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Cystitis (also called urinary tract infection, or UTI) is an inflammation of the urinary bladder. The lower urinary tract consists of the urethra (the tube that carries urine from the bladder) and the bladder. The upper urinary tract includes the kidneys and ureters (tubes that carry urine from the kidneys to the bladder). Where inflammation occurs determines whether the condition is called cystitis, pyelonephritis, or urethritis.
Not everyone with cystitis develops symptoms, but the most common ones include a burning sensation or discomfort during urination, more frequent urination, the urge to urinate even when the bladder is not full, urinary incontinence (leakage), pain or pressure in the pelvic area, and dark-colored, cloudy, or malodorous urine. If not resolved, cystitis can lead to more serious symptoms, including blood in the urine, fever, nausea, vomiting, backache in the kidney area, pain in the pubic area, and occasional discharge of pus in the urine or from the urethra – signs of pyelonephritis (kidney inflammation) or urethritis (inflammation of the urethra).
In most cases, Escherichia coli (E. coli) bacteria are involved, although other types of bacteria or yeasts (such as candida) have been found. These bacteria and yeasts are foreign to the urinary tract and do not belong there. The E. coli or other bacteria come from feces; candida comes from the vagina. They can adversely affect an irritated or compromised urinary tract, particularly if the bacteria are “sick” (having engulfed wastes or toxins). The bacteria from feces make their way through the urethra into the bladder or, rarely, to the kidneys. In men, the sick bacteria may stress the prostate. Although the tendency is to blame some microorganism, inflammation of the bladder can occur without infection from bacteria foreign to the urinary tract. Even if there are foreign bacteria or yeasts involved, this does not mean that they cause the problem. A healthy urinary tract flushes out any toxic or foreign substances through the urine. The underlying cause would more likely be an unhealthy urinary tract lining, which has increased susceptibility to insult or irritation from foreign bacteria or yeasts.[1,2]
Cystitis is much more common in women (one in five women will have cystitis during her lifetime). One reason is that the female urethra is shorter than a male’s. Also, the urethral opening is near the peri neum (the region between the vulva and anus), which tends to harbor fecal matter, including sick bacteria that may contribute to cystitis. In men, the urethra is much longer, making it harder for bacteria to migrate; there is a greater distance between the opening of the urethra and the anus; and prostatic fluid has antibacterial properties. When foreign bacteria, toxins, or other substances that don’t belong in the urinary system are not flushed out quickly enough, irritation or injury to the lining of the bladder and urethra can occur. For women, sexual intercourse, delayed urination after intercourse, use of diaphragms with a spermicide, spermicides alone, oral contraceptives, obesity, incontinence (urinary or fecal), and a history of recent cystitis all increase risk. Intercourse that is rough or frequent can cause irritation or push bacteria up into the bladder (a condition sometimes known as “honeymoon cystitis”). Spermicides induce colonization of E. coli and alter vaginal flora. Exposure to irritants such as perfumed soaps and scented douches can also contribute to the tendency for cystitis.
Men experience a higher prevalence of cystitis starting in their mid-50s and 60s, when an enlarged prostate and obstruction of the urinary tract are more probable. In older women, reduced estrogen can cause marked changes in the bacteria living in the vagina and the area around the urethral opening, as well as weaken the vaginal lining. Estrogens also help maintain the muscle and ligament structures in the pelvic area. Postmenopausal women tend to have lower levels of lactobacillus in particular. This type of healthy bacteria helps lower the pH of the vagina, making it less hospitable to sick bacteria and thus helping prevent their spread to the urinary tract.
Generally, there is some tissue weakness or a lack of resistance to stress involved in the development of cystitis. Occasionally, kidney or bladder stones, catherization, or anatomical or functional abnormalities can increase risk in both men and women. Usually, however, the lining of the bladder and/or urethra is somehow compromised and not as healthy as it should be. A bladder that has been irritated, has lax tissues, or is affected by reactions to toxins, drugs, or food intolerances is more susceptible. If the tissues have become so weak that the back of the bladder hangs lower than the opening, urine may stagnate in the bladder, which never completely empties. This too can irritate the bladder and lead to inflammation.
