Background

Cystitis literally means inflammation of the bladder, although in practice cystitis refers to inflammation of urethra and bladder. Before moving on to discuss cystitis in women further it is prudent to mention that men can also suffer from cystitis. However, in men cystitis is uncommon because of the longer urethra, which provides a greater barrier to bacteria entering the bladder; fluid from the prostate gland also confers some antibacterial property. This is especially so in men under the age of 50. After 50 years of age urinary tract infections in men become more common due to prostate enlargement.

Prevalence and epidemiology

Urinary tract infections (UTI) are one of most common infections treated in general medical practice and will affect up to 15% of women each year. Patients aged between 15 and 34 account for the majority of cases seen within a primary care setting and it is estimated that up to 50% of all women will experience at least one episode of cystitis in their lifetime; half of whom will have further attacks. Certain factors do increase the risk of a UTI: in young women, frequent or recent sexual activity and previous episodes of cystitis; the use of diaphragms or spermicidal agents; advancing age; and diabetes (can indicate poor diabetic control). Additionally, cystitis affects 1 to 4% of pregnant women (Le et al 2004).

Recurrent cystitis (usually defined as three episodes in the past 12 months or two episodes in the past 6 months) is relatively common even though no identifiable risk factors are present.

Aetiology

Infection is caused, in the majority of cases, by the patient’s own bowel flora that ascend the urethra from the perineal and perianal areas. Bacteria are thus transferred to the bladder where they proliferate. The most common bacterial organisms implicated in cystitis are Escherichia coli (>80% of cases), Staphylococcus (up to 10%) and Proteus. However, several studies have shown that up to 50% of women do not have positive urine cultures according to traditional criteria (>10⁵ bacteria per mL of urine), although they do have signs and symptoms of infection. These patients with ‘low count bacteriuria’ are classed as having a urinary tract infection.

Arriving at a differential diagnosis

The majority of patients who present in the community pharmacy will have acute uncomplicated cystitis (Table 5.1). and accurately made a self-diagnosis. The pharmacist’s aims are therefore to confirm a patient self-diagnosis, rule out upper urinary tract infection (pyelonephritis) and identify patients who are at risk of complications as a result of cystitis. Asking symptom-specific questions will help the pharmacist to determine if referral is needed (Table 5.2).

Clinical features of acute uncomplicated cystitis

Cystitis is characterised by pain when passing urine and causes frequency, urgency, nocturia and haematuria. The diagnostic probability of cystitis is over 90% if patients exhibit dysuria and frequency without vaginal discharge or irritation. In addition, the patient might report only passing small amounts of urine, with pain worsening at the end of voiding urine. Symptoms usually start suddenly. Suprapubic discomfort not associated with passing urine might also be present but is not common. Haematuria, although common, should be viewed with caution because it might indicate stones or a tumour. Such cases are best referred.

Conditions to eliminate

Evidence base for over-the-counter medication

Practical prescribing and product selection

Prescribing information relating to cystitis medicines reviewed in the section ‘Evidence base for over-the-counter medication’ is discussed and summarised in Table 5.3 and useful tips relating to patients presenting with cystitis are given in Hints and Tips Box 5.1.

Jepson, RG, Williams, G, Craig, JC. Cranberries for preventing urinary tract infections. Cochrane Database of Systematic Reviews. (Issue 10):2012. [Art. No.: CD001321. DOI: 10.1002/14651858.CD001321.pub5].

Jepson, RG, Mihaljevic, L, Craig, JC. Cranberries for treating urinary tract infections. Cochrane Database of Systematic Reviews. (Issue 4):1998. [Art. No.: CD001322. DOI: 10.1002/14651858.CD001322].

Le, J, Briggs, GG, McKeown, A, et al. Urinary tract infections during pregnancy. An Pharmacother. 2004;38(10):1692–1701.

Spooner, JB. Alkalinisation in the management of cystitis. J Int Med Res. 1984;12:30–34.

