Fact sheet: Cystitis in women

Many women know only too well the symptoms of cystitis, an inflammation of the bladder also often referred to as a urinary tract infection (UTI): frequently having to go to the bathroom, stinging and burning when passing urine. Although uncomplicated cystitis usually clears up without any problems, the symptoms are often very unpleasant.

Unfortunately, there is no sure-fire way to reliably prevent cystitis – and a lot of the prevention strategies that women use in everyday life have not yet been tested in scientific studies. But acute symptoms can be treated. In this fact sheet we explain what causes bacterial cystitis and what prevention and treatment options there are. However, we will not treat chronic cystitis such as interstitial cystitis, which are not caused by bacteria, in this fact sheet. We will also not get into the specifics of treatment in pregnant women here.

What is cystitis?

Uncomplicated cystitis is an inflammation of the mucous membrane of the bladder. It is normally caused by bacteria that get into the urethra and enter the bladder. Once in the bladder, the bacteria stick to the bladder wall and multiply, leading to an inflammation of the tissue lining the inside of the bladder. You can read more about the urinary system here.

Cystitis is far more common in women than in men, because women’s urethras are shorter, so the bacteria do not have as far to travel. More than half of all women get cystitis at least once in their life. And half of those who have cystitis get it again within a year.

What are the symptoms of cystitis?

People who have cystitis have to pass urine frequently and this can be associated with a stinging and burning pain. So they not only have to go to the bathroom more often, but this can be far more unpleasant, too. Many women find that it is particularly painful when their bladder is almost or completely empty. The urge to pass urine often comes very suddenly and they quickly have to go to the toilet, but then only a small amount of urine comes out. Some women also have difficulties holding back urine, which can be very unpleasant and distressing. The urine sometimes has blood in it, may be cloudy in color and have a noticeable smell.

Women report that cystitis cannot only cause unpleasant sensations in the affected area, but can also cause pain in other parts of the body, including the pelvis or the back. They often have pain in the whole abdomen, and may generally feel unwell and groggy, have difficulties sleeping, or feel tired, irritable and unable to concentrate.

If symptoms are limited to the lower urinary tract, an uncomplicated cystitis is assumed. This is the case when the following symptoms occur:

• Pain when passing urine,
• Strong urge to urinate,
• Frequent urination,
• Pain above the pubic bone.

If someone belongs to a certain risk group or when the inflammation spreads to the kidneys, this is called complicated cystitis. These risk groups include people with reduced immune system or people with an existing kidney condition, for example. Changes or anatomical peculiarities in the urinary tract can favor complications in cystitis. You can read more about how the urinary system works here.

Especially the following symptoms can indicate complications and a spreading to the kidneys:

• Pain in the kidney area (flank pain),
• Fever,
• Possible nausea and vomiting.

This can happen when bacteria travel up the ureters and into the kidneys, leading to an inflammation of the renal pelvis, called pyelonephritis. Pyelonephritis can be dangerous and should be treated quickly to avoid further health problems. This disease is very rare however – in otherwise healthy women cystitis usually has no serious consequences.

How is cystitis diagnosed?

Based on your medical history and symptoms, your doctor can assess whether or not you have uncomplicated cystitis. In addition, you can provide a urine sample to the doctor’s office to be tested for bacteria, white and red blood cells, proteins and nitrite (a salt that can serve as an indirect indicator of bacteria).

Using an ultrasound device your doctor can look at your kidneys or bladder (sonography). This examination is generally only needed in complicated cases or if pyelonephritis is suspected. The same is true for x-rays and cystoscopies, for example in severe cystitis that frequently recurs. A cystoscopy is a procedure that involves inserting a tube with a small camera at the end of it (an endoscope) into the urethra and guiding it through to the bladder. In this way the doctor can see any changes on the bladder wall.

Do antibiotics help relieve acute symptoms?

Antibiotics have been proven to help in acute cystitis. They can make the symptoms go away completely. The pain and burning subside quickly – usually within 1 to 3 days.

It depends on the type of antibiotic how long it needs to be taken. Most antibiotics nowadays are taken for 3 days, or for more than 5 days. Previously, single doses were prescribed more frequently, which often was enough to relieve symptoms. But surviving bacteria often caused a relapse.

Three days of treatment is usually enough to relieve symptoms in most women. Taking antibiotics for longer does not improve symptom relief, but it does lead more frequently to adverse effects, such as fungal infections of the vagina, stomach and bowel problems or skin rashes. On the other hand, researchers have found that more bacteria were left over in the bladder after the shorter course of antibiotics. It is not clear whether this could, for instance, lead to more frequent recurrences of cystitis.

So the choice of therapy needs to be considered individually: Women who want to be as sure as possible that the infection is completely gone might choose antibiotics that are taken for 5 or more days. Women who are concerned about taking antibiotics only briefly and minimize the risk of adverse effects might prefer a medication that only needs to be taken for a short time. You can talk to your doctor about which antibiotic can be used in your case. Once you have decided on a medication it is important to take it as prescribed and not to stop therapy early. You can read more about the research on antibiotics in cystitis here.

For more information about what should generally be considered when using antibiotics, click here.

What else can I do if I have cystitis?

Many women try to “flush out” the bacteria by drinking a lot of water or tea. Home remedies like applying heat (for example, with a hot water bottle, electric blanket or warm bath) are also used to try to relieve pain and to relax. But there is no research on how effective these remedies are.

Numerous herbal and homeopathic remedies are also used to treat cystitis. The products and remedies tried by some women include:

• Diuretic herbal products like birch leaf, horsetail or stinging nettles
• Products with bearberry leaves, cranberries or bilberries
• Traditional Chinese medicine procedures

None of these remedies has been scientifically proven to help, though, and some might even do harm when used long-term.