Symptom reports, urine dipstick tests, urine analysis, and/or urine cultures are usually used for diagnosis. Using a dipstick, however, is not always accurate. The U.S. Preventive Services Task Force does not advise urine testing for people without symptoms, because the antibiotic regimen prescribed by many doctors is riskier than no treatment for people with symptomless UTIs. Adverse effects from antibiotics and development of bacterial resistance (from overuse) are reasons given. Medical treatment is almost always a prescription for antibiotics, yet studies have shown that this does not decrease risk of recurrent UTIs, although it does increase risk of antibiotic resistance. Antibiotics become less effective with each episode of cystitis, and stronger ones are prescribed until they too are no longer effective. In addition, the underlying cause of the cystitis is not addressed.
Most people have heard that cranberry juice can help prevent the recurrence of cystitis. However, study results have been mixed, evidently depending on the content and quality of the juice, and the additives and processing methods employed.[5,6,7] Unsweetened juice – without refined sugars – appears to be best. (Raw honey or pure maple syrup can be added to offset the tartness, if needed.) Cranberries may interfere with the attachment of foreign bacteria to the lining of the urinary tract. One component in cranberries that may do this is D-mannose, a simple sugar discussed in more detail below. Isolated D-mannose has been used to prevent recurring cystitis. However, cranberries contain many other ingredients, including organic acids, natural fructose, vitamin C complex with flavonoids, anthocyanidins, proanthocyanidins, catechins, triterpenols, and more. There are indications that many of these can prevent foreign bacteria from sticking to the urinary tract wall. Even though it’s thought that inhibiting the adherence of bacteria is the main action by which cranberries help prevent cystitis, the exact mechanism has not been established.
A 2012 Cochrane Review found a “small trend towards fewer UTIs in people taking cranberry product[s] compared to placebo or no treatment,” but this finding was not significant. They concluded that “until there are more studies of products containing enough of the active ingredient [emphasis added], measured in a standardized way, cranberry products cannot be recommended for preventing UTIs.” This exemplifies the drug mentality, which insists on using one measured active ingredient. Different dosages and product types were used in the studies reviewed, so a standardized dosage – as with a pharmacological agent – was not employed. Another reason given for their conclusion is the need for improvements in the design of studies.
Some scientists have questioned the validity of the Cochrane group’s conclusions. For example, Amy Howell, PhD, who has been researching cranberries for two decades, doesn’t agree with the Cochrane researchers’ basic dismissal of cranberries and their juice for prevention of cystitis. Her lab “has consistently found that cranberries effectively help prevent bacterial adhesion to bladder cells… If the bacteria are prevented from adhering, they will not be able to grow and cause an infection. They are washed out of the body in the urine stream.” A 2012 review published in the Archives of Internal Medicine, which included 13 clinical trials with 1,616 participants, found that unsweetened cranberry juice was more effective than capsules or tablets. The point, however, is that cranberry juice can be effective. It’s possible that some components in the juice may be removed when making capsules or tablets, but there are types that preserve the whole cranberry. Many experts agree that more and better research is needed.[5,6] Cranberry juice may prevent cystitis, but so far evidence is lacking to show it can be used to treat cystitis. Cranberries, blueberries, and other foods that may help prevent cystitis recurrence are rich in flavonoids (including anthocyanins and proanthocyanidins), and contain D-mannose and a host of other components that contribute to the beneficial effect.[14,15]
D-mannose is a naturally occurring simple sugar contained in cranberries, blueberries, other berries and fruits, and some plants. Some can also be produced in the human body. It adheres to the bladder epithelium and, in essence, interferes with the ability of E. coli or other bacteria that are not normal inhabitants of the urinary tract to adhere there. Then the bacteria or other foreign substances can be flushed out of the bladder with the urine. To date, research on the effects of isolated D-mannose is very limited, and little is known about the safety of long-term use of D-mannose supplements. There are some potential side effects, such as bloating. When taken in excessive doses, it may stress or damage the kidneys. Foods containing D-mannos (along with all its co-workers) may thus be the best choice.[16,17]
