Cystitis

Overview

Cystitis is a bladder infection caused by a urinary tract infection (UTI). It's really frequent, especially in women. It usually resolves on its own, but antibiotics may be used in certain cases. Some people experience cystitis on a regular basis and may require ongoing or long-term therapy.

What is Cystitis?

Cystitis is an infection of the lower urinary system, more especially of the bladder. It may be roughly classified as either simple or difficult. Lower urinary tract infection (UTI) in otherwise healthy males or non-pregnant women is referred to as uncomplicated cystitis. In contrast, complicated cystitis is related with risk factors that enhance the severity of the infection or the possibility of antibiotic therapy failing.

The occurrence of complex UTIs varies greatly depending on the underlying disease. Asymptomatic bacteriuria is predicted to be 26% more common in diabetic women than in non-diabetic women. Diabetes patients are also more likely to develop acute cystitis and pyelonephritis. UTIs are frequent in people who have received a kidney transplant, with retrospective cohort studies suggesting a prevalence of 47% to 75%.

The danger is greatest in the first year following transplantation. A symptomatic UTI affects around 2.3% of pregnant women. Nephrolithiasis, immunocompromised status, the presence of foreign bodies such as a urinary catheter, urinary tract instrumentation, renal insufficiency, functional or anatomic abnormality of the urinary tract, urinary stents, strictures, and obstructive uropathy are all risk factors for developing a complicated UTI. 

The prevalence of simple cystitis in men is minimal. It is believed that there are less than ten instances per 10,000 men under the age of 65 per year. Men experience the same symptoms as women when they have a basic UTI: dysuria, urine frequency, urgency, and suprapubic discomfort. Prostatitis is indicated by recurring symptoms or reinfections after therapy, fever, and pelvic or perineal discomfort. A severe urinary tract infection is indicated by fever, chills, flank discomfort, or any other indicators of a systemic disease.

What are causes of Cystitis?

A bacterial infection of the urinary bladder is usually the cause of acute cystitis. Women are especially vulnerable because to the rectum's close proximity to the urethral meatus and females' comparatively small urethral length. Escherichia coli is the most frequent etiologic agent in uncomplicated UTIs in women, accounting for roughly 75% to 95% of cases, followed by Klebsiella. Other prevalent etiologic pathogens include Enterobacteriaceae family members like Proteus mirabilis and bacteria like Staphylococcus saprophyticus and enterococcus.

Although Escherichia coli is the most prevalent cause of complex cystitis, a much larger range of microbial pathogens that may cause a complicated UTI includes species such as Enterobacter, Citrobacter, Serratia, Pseudomonas, enterococci, staphylococci, and even fungi.

How does cystitis develop?

Cystitis is often caused by bacteria from the fecal or vaginal flora colonizing the periurethral mucosa and ascending to the urinary bladder. Uropathogens may have microbial virulence factors that allow them to bypass host defenses and enter urinary tract tissues. Males have a longer physical urethra, a drier periurethral environment, and antibacterial defenses given by prostatic fluid, hence UTIs are far less prevalent.

Historically, all UTIs in men were thought to be difficult. Uncomplicated UTIs do occur on occasion, particularly in males aged 15 to 50 who are sexually active, uncircumcised, or engage in anal intercourse, as long as they do not have any risk factors for complicated UTIs such as urologic abnormalities, bladder outlet obstruction, urolithiasis, or recent urinary tract instrumentation.

The underlying host variables have a significant role in the development of complex UTIs. Diabetes patients may be predisposed to UTIs due to immune system impairment and voiding dysfunction caused by autonomic neuropathy. Accumulation of uremic toxins may diminish host defenses in renal insufficiency, and reduced renal blood flow may hamper antimicrobial clearance. Kidney stones can produce an obstruction and serve as an infection nidus. Internal and exterior biofilms may grow on the catheter during urinary catheterization, and bacteria may persist in retained pools of urine in the urinary bladder.

Escherichia coli is the most commonly identified bacterium causing cystitis (75% to 95% of cases). Klebsiella pneumonia and Proteus mirabilis are two more pathogens that cause cystitis. (After E. coli, Klebsiella is the most prevalent cause of UTIs.) Patients who have recently been hospitalized or received earlier treatment for a UTI may have Pseudomonas, enterococci, and staphylococci such as S. saprophyticus. Many additional species, such as lactobacilli, Group B streptococci, and coagulase-negative staphylococci, are typically regarded pollutants until there is a sufficiently high concentration of a single organism where an infection is probable.