Bent, S, Nallamothu, BK, Simel, DL, et al. Does this woman have an acute uncomplicated urinary tract infection? JAMA. 2002;287:2701–2710.

Car, J. Urinary tract infections in women: diagnosis and management in primary care. Br Med J. 2006;332:94–97.

Cystitis and overactive bladder foundation. http://www.cobfoundation.org.

Background

Patients of any age can experience vaginal discharge. The three most common causes of vaginal discharge are bacterial vaginosis, vulvovaginal candidiasis (thrush) and trichomoniasis (Table 5.4). As thrush is the only condition that can be treated OTC, the text concentrates on differentiating this from other conditions.

Prevalence and epidemiology

It has been reported that sexually active women have a 75% chance of experiencing at least one episode of thrush during their childbearing years, and half of these will have more than one episode. Most cases are acute attacks but some women will develop recurrent thrush defined as 4 or more attacks each year. The condition is uncommon in prepubertal girls unless they have been receiving antibiotics. In adolescents it is the second most common cause of vaginal discharge after bacterial vaginosis.

Aetiology of thrush

The vagina naturally produces a watery discharge (physiological discharge), the amount and character of which varies depending on many factors, such as ovulation, pregnancy and concurrent medication. At the time of ovulation the discharge is greater in quantity and of higher viscosity. Normal secretions have no odour. The epithelium of the vagina contains glycogen, which is broken down by enzymes and bacteria (most notably lactobacilli) into acids. This maintains the low vaginal pH, creating an environment inhospitable to pathogens. The glycogen concentration is controlled by oestrogen production; therefore any changes in oestrogen levels will result in either increased or decreased glycogen concentrations. If oestrogen levels decrease glycogen concentration also decreases, giving rise to an increased vaginal pH and making the vagina more susceptible to opportunistic infection such as Candida albicans; 95% of thrush cases are caused by C. albicans. The remaining cases are caused by C. glabrata although symptoms are indistinguishable.

Arriving at a differential diagnosis

Many patients will present with a self-diagnosis and the pharmacists’ role will often be to confirm a self-diagnosis of thrush. This is very important as studies have shown that misdiagnosis by patients is common (Ferris et al 2002) and can have important consequences because other conditions can lead to greater health concerns. For example, bacterial vaginosis has been linked with pelvic inflammatory disease (PID) and the preterm delivery of low-birth-weight infants and C. trachomatis can cause infertility. Symptoms of pruritus, burning and discharge are possible in all three common causes of vaginal discharge. Therefore no one symptom can be relied upon with 100% certainty to differentiate between thrush, bacterial vaginosis and trichomoniasis. However, certain symptom clusters are strongly suggestive of a particular diagnosis. Asking symptom specific questions will help the pharmacist to determine if referral is needed (Table 5.5).

Clinical features of thrush

The dominant feature of thrush is vulval itching. This is often accompanied with discharge (in up to 20% of patients). The discharge has little or no odour and is curd-like. Symptoms are generally acute in onset.

Conditions to eliminate

Recurrent thrush (four or more episodes per year)

After treatment a minority of patients will present with recurrent symptoms. This may be due to poor compliance, misdiagnosis, resistant strains of Candida, undiagnosed diabetes or the patient having a mixed infection. Such cases are outside the remit of community pharmacy and have shown to be difficult to treat. Often specialist care is needed through genitourinary medicine clinics.

Figure 5.2 will help in the differentiation of vaginal thrush from other conditions in which vaginal discharge is a major presenting complaint.

Evidence base for over-the-counter medication

Topical imidazoles and one systemic triazole (fluconazole) are available OTC to treat vaginal thrush. They are potent and selective inhibitors of fungal enzymes necessary for the synthesis of ergosterol, which is needed to maintain the integrity of cell membranes.

Imidazoles and triazoles have proven and comparable efficacy with clinical cure rates between 85 and 90%. Additionally, cure rates between single or multiple dose therapy and multiple day therapy show no differences (Nurbhai et al 2007, updated in 2009). Treatment choice will therefore be driven by patient acceptability and cost.