches.

In women, inflammatory agents such as bacteria have to travel a much shorter distance to the bladder. In addition, the opening of the urethra in women is closer to the anal region, which is where certain bacteria are found that are common causes of cystitis.

After the menopause, the risk of cystitis increases again slightly, as the fall in the level of estrogen makes the mucous membrane in the urethra thinner. This also makes it easier for germs to get to the bladder.

Cystitis in men

Cystitis in men is much less common, but when it does occur, it is often more stubborn than in women. In addition, bladder infections become more common in men as they get older, because they often suffer from an enlarged prostate. You can find out more under “Causes and Risk Factors”.

Anatomy of the bladder in men and women

Women are significantly more likely to develop cystitis than men. The reason: At two and a half to four centimeters, your urethra is shorter than the male urethra, which is 20 centimeters.

Cystitis in children

Cystitis can also occur more often in children of both sexes, if only because the immune system is not as well developed as in adults. In young boys, however, possible malformations in the genitourinary tract should be considered if cystitis is particularly common.

Cystitis: causes and risk factors

By far the most common cause of cystitis is bacteria. In most cases, the pathogens come from the intestine, penetrate the urethra and “climb” up to the bladder. One then speaks of an ascending, i.e. ascending, infection.

However, inflammation can also begin in the kidneys. The germs then descend from there via the ureters to the bladder (descending infection). However, this happens very rarely.

In the vast majority of cases, the triggering bacteria are representatives of the species Escherichia coli (E. coli for short), which are completely normal in the intestine. However, if they get into the urinary tract, they can cause inflammation there.

In addition to E. coli, other types of bacteria (e.g. Proteus, staphylococci) and, in rarer cases, fungi (e.g. Candida albicans), parasites and viruses (e.g. adenoviruses, polyoma) can trigger cystitis.

If a bladder infection occurs after a tropical trip, schistosomiasis (schistosomiasis) can also be the trigger. The disease-causing flukes preferentially infect the urinary tract. Definitely go to the doctor.

Otherwise, cystitis can also occur as a side effect of certain medications, such as cyclophosphamide, which is used in tumor diseases. Irradiation in the pelvic area can also lead to cystitis (radiation cystitis).

What makes a cystitis more likely?

Certain risk factors or circumstances increase the likelihood of a bladder infection. This includes:

Frequent sexual intercourse (honeymoon cystitis). The mechanical friction makes it easier for the intestinal pathogens from the anal region to get into the urethra.
The use of some methods of contraception, such as a diaphragm or spermicides.
Longer urinary catheters.
Bladder dysfunction: If the urine builds up, bacteria find an optimal breeding ground for them to multiply. This can result in recurring urinary tract infections.
Diabetes mellitus, as those affected are generally more susceptible to infection and the increased sugar in the urine also serves as a nutrient for bacteria.
A weakened immune system, e.g. B. by hypothermia or psychological influences such as stress.
A disorder in the flow of urine. This is caused by a narrowing of the urethra or when the valve mechanism between the ureter and bladder does not work properly and urine flows back from the bladder into the ureter (reflux). An enlarged prostate can also cause urinary retention in men.
Mechanical interventions such as cystoscopy and irrigation.
Pregnancy and the puerperium: Due to the changed hormone levels during pregnancy and in the first few weeks after the birth, the urinary tract is dilated, and germs can penetrate and rise more easily.
Wrong "wiping technique" after defecation. When wiping from back to front, intestinal bacteria are transported in the direction of the urethral entrance.

The greatest risk factor is the female sex due to the aforementioned anatomical features. Accordingly, bladder infections occur most frequently in young, sexually active women.

Possible complications of a cystitis

Simple cystitis either heals spontaneously or after a few days with the right antibiotic therapy. In unfavorable cases, however, complications can arise.

Recurrent cystitis (recurrent cystitis): Doctors also speak of chronic or recurrent cystitis in people who suffer from cystitis particularly frequently. By definition, at least two bladder infections must occur every six months or three per year. Here too (as with a simple cystitis) symptoms of bladder irritation such as burning sensation when urinating occur.