What are Symptoms of cystitis?

Acute cystitis frequently causes urine symptoms such as dysuria, urinary frequency, urgency, suprapubic discomfort or soreness, and, in rare cases, hematuria. According to a comprehensive study of women with simple UTI's history and physical results, the combination of dysuria and urinary frequency in the absence of vaginal discharge or irritation is strongly predictive of uncomplicated cystitis (90% association). In the extremely young and very old, symptoms may be modest or unusual.

Those with complex acute cystitis frequently present in the same way as patients with simple cystitis. Atypical symptoms may occur in some patient populations with complex cystitis. Patients with multiple sclerosis, for example, may experience abrupt neurologic deterioration on occasion, whereas individuals with spinal cord damage may experience autonomic dysfunction or increased spasticity.

The lack of systemic symptoms such as fever, chills, or sepsis distinguishes cystitis from pyelonephritis. Upper UTI or pyelonephritis is indicated by symptoms such as flank discomfort, costovertebral angle soreness, nausea, and vomiting.

When evaluating a patient with UTI symptoms, it is critical to obtain a history of any previous episodes of UTI, recent antibiotic use, or any other risk factors that may predispose one to a complicated infection, such as diabetes, immunocompromised status, recent urologic procedures or instrumentation, renal transplantation, history of kidney stones, anatomical or functional urinary tract abnormalities, or pregnancy.

A pelvic examination is a crucial element of diagnosing cystitis in women, especially if they have recurrent urinary tract infections. Two recorded UTIs in six months or three in a year are considered recurrent infections. Recurrent infections with the same organism (referred to as a relapsing infection) indicate the presence of a urinary stone. Recurrent infections in men may suggest chronic bacterial prostatitis. To achieve a definite diagnosis of recurrent UTIs, positive urine cultures are required.

Many general symptoms, such as changes in mental or functional status, fevers, chills, and falls, are linked with a presumptive diagnosis of UTI in fragile and debilitated individuals. According to recent findings, only urine alterations (color changes, odor, gross hematuria) and acute dysuria are consistently related with confirmed UTIs. Changes in urine odor and color alone imply bacteriuria, but there is little evidence to support antibiotic therapy until or until additional symptoms, such as fever, arise. Hydration (for suspected dehydration), monitoring, and evaluation for other reasons are recommended treatments for changes in mental state. 

Cystitis Diagnosis

Acute cystitis is generally diagnosed clinically in a patient who has signs and symptoms consistent with a lower UTI and laboratory evidence of pyuria and/or nitrites. Physical examination findings are not always required to diagnose cystitis, although they may be more essential in individuals with pyelonephritis or vaginitis.

Clinical suspicion may be adequate in making the diagnosis and commencing therapy in young, non-pregnant women with classic cystitis symptoms, particularly in the absence of vaginal discharge or discomfort. However, it is strongly advised to acquire a urinalysis and a urine culture before beginning antibiotic treatment. If the patient does not improve after the first antibiotic, there will be insufficient clinical data to manage therapy adjustments appropriately.

Urinalysis is the most essential laboratory test in identifying a UTI when warranted. A clean catch sample is typically adequate, but if an uncontaminated specimen with few epithelial cells cannot be collected otherwise, as in certain morbidly obese women, urethral catheterization might be considered. In previously uninfected women, the risk of UTI following a single urethral catheterization is just approximately 1%.

When it comes to diagnosing a UTI, the visual appearance of the urine is notoriously inaccurate. Clear urine may be highly infectious, but the cloudy urine may be sterile due to calcium phosphate debris or protein. Add a few drops of glacial acetic acid to a test tube containing the murky urine samples for a simple test. If the "cloudiness" disappears, the urine is most likely high in calcium phosphate.

Pyuria is nearly always present, defined as the presence of at least 10 white blood cells (WBCs) or leukocytes in an unspun midstream urine specimen. The lack of pyuria suggests a different diagnosis.

Urinary dipsticks can also be used to diagnose UTI. They look for leukocyte esterase, an enzyme generated by leukocytes, as well as nitrites, which suggest the presence of Enterobacteriaceae. In individuals with typical acute cystitis symptoms, a positive dipstick test for leukocyte esterase or nitrite is beneficial. A negative dipstick test, on the other hand, does not always rule out UTI.

It is permissible to treat individuals with UTI symptoms with antibiotics based on positive nitrites, but if the leukocyte esterase is negative, an alternative diagnosis should be evaluated. The positive predictive value of having both a positive leukocyte esterase and nitrites is 85%, with a negative predictive value of 92%.

