Cystitis is common in women of all ages, but for some, recurrent infections occur frequently and have a detrimental impact on quality of life. We examine the latest thinking on urinary tract infections and look at how to minimise their recurrence.
If you've ever had cystitis (and almost 50% of healthy women in the UK will have it at some point in their lives) you will know that it really does feel like 'peeing broken glass'. As well as stinging and burning on urination, other unpleasant symptoms include feelings of urgency and frequency, cloudy foul-smelling urine (which may contain blood), abdominal pain and a general feeling of achiness and exhaustion. For some women, these difficult symptoms recur with frustrating frequency.
Urinary tract infections (UTIs) are more commonly referred to as cystitis if the bladder is specifically involved. They are usually caused when bacteria that live harmlessly in the bowel, or on the skin, get into the bladder through the urethra (the tube that releases urine from the body) and start to multiply. These infections are far more common in women than in men, as the urethral opening is in such close proximity to the anus in women.
What defines 'recurrent'
"The most commonly used definition for recurrent urinary tract infections is having at least two UTIs in six months or three or more in a year," says Miss Sarah Itam, a urological surgeon at University College London Hospitals. "UTIs are more common in postmenopausal women as levels of oestrogen are much lower, which results in thinning and shrinking of the vaginal tissues, as well as decreased lubrication, so they are more predisposed to these infections."
Why are some women more susceptible?
It is not fully understood why some women are more susceptible to UTIs than others and symptoms may return for no apparent reason. However, in some cases, specific factors are thought to be involved.
"Some postulate that for pre-menopausal women it is related to frequency of sexual intercourse, maternal history of UTIs and the use of spermicides," says Itam. "Recurrent UTIs are also more common in people with urological risk factors such as kidney or bladder stones, urinary catheters and incomplete bladder emptying (resulting in old urine lingering in the bladder). Likewise, diseases which impair the immune system, such as diabetes and chronic kidney disease, may increase a person's susceptibility to a UTI."
Sex without sufficient lubrication may also be a factor for some women and cystitis is also more common during pregnancy because of changes in the urinary tract.
Mr Ased Ali is a member of the Bladder Health UK medical panel and a consultant urologist with Mid Yorkshire Hospitals NHS Trust.
"For most women, the problem is believed to involve a combination of factors," he comments. "Increased genetic susceptibility: there are studies that show variations in genes for parts of the immune system in women who are susceptible; and bacteria with increased pathogenicity - often patients with recurrent UTIs have managed to acquire clever bacteria that are able to survive by hiding in the deep layers of the bladder or within the gut."
How to prevent recurrent UTIs
Drink at least 1.2 litres of water (six to eight glasses) a day, or two litres if you currently have symptoms (assuming you have no medical problems that require fluid restriction). Reduce fizzy drinks, fruit juice, caffeine and alcohol (and avoid entirely if you currently have a UTI).
Pay attention to personal hygiene and toilet habits
Ensure you empty your bladder entirely after urination, wipe from front to back, and avoid constipation. Steer clear of intimate wash products and wipes that can disrupt the normal microflora. Just wash with water or a gentle emollient.
If symptoms are associated with sexual intercourse
Avoid use of spermicides, and flavoured condoms and lubricants; use an organic, pH-balanced, water-based lubricant; empty the bladder immediately after sex.
Menopausal women often find that topical vaginal oestrogen helps prevent UTIs and makes sexual intercourse more comfortable.
Take a single-dose antibiotic tablet within two hours of having sex, or a regular low-dose oral antibiotic daily for six months. But bear in mind that these options require management by your GP and may not be appropriate in all cases.
Try the latest dietary advice
"Keep your urine acidic by taking regular vitamin C and consuming foods and probiotics containing lactobacillus," advises Itam.
"And a probiotic applied directly to the vulva/vagina to help restore the normal flora can be helpful. Another dietary tip is D-mannose which is a naturally occurring sugar and can be bought from health food shops."
Ali agrees that D-mannose has proven benefits.
"There's a clinical trial showing the effectiveness of D-mannose. And grapefruit seed extract and oil of oregano have also been found to be beneficial," he explains. "As for cranberry juice and extract the evidence is variable mainly because there are so many different juices and tablets. The problem with the juice is that one may have to drink a lot which increases sugar intake and that isn't good."
When to see a doctor
Mild cystitis will usually resolve with increased fluid intake and over-the-counter pain relief, but if symptoms persist for more than two days - or include a fever, loin pain and/or nausea and vomiting - it is important to see your GP. A urine sample may help confirm diagnosis and determine which antibiotic will work best, if one is necessary.
You may require further investigations or referral to a specialist if you have frequent UTIs, the infection spreads to your kidneys, or you see blood in your urine.
What else could be causing your symptoms?
Similar symptoms to those of a UTI can be caused by other conditions such as sexually transmitted infections (chlamydia and gonorrhoea in particular), bacterial vaginosis, vaginal thrush, vulvodynia, lichen sclerosus, endometriosis, bladder cancer, overactive bladder, and interstitial cystitis. Your local hospital's sexual health clinic can test for many of these conditions, including UTIs.
Interstitial cystitis (IC), also known as painful bladder syndrome, is a chronic, non-infectious condition of the urinary bladder that causes frequency and urgency of urination and pelvic pain. It is often difficult for clinicians to diagnose and treat, but it is crucial that IC is not mistaken for recurrent cystitis, as antibiotics are not an appropriate treatment.
"The key feature of IC," says Ali, "is pain during filling of the bladder, relieved by passing urine, whereas UTIs are often worse when passing urine. Interstitial cystitis can flare suddenly, often after sexual activity, with a relapsing and remitting course. It is a diagnosis of exclusion and not usually made in one visit to the doctor."
If you think you may have IC, visit your GP, and the Interstitial Cystitis Association and Bladder Health UK for advice and support.