This article will explain what recurrent cystitis is and why it affects some women more than others. We will also cover how to reduce the risk of recurrent cystitis by making some simple changes to diet and lifestyle, and how it may be possible to avoid recurrence.
Cystitis is an inflammation of the bladder lining, and is commonly a painful and debilitating condition, most often caused by a urinary tract infection (UTI). Cystitis has a tendency to keep coming back, which is known as recurring cystitis.
A common cause of cystitis is from bacterial in the urinary tract also known as a Urinary Tract Infection (UTI). Bladder infections are one of the most common infections of the genitourinary system in the female population. UTIs that occur at least three times per year or two times in the last six months are referred to as recurrent UTI.
Recurring cystitis can be extremely disruptive and frustrating for those impacted, and it can have a major impact on quality of life.
This article will explain what recurrent cystitis is and why it affects some women more than others. We will also cover how to reduce the risk of recurrent cystitis by making some simple changes to diet and lifestyle, and how it may be possible to avoid recurrence.
While cystitis and a UTI have similar symptoms, they may be different conditions. Cystitis specifically refers to inflammation of the bladder, which can stem from non-infectious causes, while a UTI is the result of an infection in the urinary tract. Some women have cystitis-like symptoms but without an infection.
Another important difference is that cystitis affects only the bladder, while a urinary tract infection can occur in any part of the urinary system. The bladder is the hollow, spherical-shaped organ that holds urine located in the pelvic cavity. Inflammation of this area can make both the bladder and urethra very sensitive and painful, particularly when passing urine. The causes of this inflammation can be diverse and in many cases are not always known.1 It is hard to tell the difference between cystitis and a UTI which is why a consultation with a health professional is always important, as complications can arise from an untreated UTI.
When caused by bacteria, recurring cystitis is generally defined as three separate episodes I in the previous 12 months, or two episodes in the previous 6 months.2
Recurring cystitis is common. It’s estimated that 27–46% of women who have cystitis will have another episode within a year.3 Recurrences usually occur within the three months following the original infection, and 80% are reinfections.4
There are many reasons why cystitis occurs, and why some women have repeated bouts. Fortunately, with the right support, it is possible to reduce the frequency of cystitis.
Cystitis can be a complex medical condition with a range of symptoms. It typically results in severe discomfort and an urgent need to urinate frequently, but often with the passing of only small amounts of urine. Cystitis symptoms can range from mild discomfort in the lower abdomen to hemorrhagic infection in the most extreme cases5 which always requires immediate medical attention.
Although most often caused by a bacterial infection, there can be other causes.
However, one of the main differences between cystitis and a urinary tract infection is that cystitis can result from non-infectious causes. In other words, a UTI can also cause cystitis, but cystitis is not always caused by a UTI.
Symptoms of cystitis may include:
Cystitis may be either uncomplicated or complicated. Uncomplicated cystitis is a lower UTI that occurs in either men or non-pregnant women who are otherwise healthy. Complicated cystitis is less likely to be resolved by antibiotics, and is often the result of multiple factors that increase the risk of infection.6
The most common cause of cystitis is bacteria entering the bladder through the urethra. This occurs more often in women than men because the openings to the urethra, vagina and anus (bowel) are much closer together, allowing bacteria to enter the bladder more easily. Women also have a shorter urethra, which means bacteria can travel up the urethra and cause infection easier.7 This proximity means that cystitis may also be triggered by sexual intercourse.
Around 75-95% of cystitis cases are caused by the bacteria E coli.8 While most E. coli strains are not harmful to humans, an imbalance of bacteria in the genitourinary tract can lead to an infection.
Urine pH is a major factor in UTI infections, as pH affects how hospitable the urinary tract will be to bacteria.
The vaginal microbiome plays a major role in protecting against recurring cystitis.
Vaginal microbiota in women of reproductive age is dominated by several lactobacillus species, which maintain a low pH by producing lactic acid as well as producing antimicrobial compounds such as hydrogen peroxide and bacteriocins.9
Alterations and variations in the vaginal microflora can significantly influence urinary tract health and play a key role in the pathogenesis of acute and recurrent UTIs. An imbalance in vaginal flora (dysbiosis) is one of the main reasons that an infection may keep coming back. Vaginal dysbiosis may result in Escherichia coli colonisation and prompt recurrent cystitis, 10
Dysbiosis of the vaginal flora is common not only in women with recurring cystitis but also at the time of an acute infection, even in women without a history of recurrence.11 Studies of the urinary microbiome suggest both acute cystitis and interstitial cystitis are related to dysbiosis within the urinary system, although the nature of the dysbiosis may differ between the two conditions.12
Reproductive-aged women with recurring cystitis are thought to have lower levels of lactobacilli and increased rates of colonisation with E. coli.