For women with recurrent cystitis, bladder irrigations are available, which aim to prevent bacteria from sticking to the bladder. Whether or not these bladder irrigations help has not been studied enough. German statutory health insurances do not cover the costs of this therapy.

In acute cystitis, pain killers can reduce the burning pain while passing urine. If you take this kind of drug, you will find more information about the possible adverse effects in the package insert of the drug. If you are not sure whether a particular painkiller is suitable for your situation, ask your doctor.

What increases the risk of getting cystitis?

Sexual intercourse increases the risk of getting cystitis, because that makes it more likely that bacteria will get into the urethra. The use of sperm-killing agents (spermicides) and contraceptive diaphragms can also increase the risk somewhat.

Pregnant women are more likely to get cystitis. Other risk groups include people who have a bladder catheter, people who have anatomical changes in their urinary tract, and people who have diabetes mellitus, multiple sclerosis or a urological disease.

Cystitis is also more common in older women, which is probably due to the hormonal changes in the menopause. Women who have already had cystitis are also more likely to get it again.

How can cystitis be prevented?

Although cystitis is usually not a serious problem from a medical point of view, the symptoms are so unpleasant that they can interfere severely with everyday life. People who have recurrent cystitis may feel less like having sex or may be afraid to take part in certain leisure activities. Some women also find their symptoms embarrassing. For these reasons it is very important for many women to try to avoid getting cystitis.

Sometimes cystitis comes “out of the blue” and it is not clear what has caused it. But many women have had good experience paying attention to what factors in everyday life increase their likelihood of getting cystitis, and making the necessary changes. If that is not enough to make a difference, and they still have recurrent cystitis, there are medication options.

Lifestyle

Various everyday measures are said to help prevent cystitis. Because it has been shown that sexual intercourse can cause more bacteria to enter the urethra, one common piece of advice is to urinate soon afterwards in order to flush bacteria out of the urethra. Drinking a lot of water or tea is recommended for the same reason. Since sperm-killing agents and diaphragms can also increase somewhat the risk of getting cystitis, it can be worth to try out other methods of contraception.

Another strategy that is often mentioned is good intimate hygiene to try to stop intestinal bacteria getting into the vagina and urethra. For example, women are advised to always wipe themselves from front to back after going to the toilet.

It is often recommended that women make sure that their feet and abdomen do not get cold. General advice like getting enough sleep and avoiding stress are also sometimes given.

Even if these tips seem to make sense and are generally easy to incorporate into everyday life, there is no scientific evidence to say whether they help or not. Many of them will most likely never be studied in good-quality research.

Cranberry products

Cranberry products are sometimes recommended for the prevention of cystitis. These are available in pharmacies and drugstores in the form of juices, powder, capsules and tablets. It is not clear, however, whether taking these products on a regular basis can help to prevent cystitis. Research so far has not presented clear results. We will inform you as soon as new findings become available.

Antibiotics

Antibiotics can also be used as a preventive measure in women with recurrent cystitis. But they then have to be taken over very long time periods, often for 6 to 12 months. The optimal amount of time is still not known. Although women generally get cystitis less frequently when they take antibiotics, they also quite often have adverse effects. These are usually digestive problems, rashes and vaginal irritations. A relatively large proportion of women stop taking them after a while. What is more, using antibiotics too often carries the risk of bacteria becoming increasingly resistant to antibiotics, which means that these drugs might no longer work. You can read more about the problem of antibiotic resistance here.

Hormones

In menopause, women’s bodies start to produce less of the female sex hormone called estrogen. In some women this makes the membranes lining the vagina thinner and drier, which means that it is easier for bacteria to colonize them, so these women are more likely to get cystitis. Estrogen creams aim to prevent this from happening. They are applied to the inside of the vagina regularly and can help some women to get cystitis less frequently. But they can also have adverse effects, like vaginal itching and burning. Also, not much is known about the effects of using estrogen creams for longer periods of time (longer than 8 months).

Estrogens are also available as vaginal tablets. It has not been studied yet whether applied in this form they also have an effect on preventing cystitis.

Taking estrogen tablets orally, on the other hand, cannot prevent cystitis. What is more, they can lead to adverse effects after a few months, such as breast tenderness, light vaginal bleeding and rashes. You can read more about the long-term use of hormones in menopause here.

Drugs with inactive strains of bacteria

A vaccine against cystitis has been on the market in Germany since 2004. The vaccine has several inactive strains of bacteria in it and, according to the manufacturer, helps the body to fight bacteria better. There are also capsules to take orally containing inactive strains of bacteria and that aim to prevent recurrent cystitis. Whether or not these products and measures help has not been studied sufficiently yet. The German statutory health insurances do not cover the costs.

How can I cope with this problem in the long term?

For many women cystitis is a one-off unpleasant experience. In other women it keeps coming back. Whichever group you belong to: antibiotics usually provide quick relief in acute cystitis. Some products can prevent cystitis from recurring, but only if they are taken regularly, and they can have adverse effects. Besides, if antibiotics are taken too frequently, there is an increased risk of the germs becoming more resistant. If you have recurring cystitis, finding out for yourself what changes in everyday life can reduce your risk of getting cystitis could make it a lot easier to cope with this distressing problem.

Author: German Institute for Quality and Efficiency in Health Care (IQWiG)

Next planned update: April, 2014. You can find out more about how our health information is updated here.

© IQWiG (Institute for Quality and Efficiency in Health Care)