Symptomatic non-bacterial Cystitis

Symptomatic non-bacterial Cystitis is an inflammation of the bladder that causes pain and urinary problems and is not caused by bacteria.

Leukocytes and blood can be detected through urine tests or urine strips. Nitrites are absent. Urine culture is negative.

Even when there are no bacteria in the urine, they are often still blamed for the pain and treated with antibiotics.

• Causes of abacterial Cystitis
• False negatives
• Treatment of abacterial Cystitis

"I had my urine culture tested and, as Rosanna predicted, it was negative. On the other hand, I feel the urge to urinate very frequently today. It's even worse when I'm sitting down, not to mention when I'm travelling by car – maybe it's the vibrations, I don't know... but it's really annoying. (...) Oh well... I'm really demoralised today. If there are no bacteria... then what could be causing this urge?"
Simo76 08/02/2011 (cistite.info)

"Update. Urine culture performed on Friday: negative. In fact, I have never had a positive urine culture despite my urinary problems (heaviness in the bladder, pain similar to that felt after catheter removal, spasms that sometimes reach almost to the navel, urinary urgency)."
Silviaf 30/03/2011 (cistite.info)

So when the culture comes back negative, you despair because the only possible cause you know has been ruled out, your magic pill (the antibiotic) has been deprived of its healing power, and you find yourself without a diagnosis, without possible treatments, and considered a psychosomatic hypochondriac.

"I go to the doctor who prescribes another urine culture and nothing new. no bacteria. I am disconsolate, my GP looks at me as if I were alienated."
Elly 16/11/2010 (cistite.info)

"in recent months, they've been telling me: but the urine cultures are negative, how can you be in pain? Maybe it just seems that way... Yeah, right, IT JUST SEEMS THAT WAY????"
Paola60 18/10/2012 (cistite.info)

Causes

What causes abacterial Cystitis?

In reality, Cystitis can be caused by dozens of non-bacterial factors that explain why antibiotics are ineffective. That's why every time you pick up your urine culture results, you cross your fingers and hope that there are at least four measly microorganisms to blame for your pain: it's reassuring to attribute the cause of your pain to something external that can be quickly defeated with a pill you can swallow in a second.

There are many non-infectious (non-bacterial) causes that can trigger Cystitis:

• food or drink intolerances (read the recommended diet)
• sexual intercourse (post-coital Cystitis)
• stones and gravel
• autoimmunity
• excessively acidic pH
• bladder endometriosis
• interstitial Cystitis
• inability to distinguish between pain originating in the bladder and pain originating in the vagina, urethra, vulva, ovaries or muscles, related to conditions such as Vulvodynia, pelvic contracture and pelvic neuropathy

These factors cause irritation and inflammation similar to that caused by a bacterial bladder infection. What causes pain is the inflammation that the bladder produces to defend itself against the attack. Whether caused by bacteria, acidity or other irritants, the resulting inflammation is the same and therefore the symptoms will also be similar. In interstitial Cystitis, for example, there is constant bladder inflammation in the absence of bacteria in the urine. Another example is classic “honeymoon” Cystitis, which occurs after sexual intercourse, where the trauma caused by friction during intercourse and the impact on the bladder and urethra during the act cause symptoms identical to those of a bladder infection. Furthermore, the presence of gravel or crystals in the urine causes scratches on the urethral and bladder mucosa and, consequently, pain when urinating, even in the absence of bacteria.

Further information: Interstitial Cystitis

Further information: Post-coital Cystitis

“Hear ye, hear ye... I've got cystitis!!!!!!(...) I don't know if it was caused by: sexual intercourse (thursday evening), too much wine (friday evening), imminent menstruation (the premenstrual period always brings me magical moments). Anyway, tomorrow I'm having a urine culture done (I forced my GP to give me a referral despite her ‘but wouldn't it be better if I prescribed something? can you hold out for 3 days?’)...and I'll see what nasty bugs are there, if any."
Serena84 10/05/2011 (cistite.info)

"Here I am...urine culture results: insignificant microbial load - negative aerobic culture. So...the result is that I'm an idiot!!! :-)
And that I no longer have the physique to be a sixteen-year-old!!!"
Serena84 19/05/2011 (cistite.info)

"perform a urine test = presence of numerous squamous epithelial cells but otherwise no abnormalities. Urine culture = negative. Ultrasound = only a few ’echoes‘ showing “sand” [kidney stones. Ed.] or other deposits. The urologist tells me to start taking antibiotics (C****xin) anyway, which I take this time without any benefit."
Beola70 10/02/2011 (cistite.info)

In these cases, it is therefore essential to strengthen the bladder in order to make it less sensitive to stimuli and to understand exactly what the underlying condition is in order to resolve it and prevent further Cystitis.

