Cystitis

Cystitis – Scope of Homeopathy

In health, the upper urinary tract it sterile but the lower urinary tract there are bacteria which thrive in lower urinary tract. The urinary tract can become infected with various bacteria but the most common is E. coli derived from the gastrointestinal tract. The most common presenting problem is cystitis with urethritis (generally referred to as urinary tract infection).¹

Urinary tract infection (UTI) is the term used to describe acute urethritis and cystitis caused by a microorganism. It is a common disorder, accounting for 1–3% of consultations in general medical practice. The prevalence of UTI in women is about 3% at the age of 20, increasing by about 1% in each subsequent decade. In males, UTI is uncommon, except in the first year of life and in men over 60, when it may complicate bladder outflow obstruction.¹

Pathophysiology¹

Urine is an excellent culture medium for bacteria; in addition, the urothelium of susceptible persons may have more receptors, to which virulent strains of E. coli become adherent. In women, the ascent of organisms into the bladder is easier than in men; the urethra is shorter and the absence of bactericidal prostatic secretions may be relevant. Sexual intercourse may cause minor urethral trauma and transfer bacteria from the perineum into the bladder. Instrumentation of the bladder may also introduce organisms. Multiplication of organisms then depends on a numberof factors, including the size of the inoculum and virulence of the bacteria. Conditions that predispose to UTI.¹

Clinical features¹

Typical features of cystitis and urethritis include:

• Abrupt onset of frequency of micturition and urgency.
• Burning pain in the urethra during micturition (dysuria).
• Suprapubic pain during and after voiding.
• Intense desire to pass more urine after micturition, due to spasm of the inflamed bladder wall (strangury).
• Urine that may appear cloudy and have an unpleasant odour.
• Non-visible or visible haematuria.

Systemic symptoms are usually slight or absent. However, infection in the lower urinary tract can spread to cause acute pyelonephritis (inflammation of a part of the kidneys). This is suggested by prominent systemic symptoms with fever, rigors, vomiting, hypotension and loin pain, guarding or tenderness, and may be an indication for hospitalisation. It is important to note that only about 30% of patients with acute pyelonephritis have associated symptoms of cystitis or urethritis. Prostatitis is suggested by perineal or suprapubic pain, pain on ejaculation and prostatic tenderness on rectal examination. The differential diagnosis of lower urinary tract symptoms includes urethritis due to sexually transmitted disease, notably chlamydia and urethritis associated with reactive arthritis. Some patients, usually female, have symptoms suggestive of urethritis and cystitis but no bacteria are cultured from the urine (the ‘urethral syndrome’). Possible explanations include infection with organisms not readily cultured by ordinarymethods (such as Chlamydia and certain anaerobes), intermittent or low-count bacteriuria, reaction to toiletries or disinfectants, symptoms related to sexual intercourse, or post-menopausal atrophic vaginitis.¹

When a UTI is suspected, it can be classified into three types: ²

• Asymptomatic bacteriuriais diagnosed when a screening urine culture performedfor a reason unrelated to the genitourinary tract is incidentally found to contain bacteria, but the pt has no local or systemic symptoms referable to the urinary tract.
• Cystitis presents as dysuria, urinary frequency, and urgency; nocturia, hesitancy, suprapubic discomfort, and gross hematuria are often noted as well. Unilateral backor flank pain and fever are signs that the upper urinary tract is involved.
• Pyelonephritis presents as fever, lower-back or cost vertebral-angle pain, nausea, and vomiting. Bacteremia develops in 20–30% of cases.

– Papillary necrosis can occur in pts with obstruction, diabetes, sickle cell disease,or analgesic nephropathy.

– Emphysematous pyelonephritis is particularly severe, is associated with the production of gas in renal and perinephric tissues, and occurs almost exclusively in diabetic pts.

– Xanthogranulomatous  pyelonephritis occurs when chronic urinary obstruction(often by staghorn calculi), together with chronic infection, leads to supportive destruction of renal tissue.

