Bladder infection is a very common condition. The fact that women experience it far more commonly than men can be confirmed by asking a group of new medical students about the symptoms of cystitis: blank looks from the males and correct responses from the females!
Most episodes of urinary infection seen in general practice are uncomplicated bacterial cystitis, most commonly in young women. Other at risk groups are the elderly and any patients with structural bladder problems (e.g. stones or tumours). In addition, several non-infective problems can give the same clinical picture as infective cystitis.
Typically, cystitis will present with frequency of micturition and nocturia. There is usually, but not always, pain on voiding (dysuria). Depending on the degree of inflammation of the bladder mucosa there may also be a feeling of incomplete emptying or pain after voiding (strangury). Patients may have severe urgency and even incontinence, due to reactive detrusor overactivity. In severe infections, persistent bladder pain, fever and haematuria may be seen.
The symptoms of cystitis mimic an irritative foreign body in the bladder, with a proprioceptive over reaction to try to expel whatever is there. Patients in past centuries with bladder stones had exactly the same symptoms, as readers of Samuel Pepys' diary will be aware. Indeed it is a complete mystery to us why bladder stones, once such a common disease, are now rarely seen and then only in association with serious bladder or prostatic dysfunction.
In untreated episodes of cystitis, or where there is underlying vesico-ureteric reflux, ascending urinary infection may lead to acute pyelonephritis which can of course be a life threatening infection if unchecked. Classically there will be a swinging pyrexia with loin pain and frequency, but the picture may be modified, especially in the elderly or those with intercurrent illness such as diabetes or immunosuppression.
Not uncommonly one finds a young adult with pyelonephritis who remembers having urinary problems in childhood and this is a strong predictor of possible reflux, which may abate in the teenage years and the recur later.
It is important to differentiate between asymptomatic bacteruria and infection, since many patient groups (for example the elderly and patients with stents or catheters) will have bacteruria in the absence of any clinical infection. Thus the presence or absence of white blood cells in the urine culture is important. In catheterised patients, particularly the elderly who may be catheterised for "social " reasons, it is important not to treat bacteruria unless there are symptoms, and care home staff should be discouraged from routine urinalysis in these patients.
The commonest infecting organisms are those found in the gut. E Coli strains are responsible for most proven bacterial cystitis. Bacteroides, Klebsiella and faecal streptococci are also commonly seen. Certain infections such as Proteus may indicate underlying urinary tract pathology such as stone disease, particularly if there is recurrent infection.
The current consensus on why women have much higher rates of cystitis than men holds that there is a much greater risk of bacterial colonisation of the urethra in the region of the bladder neck. In women the urethra is some six centimetres long, against one four to five times that length in the male. Minor abrasions in the vulval skin may allow bacterial colonisation and overgrowth which then favours migration up the urethra to the bladder. This would explain why cystitis is more commonly seen with sexual activity ("honeymoon cystitis") and, in peri-menopausal women (in whom the resilience of the vaginal skin may be reducing due to local oestrogen deficiency).
There is debate as to whether uncomplicated cystitis in a young woman requires investigation. Certainly most women will experience this problem at least once in their life, and indeed the patients who present to the doctor are usually self selected as having recurrent cystitis, since many women will not report an isolated episode which clears with over the counter remedies.
Children with proven UTI should be investigated to rule out the possibility of any ureteric abnormality such as reflux or obstruction.
The primary investigation is a fresh urine sample sent to the laboratory: many "negative" tests from general practice may be due to long transit times between surgery and microbiology. The presence or absence of organisms, and the number of inflammatory cells seen must be documented.
In patients with recurrent symptoms it is helpful to check a post treatment sample to see if the urine is infected in between attacks, but for isolated cases this is probably unnecessary.
If one suspects Bilharzia then a terminal urine specimen is most likely to show any eggs, and for tuberculosis early morning urine samples are preferred. Urine cytology may be useful in excluding malignancy in cases without documented infection but as it has a relatively low sensitivity in all but high grade tumours it does not have an obvious place in primary care.
In cases of persistent negative cultures the possibility of interstitial cystitis should be entertained: this diagnosis is difficult and usually requires a mixture of urodynamics, cystoscopy and history. Treatment is similarly difficult, with first line therapy being anticholinergics drugs but with the mucosal protective agent Pentostan polysulphate (Elmiron) being most effective.