A separate discussion is needed for the very few false negatives, i.e. those cases in which the urine culture does not show the presence of bacteria, even though they are actually present.

False negatives

Why do false negatives occur?

There are cases in which bacteria are present despite the urine culture not detecting their presence. There are several reasons why this may occur:

• Positivity limit.
  Urine culture is considered negative if the load is less than 100,000 CFU (colony-formin units).
  However there are many women who have acute symptoms with a load below this threshold. This may be due to the fact that even a few bacteria, if very aggressive, can trigger a massive inflammatory response. Or because the GAG layer of the urothelium, damaged by previous recurrences, is no longer able to protect the underlying tissue, which is extremely sensitive and delicate, and even a weak bacterial load can trigger significant symptoms. Or because the proliferation of new nerve endings has made the bladder mucosa so sensitive that it detects even the slightest presence of bacteria. In this case, however, it is useless to defeat the bacteria if you do not rebuild the bladder walls: Cystitis will continue to recur.
• Bacteria trapped in the urothelium.
  There is a hypothesis that the bacterial load is not free in the urinary flow, but trapped in the bladder walls and/or urethra.
  Consequently, urine culture, which only evaluates the emitted fluid, will not detect the presence of bacteria. I have reported this theory, although I do not agree with it, because it is often used to justify the prescription of antibiotics despite negative urine culture. In my opinion, these bacteria multiply, move, detach and are eliminated with the normal flaking cells to which they are attached. If this were not the case, these colonies would implode in their confined space. Therefore, I believe that the reproduced bacteria should still be found in the urine. Therefore, if the urine culture is negative, there is no doubt about the reliability of the test.
• Uncommon germs.
  It may also happen that the infection is caused by a microorganism that is not detected by a normal urine culture.
  These could include: gonococcus, chlamydia, ureaplasma, herpes virus, candida, tuberculosis bacillus. They can be detected with specific tests designed to look for them. However, it should be noted that even after these uncommon germs have been eradicated, the symptoms often persist.
• Antibiotic therapy.
  If a urine culture is performed during antibiotic therapy or immediately after completing it, the presence of antibiotics in the urine will distort the results by preventing the bacteria present from emerging.
  At least 10 days must pass from the last day of therapy before performing a urine culture.
• VBNC. This term refers to the “viable but non-culturable” state, i.e. the condition in which certain bacteria are alive but unable to reproduce in specific conditions in urine or in traditional culture media (i.e. those used to test urine samples for the presence and growth of bacteria).
  They remain dormant but retain their pathogenicity, which they express as soon as they begin to multiply again in urine or suitable culture media. The bladder walls appear to be a reservoir for these bacteria, which seem to be able to survive for months in a dormant state, giving negative urine cultures and only later causing symptomatic Cystitis and positive urine cultures. Anderson and colleagues analysed urine samples that tested negative in culture and found bacteria in this dormant, yet viable, state. Domingue et al. demonstrated that in 29% of tissue samples taken by bladder biopsy from patients with interstitial Cystitis (notoriously with negative urine cultures), there was the presence (genes) of Gram-negative bacteria in a dormant form. It should be assessed whether these bacteria are capable of causing tissue damage when they are dormant (I have not found any studies on this), because if this were not the case, VBNC would justify false negatives in the asymptomatic phase, but not false negatives in the symptomatic phase. In fact, when these bacteria in the VBNC state reactivate, multiply and become pathogenic, causing Cystitis, in my opinion they should be detectable in urine cultures, just like traditional bacteria.

In all these cases, the antibiotic may be effective despite the negative urine culture.

“You experienced exactly what happened to me during my last bout of cystitis!!!! Excruciating pain, negative urine culture but high leukocytes count, so I was prescribed antibiotics too... But it worked for me as well.”
Fittina70 30/11/2009 (cistite.info)

In any case, even if these undetected bacteria were responsible, the question to ask is not "What can I take to eradicate these bacteria?", but rather:

“What can I do to strengthen my defences and prevent these bacteria from reaching my bladder?”

Treatment

How is abacterial Cystitis treated?

Once you understand that antibiotics are not necessary if you have symptoms of Cystitis but no bacteria, you can focus on reducing bladder inflammation through treatments and behavioural strategies.

Together with the doctors we work with and based on thousands of experiences reported by women with whom Cistite.info has been working for decades, we have formulated a treatment plan that summarises what to take, how and when, on a day-by-day basis.

Receive a free treatment plan for abacterial Cystitis

Further information: Treatment of abacterial Cystitis

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