Bladder Infection (Cystitis)

  • Medical Author: Pamela I. Ellsworth, MD
  • Medical Editor: William C. Shiel Jr., MD, FACP, FACR
    William C. Shiel Jr., MD, FACP, FACR

    William C. Shiel Jr., MD, FACP, FACR

    Dr. Shiel received a Bachelor of Science degree with honors from the University of Notre Dame. There he was involved in research in radiation biology and received the Huisking Scholarship. After graduating from St. Louis University School of Medicine, he completed his Internal Medicine residency and Rheumatology fellowship at the University of California, Irvine. He is board-certified in Internal Medicine and Rheumatology.

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What is the bladder?

The bladder is a hollow muscular organ that is located in the pelvis. The bladder has two functions: one is to store urine and the other is to release/expel urine. Urine drains from the kidneys (one on each side of the body), down the ureters (one on each side of the body), and into the bladder. The urine is stored in the bladder where it remains until urination. When it is time to urinate, the bladder muscle contracts and the outlet of the bladder and sphincter muscles relax to allow urine to pass through the urethra to leave the body. The bladder and urethra are part of the lower urinary tract, whereas the kidneys and ureters are part of the upper urinary tract.

What is a bladder infection?

Cystitis is inflammation of the bladder. Most cystitis is from bacterial infections involving the bladder and less commonly may be the result of yeast infections, viral infections, chemical irritants of the bladder, or for unknown reasons (interstitial cystitis). Bladder infection (infectious cystitis) is a type of urinary tract infection (UTI). This review will specifically address infectious cystitis.

The urine in the bladder is normally free of bacteria (sterile). However, bacteria may be present in the bladder but not cause inflammation or symptoms of an infection. This is called asymptomatic bacteriuria and is not cystitis.

Cystitis can be complicated or uncomplicated. Uncomplicated cystitis is a bladder infection in a healthy person with a structurally and functionally normal urinary tract. A complicated bladder infection is one that occurs in association with factors that increase the chance of developing a bacterial infection and decrease the chance of antibiotic therapy being effective. Such abnormalities include obstruction from stones, congenital blockages, urethral strictures, and prostate enlargement.

What causes bladder infections?

All urinary tract infections are the result of interactions between the infecting organism (bacteria, yeast, virus), the number of the organisms that are present in the bladder, and the body’s ability to fight off the organism (host defense mechanisms).

The most common way bacteria gain access to the urinary system from outside is through the urethra (the tube that allows urine to pass from the bladder to outside of the body).

  • The most common source of bacteria that cause UTIs is from the stool.
  • In women, the bacteria from the stool travel first to the vagina and then enter the urethra.
  • Sometimes bacteria may enter the bladder via the urethra from nearby skin.
  • In general, women are more susceptible to bladder infections due to their shorter length of urethra.
  • In the first year of life, boys have a higher risk of UTIs, but thereafter girls have a higher risk that persists in adulthood.

In terms of specific bacteria, E. coli (Escherichia coli) is by far the most common organism responsible for bladder infection or cystitis. Staphylococcal (staph) organisms (from skin) and other gut bacteria (Proteus, Klebsiella, Enterococcus) are other bacteria that can cause cystitis and other forms of urinary infections. The type of organism causing the infection can vary with the individual’s age. For example, Staphylococcus saprophyticus, a skin bacteria, causes approximately 10% of symptomatic bladder infections in young sexually active women, whereas it rarely causes bladder infections in males and elderly individuals.

Rarely, bladder infection can be caused by a fungus. Candida is the most common fungus to cause bladder infection. Candida infections of the bladder and urinary tract are much less common than bacterial infections. Bladder infections from Candida can occur in patients whose immune system is weakened, individuals who have been treated with powerful antibiotics for other infections, and individuals who have had indwelling urinary catheters.

Viruses can rarely cause bladder infections. Viral cystitis can occur in individuals after bone marrow transplantation and in other individuals with a weakened immune system (immunocompromised individuals). Adenovirus can cause bladder infections and BK virus is another virus that can cause bladder infections in individuals who have undergone bone marrow transplantation.