Lactobacillus bacteria are a normal component of the urinary and genital flora of healthy women. Various strains of lactobacillus have been found helpful in preventing and treating cystitis and other genitourinary problems. In a double-blind trial, orally administered L. rhamnosus GR-1 and L. reuteri RC-14 were found to be nearly as effective as antibiotics for preventing UTI recurrence. Another study involved the use of intravaginal suppositories containing either L. crispatus or a placebo after a course of antimicrobials by women with acute cystitis and a history of recurrent cystitis. There was a 50 percent reduction in recurrent cystitis with lactobacillus use. L. acidophilus used in a clinical trial was shown to hinder attachment of sick or foreign bacteria to the lining of the urinary tract. In addition, the carbon dioxide-producing lactobacilli most commonly found in the normal bladder flora (L. crispatus and L. jensenii) can help keep the bladder in its preferred acidic state. Probiotics can help prevent cystitis but may not relieve the situation when inflammation is already present.[20,21] A review of studies stated that the evidence suggests that probiotics are safe and may indeed be effective at preventing UTIs in women.[22,23] Consuming fermented foods such as yogurt and kefir lowers the likelihood of recurring UTIs up to 80 percent..
There is some evidence that the risk for cystitis may be altered by dietary influences and digestive health. Refined sugars, refined flours, altered oils or fats and other overprocessed, chemicalized nonfoods can be irritating to the urinary tract. Frequent consumption of fresh (not canned or bottled) juices, especially berry juices, and fermented milk products containing live probiotics (lactobacilli) was associated with a decreased risk of recurring UTIs. Consuming fermented milk products three or more times per week was more effective than doing so less than once per week. Increasing garlic and onions in the diet – both of which produce antimicrobial activity – may also be helpful. These two foods have been shown to inhibit the growth of E. coli and other sick bacteria types.[25,26,27]
Although focus has been on the connection between bacteria and UTIs, it seems that virtually every woman is likely to, at some time, get E. coli or other sick bacteria in her urinary tract. However, not all women get cystitis, and fewer get recurrent cystitis. Thus, the health of the urinary tissues must have a lot to do with this issue. Providing support to these tissues and to the inflammation and repair process is imperative for those who have a cystitis tendency. Vitamin C complex has numerous beneficial effects and functions, including support for immune processes, proper absorption and utilization of other nutrients, and production of many hormones and nerve-conduction substances. It is involved in the production of collagen, the main protein substance in the body, which plays a role in wound repair, connective-tissue structures, and more. Vitamin A complex, carotenes, vitamin E complex, and zinc are also supportive to the health of the tissues involved, as well as to the immune system.
A number of herbs have a history of use for preventing and/or treating recurrent cystitis. Uva ursi, pipsissewa, Oregon grape root, and goldenseal have been shown to be effective. Mucilaginous herbs are soothing to the irritated bladder lining, allowing inflammation to heal. These include corn silk, marshmallow root, and plantain leaf. Echinacea supports the immune system and inflammation/repair processes. Some herbs act to increase blood flow to the kidneys and thus raise the glomerular filtration rate (a measure of kidney function); dandelion leaf or root, parsley, buchu seed, cough grass root, juniper leaf, lovage root, and birch bark are among these.[14,27-30]
Preventive measures include:
- Drink plenty of filtered or purified water and other healthful fluids to increase urinary output and flush out any substances that do not belong in the urinary tract.
- Consume unsweetened cranberry juice or fresh or frozen cranberries. These are very tart.
- Eat foods that contain D-mannose (or drink their freshly made juices): cranberries, blueberries, black or red currants, gooseberries, peaches, apples, green beans, capsicums (peppers), cabbage, eggplant, turnips, and homegrown ripe tomatoes. Aloe vera is also a source. Fresh orange juice and pineapple juice may inhibit adherence of bacteria to the urinary tract wall.
- Take a good probiotic supplement that contains lactobacillus bacteria.
- Include plenty of fiber (found in whole grains, vegetables, fruit, and legumes) in your diet, as well as fermented dairy products, nuts, seeds, and unrefined oils and other unaltered natural fats.