• Prostatitis can is either infectious or noninfectious; noninfectious cases are farmore common. Acute bacterial prostatitis presents as dysuria, urinary frequency, fever, chills, symptoms of bladder outlet obstruction, and pain in the prostatic, pelvic, or perineal area.
• Complicated UTI presents as symptomatic disease in a man or woman with an anatomic predisposition to infection, with a foreign body in the urinary tract, or withfactors predisposing to a delayed response to therapy.²

Investigations¹

In a healthy woman with a single lower urinary tract infection, urine culture prior to treatment is not mandatory. Investigation is necessary, however, in patients with recurrent infection or after failure of initial treatment, during pregnancy, or in patients susceptible to serious infection, such as the immune compromised those with diabetes or an in dwelling catheter, and older people. The diagnosis can be made from the combination of typical clinical features and abnormalities on urinalysis. Most urinary pathogens can reduce nitrate to nitrite, and neutrophils and nitrites can usually be detected in symptomatic infections by urine dipstick tests for leucocyte esterase and nitrite, respectively. The absence of both nitrites and leucocyte esterase in the urine makes UTI unlikely. Interpretation of bacterial counts in the urine, and of what is a ‘significant’ culture result, is based on probabilities. Urine taken by suprapubic aspiration should be sterile, so the presence of any organisms is significant. If the patient has symptoms and there are neutrophils in the urine, a small number of organisms is significant. In asymptomatic patients, more than 105 organisms/ml is usually regarded as significant (asymptomatic bacteriuria).¹

Typical organisms causing UTI in the community include E. coli derived from the gastrointestinal tract (about 75% of infections), Proteus spp., Pseudomonas spp., streptococci and Staphylococcus epidermidis.¹

Investigations to detect underlying predisposing factors for UTI are used selectively, most commonly in children, men or patients with recurrent infections.¹

Investigation of patients with urinary tract infection¹

All patients

Dipstick* estimation of nitrite, leucocyte esterase and glucose

Microscopy/cytometry of urine for white blood cells, organisms

Urine culture

Infants, children, and anyone with fever or complicated infection

Full blood count; urea, electrolytes, creatinine

Blood cultures

Pyelonephritis: men; children; women with recurrent infections

Renal tract ultrasound or CT

Pelvic examination in women, rectal examination in men

Continuing haematuria or other suspicion of bladder lesion

Cystoscopy

Urinary infection in old age¹

Prevalence of asymptomatic bacteriuria: Rises with age. Among the frailest in institutional care it rises to 40% in women and 30% in men.

Decision to treat: Treating asymptomatic bacteriuria does not improve chronic incontinence or decrease mortality or morbidity from symptomatic urinary infection. It risks adverse effects from the antibiotic and promotion of the emergence of resistant organisms. Bacteriuria should not be treated in the absence of urinary symptoms.

Source of infection: The urinary tract is the most frequent source of bacteraemia in older patients admitted to hospital.

Incontinence: New or increased incontinence is a common presentation of UTI in older women.

Treatment: post-menopausal women with acute lower urinary tract symptoms may require longer than 3 days’ therapy.

Risk factors for urinary tract infection¹

Bladder outflow obstruction

Benign prostatic enlargement

Prostate cancer

Urethral stricture

Anatomical abnormalities

Vesico-ureteric reflux

Uterine prolapse

Bladder fistula

Neurological problems

Multiple sclerosis

Spina bifida

Diabetic neuropathy

Foreign bodies

Urethral suprapubic catheter

Ureteric stent

Nephrostomy tube

Urolithiasis

Loss of host defences

Atrophic urethritis and vaginitis in post-menopausal women

Diabetes mellitus

Management¹

For infection of the lower urinary tract, in conventional therapy treatment for 3 days is the norm and is less likely to induce significant alterations in bowel flora than more prolonged therapy. Relevant antibiotics are used which are used as the usual first choice of drug for initial treatment; however, between 10% and 40% of organisms causing UTI are resistant to first line antibiotics, the lower rates being seen in community-based practice. Then, higher grade antibiotics need to be used. They may be used once cultures confirm that the organism is sensitive. The safety of antibiotics for children and pregnancy has to be looked into, so it’s imperative to consult a physician and do not do self-prescription.

In more severe infection, antibiotics usage is longer. A fluid intake of at least 2 L/day is usually recommended, although this is not based on evidence and may make symptoms of dysuria worse.

Homeopathic Management of Cystitis

Homeopathic medicines are helpful for acute as well as chronic cystitis. There are few medicines like Apis mellifica, Cantharis and Apocyanum which are very good for acute infections. There are few medicines which are mainly known for mild cystitis or chronic cases. Some are detailed below. Contact your homeopathic practitioner for right selection of medicines.