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2017 HCHB_digital

Cystitis [Bladder

Cystitis [Bladder Infection] Cystitis is an infection of the bladder, usually caused by bacteria, which causes the bladder wall to become inflamed. The term urinary tract infection (UTI) may be used interchangeably with cystitis; however, a UTI infection technically means an infection in some part of the urinary tract system (ie, ureters, kidneys, urethra or bladder), not just the bladder. Common symptoms include a burning pain or stinging sensation on urination and a frequent urge to pass small volumes of urine. The urine may also be cloudy and strong smelling. Lower back pain, discomfort just above the pubic area, nocturia (getting up repeatedly during the night to urinate) and haematuria (blood in the urine) may also occur. Cystitis is caused in most cases by the person’s own bowel flora ascending the urethra from the perineal and perianal areas. The bacteria most often involved are Escherichia coli (responsible for up to 80% of uncomplicated cystitis), Staphylococcus and enterococci. If infection spreads to the kidneys, it can cause serious problems, eg, pyelonephritis (inflammation of the kidneys and pelvis). Women are most commonly affected because they have a shorter urethra than men, so it is easier for bacteria to travel up the urethra to reach the bladder. The condition is more prevalent in women aged 15–40 and in elderly women living in aged-care facilities. Cystitis is rare in men, but may occur in men aged over 50 due to prostate enlargement. Refer all men with suspected cystitis to a doctor. Children or adults with recurrent UTIs may require further investigations to look for abnormalities in the structure or function of the urinary tract. Initial assessment All men and children with suspected cystitis will need to be referred to a doctor, and all women will need to be referred to a pharmacist who will ask a series of questions to decide whether trimethoprim is appropriate for them. Treatment Cystitis can often come right on its own; however, antibiotics will help this happen faster. Trimethoprim can be sold under the following conditions by pharmacists who have successfully completed the Trimethoprim Accreditation Training Programme. • Treatment must be for a woman aged between 16 and 65 years. • She must not be pregnant. • She must not have taken antibiotics within the past six months. • Her symptoms must be consistent with those of uncomplicated cystitis and include two or more of: »» painful urination »» urinary frequency »» urinary urgency »» suprapubic pain. • Refer to a doctor any woman with: »» vaginal symptoms such as itch or discharge (may be vaginal thrush or a TREATMENT OPTIONS Category Examples Comments Urinary alkalinisers Preventive [GENERAL SALE] eg, contain a mixture of sodium and potassium salts (eg, Ural*) [GENERAL SALE] eg, methenamine hippurate (eg, Hiprex) Dissolve sachets in a glass of water and drink up to four times a day. There are a lack of good quality trials regarding the safety and effectiveness of urinary alkalinisers. Should not be used in pregnancy, renal impairment, cardiac disease, and with some medicines. Contain sodium and potassium; exercise caution when giving to people on potassium-sparing medicine or a sodium-restricted diet. Do not take with methenamine hippurate because an acidic urine is needed for methenamine to work. Methenamine hippurate has antibacterial properties and evidence suggests it may help prevent recurrent UTIs when used short-term (less than one week) in people without renal tract abnormalities. Evidence is lacking regarding long-term use. Not effective for neuropathic bladder. Preventive/Treatment eg, d-mannose (UroFem D-mannose*) UroFem D-mannose is a concentrated form of d-mannose, a naturally occurring carbohydrate that is thought to work by preventing bacteria from adhering to the bladder wall. D-mannose powder (2gm) was as effective as nitrofurantoin at preventing recurrent UTIs over a six month period. Some evidence suggests D-mannose is also effective for reducing symptoms of an acute UTI such as dysuria, urgency, supra-pubic pain, tenesmus, and nocturia. Antibiotics (treatment) Natural / herbal products / supplements [PRESCRIPTION]- unless sold by an accredited pharmacist ie, Trimethoprim (3) eg, Cranclense, Cranstat, Ethical Nutrients Urinary Tract Support See Treatment above for conditions under which a pharmacist may dispense trimethoprim. Dosage: one tablet at bedtime for three days. Drink plenty of fluid. Evidence for cranberry extracts is conflicting and recent reports suggest little or no benefit for the prevention (or treatment) of bladder infections. Probiotics may help support urinary health. Products with an asterisk have a detailed listing in the Cystitis (Urinary Tract Infections) section of OTC Products, starting on page 233. Clinically Researched, Specialist Recommended. Available without prescription from your pharmacy. Page 50 HEALTHCARE HANDBOOK 2017-2018 Common Disorders

