Sadly, cystitis is incredibly common in women. Around 10–20% will get at least one attack of cystitis in a lifetime. The symptoms can be extremely unpleasant, and you may be desperate for help – and fast. Some women have recurrent urine infections, which can be very troublesome and annoying.
This information below is only for women with a suspected urine infection, and for stand-by non-urgent antibiotics.
If men think they may have a urine infection, this needs a totally different approach.
Read on to find out all you need to know about urinary tract infection, antibiotics and stand-by treatment.
‘Cystitis’ is the non-medical term for a urinary tract infection – often called a ‘UTI’ or ‘water infection’. It means inflammation of the bladder.
It occurs when there is a build up of bacteria within the urine. These irritate the bladder wall and the neck of the bladder, the urethra. As the bacteria multiply, inflammation worsens, giving rise to symptoms such as needing to pee frequently, burning and stinging on passing urine.
What are the symptoms of cystitis?
- The need to pee more often
- Getting up at night to pass urine
- Burning and stinging on passing urine
- Smelly urine
- Blood in the urine*
- Lower tummy pain
- In the elderly, a UTI should be suspected if they become unwell, drowsy or confused.
*Blood in the urine is common with cystitis – but not everybody has it. However, it is a significant symptom and if there is blood in your urine you must see a doctor – NHS – Blood in the urine.
If cystitis worsens, sometimes the infection may spread to your kidney. This is called pyelonephritis.
What are the symptoms of pyelonephritis?
- Pain in the loin area
- Generalised symptoms: fatigue, anorexia, nausea, vomiting, feeling very unwell
Pyelonephritis is more serious than a simple bout of cystitis, and requires urgent medical attention.
What’s the difference between ‘uncomplicated’ and ‘complicated’ cystitis?
This is the term used for a urine infection which is localised to the bladder, and associated with mild symptoms only. These may include passing urine frequently, and burning/stinging. You may feel a bit under the weather. Your urine may be cloudy. However, there are no signs of a more severe infection, such as a kidney infection.
Cystitis becomes complicated when the infection is more severe. In this case you will have more pronounced symptoms/signs.
In addition to the symptoms of uncomplicated cystitis above, these might include blood in the urine, fever, shaking, flushing, rigor, nausea and vomiting. You might have pain in the lower part of the tummy wall, or in your loin area. You may feel generally unwell, and feel drowsy or suffer from confusion.
Cystitis would also be viewed as complicated if you have risk factors which give the infection more potential to spread and develop, or if the consequences of the infection might be more severe. Examples are urine infections in pregnancy, or in women with diabetes, or lowered immunity such as HIV infection.
Why do women get cystitis so commonly?
Women are thought to develop cystitis because the passageway through the neck of the bladder – the urethra – is only a short distance. This means bacteria for example from the bowel (in your faeces), or perhaps from having sex, can travel up inside the bladder with relative ease.
Because of the anatomy of the male penis this situation is very different for men – and it is unusual for men to get urinary tract infections.
There may be other factors associated with the development of urinary tract infections such as:
- Bladder/kidney stones – these represent a foreign body in the urinary tract
- Pregnancy – the pressure of the pregnant uterus can affect bladder function
- Difficulty emptying the bladder properly, e.g. after gynaecological surgery
- Indwelling catheters – for which the management is different
- Constipation in children – not covered in this section
- Medical conditions, e.g. diabetes (bacteria like the high glucose level in the urine); or HIV, where natural immunity is low.
- Sexually Transmitted Infections (STIs) may present with urinary symptoms, e.g. chlamydia, gonorrhoea, and herpes
- May be associated with using a contraceptive diaphragm
- Hormonal deficiency, e.g. estrogen deficiency after menopause
- After radiotherapy for cancer
- After Female Genital Mutilation (FGM)
What are the causes of cystitis?
- Escherichia coli – these bacteria cause more than 85% of all UTI’s. They originate in the bowel, and when they enter the bladder, they cause intense irritation and inflammation. Newer strains of E. coli called extended-spectrum beta-lactamase (ESBL), are resistant to most antibiotics.