A urine culture is useful for evaluating antibiotic susceptibility profiles and identifying causative microorganisms. Larger than or equal to 100,000 CFU (colony forming units)/mL suggests clinically relevant bacteriuria, whereas greater than or equal to 1,000 CFU is regarded important in males and from bladder samples acquired during straight catheterization. A urinary tract infection is not ruled out if the CFU/mL level is less than 100,000. Urine cultures are often considered unnecessary and not routinely performed in cases of acute uncomplicated cystitis, despite the fact that they can be very helpful in patients with persistent symptoms and presumed treatment failures, especially given the rising rates of antibiotic resistance.

Prior to antibiotic therapy, all men with acute cystitis symptoms and women with risk factors for severe UTIs must have urinalyses and urine cultures conducted. They are also prescribed for individuals who have abnormal symptoms, do not respond to therapy, or whose symptoms return within 2 to 4 weeks. Women of reproductive age should get a pregnancy test.

Men who experience recurring bouts of cystitis should be evaluated for prostatitis. Urologic examination may not be necessary in young men who are sexually active and have a single episode of cystitis. A urologic assessment and workup should be performed if there are risk factors for a complex UTI.

Multiple drug-resistant pathogens are becoming a more problematic issue. They are microorganisms that are resistant to three or more types of antibiotics. The fundamental rationale for obtaining urine cultures in any potentially problematic or challenging illness, as well as in all high-risk individuals with urinary infections, is antibiotic drug resistance.

Patients with complex cystitis who do not react after 48 to 72 hours of proper antibiotic therapy may need to be evaluated further using upper urinary tract radiographic imaging. This might be done via computed tomography (CT) or ultrasonography. CT imaging is typically the preferred test because it detects aberrant processes that may interfere with therapy response, such as urinary blockage, stones, diverticula, or abscess development.

In individuals who should limit radiation exposure or avoid CT imaging, ultrasound of the kidneys, especially when paired with a KUB (short for kidneys, ureters, and bladder: i.e., a flat plate of the abdomen), may be sufficient. Optionally, a cystoscopy will be performed. 

Management of Acute cystitis

Antibiotics are used to treat acute cystitis. The antimicrobial agent used is determined by a patient's risk factors for infection with numerous drug-resistant pathogens. Patients with limited susceptibility to resistant etiologic organisms are treated with one of the first-line or recommended antimicrobial medicines, which include:

• Nitrofurantoin 

Nitrofurantoin is the antibiotic of choice for uncomplicated cystitis. It does not cause resistance or yeast overgrowth, has a high clinical cure rate of 79% to 92%, and may be administered safely even in elderly patients if their glomerular filtration rate is more than 30 ml/min. Because it has low tissue penetration, it is not suited for individuals with fevers, pyelonephritis, or other signs of systemic disease.

• Sulfamethoxazole-trimethoprim (SMX-TMP)

When local antibiotic resistance exceeds 20%, SMX-TMP is suggested. It penetrates the tissue well, including the prostate. The total clinical cure rate ranges from 79% to 100%. In patients with a sulfa allergy, trimethoprim can be taken alone with equivalent efficiency. Unfortunately, resistance to SMX-TMP develops rather quickly.

• Fosfomycin 

Antimicrobial therapy should be tailored to the individual patient, taking into account allergies, adverse effects, tolerability, local bacterial resistance patterns, potential drug interactions, cost and insurance coverage, renal function, compliance history, and recent use of a specific antimicrobial agent within the previous three months. Nitrofurantoin should not be administered in individuals with creatinine clearance or a glomerular filtration rate (GFR) of less than 30 mL per minute, and SMX-TMP should be avoided in areas with higher than 20% regional resistance, as well as in patients with sulfa allergies.

Recent prior interaction with healthcare, usage of SMX-TMP within the last six months, and travel, particularly foreign travel, are all risk factors for such resistance. Because of their low penetration into renal tissues, nitrofurantoin, fosfomycin, norfloxacin, and pivmecillinam are not recommended if pyelonephritis or a severe UTI is suspected.

In acute cystitis patients, alternative or second-line antimicrobial medications are utilized when conditions or circumstances exclude the use of first-line medicines. A 5- to 7-day course of oral beta-lactams such as amoxicillin-clavulanate 500 mg twice daily, cefpodoxime 100 mg twice daily, cefdinir 300 mg twice daily, cefadroxil 500 mg twice daily, and cephalexin 500 mg twice daily is commonly favored.

