Urinary tract infection is the infection of the kidney, ureter, bladder and urethra. Urinary tract infections are common in older men and women. However, due to anatomical reasons, the infection is more common and recurs in women than in men. The micro-organism that most commonly causes urinary tract infections is the bacterium Escherichia coli (E. coli). In addition, frequently recurring cystitis is one of the important health problems we encounter in young women.

Cystitis is also a urinary tract infection. In this article, I will explain the causes of frequently recurring cystitis in women, prevention and treatment methods in the light of our own experiences and general literature.

What is recurrent cystitis?

Chronic cystitis or recurrent cystitis, recurrent urinary tract infection is a common urological problem in women. Not all cystitis means chronic cystitis or recurrent cystitis. The duration of the complaints is important to be able to say recurrent cystitis.

Chronic urinary tract infection (chronic cystitis) is an infection that does not improve with treatment or reoccurs after treatment. It does not improve despite appropriate treatment or recurs after recovery. About 1/5 of young adult women have recurrent urinary tract infections.

We can define chronic cystitis as follows: A person who has bladder infections more than three times a year or two or more in 6 months has chronic or recurrent cystitis.

What are the symptoms of cystitis?

Diagnosing urinary tract infection or cystitis is not very difficult. Diagnosis can be easily made by what the patients tell. Further investigation is usually not required. Patients with cystitis mainly complain of frequent urination, painful urination, sudden urination and pain in the bladder area. Patients with urinary tract infections usually apply to the doctor with the following complaints;

• Frequent urination: It is one of the common complaints in patients with urinary tract infection. It is usually accompanied by a burning sensation in the urinary tract.
• Painful urination: Painful urination or dysuria is one of the common complaints. During urination, burning, itching, pain in the form of pain occurs along the urethra.
• Sudden sense of urination: Sudden urination and if it is late, patients may have urinary incontinence.
• Blurred, smelly, bloody urination: Depending on the severity of the infection, patients may apply to the doctor with the complaint of smelly and turbid urine. In rare cases, there may be bleeding in the urine.
• Suprapubic pain: If there is pain in the bladder area, lower abdomen, cystitis should be considered in these cases.
• Flank pain: There may be pain in the parts that fit the kidney areas on the side.
• Stress: Frequent recurrent infections cause serious stress in patients, impairing their quality of life, and negatively affecting their daily work.

If the urinary tract infection has affected the kidneys, the following complaints may occur:

• Nausea, vomiting
• High fever
• Chills – shivering
• Weakness-fatigue

Why is chronic cystitis more common in women?

There are some reasons for the frequent recurrence of urinary tract infections in women. Some of these are anatomical and some are endocrine causes.

The reasons for the frequent recurrence of infection in women compared to men are as follows:

• Urinary system stone disease: Urinary system stones such as kidney, bladder and ureteral stones cause recurrent infections. This is important for both male and female patients.
• Short urethra: While the length of the urethra is 4-5 cm in women, it is 18-20 cm in men. In this way, microorganisms can easily reach the bladder because the female urethra is short. Again, the shortness of the urethra in women paves the way for the transmission of infectious agents to the bladder during sexual intercourse.
• Menopause: Decreased estrogen hormone paves the way for infection.
• Bladder prolapse: The sagging of the bladder and the resulting incomplete emptying of the bladder, especially in women who have had a very difficult and difficult delivery, cause frequent urinary tract infections in women.
• Functional problems in the urinary system: If there are bladder disorders such as neurogenic bladder, infection is more common in these people.
• Genetic causes: There may be a genetic predisposition to the development of cystitis.
• Diabetes: Urinary tract infections and chronic cystitis are common in people with diabetes.
• Frequent sexual intercourse: Since the infectious agents can easily reach the bladder during sexual activity in young female patients, cystitis recurs frequently.

How is chronic cystitis diagnosed?

It is not difficult to diagnose the disease. The diagnosis is made by the patient’s complaints, urological examination, and laboratory and radiological tests.

• History: The patient’s complaints are important in the diagnosis. The onset of complaints, the patient’s lifestyle, and general health status are questioned.
• Urine test: Infection is diagnosed simply by microscopic examination of the urine.
• Urine culture: It is necessary to take a urine culture and start effective treatment according to the result, especially in recurrent and resistant infections.
• Cystoscopy: It is the endoscopic examination of the bladder. This procedure should be done in a period when there is no active infection. The urethra and interior of the bladder are examined endoscopically. Burning during urination, pain, frequent urination (irritative complaints) are also seen in a type of cancer called carcinoma in situ (CIS), which can only be seen with cystoscopy. Therefore, cystoscopy is important in the differentiation of this disease.
• USG, CT: In some patients, radiological examinations may be required to investigate the causes of recurrent infections (stones, congenital defects).

What preventive measures should be taken so that cystitis does not recur frequently?