- Staphylococcus saprophyticus – a common infecting organism in women who are sexually active. This originates in the gut. Further information: Who are you Staphylococcus saprophyticus.
- Proteus – usually originates in the digestive tract. Further information: Proteus urinary tract and vulvovaginal infections.
- Klebsiella – a common cause of a UTI – found in soil and water but also in the digestive tract. Further information: Urinary infections caused by klebsiella.
- Pseudomonas aeruginosa – tends to occur in hospital settings and may be associated with an underlying medical condition affecting the kidneys/renal tract.
- Staphylococcus epidermidis and Enterococcus faecalis – these are common organisms found in women for example with indwelling urinary catheters.
Overview: NICE: urinary tract infections.
What should I do if I think I have cystitis?
Many women have only mild symptoms of cystitis and these may improve by following simple advice. This is called uncomplicated cystitis. You do not always need to be seen by a doctor, and do not always need an antibiotic.
If you are not generally unwell, and your symptoms are mild, you can follow simple treatment advice at home:
- Drink plenty of fluids – at least 2 litres per day
- Take paracetamol / non steroidal anti-inflammatories, e.g. ibuprofen
- In the past women were recommended to take Cranberry juice or concentrated Cranberry capsules, but there is no medical evidence this is helpful.
- Bladder Health UK recommends short term alkalinisation of the urine. Although there is no medical evidence to support this, and it is not advised for anyone with high blood pressure or cardiovascular disease, it may be helpful for some.
When to see a doctor if you think you have a UTI?
If your urine infection is failing to improve after 72 hours with simple home treatments, or if you have any symptoms/signs of complicated cystitis, you should see a doctor without delay.
See a doctor if:
- After 72 hours of simple home treatment, your symptoms are failing to improve.
- You have severe symptoms which are distressing, or affecting your daily functioning.
- You have systemic symptoms such as fever, rigors or loin pain suggestive of a kidney infection.
- You are feeling nauseous or vomiting.
- You are feeling drowsy or confused.
- You have blood in your urine.
- You have underlying health problems such as diabetes; or are immune suppressed, e.g. chemotherapy, radiotherapy, or HIV infection.
- You could have an STI.
- You are pregnant.
- You have any underlying cause such as kidney stones, kidney disease, or abnormality of the urinary tract.
- You have an indwelling catheter.
What happens if my cystitis does not get better with simple treatments?
If after 72 hours things are not better, or if your symptoms are worsening, you are strongly advised to make an appointment with your doctor or practice nurse.
Do I need any tests for a possible attack of cystitis?
When you go to see the doctor/nurse about a possible bout of cystitis (UTI) you will be asked a series of questions about your medical history. They will need to be up-to-date about your full medical history, drug, and allergy history.
Basic examinations may be undertaken such as your pulse, temperature, and blood pressure. It may be necessary to ask you to lie down and gently feel your abdomen.
You are likely to be asked to give a sample of urine. This is called a mid stream urine sample or an MSU.
This may be sent to the laboratory in order to culture the urine. If there are bacteria there, these can be identifiable from the laboratory culture. The laboratory then determine which antibiotic these bacteria are sensitive to, and which they are not. It takes around 3 days to get a result from an MSU specimen.
The doctor/nurse will put a dipstick in the urine. The dipstick is a special tool which changes colour at the tip if there are abnormalities in the urine. It tests for glucose, blood, ketones, pH, nitrites, and leucocyte esterase. If the nitrites and leucocyte esterase test is positive, this is suggestive of a UTI. Further information: Urine Dipstick Analysis – Patient.info.
It is important to realise that a proportion of women, especially those aged over 65, have bacteria in the urine as a matter of course. If this is the case, and you have no symptoms, there is no absolute necessity for treatment. This is called asymptomatic bacteriuria.
Antibiotic treatment for cystitis
If you are diagnosed with a UTI, and this has not improved with simple treatment, you will usually be offered antibiotics.
The National Institute for Care and Excellence (NICE) issues Guidelines for the Treatment of UTIs.