If beta-lactam drugs are not tolerated, a fluoroquinolone such as ciprofloxacin, norfloxacin, or levofloxacin may be taken for three days (simple UTIs) or seven to fourteen days (complex UTIs). Resistance to SMX-TMP and amoxicillin is reaching or exceeding 20% globally, making these drugs less helpful in many places.

Urine culture and sensitivity tests are essential to guide antibiotic regimens in individuals who are at risk for MDR pathogens. Last MDR isolate (resistance to three or more antibiotic classes), recent hospitalization, recent travel to places with a high frequency of MDR organisms, or use of broad-spectrum antimicrobial drugs in the previous three months are all risk factors.

In individuals with severe dysuria, symptomatic therapy with analgesics may be employed. Phenazopyridine is a urinary analgesic that is used to treat urine dysuria or pain in the short term.

Cystitis in males is rare and has received little attention. The treatment approach for a healthy guy without any risk factors for a severe UTI or any symptoms suggestive of infection outside the bladder should be the same as for a woman with a difficult UTI. Fluoroquinolones have been advised as empiric treatment for males with severe symptoms, morphological or urologic abnormalities, or suspicion of prostate involvement, awaiting culture and susceptibility testing findings and local quinolone resistance patterns. Quinolones are favored as first-line treatments because of their broad range of action and high tissue penetration levels.

Initially, doxycycline, SMX-TMP, and cephalosporins may be administered to help reduce quinolone resistance. All men with clearly identified UTIs are regarded to have complex infections and are at risk of developing chronic prostatitis, which may not manifest clinically for weeks or even months after the original infection. As a result, some experts advise using prostate penetrating antibiotics (doxycycline, SMX-TMP, quinolones) for at least four to six weeks in all men with UTIs to allow for the accumulation of adequate antibiotic concentrations inside the prostate and reduce the risk of developing subsequent chronic prostatitis.

Patients who do not react to a suitable antibiotic treatment after 48 to 72 hours or who have a return of symptoms within a few weeks will need to be evaluated further, which may include a look at other probable causes or infection with resistant organisms. Susceptibility tests and urine culture should be acquired, and patients should be treated with a different empiric antimicrobial drug, with subsequent regimen tailoring depending on susceptibility data.

Prognosis

Patients with simple cystitis usually see an improvement in their symptoms three days after starting antibiotics. Recurrent cystitis affects 25% of women six months after their initial UTI, and the prevalence rises in women who have had more than one prior UTI. Complications are uncommon, particularly in individuals who are well managed. Bacteremia and sepsis are unusual complications of simple cystitis.

Emphysematous cystitis is an uncommon but potentially fatal consequence of a urinary tract infection. It is caused by gas buildup in the bladder wall and can be dangerous if not treated appropriately. Emphysematous cystitis is more likely to induce abdominal discomfort (80%) than simple cystitis (50%); pneumaturia is likely in 70% of patients, and bacteremia is present in half. A CT scan provides the most reliable diagnosis. Diabetes is the major risk factor, affecting around two-thirds of those affected. Female gender, immunocompromised diseases, urinary anomalies, urinary blockage or retention, indwelling urinary catheter, age over 60, and persistent UTIs are all risk factors.

Antibiotics are the primary treatment but catheter drainage should be performed in situations of retention, inadequate bladder emptying, or severe hematuria. In around 10% of cases, necrotizing infection of the bladder wall develops, necessitating surgical surgery requiring partial or total resection.

Conclusion 

A urinary tract infection (UTI) is characterized as substantial bacteriuria accompanied by cystitis or pyelonephritis caused by pathogenic inflammation of the upper or lower urinary tract. In an otherwise healthy, premenopausal, non-pregnant female, acute uncomplicated cystitis would be a urinary tract infection localized to the bladder. Women are more likely than males to get UTIs, owing to the closeness of the urethral meatus to the rectum and the shorter urethral length.

Females are four times as likely than males to have urinary tract infections. Cystitis symptoms include urinary frequency (many visits to the bathroom fewer than 2 hours apart), urgency, and a stinging or burning feeling (dysuria) when passing pee. Hematuria and suprapubic pain may also occur. Medical history, physical examination findings, urinalysis (UA) results, and urine cultures can all be used to make a diagnosis of simple cystitis. While the condition is normally treated as an outpatient, the severity of the disease might vary greatly and necessitate hospitalization.