It is reasonable to divide patients with recurrent cystitis into two groups: those who are likely to have infection due to bladder outflow obstruction and all others.
For the first group, mainly representing middle aged and elderly men, a urology symptoms score should be obtained and a urinary flow rate and residual ultrasound will be helpful in ascertaining the degree of outflow obstruction. It is sensible to scan the kidneys and ureters at the same time as the bladder.
If there is no sign of outflow obstruction then a plain abdominal X-ray will be helpful to exclude radio-opaque stones.
One must remember that in this group of patients the PSA may be artefactually high. If there is no clinical evidence of advanced prostate cancer in this group, my practice is to treat with ciprofloxacin (250mg BD) for three weeks and recheck the PSA one week after the course has finished. A persistently high PSA should be investigated as per normal local protocols.
In other patients, imaging should begin with urinary tract ultrasound, ideally in conjunction with a plain abdominal X ray (ultrasound alone will miss some 20% of small renal stones whereas the combination should detect around 96% of urinary stone disease). There is an argument for spiral CT scanning to detect stone disease and this is the standard in some other countries, but there is not enough CT scanning capacity in our health care system at present to really start discussing the marginal clinical benefits that might be seen with this approach.
Patients with recurrent symptoms suggestive of pyelonephritis should have imaging (either micturating cystogram or MAG-3 renography) to exclude vesico-ureteric reflux. As mentioned above, many such patients will give a history of childhood infections.
It is debatable in which patients cystoscopy is necessary, but the advent of local anaesthetic flexible cystoscopy means that this test can be carried out, often on the same visit as the imaging and consultation, with no more discomfort or inconvenience than a cervical smear. Certainly anyone with haematuria, Bilharzial exposure and any men should have this test discussed. Flexible cystoscopy is a procedure which causes no more discomfort than a cervical smear for women, although men may find it a little painful if the prostate is not relaxed. Small biopsies can be taken through the flexible cystoscope but if there is a suspicion of any major bladder lesion most urologists will opt for a general anaesthetic cystoscopy which will allow simultaneous resection of any tumours or abnormalities found.
Again patients can be divided into two groups: those in whom an abnormality is found on investigations and the rest (the majority!).
Should investigations reveal a problem either in the bladder or elsewhere in the urinary tract, referral to the appropriate specialist is appropriate.
Treatment of uncomplicated cystitis involves an adequate course of an appropriate antibiotic. Local knowledge of bacterial prevalence and sensitivity should be used here but in general an antibiotic such as trimethoprim or amoxycillin should be used. If possible the results of a urine culture should be obtained prior to treatment but in practice an empirical therapy is often given. There is no evidence that giving long course of antibiotics are beneficial in most patients.
In cases of proven cystitis it is customary to obtain a post-treatment sample to confirm that the infection has been adequately treated, but there is little evidence to support this in uncomplicated cases.
For patients with recurrent cystitis it may be helpful to discuss lifestyle matters. Of more practical use is the prescription of a stock of appropriate antibiotics to be kept at home and used when the symptoms of cystitis start, taken until 24 hours after the symptoms have disappeared. This seems to be more effective than long term rotating antibiotics and recognises the fact that many cases of cystitis become evident outside normal practice hours.
Patients with urinary catheters or stents who develop pain or fever should be treated and in this group the possibility of multiply resistant organisms must be remembered. Quinolone antibiotics are the community drug of first choice for the majority of these patients.
Future therapy of recurrent simple cystitis is likely to centre round the use of either vaccines (in development against pathogenic strains of E Coli) or using instillations of "benign" bacteria into the bladder and urethra to stop overgrowth of pathogenic organisms.
Most of the advice given to patients is empirical and some is probably without any real foundation, I rarely for example see patients who wear nylon underwear yet avoidance of such retro lingerie seems to be universally advised.
Voiding after sexual intercourse, adequate hydration and possibly cranberry juice all appear to be of help, and other measures usually advised are to consider extra sexual lubrication and wiping from front to back. In menopausal women local or systemic oestrogens may help. The patient advice sheet I give out can be freely downloaded from the information resource at my website (www.london-urology.co.uk).
However a visit to any public library will reveal a shelf full of self help books on cystitis, indicating that nobody yet has the answer. A pragmatic approach to the problem is needed and above all patients should not be made to feel as if there is any underlying blame attached to their lifestyle if they do suffer.