First choice antibiotics:
- Nitrofurantoin MR 100mg modified-release twice a day for 3 days.
- Trimethoprim 200mg twice a day for 3 days (if low risk of resistance).
Both are usually effective in treating cystitis, although there is increasing antibiotic resistance to trimethoprim. Nitrofurantoin is the most widely prescribed first line treatment for cystitis. A first-line treatment is the one that is usually recommended and prescribed first by doctors. Up to 30% of bacteria which cause water infections are currently resistant to trimethoprim. The amount of bacterial resistance to particular antibiotics varies from one part of the country to another.
Simple cystitis will improve greatly within 24 hours of starting antibiotics. If symptoms are not improving in the first 24 hours, or have not gone completely at the end of 3 days, further medical advice is needed.
- Alternative antibiotics might also be prescribed.
- Because of antibiotic resistance, other antibiotics are sometimes indicated.
- A 3 day course may be sufficient. If not, a 5 or 7 day course is advised.
- If there are other important factors e.g. kidney failure, kidney stones, a 10 day course may be prescribed.
Why doesn’t every woman with cystitis need to have an MSU sent to the laboratory?
Studies have shown that in a simple, uncomplicated infection, if an MSU is sent to the laboratory, by the time the results are back – a minimum of 3 days – your symptoms are likely to have resolved. This means the test was not helpful, and as this has a cost to the NHS, sending an MSU at the outset is questionable. This tends to be reserved for complicated cases i.e. women with risk factors, recurrent infections, or those who have been systemically unwell with their UTI. This is in line with national guidance.
Why doesn’t every woman with cystitis need antibiotics?
Strangely enough, there is still no real agreement on how best to diagnose a UTI when a woman first presents with symptoms.
It is quite possible to have a UTI and have a negative dipstick test. It is also possible that symptoms improve with antibiotics even when an MSU culture is subsequently negative!
Research studies support the fact that many women who present with symptoms of cystitis, will get better without the need for antibiotics. In studies where women were persuaded to wait 48 hour before starting treatment, many did not need antibiotics. In those who started antibiotics immediately, the duration of symptoms was only reduced by around 1–2 days. There is growing concern about antibiotic resistance and over-use of antibiotics.
The consensus of opinion is that women who present with a possible UTI should be given antibiotics, but asked if they might consider waiting 48 hours before starting them. This is especially the case if a urine dipstick test is negative. If there are medical reasons why more prompt or rigorous treatment is needed, this advice would be different.
Further information: Dipsticks and diagnostic algorithms in urinary tract infection.
What can I do to treat cystitis most effectively?
Once you have seen a doctor/nurse, and been assessed, you are likely to have been given antibiotics.
You will have discussed when to start taking them. You may do this straight away, or if your symptoms are mild and there are no other additional risk factors, you may choose to wait 48 hours and see if your symptoms resolve spontaneously, before starting the antibiotics.
Sometimes, the symptoms are severe, and you will need to start without delay.
- Take your antibiotics exactly as instructed.
- Drink plenty of fluids – at least 2 litres per day.
- Take paracetamol or ibuprofen if you have any discomfort. Avoid ibuprofen if you have a kidney infection.
- Do not have sexual intercourse while you have symptoms as this may make your symptoms worse.
Advice to reduce the chance of further episodes of cystitis
- When you have your bowels open, always wipe front to back, not the other way round.
- Wear loose cotton underwear – allow air to circulate.
- Have a pee as soon as possible after having sex.
- When you pee, try to ensure you always empty your bladder fully.
- Shower rather than bath.
- Wear tight underwear or hot sweaty lower garments.
- Use perfumed bubble baths/soaps on the genital area.
- Use condoms which are already lubricated.
- Use a contraceptive diaphragm – try an alternative method of contraception.
How can I get antibiotic treatment for cystitis?
You can get hold of antibiotics to treat cystitis by:
- Making an appointment with your GP/practice nurse.
- Attending a Sexual Health Clinic.