Quick GuideBladder Infections: UTI Causes, Symptoms, Treatments

Bladder Infections: UTI Causes, Symptoms, Treatments
Bladder Infecton

Bladder Infection Symptoms and Signs

Symptoms of a bladder infection are similar to those of any lower urinary tract infection (UTI). These symptoms are similar in men, women, and children. The main symptoms of bladder infection are:

  • pain,
  • discomfort,
  • or burning when trying to urinate.

There may be a sense of needing to urinate frequently (urinary frequency) or having to urinate urgently (urinary urgency). Passing only a small amount of urine even though you feel the need to urinate is another common symptoms. A cloudy appearance to the urine can be present if there is a bacterial infection that produces pus in the urine. The urine also may be red in color due to bleeding. Alternatively, the urine may not be changed in appearance, but red blood cells, bacteria, or white blood cells may be detected on microscopic examination of the urine.

What are some risk factors for bladder infection?

Female gender is one of the main risk factors for bladder infection. Women are at increased risk for bladder infections for a number of reasons including the following:

  1. Women have a shorter urethra than men which allows bacteria to gain access to the bladder much easier than in men.
  2. Sexual activity can increase the risk of urinary tract infections. Sexually active women tend to have more urinary tract infections than women who are not sexually active.
  3. The type of birth control a woman uses can affect the risk of developing urinary tract infections. Women who use diaphragms for birth control may have a higher risk of urinary tract infections, as well as women who use spermicidal agents.
  4. Menopausal women are at greater risk of developing urinary tract infections. Decreased estrogen levels cause changes in the urinary tract, making it more susceptible to bacteria.

Bacteria in the bladder is one of the most common infectious issues that occurs in pregnancy. The risk of having bacteria in the urine increases with lower socioeconomic status, history of multiple children, and sickle cell trait. Pregnant women are less likely to clear the bacteria in the bladder compared to nonpregnant women and are more likely to develop symptoms.

Other risk factors include the following:

  1. Urinary tract abnormalities such as obstruction to the flow of urine at any level, vesicoureteral reflux (a structural abnormality that allows urine to go backwards from the bladder to the kidneys), and neurologic conditions that affect bladder function
  2. In men with prostate enlargement, bladder infection is also more common than in the general male population. Prostate enlargement can lead to obstruction of the normal flow of urine out of the bladder and into the urethra. Residual urine can then become infected. The higher bladder pressure needed to push urine past the enlarged prostate causes decreased blood flow to the bladder, making it more susceptible to bacteria.
  3. Urinary catheters (Foley catheters) are another potential risk for bladder infection. These urinary catheters are typically used in settings where an individual may not be able to urinate naturally. Urinary catheters simply provide a physical vehicle to transport bacteria from outside directly into the bladder and the urinary system. Foley catheters are commonly used in patients with severe illness, limited mobility, urinary incontinence (inability to hold their urine), bladder obstruction and urinary retention (prostate enlargement, urethral scarring, prostate cancer), bladder trauma, bladder cancer, bladder dysfunction due to neurologic conditions, or who are unable to get out of bed.
  4. Bladder infection is more commonly seen in patients with paralytic conditions, such as multiple sclerosis (MS), stroke, and other diseases of the nervous system, than in the general public. In these and other similar neurologic diseases, bladder function may be impaired due to abnormal nervous system control of the bladder (neurogenic bladder). As a result, urine may be retained in the bladder and not completely emptied after voiding. Urinary retention can be a cause of bladder infection. Furthermore, if urinary retention becomes more serious, causing pain and kidney dysfunction, Foley catheters may become necessary to empty the bladder and relieve the bladder pressure caused by excessive retention of urine. A catheter, in turn, can substantially increase the risk of bladder infection.
  5. In addition to the Foley catheter, any instrumentation of the urinary tract or nearby structures can potentially lead to cystitis. Medical procedures (cystoscopy, bladder biopsy, prostate procedures), vaginal pessary, and IUD (intrauterine device) placement for birth control can pose an increased risk of developing a bladder infection.
  6. In children and toddlers, the risk for bladder infection may be increased in females, uncircumcised males, those with structural abnormalities of the urinary tract, and Caucasians (four times higher than in African Americans).
  7. Elderly people are also at higher risk of suffering bladder infections as are individuals who take medications that weaken the immune defense system.