Female patients who have frequent urinary tract infections should definitely be examined by a urologist. Random use of drugs is not correct for the development of resistance to bacteria. In addition, diseases that cause the infection to recur and which can only be treated with surgery cannot be overlooked. We give some advice to our patients to prevent the recurrence of frequently recurring urinary tract infections. These are generally accepted recommendations with scientific validity. Recurrence of infection can be seriously prevented in patients who comply with these maximally.

The points that women with frequent urinary tract infections should pay attention to are as follows:

• Increasing fluid intake: Daily fluid intake should be at least 2-3 liters. In this way, microorganisms are prevented from adhering to the bladder mechanically.
• Frequent urination: Patients’ holding their urine for a long time is one of the causes of frequently recurring cystitis. If the bladder is prevented from being full of excess urine by urinating every 2-3 hours, it is possible to prevent the formation of cystitis.
• Taking a shower instead of a bath: We recommend that patients with chronic cystitis take a shower instead of a bath for hygienic reasons. In this way, the passage of microbes from the short urethra to the bladder is prevented.
• Washing the genital area with plenty of water without traumatizing the genital area: Genital area cleaning is important in the protection of cystitis. We recommend our patients to clean the genital area with plenty of warm water without using too much chemicals and without using chemicals as much as possible.
• Not using spermicide or condom: If the man uses spermicide chemicals or condoms for birth control, these pose a risk for cystitis in the partner woman. It is appropriate for spouses not to use these methods, especially in women who have frequent cystitis.
• Urinating after and before sex: Urinating and emptying the bladder before and after sexual intercourse is an effective method of prevention in preventing the frequent recurrence of cystitis.
• Do not apply irritants such as sprays to the genital area: Products such as perfumes and sprays should not be sprayed as they will irritate the genital areas.
• Not using tight pants and pants: Women’s use of comfortable clothes in their daily lives is effective against the formation and recurrence of cystitis.
• Cleaning from front to back: Toilet cleaning is important in the treatment of urinary tract infections. If a pad is used from the front to the back, not from the back to the front, during cleaning, the passage of microbes in the perianal region to the urethra and from there to the bladder is prevented.

Surgical treatment of chronic cystitis

Surgical treatment, that is, surgical treatment, is very rarely required in chronic cystitis. If there are stone disease or anatomical causes that cannot be treated with medication, these should be treated with surgery.

Causes that cause frequent cystitis in women and require surgery:

• If there is a stone disease in the urinary tract: If there are stones in the bladder, kidney or ureter, they should be removed.
• Urethral stenosis: In patients with urethral stenosis, the bladder cannot be completely emptied and as a result, cystitis recurs frequently in patients. If there is a stenosis, it must be treated.
• Bladder diverticulum: Bladder diverticulum is the enlargement of the layer (mucosa) that covers the inner part of the bladder in the form of vesicles out of the bladder. If urine remains in them and cannot be emptied, it poses a risk for urinary tract infection. Large cysts must be removed.
• Bladder prolapse: In women who have had many and difficult vaginal deliveries, the urinary bladder cannot be fully emptied due to bladder prolapse, and this leads to frequent cystitis.
• Congenital anomalies: If there are congenital anatomical defects in the urinary system, these prevent urinary flow and cause frequent infections and stone formation. Such anomalies need to be corrected surgically.

How is the treatment in women who have frequent cystitis?

Treatment and prophylaxis in patients who have frequent cystitis is possible with the use of antibiotics and antiseptics that are effective on the urinary tract. It is not correct to use these drugs unconsciously. It must be obtained as a result of the examination of a urologist. We apply current treatment methods on this subject to these patients. We can list the antibiotic treatment protocols applied in patients with recurrent cystitis as follows;

• Low-dose antibiotic therapy: Patients with frequently recurring cystitis require daily low-dose antibiotic therapy for at least 6 months. Sometimes this treatment can be extended up to 2 years.
• Antibiotic intake after intercourse or when symptoms begin: If patients are late and sexually active, a single dose of antibiotic administration immediately after intercourse or when symptoms of infection begin.
• Vaginal estrogen therapy: Although patients are in the menopause period or at a young age, cystitis frequently recurs if they have lost their ovaries for any reason and have estrogen deficiency. Vaginal estrogen therapy is absolutely necessary in these patients.

Is herbal treatment effective in chronic cystitis?

There is no effective treatment for frequently recurring cystitis in women with treatment methods such as herbal treatment and alternative treatment methods. Although there is information on the internet that the use of cranberry juice is good for cystitis, they have no scientific basis. There are no scientific studies published in internationally respected medical journals on the effectiveness of herbal treatment methods. Therefore, we do not recommend such treatments to our patients. The treatment we apply is drugs approved by modern medicine, with proven effectiveness.

As a result: In women with frequently recurring cystitis, paying attention to preventive measures, treatment and recurrence of the disease can be prevented with appropriate antibiotic therapy. If there is an underlying condition causing cystitis, this condition must be treated.

Prof. Dr. Emin ÖZBEK

Urology Specialist