- Purchasing antibiotics for cystitis online from an online clinic such as Dr Fox . However, if you currently have symptoms, you will not be suitable for this service due to postal delays. This is a ‘stand-by’ antibiotic prescribing service. It is only available for women who have had cystitis in the past and wish to keep antibiotics at home in order to start quickly if they have another attack. If you already have symptoms, you are strongly advised to see a doctor or visit a clinic.
Do I need a prescription to buy antibiotics for cystitis?
If you want to purchase antibiotics for cystitis, such as nitrofurantoin or trimethoprim, these can only be obtained if you have a prescription. This is because these are licenced as Prescription only (P) medicines.
- You can obtain an NHS prescription from your GP. You will then take this to a pharmacy to be dispensed in the usual way, subject to NHS prescription fees unless you are exempt.
- If you use an online pharmacy such as Dr Fox, the medical team will assess your suitability for the medication, and provide an online prescription for you. Payment is taken online and medicine will be delivered direct.
Why provide stand-by treatment?
Antibiotics are only available to purchase online for future use, as a stand-by supply. If you are prone to attacks of urine infection, you may wish to keep some antibiotics on hand in case you need them. Expiry dates of medicine packs are usually several years.
When you get a bout of cystitis you need help right away and cannot wait 3 days for a postal delivery of medication. It makes sense, if you suffer with recurrent attacks, to have some tablets in the medicine cabinet to start right away if you have symptoms.
You can purchase antibiotics for cystitis, such as nitrofurantoin or trimethoprim, from Dr Fox provided you meet the following criteria:
- You have had a previous bout of cystitis and recognise the symptoms.
- You have a simple – uncomplicated infection. This means the infection is localised to your bladder and there is no kidney involvement. Plus you are generally well, with no fever, or loin pain.
Are there any alternative treatments for cystitis?
Urinary tract infections are so common, and with the mounting problem of antibiotic resistance, much work is underway to discover alternative remedies.
Below are listed some of the main options:
- Nettle Tea/Herbal remedies
- Topical estrogen
There has been much interest in D-mannose. This is a type of sugar which is not metabolised by the body. Once swallowed, it is absorbed in the stomach and passes via the blood stream to the kidney and then to the bladder. Once in the bladder, it sticks to the bladder wall, preventing bacteria from sticking there. Then, when you pee, the bacteria are passed out in the urine, having attached to the D-mannose particles.
There is some medical evidence that D-mannose is effective in treating/preventing urine infections. A 2016 study showed a significant benefit from taking D-mannose for acute urinary tract infections in women.
Other studies have shown D-mannose is effective as a long term prophylactic option for women with recurrent UTIs.
There are a variety of herbs which are thought to help improve the symptoms of a urinary tract infection. These include nettle leaves, dandelion, and burdock roots for example.
Quercetin is a flavonoid, a natural substance derived from plants. It has antioxidant properties – oxidation is a chemical reaction which can result in cell damage. Antioxidants help reduce this process.
Quercetin has been shown to be useful in reducing the frequency and severity of recurrent urinary tract infection in post menopausal women, especially when administered with vaginal oestrogen.
Quercetin is ingested in your diet. Foods rich in quercetin include onions, spring onions, red onions, tarragon, dill, capers, kale, broccoli, spinach, and cocoa. It can also be taken as a dietary supplement.
Post menopausal oestrogen deficiency results in shrinkage of cells (vaginal atrophy) lining the genital tract and the bladder neck – the urethral sphincter. It is thought that these cellular changes in some way predispose to recurrent urinary tract infections in some women. Using local oestrogen replacement, will help restore these cells to their normal size and function.
Local oestrogen – sometimes called topical oestrogen – is not the same as taking standard HRT. This is administered as pessaries or cream – not taken by mouth. These are directly inserted into the vagina where they have a local action. The oestrogen within these preparations is a mild, weak oestrogen. There is almost no absorption into the circulation, and therefore using local oestrogen treatment is felt to be safe for the vast majority of patients.
There is medical evidence that in post menopausal women, using topical oestrogen seems to be effective in reducing the frequency and severity of recurrent urinary tract infections.