In contrast to normal cystitis, with the recurring form, atypical pathogens are often the trigger, which is why a urine culture is useful to determine the germs (see "Diagnosis"). Treating simple bladder infections with antibiotics in good time can reduce the risk of recurring cystitis.

Kidney inflammation: Kidney inflammation (pyelonephritis) is a more dangerous complication of cystitis. It occurs when the pathogens rise from the bladder via the ureters to the renal pelvis. The renal pelvis acts as a kind of collecting funnel and describes the point where the ureters leave the kidneys. This is where the primary urine filtered by the kidneys is collected. In pyelonephritis, part of the kidney tissue is also inflamed.

In addition to a general, severe feeling of illness, the symptoms typical of an infection of the upper urogenital tract also occur in pyelonephritis. Symptoms specific to cystitis are also often found. The kidney function, however, is not impaired.

Development of inflammation of the renal pelvis

In the case of a bladder infection, bacteria can enter the kidney pelvis from the bladder through the ureter. This ascending urinary tract infection can lead to inflammation of the kidney pelvis.

Blood poisoning: The life-threatening urosepsis, i.e. blood poisoning by the causative pathogen, is particularly feared in the context of kidney inflammation. This happens when the germs enter the bloodstream in large numbers from the kidney tissue. This can easily happen because the kidneys are very well supplied with blood. Timely therapy with antibiotics is therefore particularly important.

Epididymis: Just as the pathogens in some cases ascend the ureter to the renal pelvis, in men they can reach the epididymis via the spermatic duct, which sit directly on the testicles. The result is inflammation (epididymitis), which is accompanied by swelling and sometimes severe pain. Since the sperm cells mature in the epididymis, in extreme cases it can even lead to infertility.

Shrink bladder: This is a reduced urinary bladder with a rigid bladder wall. It holds less volume, and those affected often feel a strong need to urinate, but can hardly pass urine. In many cases, an unhealed or chronic cystitis causes a shrink blister because it damages the organ over the long term and causes the tissue to scar.

Pregnancy Complications: Women are more likely to experience bladder infections during pregnancy due to certain hormonal changes. Experts believe that premature births, reduced birth weight and a certain form of high blood pressure during pregnancy (preeclampsia) can be the result of such a cystitis.

However, this does not mean that every cystitis during pregnancy must trigger such complications. On the contrary, this occurs only in rare cases and with particularly unfavorable processes.

Pregnant women who suspect a bladder infection (symptoms such as painful urination, frequent urination, etc.) should consult a doctor quickly in any case. This is the only way to start appropriate antibiotic therapy in good time, which minimizes the risk of complications.

Hemorrhagic cystitis: Strictly speaking, this is not a complication, but a special form of cystitis. In contrast to normal cystitis, it has atypical pathogens as a trigger, namely mostly viruses or so-called Enterobacteria. However, as with normal cystitis, symptoms such as painful urination occur.

As a special feature of hemorrhagic cystitis, there is also a large amount of blood in the urine of the patient. Blood in the urine always looks dramatic, but in this case does not mean that hemorrhagic cystitis is particularly dangerous.

Is Cystitis Contagious?

Even if the risk is low with appropriate hygiene, cystitis can be quite contagious. Since it is mainly caused by E. coli bacteria, public toilets, where they like to romp, are a potential source of infection. Bacteria can also get to the hands via the shopping trolley bar, handles in public transport or doorknobs and taps in the office and from there at some point by touching them into the intimate area. Regular hand washing can prevent such transmission.

A direct infection is also possible through

E. coli bacteria in human stool. However, the risk of them getting from the anus into the urethra is lower if you wipe yourself from front to back after defecation.
Sexual intercourse. This is where condoms can prevent the bacteria from entering the urethra via the penis.

Cystitis: examinations and diagnosis

First, the doctor collects the patient's medical history, primarily asking about the symptoms and possible risk factors. The group to which the patient belongs also plays an important role in subsequent examinations and treatment.

In a young, otherwise healthy woman, a cystitis has a different status than in a young man, a pregnant woman or a diabetic.

The medical history often also shows whether the patient has complicated or uncomplicated cystitis.