What are the signs and symptoms of a bladder infection in women?

Because cystitis is seen more commonly in women, most signs and symptoms listed below pertain to cystitis in women unless otherwise indicated.

General symptoms of bladder infection may include the following:

  • Dysuria (painful urination)
  • Urinary frequency
  • Urinary urgency (sudden, compelling urge to urinate)
  • Hesitancy to void urine
  • Bladder pain (pain in the lower abdomen around the pubic bone and pelvic area)
  • Incomplete voiding of urine (leaving urine in the bladder after urinating)
  • Urinary incontinence (involuntary loss of urine), which may be associated with urgency

Fevers, chills, nausea, vomiting, and poor oral intake are rarely seen in bladder infection, although they are more common upper urinary tract infections, such as pyelonephritis (kidney infection).

Some common signs of bladder infection are

  • lower abdominal tenderness;
  • blood in urine (hematuria);
  • less commonly, tenderness on the sides of the back (flanks);
  • foul-smelling urine; and
  • in elderly patients, lethargy or confusion may be the only signs.

Quick GuideBladder Infections: UTI Causes, Symptoms, Treatments

Bladder Infections: UTI Causes, Symptoms, Treatments

What are the signs and symptoms of a bladder infection in men?

In men, signs and symptoms of probable bladder infection (cystitis) are as follows:

  • Dysuria (painful urination)
  • Urinary frequency
  • Urinary urgency
  • Suprapubic pain (pain above the pelvic bone in lower abdomen)
  • Hematuria (blood in urine): Blood in the urine may occur with a bladder infection. However, if an individual has grossly bloody urine, consultation with a urologist (a doctor who specializes in the treatment of conditions affecting the urinary tract) is essential as other conditions, such as bladder cancer, can also cause the urine to be bloody.
  • Incomplete voiding of urine (leaving urine in the bladder after urinating)
  • Urinary incontinence, which may be associated with urgency

What are the signs and symptoms of a bladder infection in children?

Signs and symptoms of bladder and urinary infection in young children and infants may be more vague and can include the following:

  • Irritability
  • Fussiness
  • Poor eating
  • Vomiting
  • Failure to thrive
  • Generalized malaise
  • Strong-smelling urine
  • Abdominal pain

How do health care professionals diagnose a bladder infection?

Bladder infection is generally diagnosed by a urinalysis (UA). In most cases, a voided urine specimen is use, however, there is a risk of contamination by skin bacteria. A catheterized urine sample is more accurate, but has the risk of introducing bacteria into the bladder.

The method of collecting a voided urine sample differs between men and women, as well as between circumcised men and uncircumcised men. In circumcised men, there is no special preparation. However, in uncircumcised men, the foreskin should be retracted. If the source of the infection is unclear, three separate urine samples may be collected: the first void (the first 10 ml of urination) reflects whether or not bacteria are in the urethra; and the second sample is a midstream void (that which occurs after the first 10 ml) and reflects whether or not bacteria are in the bladder. If there is a concern for bacteria in the prostate, a rectal examination is performed and the prostate massaged to express fluid from the prostate into the urethra, and the third urine sample is obtained after the prostate massage. In both males and females, the urine should be collected midstream. It is unclear if washing the penis or perineum with gauze or an antibiotic wipe is more effective in preventing contamination from the skin. In children who are not toilet-trained, a catheterized specimen is more accurate than placing a collection bag over the urethra. In infants, a health care professional can perform a suprapubic aspiration (placing a small needle through the lower abdomen into the bladder and withdrawing a urine sample). In toilet-trained children, a health care professional may obtain a voided urine sample.

A quick office-based urinalysis, called a urine dipstick, is unable to detect if bacteria are present. However, it is used to detect the presence of nitrite in the urine and leukocyte esterase. Nitrite is a chemical that is formed when bacteria in the urine break down a chemical called nitrate, which is normally present in the urine. In addition, the urine dipstick is unable to determine the number of white blood cells (infection cells) present in the urine but assesses whether or not white blood cells are present by measuring leukocyte esterase activity. Leukocyte esterase is a chemical produced by white blood cells. The presence of both nitrites and an elevated leukocyte esterase are very suggestive of a urinary tract infection. The absence of nitrite does not mean that there is not an infection, because not all bacteria can break down nitrate to nitrite.

