8.7 Cystitis

Cystitis refers to inflammation of the bladder that can result from various causes such as infectious cystitis, noninfectious cystitis, and interstitial cystitis. Infectious cystitis, a common type of urinary tract infection (UTI), is the most common cause of cystitis. It can be caused from a bacterial, viral, or parasitic infection. Although bladder infections may seem benign, if untreated they can progress to severe complications like pyelonephritis (infection of the kidneys) and sepsis. Sepsis refers to the body’s response to severe infection that causes widespread inflammation and can be life-threatening due to multiorgan failure. In older adults, UTI s are the leading cause of sepsis. Noninfectious cystitis arises from irritants, such as chemicals in chemotherapy drugs or radiation exposure, that trigger bladder inflammation. Interstitial cystitis is an inflammatory disease characterized by chronic bladder inflammation that lacks a known cause. It disproportionately affects women, occurring about ten times more frequently than in men. Due to its complex nature and the absence of clear causative factors, interstitial cystitis can be difficult to diagnose.^[1],[2] The focus of this section will be in infectious cystitis.

Pathophysiology and Risk Factors

Infectious cystitis commonly begins when bacteria, most commonly Escheria coli, enters the bladder through the urethra. The bacteria adheres to the bladder wall and begins to multiply. This colonization triggers the body’s immune response, and inflammatory mediators are released, causing swelling and irritation of the bladder lining.^[3],[4]

There are many risk factors for developing infectious cystitis^[5],[6]:

• Women are at higher risk for cystitis due to their shorter urethra and its closer proximity to the anus compared to a male, making it easier for bacteria to enter into the bladder.
• Pelvic organ prolapse (POP) such as rectocele or cystocele can cause chronic recurrent cystitis, especially after vaginal childbirth and history of chronic constipation.^[7]
• Individuals with an enlarged prostate gland or who experience recurrent kidney stones may experience blockage, resulting in urinary retention, predisposing them to infection.
• Urinary catheterization predisposes clients to increased risk, so it should only be performed when medically necessary, and catheters should be removed as soon as possible.
• Changes in hormone levels during menopause can also lead to changes in vaginal flora, making women more susceptible to colonization.
• Hygiene habits can cause increased risk. Wiping should be performed from front to back, particularly after a bowel movement, or bacteria can be introduced into the urethra.
• Sexual intercourse can also introduce bacteria into the urethra. Voiding after intercourse can help prevent infection.
• Diabetes mellitus places clients at increased risk for infection due to the elevated glucose levels in the urine that can promote bacterial growth.
• Individuals with a neurogenic bladder have incomplete bladder emptying and are at increased risk for infection.

Assessment

Cystitis primarily causes urinary symptoms such as frequency, urgency, pain during urination, and changes in urine characteristics. Additional associated symptoms in other body systems may occur due to pain or gastrointestinal symptoms associated with infection. It is also important to remember that for older adults, change in mental status may be the only symptom of a urinary tract infection. Table 8.7 outlines clinical manifestations of cystitis across body systems.

Table 8.7 Clinical Manifestations of Cystitis^[8],[9],[10]

Diagnostic Testing

Diagnostic testing for cystitis typically includes a urinalysis to examine for increased levels of white blood cells, red blood cells, leukocyte esterase, or bacteria. If the urinalysis reflects signs of infection, a urine culture may be ordered to help the provider identify the most effective antibiotic to treat the infection.

For recurrent cystitis, imaging studies such as bladder ultrasound, KUB, CT scan, or cystoscopy may be ordered to help identify structural abnormalities. Cystoscopy involves the insertion of a small thin tube with a flexible camera to help visually examine the inside of the bladder and urethra.^[11],[12]

Nursing Problems & Diagnoses

Nursing problems and diagnoses for clients with cystitis can help guide nursing care and address the specific needs of these individuals. Common diagnoses include the following:

• Acute Pain
• Impaired Urinary Elimination
• Ineffective Self-Care Management
• Readiness for Enhanced Knowledge

Outcome Identification

Outcome identification includes setting short- and long-term goals and creating expected outcome statements customized for the client’s specific needs. Expected outcomes are statements of measurable action for the client within a specific time frame that are responsive to nursing interventions. Examples of expected outcomes for clients with cystitis are as follows:

• The client will report reduced pain with urination with a score of 3 or below on a scale of 0-10, within 48 hours.
• The client will experience reduced urinary frequency and urgency, achieving a voiding pattern of every 3-4 hours within 72 hours.
• The client will verbalize healthy hygiene practices, resulting in a reduction in the frequency of recurrent infections within three months.
• The client will verbalize effective preventive strategies, such as adequate hydration and regular voiding, upon completion of the teaching session.