If a complicated cystitis can be ruled out, no further examination is required in young women if they are otherwise healthy. The mostly typical symptoms are enough to make the diagnosis. Standardized therapy is then initiated. No special features are to be expected.

Urine diagnostics

In other cases, such as pregnant women or young men, further examinations are made after the medical history is taken. Urine diagnostics are of particular importance if a cystitis is suspected. The urine of the patient is examined for bacteria and blood contamination, whereby various methods are used:

The urine test strip (Stix): With the help of this simple procedure, the number of bacteria in the urine can be roughly determined and any admixture of blood can be determined.
The microscopic urine examination that allows a more accurate estimate of the bacterial count and identification of cells.
The urine culture: Here, the pathogens present in the urine are grown on a special nutrient medium in order to be able to identify them precisely.

The urine strip is not sufficient as the sole diagnostic tool. However, he can help if the first question to be clarified is whether there are any bacteria in the urine in large numbers. The sole examination with test strips, without any symptoms of a bladder infection, does not make sense, however, since no further steps have to be initiated without symptoms, even with an increased number of bacteria (asymptomatic bacteriuria).

Pregnant women are an exception: asymptomatic bacteriuria leads to inflammation of the kidneys (pyelonephritis) in around 30 percent of pregnant women and must therefore always be treated.

If the patient is asked for a urine sample for examination, he should definitely use the so-called "midstream urine". This means that the urine from the urine stream that is already running should be caught and the first or last milliliters should be discarded.

The reason is that the urine should be contaminated as little as possible with the normally occurring bacteria on the mucous membrane, which can otherwise falsify the result. Therefore, the genitals must be cleaned thoroughly with water beforehand. Women should also spread their labia when urinating.

If a kidney inflammation or other complication factors are suspected, sonography (ultrasound) is available as a further examination, with which a residual urine determination can be carried out. This also allows conclusions to be drawn about a bladder emptying disorder such as a urine flow measurement (uroflowmetry) or a micturition cystogram.

In the latter, a contrast agent is injected through the urethra into the bladder and the emptying is documented by X-ray. A cystoscopy can also be useful under certain circumstances.

Cystitis: How to prevent it

Some people are more likely to develop a bladder infection than others. It depends on various factors. However, you are not completely at the mercy of the infection, certain measures are intended to help keep the urinary tract healthy:

Drink a lot (at least 1-1.5 liters per day): Preferably water and unsweetened herbal or fruit tea. When consumed regularly, cranberry juice is said to have a positive effect on recurring cystitis. However, this is not scientifically proven.
Go to the bathroom often: if you have to, don't wait. If the urethra is flushed more often, it will be harder for bacteria to ascend there. Even after intercourse (within 10 to 15 minutes) women should try to urinate to flush out the bacteria that could be forced into the urethra by the act.
Antibiotics: In special cases a preventive administration of antibiotics can be useful. Long-term antibiotic use can be considered in the case of recurring or chronic cystitis.
Wipe properly: If you wipe from front to back after using the toilet, you don't rub the bacteria from the anus into the urethra.
Keeping warm: especially your feet and abdomen. Cooling down weakens the immune system, bacteria have an easy job.
Fresh, comfortable underwear: Avoid tight panties as they can irritate the pubic area and transport germs to the vagina. Better: well-fitting cotton underpants.
Intimate hygiene: regular, but not excessive. It is best to wash the genital area only with warm water. Soap, intimate sprays or disinfectants can irritate the sensitive mucous membrane.
Avoid bubble-friendly prevention: condoms protect against pathogens while vaginal suppositories and diaphragms tend to favor infection.

Cystitis: disease course and prognosis

The vast majority of bladder infections are harmless and heal after a few days with antibiotic therapy. Cystitis recurs in some women at regular intervals, and the risk increases, especially with age.

Serious complications only arise rarely and mostly due to special circumstances. Particular caution is required if the kidneys are involved as a result of a bladder infection, since in unfavorable cases this can lead to blood poisoning (urosepsis).

Additional information

Guidelines:

S3 guideline "Epidemiology, diagnostics, therapy, prevention and management of uncomplicated, bacterial, community-acquired urinary tract infections in adult patients" of the working group of the Scientific Medical Society (status: 2017)

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