Could it be an infection?

The three key signs and symptoms considered to indicate urinary tract infection are dysuria (pain when passing urine), new nocturia (needing to pass urine in the night) and cloudy urine (visible cloudy colour when passing urine). TARGET/NHS advice is that the presence of two or more of these with the absence of vaginal discharge means a UTI is more likely. (TARGET stands for Treat Antibiotics Responsibly, Guidance, Education and Tools and is a toolkit designed to support antimicrobial stewardship activities.)

Cystitis is more common in women than in men because bacteria need to pass up the urethra to enter the bladder. The urethra is much shorter in females than in males, so the passage of bacteria is much easier, and the process may be facilitated by sexual intercourse.

Any pregnant woman who presents with symptoms of cystitis needs referral because bacteriuria (presence of bacteria in the urine) in pregnancy can lead to kidney infection and other problems.

Cystitis sufferers often report that the first sign of an impending attack is an itching or pricking sensation in the urethra. The desire to pass urine becomes frequent; the woman may feel the need to pass urine urgently, but passes only a few burning, painful drops. This frequency of urine occurs throughout the day and night (nocturia).

Dysuria (pain on passing urine) is a classical symptom of cystitis. After urination, the bladder may not feel completely empty, and even straining produces no further flow. The urine may be cloudy and strong smelling.

Urine that is cloudy to the naked eye is an important diagnostic feature that may indicate antibiotic treatment. It is mainly caused by an excess of white blood cells in reaction to infection. Women may report that their urine appears cloudy; they may notice a change in appearance or odour when using the toilet. Ideally all patients should be asked to provide a sample of urine, if practicable, so that it can be assessed for cloudiness. The Pharmacy First clinical pathway for England states “visual inspection by pharmacist if practicable”.

Other key points include:

• Absence of vaginal discharge is a key feature of acute uncomplicated cystitis; 80 per cent of women with vaginal discharge and symptoms of cystitis do not have a UTI. The presence of vaginal discharge may indicate local fungal (usually candida or ‘thrush’), trichomoniasis or bacterial infection that would require referral. Vaginal pruritus or discharge may suggest vaginitis. The sexually transmitted infection, chlamydia, is most commonly seen in women aged 16-24 years. Chlamydia can cause pelvic inflammatory disease (PID) and infertility so it is important that the infection be detected and treated. Screening programmes for chlamydia are now widespread
• Sexual intercourse may precipitate an attack of cystitis due to minor trauma or resulting infection when bacteria are pushed along the urethra. The occurrence of urinary symptoms after starting a new sexual relationship is still sometimes referred to as ‘honeymoon cystitis’
• Oestrogen deficiency in postmenopausal women leads to thinning of the lining of the vagina. Lack of lubrication can mean the vagina and urethra are vulnerable to trauma and irritation, and attacks of cystitis can occur
• Cystitis can be caused by cytotoxic drugs, such as cyclophosphamide. Other drugs, such as opioids and nifedipine, can also cause urinary tract symptoms
• Other precipitating factors may include the irritant effects of toiletries (e.g. bubble baths and vaginal deodorants) and other chemicals (e.g. spermicides and disinfectants). Use of a diaphragm for contraception can also cause symptoms of cystitis. Lack of personal hygiene is not thought to be responsible for this problem, except in extreme cases.