Interventions

Medical Interventions

Medical interventions for cystitis aim to treat the infection, alleviate symptoms, and prevent recurrence. Common interventions include medication therapy and identifying and treating causes of recurrent cystitis.

Medication Therapy

Several types of medications may be prescribed to treat cystitis^{[13],[14],[15],[16]}:

• Antimicrobials: Antimicrobials treat and eliminate the causative bacteria. Classes of antimicrobials include the following:
  • Sulfonamides (Trimethoprim/Sulfamethoxazole): Inhibit the growth of bacteria by interfering with the synthesis of folic acid, essential for bacterial DNA production. They work synergistically to prevent bacterial growth, particularly by E. coli, a common UTI-causing bacteria.
  • Quinolones (Ciprofloxacin, Levofloxacin): Inhibit enzymes necessary for bacterial DNA replication, effectively preventing bacterial growth and causing bacterial cell death. They’re effective against a wide range of bacteria causing UTIs.
  • Penicillins (Amoxicillin, Amoxicillin/Clavulanate): Disrupt the bacterial cell wall synthesis, leading to cell lysis and death. However, their effectiveness against UTIs caused by E. coli may be limited due to bacterial resistance.
  • Cephalosporins (Cefadroxil, Cefixime): Similar to penicillins, cephalosporins interfere with bacterial cell wall synthesis, leading to bacterial cell death. They are often used as an alternative for UTIs when other antibiotics aren’t suitable.
  • Urinary Antiseptics (Nitrofurantoin): Damage bacterial DNA, proteins, and cell walls, inhibiting bacterial growth. It’s specifically concentrated in the urine, making it effective for treating lower urinary tract infections caused by susceptible bacteria.
• Bladder Analgesics (Phenazopyridine): Work as urinary analgesics by directly soothing and numbing the urinary tract mucosa, providing relief from pain, burning, and discomfort during urination. However, this medication can cause the color of urine to become reddish-orange and can also stain contact lenses. This medication is not typically prescribed for more than three days because it can mask signs of a continuing urinary tract infection.
• Antispasmodics (Hyoscyamine): These drugs work by relaxing smooth muscles, including those in the bladder, reducing bladder spasms and the urgency and frequency of urination. They help alleviate discomfort associated with UTIs.

Treat Underlying Causes

Health care providers order additional diagnostic testing for clients with recurrent cystitis to identify underlying factors such as urinary tract abnormalities, kidney stones, and hormonal fluctuations.^{[17],[18],[19],[20]} Underlying causes may be treated surgically.

Nursing Interventions

Nursing interventions focus on health teaching and health promotion measures to provide comfort and prevent recurrent infections.

Health Teaching & Health Promotion

Nurses provide health teaching regarding several topics:

• Take the full course of antibiotics, as prescribed, to prevent antibiotic resistance.
• Notify the health care provider of symptoms of developing pyelonephritis, such as fever, flank/low back pain, and nausea/vomiting.
• Use appropriate perineal hygiene, such as wiping from front to back after a bowel movement and voiding after intercourse to prevent the introduction of bacteria into the urethra.
• Promote adequate hydration, typically 6-8 glasses of water per day, to help flush bacteria from the urinary tract and dilute the urine.
• Encourage regular and complete bladder emptying. Encourage avoiding delaying or holding urine for extended periods to prevent bacterial growth.
• Avoid the intake of irritants like caffeine, alcohol, and spicy foods to minimize bladder irritation and reduce symptoms.
• Encourage the consumption of substances that acidify the urine, such as cranberry juice or supplements. These substances may help prevent bacterial adherence to the bladder wall.
• Suggest comfort measures, such as using a heating pad or warm compress over the lower abdomen, to alleviate discomfort or pelvic pain associated with cystitis. Take prescribed analgesics or bladder analgesics to alleviate discomfort during urination.  Encourage rest and positioning to reduce bladder pressure or discomfort, such as lying down with knees bent.
• Avoid irritants to perineal area that can contribute to the development of cystitis, such as harsh soaps and bubble baths, douches, ill fitting clothing/underwear, or fragrances.

Evaluation

During the evaluation stage, nurses determine the effectiveness of nursing interventions for a specific client. The previously identified expected outcomes are reviewed to determine if they were met, partially met, or not met by the time frames indicated. If outcomes are not met or only partially met by the time frame indicated, the nursing care plan is revised. Evaluation should occur every time the nurse implements interventions with a client, reviews updated laboratory or diagnostic test results, or discusses the care plan with other members of the interprofessional team.