Treatment of acute bacterial cystitis

Bacterial Cystitis is a urinary tract infection characterized by the presence of bacteria in the urine, nitrites and leukocytes on the urine dipstick, and the following painful symptoms caused by bladder inflammation:

• urgency
• frequency
• pain during urination (stranguria)
• bladder heaviness (tenesmus)

Eighty percent of bacterial Cystitis cases are caused by Escherichia coli.

When suffering from an acute Cystitis attack, one can feel lost, tend to lose clarity, and not know how to face the problem. Here is a list of what to do during an acute Cystitis attack and a summary table of what to take and when.

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• During an acute attack
• In case of antibiotic therapy
• In pediatric age
• At the end of the acute phase
• During pregnancy and breastfeeding

Treatment of bacterial Cystitis in the acute phase

 What to do in case of bacterial Cystitis?

• Urine analysis. The first thing to do is to collect 2 urine samples (preferably from the first morning urination). One sample will be used to perform a urine dipstick test that evaluates the main parameters (leukocytes, nitrites, and pH). If leukocytes and nitrites are present, it is bacterial Cystitis. If leukocytes are present but not nitrites, it is aseptic Cystitis. If nitrites are present but not leukocytes, it is asymptomatic bacteriuria. If neither leukocytes nor nitrites are present, the problem is not bladder-related.
  The second sample will be used to perform a urine culture to determine which antibiotic is most effective in case natural therapy proves ineffective. We recommend always keeping a sterile container at home to collect urine for laboratory analysis. Read on the forum how to properly collect urine samples.
• D-mannose. It is a natural sugar that binds to the bacteria’s “legs,” preventing them from attaching to the bladder walls. In this way, they are easily expelled with the urine. After emptying the bladder, take 1 gram of D-mannose. Only after the first dose, take a second capsule after one hour; afterward, one capsule every 3 hours will be sufficient, for a total of 6–8 capsules per day (read the complete instructions on how to take mannose). Do not drink anything in the hour following mannose intake to allow it to remain in the bladder and act for at least one hour. It is possible to add the 6 grams to the bottle of water you will drink during the day or to the herbal tea (mallow, couch grass, and horsetail). If you wake up at night to urinate, take another capsule.
  D-mannose has no side effects, is not metabolized, and can be taken during pregnancy, breastfeeding, by people with diabetes, and by children.
• Bladder flushing. After collecting the urine samples, start introducing fluids (water or herbal tea) one hour after taking mannose by performing a bladder flush. Bladder flushing is done by drinking about 50 ml of water every 15–20 minutes for a total of 2–2.5 liters or more per day. At night, drink only if you wake up. Continuous bladder flushing prevents bacteria from stagnating in the bladder and reproducing.
• Urinate frequently. The human body is a (almost) perfect machine: if during Cystitis we feel frequent urges, it is right to follow them because there is a useful reason. In fact, the longer urine full of bacteria stagnates in the bladder, the more time these bacteria have to reproduce and adhere to the bladder walls, fueling Cystitis. It is therefore important to follow the urge and urinate as soon as we feel it (except for the hour following D-mannose intake).
• Anti-inflammatories/painkillers. Painkillers and anti-inflammatory drugs help reduce symptoms while the bacteria are being defeated by antibiotics or natural treatments. Among synthetic drugs, the most commonly used is Cistalgan (with antispasmodic and analgesic effects). An excellent natural alternative is Purodefend Urto, which our association had specially produced, composed of natural antibiotic/immunostimulant substances (turmeric, echinacea, and lactoferrin), anti-inflammatory substances (beta-caryophyllenes, turmeric), substances that relax the muscles (boswellia), and acetylcysteine, which dissolves bacterial biofilms.
• Mallow, horsetail, and couch grass herbal tea. Mallow, couch grass, and horsetail are three plants that we have found to be decisive in the treatment of Cystitis because they have anti-inflammatory, pain-relieving, and antispasmodic effects. D-mannose can also be dissolved in this tea. The fluids taken with the tea count toward the total 2.5 liters to be consumed over 24 hours. You can also prepare 2 liters of tea, dissolve the D-mannose in it, and drink it throughout the day to ensure a constant intake of the active ingredients it contains. Read in our forum about experiences with this herbal tea (in Italian). Our association has had a concentrated tea in drops produced to dilute in water wherever you are.
• Alkalinize the urine. An acidic solution passing over an inflamed surface can irritate it even more (think of lemon on a small cut, or acidic food in a stomach suffering from gastritis). By raising the urine pH, you will have a solution closer to neutrality (7 is the neutral value) and consequently less burning. In case of low pH (below 6), you can alkalinize with Basenpulver, Basentabs, Regobasic, or simply with the tip of a teaspoon of sodium bicarbonate (about one euro per pack at the supermarket!). Read our opinions on alkalinizers.
• Acidify the urine. Some bacteria are urease-positive, meaning they can transform the urea in urine into ammonia, which is strongly alkaline; therefore the urine will have a high pH (7 or more). Only in these rare cases is alkalinization not recommended. Urease-positive bacteria include Pseudomonas, Proteus, Morganella, and Providencia. You can acidify with a diet rich in carbohydrates and proteins or with specific products such as Acidif.
• Urinate in the bidet. Acute Cystitis is characterized by strong urethral burning during urination, especially toward the end. To reduce this pain, it is helpful to urinate in the bidet with a stream of warm water directed at the urethra. This helps dilute the irritating substances in the urine and reduce acidity so that the urine causes less burning as it passes over the vulvar mucosa. In addition, the warmth of the water helps relax the pelvic muscles, reducing the involuntary contraction of the pubococcygeus muscle.
• Finger maneuver. The finger maneuver is a technique that allows D-mannose to act in the urethra and adhere to the urethral mucosa for a longer time than during normal urination. In fact, urination lasts about 10 seconds, and the mannose contained in the urine remains in contact with the urethral mucosa for an insufficient time to eradicate the bacteria present there. With the finger maneuver, however, the urethra is blocked during urination for 60 seconds, so the urine full of mannose stays in contact with the urethral walls for a sufficient time, longer than during normal urination.
  This maneuver is also useful for dilating the urethral canal in cases of stenosis (narrowing) caused by pelvic hypertonia.
• Heat. To reduce pain, applying heat to the pelvic, lumbar, and genital areas is helpful. Heat relaxes the muscles, reducing pelvic floor contraction, which contributes to increasing the perceived pain. Heat can be applied using an electric heating pad, hot water bottle, warm blanket, warm bidet, sitz baths, or other heat sources.
• Pelvic muscle relaxation. Relaxing the pelvic muscles helps reduce pain. You can achieve this by regularly performing reverse Kegel exercises and diaphragmatic breathing. Doing reverse Kegels and diaphragmatic breathing during urination will help reduce muscle contraction and, consequently, the pain while you urinate.
• Diet. During an acute Cystitis attack, we recommend plenty of alkalizing foods, reducing acidifying ones (such as cereals and starchy foods), and avoiding foods high in oxalates, which form irritating crystals for the urinary mucosa in an acidic environment. To understand which foods worsen symptoms, read: Nutrition in 6 points.
• Blood in the urine. Sometimes, blood may be noticed in the urine during an acute phase. This condition is called hematuria and should not scare you: the presence of blood in the urine is not a sign of severity. The blood loss is not a hemorrhage but the leakage of red blood cells from small capillaries and tends to disappear on the same day it begins. Hematuria from acute Cystitis occurs because inflammation causes the blood vessels to dilate. As they dilate, the pores in the vessels enlarge to allow white blood cells and substances that fight bacteria to exit. Sometimes these pores open a bit more than necessary and also allow red blood cells (which are larger than white blood cells) to pass through, causing the red color of the blood. For this reason, symptoms often tend to decrease after hematuria.
• Antibiotics. It will be necessary to take antibiotics in the following cases:
  - if after 3 or 4 days of natural treatment you do not see any improvement
  - if you develop flank pain, high fever, extreme fatigue, and nausea
  - if the symptoms worsen instead of improving during natural treatment
  It is advisable to take the antibiotic that shows the highest sensitivity in the antibiogram. Penicillins (such as Augmentin) are discouraged because several studies have shown that they are among the antibiotics that most disrupt the vaginal and intestinal bacterial flora. Fluoroquinolones (such as Levofloxacin and Ciproxin) are also discouraged: a 2019 notice from AIFA warned against their use in uncomplicated Cystitis due to numerous reports of neuropathies following fluoroquinolone use.