Post-menopausal women are at greater risk of cystitis due to lower levels of the
hormone oestrogen. Lower levels of oestrogen decreases the relative amounts of lactobacilli, as lower oestrogen levels decreases glycogen levels which is an important fuel for lactobacilli to produce lactic acid which creates a defensive acidic environment .13
Studies have repeatedly shown that women with low levels of vaginal lactobacilli are more susceptible to E. coli than those with high levels of lactobacilli.14 A disruption in lactobacilli can occur due to poor diet, frequent use of antibiotics, or menopause.
Hormonal fluctuations have a significant role in the changes to vaginal and urine microbiome composition. Oestrogen supports the growth and development of lactobacillus in the bladder and vagina, which contributes to their defensive role against pathogens and infections. The loss of oestrogen following menopause therefore causes a reduction in vaginal lactobacilli and an increase in recurrent cystitis.15
Healthy microbial balance acts as a barrier against pathogens. However, depletion of ‘healthy’ bacteria is an important factor for the development of recurrent cystitis.
Frequency and urgency to urinate are common symptoms of most patients with cystitis. This urgency can sometimes lead to incontinence or urinary leakage.16
While recurrent cystitis mostly affects women, it can also occur in men. Men with conditions that suppress immune function (such as diabetes or HIV), may be at greater risk of recurrent cystitis.17 Poor hygiene, unprotected sex, and being uncircumcised can also increase the risk.
Cystitis is diagnosed by a health professional, who will discuss your symptoms and run urine tests. Urinalysis is the most important laboratory test in diagnosing the condition.18
Medical history and physical symptoms will also be examined.
Acute or uncomplicated cystitis is most often treated with a course of antibiotics for anything from a few days to several weeks.
A 2022 meta-analysis of 23 studies concluded that antibiotic treatment is effective for preventing recurrent cystitis caused by an infection when compared with placebo. However, researchers have noted that antibiotic treatment can lead to vaginal candidiasis, antimicrobial resistance, and alterations to the microbiome.19
Long-term antibiotic use is associated with resistance selection, especially with the antibiotic trimethoprim-sulfamethoxazole. Antibiotic resistance is known to complicate the treatment of future UTI episodes and can lead to recurrent episodes.20
Certain strains of E. coli bacteria are now able to produce enzymes called extended-spectrum beta-lactamases (ESBLs) which are resistant to most beta-lactam antibiotics. This allows the bacteria to multiply and spread, potentially leading to a more severe infection which is much more difficult to treat.
A large study found that ESBL producers were responsible for one-third of UTIs caused by these resistant bacteria.21 This and other studies has led to recommendations for health professionals to avoid routinely prescribing antibiotics for UTIs. Fortunately, there is growing evidence that non-antibiotic treatment may be best for recurrent UTIs.22
Numerous clinical studies show that cranberry (Vaccinium macrocarpon Ait.) extract is effective in maintaining urinary tract health, and may also reduce the occurrence of cystitis.
Cranberries work principally by preventing the adhesion of bacteria (particularly E. coli) to the lining of the urinary tract. Without adhesion, the bacteria cannot infect the bladder by attaching and replicating on the mucosal surface
The Cochrane Database of Systematic Reviews concluded that cranberry juice may reduce the frequency of UTIs over a 12 month period, particularly in women with recurrent UTIs.23
Cranberries contain proanthocyanidins (PACs), a class of polyphenolic compounds comprising A-type linkages that have been associated with preventing adhesion of P-fimbriated uropathogenic E. coli to uroepithelial cells.24
Cranberry extract containing 36 mg* PACs is shown as the specific dose for reducing recurrence of cystitis.25 PACs help to maintain a healthy balance of urogenital flora by preventing bacteria from sticking to the wall of the urinary tract and flushing of the urinary tract.
Look for a supplement that contains Vaccinium macrocarpon (cranberry) extract equivalent to 36 mg proanthocyanidins.
A few lifestyle changes can help to reduce the frequency of cystitis.
Hydration is key to supporting urinary tract health. Drink at least 2L (six to eight glasses) of fresh, filtered water daily to help flush some bacteria out of the urinary tract and support the recovery process.
Eat foods that are rich in probiotic bacteria, such as acidophilus yoghurt, sauerkraut, kefir, kimchi.
Non-acidic foods that are rich in antioxidants and vitamin C can also support the immune system during an infection. Broccoli, bell peppers, blueberries, cranberry juice, and leafy greens are good options.
Avoid foods that can irritate the urinary tract, such as citrus, spicy foods, alcohol, coffee and other caffeinated drinks, or food and drink containing artificial sweeteners.
Sex is a common trigger of UTIs as it can allow bacteria from the anus to pass to the urethra. To reduce the risk, it’s recommended to urinate before sex and promptly after, as well as cleaning around your genitals and anal areas. Always wipe front to back. It’s recommended that you avoid having intercourse during an active urinary tract infection.
Cranberry supplements are often recommended for reducing occurrence of cystitis. When choosing a supplement, check that it contains 36 mg PACs.
This is the optimal concentration of proanthocyanidins shown to prevent bacteria from adhering to the wall of the urinary tract. Probiotics may also be effective in supporting vaginal health & preventing the recurrence of UTIs.