- Avoid consuming common bladder irritants such as alcohol, refined sugars, chocolate, artificial sweeteners, carbonated beverages, caffeine, black tea, decaffeinated coffee, distilled vinegar, tomatoes (other than homegrown), and very spicy foods.
- Don’t resist the urge to urinate. Holding it may increase risk, particularly if the muscles are weak.
- Avoid tight-fitting underwear and clothing. Wear cotton undergarments; synthetics (such as nylon) trap heat and moisture. For women in particular, thongs are so close to the anus that it is easy for fecal bacteria/matter to get into the urethra.
- Be aware that food sensitivities/intolerances can lead to cystitis-type symptoms. An elimination diet may help determine if this is the case.[25-28,31-34]
Some additional guidelines for women include:
- Wipe from front to back after bowel movements, to avoid getting sick bacteria or other unwanted substances near or in the urethra.
- Urinate after sexual activity.
- Avoid the use of diaphragms and spermicides for contraception; switch to another form of birth control if possible. When menstruating, change sanitary napkins or tampons frequently.
Interstitial cystitis (IC) is a syndrome in which the lining of the bladder is constantly irritated, causing urgency to urinate (sometimes immediately after urinating), pain or discomfort that worsens as the bladder fills or is improved after emptying the bladder, pain when urinating, pelvic pain or pressure, and urinary frequency (eight to 50 times per day and eight to ten times per night). It occurs in both men and women, but it’s five times more common in women.[35,36] It often takes five to seven years of suffering with symptoms before a proper diagnosis is made. IC is thought to be a chronic inflammation of the bladder, possibly due to a disorder of its inside wall. The innermost portion of the wall (the glycosaminoglycan [GAG] layer, or mucus membrane) may be damaged. Pain can range from mild burning or discomfort to severe, debilitating pain in the bladder, lower abdomen, perineum, pelvis, vagina, low back, and thighs. Menstruation and sexual intercourse aggravate symptoms in as many as 75 percent of women with IC. There are often flare-ups and remissions. Onset typically occurs in youth or middle age.
Various causes have been speculated – from autoimmune or genetic factors to allergies or fibromyalgia – making it a complex condition to treat. Although there are a number of theories, there is imperfect evidence supporting them. Some theories seem to fit some people but not others.[39,40] Ulcerations of the bladder occur in 20 percent of patients. In many sufferers, mast cells infiltrate the bladder wall, but no one knows why. Mast cells are large tissue cells essential for inflammatory reactions mediated by the antibody immunoglobulin E (IgE). High levels of histamine and methylhistamine are found in the urine of IC sufferers as compared to controls, suggesting that there could be an allergic or sensitivity reaction or a reaction to toxins. Other inflammatory mediators, such as interleukin-6, have also been found in the urine. The majority of people with IC have sterile urine, so any role for microbes remains uncertain. Some suggest renaming the syndrome “irritable bladder syndrome” as it’s similar in some respects to irritable bowel syndrome. It has also been suggested that IC is a combination of issues involving the immune system, sensitivities or intolerances, psychological aspects, and other factors. It is common in people who have irritable bowel syndrome, spastic colon, abdominal cramping, hysterectomy, rheumatoid arthritis, fibromyalgia, hypothyroidism, chronic fatigue, vulvodynia, premenstrual syndrome, endometriosis, Sjogren’s syndrome, hay fever, asthma, and intolerances to foods and medications.[45,46]
Some research indicates that there may be an acidic, heat-stable protein that is found predominantly in people with IC. It may prevent the lining of the bladder from repairing itself, resulting in epithelial thinning and wounding. Up to 95 percent of more than 200 patients with IC had this protein in their urine compared with fewer than ten percent of the control subjects. Urine from IC patients also contains lower levels of one type of growth factor and higher levels of other growth factors compared with urine from people who do not have IC. Other research indicates that substances such as urea and potassium penetrate into deeper layers of the bladder wall in people with IC. The bladder lining or wall may be so damaged or disrupted that caustic or toxic substances in the urine, normally prevented from entering the deeper layers of the bladder wall, are able to penetrate into the connective tissue and muscle. There they may trigger nerve endings and mast cells, resulting in pain, inflammation, and bladder spasms. Also, there may be a difference in the composition, quality, or rate of turnover of the mucus. A study found less type IV collagen in the basement membrane of the bladder epithelium. A clinical trial directly applied a naturally occurring GAG (like that in the bladder wall), which resulted in reduced inflammation and symptoms. There is a significant amount of evidence that the bladder lining has abnormal cells, causing the bladder surface to be “leaky,” owing to the loss of the normal barrier function. This has prompted a likening of IC to “leaky gut” (increased intestinal permeability). Since the bladder surface is more permeable than it should be, nerves in the wall can also become inflamed and more sensitive to metabolites of foods, beverages, some supplements, and toxins in the urine. Some people can have IC as a result of one mechanism more than another, or as a result of multiple mechanisms.