CONTINUING OTC EDUCATION sexually transmitted infection [STI]). Treatment for vaginal thrush may be sold by a pharmacist if the woman has had it before »» risk factors for an STI (eg, recent change in partner, unprotected sex) »» systemic symptoms (eg, fever, chills, nausea, vomiting, feeling particularly unwell, pain in sides or back) »» more than three occurrences of cystitis or a UTI in the past year, or within the past two weeks »» renal impairment, an abnormal urinary tract, a catheter, history of kidney problems or kidney stones, who is immunocompromised or taking immunosuppressants (eg, azathioprine, ciclosporin, cyclophosphamide, methotrexate), a spinal cord injury, diabetes »» a history of hospitalisation in the past four weeks »» recent travel to a developing country. A wait-and-see approach is recommended for women with prior trimethoprim failure or hypersensitivity, blood dyscrasias, porphyria, who are breastfeeding, who take clozapine, warfarin or phenytoin or who have been prescribed antibiotics in the past six months. These women should be instructed to drink plenty of water (although the benefits of this have not been proven) and to see their doctor if there is no response in 48 hours or their symptoms worsen. A Cochrane review could not recommend the use of urinary alkalinisers for UTI symptoms because there was a lack of good quality trials. Advice for customers • Keep up your intake of fluids, although there is no evidence that drinking more fluids than normal decreases the duration of a UTI. • Rest and a hot water bottle on the stomach may help relieve pain. Paracetamol or an anti-inflammatory agent is a suitable analgesic. Avoid aspirin. • Consider D-mannose to reduce UTI symptoms such as dysuria, urinary urgency, supra-pubic pain, and nocturia (excessive night-time urination). • “Honeymoon cystitis”, caused by repeated trauma in the genital area, may be prevented by using a water-based lubricant if the vaginal area is dry. Avoid irritants such as perfumed douches. Clean the anogenital area before and after sex. • Avoid bath products and toiletries (bubble baths, bath oils, vaginal deodorants) if they cause irritation. • Some medications may result in inefficient emptying of the bladder. Talk to your doctor if the cystitis seems to have coincided with a recently started medicine. • Incorrect toileting may cause cystitis. Wipe “front to back”, preferably using a “blotting” technique. Respond to the urge to urinate – do not “hold on” as this can cause urine to concentrate and give bacteria an opportunity to multiply. • Acidic drinks (eg, fruit juices, fizzy drinks) and spicy foods may irritate the bladder in some people. • Wear loose-fitting cotton underpants and trousers. Tight clothing can make the anogenital area moist, encouraging bacterial growth. Refer to PHARMACIST All people with suspected cystitis should be referred to a pharmacist. Pharmacists should ask specific questions relating to the cystitis, and refer any “yes” answers to a doctor. People for whom trimethoprim or urinary alkalinisers are found to be unsuitable should also be referred to a doctor. • Does the person have any other health conditions (eg, immunosuppression, diabetes, kidney problems including kidney stones, spinal cord injury)? • Is the customer a child aged less than 16 years or an adult aged over 65 years? • Is the customer male? • Is the customer pregnant? • Does the customer have an abnormal urinary tract or a urinary catheter in place? • Does the customer have fever, nausea, vomiting, or pain on the sides of the lower back over the kidney area (likely to be a kidney infection)? • Is there any haematuria (blood in the urine)? • Are vaginal symptoms also present, such as itch or discharge (there may be a fungal or sexually transmitted infection) and over-thecounter treatment is not available or appropriate? • Have the symptoms lasted longer than two to three days? • Does the customer have recurrent cystitis (repeated UTIs can lead to kidney infection)? • Have the symptoms persisted despite treatment? • Does the customer have an allergy to trimethoprim? • If antibiotics are prescribed, encourage compliance, especially the need to complete the course. Ensure the customer understands any drug interactions and how to avoid or minimise them, and can recognise common adverse effects. Once-daily doses are best taken before bed after emptying the bladder. • Evidence is conflicting regarding the benefits of cranberry juice at reducing the incidence of UTIs. »» Recent reports suggest benefit is minor or non-existent. »» Evidence supporting D-mannose is more robust. Guidelines now specifically do not recommend: Cranberry containing products Urinary Alkalisers Choose to recommend UroFem for your customers. Always read the label and take as directed. If symptoms persist see your healthcare professional. 1. NICE Guidelines UK 2009. 2. Cochrane Review 2012. 3. Cochrane Review 2016. Te Arai BioFarma Ltd, Auckland. 0800 TE ARAI 832 724 Page 51

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