 Treatment of acute bacterial Cystitis in children

What to do in case of acute bacterial Cystitis in children?

Children can take mannose, provided it is pure, so they do not ingest other components not tested for pediatric use. If the child weighs less than 25 kg, they should take approximately 250 mg of D-mannose. For children over 25 kg, a 500 mg dose is appropriate. The frequency and method of administration are the same as for adults. The D-mannose powder can be dissolved in a glass of water (or in a bottle for very young children). The powder dissolves immediately, and children usually like the taste because it is quite sweet.
Read in the forum how other mothers have dealt with cystitis in their children (in Italian).

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Treatment of Cystits in children

Treatment of acute bacterial Cystitis during pregnancy and breastfeeding

What to do in case of acute Cystitis during pregnancy and breastfeeding?

Pregnant or breastfeeding women can take mannose, provided it is pure so as not to ingest other components untested in pregnancy. The frequency and method of administration are the same as for adults. Mannose therapy can be combined with natural products according to guidelines.

Read on the forum the testimonies of pregnant women who have taken mannose (in Italian). 

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Treatment of cystitis during pregnancy and breastfeeding

Treatment of acute bacterial Cystitis and antibiotic therapy 

What to do during antibiotic therapy?

During antibiotic treatment, to reduce side effects and enhance the effectiveness of the antimicrobial action, follow these tips:

• Use products containing GAGs (such as Purorepair GAG) to repair the bladder walls, as described in the Miriam protocol.
• Restore the vaginal and intestinal bacterial flora by orally taking probiotics and applying lactobacilli locally, as described in the Miriam protocol.
• Take natural antibacterials (lactoferrin, piperine, turmeric, acetylcysteine, etc.) to enhance the antibacterial action of the antibiotic, to reduce bladder inflammation, and to relieve pain.
• Do not stop the antibiotic treatment even if symptoms improve: stopping early could lead to future antibiotic resistance.

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Recurrence of acute bacterial Cystitis

What to do when the acute attack ends?

When the acute attack passes, very gradually reduce the D-mannose intake until reaching 3 capsules per day. At this point, you can stop taking pure D-mannose as well as antibacterials/anti-inflammatories/painkillers and switch to only GAGs to repair the bladder walls and remove residual inflammation. Continue with 3 doses until the symptoms completely disappear, then gradually taper off.

After 15 days, repeat the urine culture to check the bladder condition and, if antibiotic therapy was carried out, perform a vaginal swab to assess the state of the lactobacillary flora.

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