A formal urinalysis with examination of the urine under the microscope is able to identify whether or not bacteria are present in the urine as well as determine the number of white blood cells present in the urine. Examination of the urine under the microscope can also determine if yeast are present in the urine. Viruses cannot be seen under the routine microscope and require special tests to identify.

The definitive test to determine if there is a bladder infection is the urine culture. The urine culture identifies the number of and type of bacteria in the urine as well as determine the sensitivity of the bacteria to a number of different antibiotics. The usual cutoff for a urinary tract infection is the presence of greater than 10,000 bacteria, however, in the presence of symptoms, even fewer bacteria in the urine is supportive of a urinary tract infection.

If symptoms of an upper urinary tract infection, fever, flank pain, nausea or vomiting are present, a blood test, a complete blood cell count (CBC) is often obtained. If there is a concern for a severe infection, a sample of blood will be cultured to see if there are bacteria in the bloodstream. Radiologic studies are not routinely obtained in the case of cystitis, however, if there are signs of a kidney infection such as flank pain, fevers/chills, or there is a failure to respond to antibiotics (with persistent or worsening symptoms), then radiologic testing (renal ultrasound, CT scan, or MRI) can be performed to rule out an abscess or other abnormalities.

What are treatment options and medications for a bladder infection?

Bladder infection can be treated and cured by appropriate use of antibiotics. The selection and duration of antibiotic treatment depends on severity of the infection, previous history of similar infection, and patient factors (age, gender, allergies, other medications, other medical problems). The antibiotic initially chosen will be dependent on these factors as well as urine culture results from prior infections. Sometimes the antibiotic will be changed if the urine culture results show that the bacteria is resistant to the antibiotic used initially. In most bladder infections, oral (by mouth) antibiotics are used. The length of treatment will vary with whether or not the infection is complicated or not, as well as other risk factors. Sometimes intravenous antibiotics may be needed until a suitable oral antibiotic has been identified. A number of different types of antibiotics have been used to treat bladder infections, including trimethoprim-sulfamethoxazole (Bactrim), nitrofurantoin (Macrobid, Furadantin, and Macrodantin), fosfomycin (Monurol), cephalosporins, and fluoroquinolones. Resistance to various antibiotics varies in different areas of the country, and this may also affect the antibiotic that your physician chooses initially until the culture results are available. It often takes up to 72 hours, sometimes longer, to have the final culture result and antibiotic sensitivities available.

Self-medication for bladder infection is occasionally an option in patients with mild, recurrent infections. In reliable and compliant individuals who are familiar with the symptoms of frequent bladder infections, appropriate bladder infection antibiotics can be prescribed to them in advance by their treating physicians. The bladder infection medication may then be started by the patient on their own at the onset of their symptoms. If the symptoms do not improve after several days of treatment, a urine culture will be needed to ensure that the proper antibiotic is being used.

Bladder muscle spasm and bladder inflammation are responsible for some of the symptoms associated with bladder infection, such as bladder pain, urinary frequency, urgency, and dysuria. Phenazopyridine (Pyridium) is a medication often used to treat symptoms of painful urination due to bladder infection. Other similar medications are available over the counter.

Prophylactic antibiotics (a low dose of antibiotic on a daily basis) is sometimes recommended for individuals who develop frequent symptomatic UTIs. Similarly, women who develop UTIs related to sexual activity may take a single dose of antibiotic around the time of intercourse.

Quick GuideBladder Infections: UTI Causes, Symptoms, Treatments

Bladder Infections: UTI Causes, Symptoms, Treatments

Are home remedies effective for a bladder infection?

Cranberry products have been known to prevent bladder infections to some degree, although it is not advised to use them in lieu of antibiotics for treating an infection.

Adhering to the prescribed antibiotic regimen and staying well hydrated are essential components of home remedy for bladder infection.

What is the treatment for a bladder infection during pregnancy?

In pregnant women, bladder infection can be complicated. Sometimes the presence of bacteria without obvious signs of infection in pregnant patients could be harmful and may lead to severe infections and the pregnancy can be compromised. The choice of antibiotics during pregnancy may be different for bladder infection during pregnancy due to potential harm to the fetus and thus, careful evaluation by a physician is very important to start the correct therapy promptly.