There is no reliable test to detect IC. A thorough health history and physical examination may provide needed clues. Urinalysis may be performed to rule out UTI, which can have similar symptoms. There is no single magic bullet for treatment either. Medical treatment often includes pain relievers, antidepressants, antihistamines, immunosuppressives, GAG layer substitutes, transcutaneous electrical nerve stimulation, or surgical procedures to block off bladder nerve supply, enlarge the bladder, or bypass the bladder and urethra and create an internal continent pouch. Antibiotics do not relieve symptoms. Therapeutic options, both conventional and alternative, are as varied as are theories for the cause of IC.
Food-concentrate supplements can be very helpful, first to coat and soothe the urinary tract lining (slippery elm, marshmallow root, oats, etc.) and then to support repair. Sources of vitamin C complex (which includes bioflavonoids and quercetin), vitamin A and E complexes, carotenes, essential fatty acids, alkaline-producing minerals such as potassium, and amino acids important to urinary tissues can be supportive. Methyl donors include onion and garlic; if tolerated, these can serve as stabilizers for mast cells. Studies have found that people with IC have decreased nitric oxide synthase (NOS) activity in their urine, so increasing synthesis of nitric oxide with nutritional aids may yield improvements. Beets (freshly juiced, grated on salads, or in supplement form) help increase the production of nitric oxide and the enzyme NOS, which catalyzes its production in the body. Nitric oxide promotes relaxation of urinary tract smooth muscle and may play a role in the immunological responses associated with IC.[48,49,50]
The most commonly used and helpful treatment by both conventional and alternative practitioners is dietary change. Food sensitivities or intolerances can make IC worse. Specific intolerances will vary; not all foods and beverages have the same effects on individuals, and there is no consistent diet that works for all IC patients. Note that even a food that can be therapeutic for some people may cause sensitivities in others.
Thus, an elimination diet would be best, followed by reintroduction of individual foods to determine specific triggers. Items that increase symptoms may indicate intolerances or may simply be irritants.
Many people with IC notice a dramatic and immediate reduction in symptoms with dietary modifications alone. However, there is concern that people may try to eliminate more foods than necessary and thus reduce nutrient intake. So, if a person eliminates all the foods suggested below and experiences improvement in symptoms for about three weeks, one item at a time can be tried to ascertain if there is a problem with it. If not, it can be added back into the diet. Finding the best diet will require some experimentation and patience. With more healing and repair, eventually more foods may be tolerated. The avoidance of foods to which there is an intolerance and the use of supplements to support the urinary lining should be undertaken for at least six months, possibly longer. Here are foods and beverages to avoid based on the most common responses:
- Milk/dairy products: Aged cheeses, sour cream, and yogurt (cottage, ricotta, and cream cheese may be okay).
- Vegetables: Fava beans, lima beans, lentils, onions, garlic, tomatoes, and soybeans and their products (including tofu). Chives, green onions, and homegrown ripe tomatoes may be tolerated.
- Fruits: Apples, apricots, avocados, bananas, cantaloupes, citrus, cranberries, grapes, guava, nectarines, peaches, pineapples, plums, pomegranates, prunes, raisins, rhubarb, and strawberries. Melons other than cantaloupes seem fine, as do other berries, pears, and mango.
