Editorials

Postmenopausal cystitis

Recurrent lower urinary tract infections are common after the menopause and occur in more than 10% of women over the age of 60.¹ A rise in vaginal pH promotes an alteration in the normal vaginal flora, with decreased lactobacilli leading to increased colonisation by pathogenic faecal flora. This increases the incidence of urinary tract infections, especially in sexually active women. Oestrogen deficiency also results in generalised urogenital atrophy, and postmenopausal women are therefore at increased risk not only of recurrent urinary tract infections but also of dyspareunia, vaginal irritation, pruritus, pain, and symptoms of urgency, frequency, dysuria, and urinary incontinence.²

Unfortunately, urogenital atrophy is a late manifestation of the menopause and is consequently often underdiagnosed and undertreated. Many older women fear the side effects of systemic oestrogen therapy, and few wish to suffer monthly withdrawal bleeds from the commonly used hormone replacement therapy of oestrogen and cyclical progestogen. However, oestrogen therapy does promote recolonisation by vaginal lactobacilli, reducing both vaginal pH and proliferation of Gram negative faecal uropathogens.³

Uncontrolled studies have shown that low dose oestrogen therapy decreases the incidence of recurrent urinary tract infections.⁴ In the largest controlled study of its type to date Raz and Stamm showed that vaginal oestriol cream was significantly more effective than placebo in reducing the incidence of urinary tract infections, suggesting that treatment with low dose topical oestrogen may be adequate for this condition.⁵

For those women in whom oestrogen therapy is ineffective or inappropriate, it is important to exclude underlying pathology. This should include a pelvic examination, cystoscopy and bladder biopsy, intravenous urography, and, where indicated, urodynamic studies. Thereafter, antibiotic treatment should be based on microscopy, culture, and sensitivity testing of a midstream specimen of urine. Sometimes a long course of low dose antibiotics is required to eradicate infection. Symptoms may be caused by fastidious organisms, which will not be identified unless their culture is specifically requested. Ureaplasma urealyticum and Mycoplasma hominis require long term treatment (about three months) with low dose tetracyclines or erythromycin. Those women who suffer from postmenopausal cystourethritis in association with sexual intercourse may be advised to use a vaginal lubricant and a prophylactic antibiotic such as norfloxacin 400 mg at the time of sexual intercourse, as well as general hygienic measures including voiding to completion after sexual activity.⁶

Not all postmenopausal cystitis is bacterial, and interstitial cystitis should be identified at cystoscopy and by an increased mast cell count on bladder biopsy. This condition is difficult to treat, but patients may benefit from hexamine hippurate 1 g twice daily and a tricyclic antidepressant such as imipramine or amitriptyline given at night. Alternatively, low dose cortico-steroids (prednisolone 15 mg daily for the first month, 10 mg daily for the second month, and 5 mg daily for the third month) may be used. Finally, it is important to remember that irritative bladder symptoms, including urgency, frequency, and dysuria, may not necessarily be caused by cystitis. Medical conditions such as diabetes should be considered, and pelvic pathology such as fibroids must be excluded. In those women who do not respond to simple measures further investigations should be undertaken, including urodynamic studies.

Professor of urogynaecology 8 Devonshire Place, London W1N 1PB

Linda Cardozo 

1. Romano JM, Kaye D. UTI in the elderly. Common yet atypical. Geriatrics 1981;36:113-5.
2. Bachmann GA. Vulvovaginal complaints. In: Lobo RA, ed. Treatment of postmenopausal women: basic and clinical aspects. New York: Raven Press, 1994:137-42.
3. Molander U, Milson I, Ekelund P, Mellstrom D, Eriksson O. Effect of oral oestriol on vaginal flora and cytology and urogenital symptoms in the post menopause. Maturitas 1990;12:113-20. [Medline]
4. Cardozo LD, Kelleher CJ. Sex hormones, the menopause and urinary problems. Gynecol Endocrinol 1995;9:75-84. [Medline]
5. Raz R, Stamm WE. A controlled trial of intravaginal estriol in postmenopausal women with recurrent urinary tract infections. N Engl J Med 1993;329:753-6. [Abstract/Free Full Text]
6. Gillespie L. You don't have to live with cystitis. New York: Avon Books, 1986.