Cystitis (and other urinary infections)

What doctors say*

* Official guidelines from NICE, NHS and other medical authorities.

Should antibiotics be used? >

Non-pregnant women: immediately or wait 48 hours unless symptoms worsen.

Pregnant women, men, children or young people: immediately depending on severity of symptoms, risk of complications, previous urine culture and susceptibility results,

Prescribers should also take note of previous antibiotic use which may have led to resistant bacteria, and local antimicrobial resistance data.

Likely duration if untreated >

A few days up to many weeks or even longer if established. Between 25-40% of cases will clear up without antibiotics.

Conventional selfcare advice >

  • Drink a lot of extra fluids, mainly water
  • Urinate as soon as the need arises to reduce build up of infection
  • Advise paracetamol or ibuprofen for pain

Opportunities for antibiotic alternatives >

With prescription. Most home remedies are compatible with antibiotic prescription: however check with your doctor to be sure.

 

See also

 

Urinary infections such as cystitis, urethritis and (in men) prostatitis are very common infections causing much misery to millions around the world. They are most often caused by E.coli and other ‘gram-negative’ bacteria, and are thus on principle susceptible to antibiotic treatment.

However these bacteria are also likely to develop antibiotic-resistant strains and increasingly the first line of antibiotic treatments (trimethoprim nitrofurantoin) needs extending with others more capable of dealing with resistant strains (penicillins and fosfomycin).

If you have been prescribed an antibiotic it is important that you complete the course (unfinished courses are more likely to engender resistance in your own tract). However the more that urinary infections can be managed without needing antibiotics the better. It will be useful to consider some of the options below.

In self managing urinary infections do watch out for the risk of infection moving up to the kidneys. If you get pain in the abdomen, especially up the sides and to the back, or get fevers, chills, lack of urine, sickness or diarrhoea, report your symptoms to a doctor without delay.

There are no strong self care options for reducing an actual urinary infection if this is confirmed and a suitable antibiotic may be necessary. The focus may be on using the remedies below in a longer term approach to reducing recurring infections.

 

Uva-ursi
> what do these ratings mean?

Otherwise known as bearberry, uva ursi is established by the European Medicines Agency for treatment of symptoms of mild recurrent lower urinary tract infections such as burning sensation during urination and/or frequent urination in women. Daily doses should be no more than 15g of the dried leaf in hot water (or 8mg of herb as capsule or tablet) to avoid the irritating effects of high tannin levels.

As a precaution uva ursi should also be avoided  during pregnancy and breastfeeding and if there is a risk of kidney disease.

See the evidence ...

The traditional use of Arctostaphylos uva-ursi (L.) Spreng. leaf is well documented in a number of literature sources and is widely used across Europe as a medicinal product. In its Assessment Report the European Medicines Agency [EMA, 2012] summarises is application as for treatment of symptoms of mild recurrent lower urinary tract infections such as burning sensation during urination and/or frequent urination in women, after serious conditions have been excluded by a medical doctor.

However in a recent large clinical study, no benefit in  reducing antibiotics in urinary tract infections was seen with taking uva-ursi.

References

EMA (European Medicines Agency) (2012). Assessment report on Arctostaphylos uva-ursi (L.) Spreng., folium, 24 January 2012 EMA/HMPC/573462/2009 Rev.1 (HMPC).

Link to Report

Moore M, Trill J, Simpson C, et al. (2019) Uva-ursi extract and ibuprofen as alternative treatments for uncomplicated urinary tract infection in women (ATAFUTI): a factorial randomized trial. Clin Microbiol Infect. (8):973-980. doi: 10.1016/j.cmi.2019.01.011.

Link to Full Paper

Cranberry
> what do these ratings mean?

Cranberry is a very popular remedy to relieve the pain of urinary infections such as cystitis, most often in the form of juice, and also as various supplement forms. The reviewed evidence however is mixed, with one possible confusing factor the high sugar levels in cranberry juice. It seems better to use dried fruits or cranberry supplements.

See the evidence ...

A 2017 meta-analysis to assess the effect of cranberry on the risk of urinary tract infection (UTI) recurrence in otherwise healthy women [Fu, 2017], identified 7 randomized controlled trials conducted in healthy women at risk of UTI (n = 1498 participants). Results, subject to some risk of bias in two studies, showed that cranberry reduced the risk of UTI by 26% . The authors concluded that cranberry may be effective in preventing UTI recurrence in generally healthy women; however, larger high-quality studies are needed to confirm these findings.