What are potential complications of a bladder infection?

Complications of a bladder infection can occur if it is not appropriately diagnosed or treated. Untreated or poorly treated bladder infection can ascend the urinary system and lead to kidney infection (pyelonephritis) and enter the bloodstream, leading to sepsis (infection spread into the blood), which can be life-threatening. In children, particularly, kidney infections can cause permanent damage to the kidney. In pregnant women, complications of bladder infections include an increased risk of delivering low birth weight or premature infants. Urethral narrowing (stricture) in men from recurrent urethral infections can occur, more commonly with sexually transmitted diseases such as gonorrhea.

Is it possible to prevent bladder infections?

Although the use of cranberry products (whole cranberries, cranberry juice, cranberry pills) is thought to help prevent infections, more recent evidence fails to demonstrate sufficient effectiveness in preventing UTIs.

Regular voiding and bowel habits may help decrease the risk of bladder infections. Timely and effective bladder emptying as well as avoiding constipation may decrease the number of bacteria present near the urethra and decrease the likelihood of bacteria growing in the bladder.

Strict adherence to guidelines to prevent catheter associated urinary tract infections is helpful in reducing bladder infections. The Center for Disease Control and Prevention has developed guidelines with respect to appropriate urinary catheter use, proper techniques for insertion, and maintenance of urinary catheters (https://www.cdc.gov/hai/ca_uti/uti.html). Individuals who perform clean intermittent catheterization (insertion of a catheter to drain the bladder and removal several times a day) and who develop frequent infections may change to single use systems.

Sexual intercourse is another potential risk factor for bladder infection. Thus, it may be advisable to empty the bladder (urinate) after sexual activity, draining bacteria that could have entered the bladder. This is not completely supported by available clinical data and is not recommended by some experts. The use of prophylactic antibiotics at the time of intercourse may also be helpful in individuals with recurrent UTIs related to sexual activity.

Preventive use of antibiotics may also have a role in preventing bladder infections. In some female patients with frequent bladder infections (more than three to four times per year) or with symptoms of bladder infection present after sexual intercourse, a short course of antibiotics can be taken as a preventive measure. This method needs to be recommended by the treating doctor, and the strategy needs to be outlined for patients who are deemed reliable.

Preventive antibiotics are also sometimes recommended in patients undergoing invasive urologic procedures (cystoscopy, prostate biopsy, bladder biopsy). Occasionally, urinalysis and/or urine culture may be ordered before the procedure and if an infection is suggested, then antibiotics are prescribed to prevent an infection after the procedure.

What is the prognosis for a bladder infection?

The overall prognosis for a bladder infection is very good. An uncomplicated bladder infection typically does not cause any damage to the bladder. Identification of risk factors may help decrease the risk of recurrent infections.

REFERENCES:

Brusch, John L., et al. "Cystitis in Females." Medscape. Feb. 25, 2013.

Cayley, Jr., William E. "Are Cranberry Products Effective for the Prevention of Urinary Tract Infections?" Am Fam Physician 88.11 Dec. 1, 2013: 745-746.

Colgan, Richard, and Mozella Williams. "Diagnosis and Treatment of Acute Uncomplicated Cystitis." Am Fam Physician 84.7 Oct. 1, 2011: 771-776.

"Guidelines for Antimicrobial treatment of acute uncomplicated cystitis and pyelonephritis in women." Clinical Infectious Diseases 52 (2011): e103-e120.

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Reviewed on 9/25/2017
References
REFERENCES:

Brusch, John L., et al. "Cystitis in Females." Medscape. Feb. 25, 2013.

Cayley, Jr., William E. "Are Cranberry Products Effective for the Prevention of Urinary Tract Infections?" Am Fam Physician 88.11 Dec. 1, 2013: 745-746.

Colgan, Richard, and Mozella Williams. "Diagnosis and Treatment of Acute Uncomplicated Cystitis." Am Fam Physician 84.7 Oct. 1, 2011: 771-776.

"Guidelines for Antimicrobial treatment of acute uncomplicated cystitis and pyelonephritis in women." Clinical Infectious Diseases 52 (2011): e103-e120.

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