- Grains and starches: Rye and sourdough breads.
- Meats and fish: Aged, canned, cured, processed, or smoked meats and fish; pickled herring, anchovies, caviar, chicken livers, corned beef, and meats that contain nitrates or nitrites.
- Nuts: Most nuts except almonds, cashews, peanuts, and pine nuts.
- Beverages: Alcoholic beverages (including beer and wine), carbonated drinks, coffee, black tea, and fruit juices (especially citrus or cranberry). Some herbal teas may be good.
- Seasonings: Mayonnaise, ketchup, mustard, salsa, spicy foods, chilies, soy sauce, miso, other soy-based condiments, salad dressings, and vinegar (including balsamic and flavored vinegars). Homemade mayonnaise that does not include lemon juice, vinegar, or prepared mustard can be tried.
Synthetic food additives may contribute to IC and should be avoided; these include benzyl alcohol, citric acid, monosodium glutamate (MSG), artificial sweeteners (such as aspartame and saccharine), chemical preservatives, and artificial colors and flavors. Other substances best avoided include tobacco, caffeine, chocolate, recreational drugs, cold and allergy medications containing ephedrine or pseudoephedrine, diet pills, isolated or synthetic vitamins (especially ascorbic acid), and overprocessed and refined junk foods (including refined sugars, refined flours, and altered fats).[40,45,51,52]
Drinking plenty of clean water and herbal teas such as corn silk, parsley leaf, and/or dandelion leaf can help keep the bladder flushed out and lower the acidity of the urine. Herbal therapies may be useful in other ways, as well. Herbs that reduce or modulate inflammation include goldenrod (which may also lessen spasm), goldenseal, turmeric, feverfew, astragalus, ashwagandha, and schisandra. Horsetail is mildly diuretic and primarily strengthening. Urinary tonics include mullein root, pipsissewa, and shepherd’s purse.
Sedative and antispasmodic herbs may reduce pain, while other therapies work on repairing the bladder lining; these include wild yam, black cohosh, valerian, kava, and skullcap. Urinary demulcents soothe the bladder wall and include licorice root, corn silk, marshmallow root, slippery elm, oat seed, plantain leaf, and mullein leaf. Saw palmetto berry relaxes smooth muscle in the bladder neck and helps reduce tissue enlargement. Chamomile appears to soothe cystitis and is relaxing. Chinese herbal formulas are being used to treat IC; most commonly used herbs are gardenia, licorice, dianthus, poria, rhubarb, rehmannia, cornus, water plantain, ginseng, and plantain.[48,49,51]
Other useful alternative or complementary therapies can include:
- Smoking cessation (which is important for anyone with bladder problems).
- Relaxation techniques and stress management to help improve symptoms. Stress doesn’t necessarily cause IC but can make its symptoms worse. Anxiety can be a component of the problem.
- Acupuncture, which helps 40-60 percent of people with chronic pelvic pain.[48,53]
- Myofascial release, a type of physical therapy focused on trigger points that develop in muscles due to chronic pain or overuse. This is used to treat pelvic floor dysfunction, which can exist concurrently with IC.
Identification of possible underlying health issues, such as a heavy toxic load, nutritional deficiencies, a sluggish immune system, or endocrine imbalances (hypothyroidism, estrogen dominance, etc.) is very important. A detoxification program may be needed as a first step,[39,46] followed by the recommendations discussed above.
Reprinted with permission from Nutrition News and Views, July/August 2013, Vol. 17, No. 4.
About the Author
Judith A. DeCava, CNC, LNC, has worked both independently and as an associate with physicians, nutrionists, and clinical psychologists for more than 30 years. She has been writing about health science since 1985. Her work has been published in journals, newsletters, and books, and she has been a frequent contributor to the PPNF Journal. She has also published her own newsletter, Nutrition News and Views, for health professionals.
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Published in the Price-Pottenger Journal of Health and Healing
Fall 2013 Volume 37 Number 3
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