In a clinical trial among elderly residents of nursing homes, two oral cranberry capsules (delivering 72 mg of the active ingredient proanthocyanidin and equivalent to 20 ounces of cranberry juice) (n=92) when compared with placebo (n=93), showed no net benefit on the incidence of bacteriuria and pyuria  [Juthani-Mehta, 2016].

An earlier Cochrane review [Jepson, 2012] concluded that there was insufficient evidence for consumption of cranberry juice (effects perhaps confounded by compliance problems as well as high sugar consumption) but that there might be more prospects for standardised supplement products. There is however clinical trial evidence that cranberry reduces the adhesion of pathogenic organisms to the urinary wall, such as E.coli [Kaspar, 2015].

References

Fu Z, Liska D, Talan D, Chung M. (2017) Cranberry Reduces the Risk of Urinary Tract Infection Recurrence in Otherwise Healthy Women: A Systematic Review and Meta-Analysis. J Nutr. 147(12): 2282-2288

Link to Abstract and Full Text

Juthani-Mehta M, Van Ness PH, Bianco L, et al. (2016) Effect of Cranberry Capsules on Bacteriuria Plus Pyuria Among Older Women in Nursing Homes: A Randomized Clinical Trial. JAMA. 316 (18): 1879-1887

Link to Abstract and Full Text

Kaspar KL, Howell AB, Khoo C. (2015) A randomized, double-blind, placebo-controlled trial to assess the bacterial anti-adhesion effects of cranberry extract beverages. Food Funct. 6 (4):1212-7

Link to Abstract

Probiotic suppositories
> what do these ratings mean?

Women have often used yoghurt applications to provide relief from the symptoms of cystitis as well as vaginal infections. Initial justification was that the slightly acidic nature of yoghurt might help restore the protective acid environment of the vagina (often a host to recurrent urinary infections). However there is promising evidence that at leat one common probiotic organism might provide additional protection.

 

See the evidence ...

In a double-blind placebo-controlled trial, 100 premenopausal women with at least one prior UTI in the last year were randomized to receive Lactobacillus crispatus containing proprietary intravaginal suppositories (Lactin-V) or placebo following antibiotic treatment for an acute UTI. Recurrent UTI occurred in seven of 48 women (15%) receiving Lactin-V compared to 13 out of 48 women (27%) receiving placebo Raised vaginal colonization with L. crispatus was associated with a significant reduction in recurrent UTI only for Lactin-V [Stapleton, 2011].

 

References

Stapleton A.E., Au-Yeung M., Hooton T.M., et al. (2011) Randomized, placebo-controlled phase 2 trial of a Lactobacillus crispatus probiotic given intravaginally for prevention of recurrent urinary tract infection. Clin. Infect. Dis. 52: 1212–1217

Link to Abstract and Full Text

 

Probiotics
> what do these ratings mean?

Probiotics are thought to work by preventing other infectious bacteria from climbing up the urinary tract and causing infection. However there is only mixed and inconclusive evidence that taking probiotics orally can help reduce the severity and frequency of urinary infections.

See the evidence ...

A review of nine studies involving 735 participants investigating probiotics for preventing UTI: seven studies involved women or girls with recurrent UTIs, one looked at children with abnormal urinary tracts, and one investigated UTI in healthy women. Generally, studies were poor quality with high risk of bias. Aside from the different populations, there were also many different species of probiotics used, different dosage forms such as vaginal and oral, and probiotics were given for varying lengths of time. All of these factors may have led to conclusions that the evidence for benefit was poor. [Schwenger, 2015]

References

Schwenger EM, Tejani AM, Loewen PS. Probiotics for preventing urinary tract infections in adults and children. Cochrane Database Syst Rev. 2015;(12):CD008772

Link to Abstract and Full Text

Traditional home remedies worth trying

Barley water

An old and very quick-acting remedy for easing urinary pain is to make homemade barley water. Barley contains a soluble carbohydrate, mannitol, that is eliminated by the kidneys and acts directly in the urinary tract as an ‘osmotic diuretic’ (ie it pulls more water along with it so diluting the urine) and it even appears to soothe irritated urinary tract at the same time. It is extremely safe though does add calories if you are on a tightly-controlled diet. To make barley water at home take 100g of pearl barley (obtainable in larger supermarkets), rinse under a cold tap and then add to a saucepan with a litre of water. Bring to the boil and simmer for 15-20 minutes and the water turns white. Add the juice of at least two lemons to this, strain and keep in a closed container in the fridge. Drink a good cup of this at a time, and probably 2-3 times a day. If it helps you will see the benefits within an hour or so. Barley water can be used along with cranberry supplements as well.