Chapter 9 Urinary system
Chronic recurrent cystitis
Case history
| Analogy: Skin of the apple |
| Analogy: Flesh of the apple | Context: Put the presenting complaint into context to understand the disease |
| AREAS OF INVESTIGATION AND EXAMPLE QUESTIONS | CLIENT RESPONSES |
| Occupational toxins and hazards | |
| What kind of chemicals do you use in your work? | Mostly hair colouring and perming solutions. I always wear gloves to protect myself from the chemicals. |
| Functional disease | |
| Were you doing any horseback or bike riding when you developed the symptoms of the stinging sensation on urination and vaginal discharge? (mechanical urethritis) | No, I am not that fit! |
| Infection and inflammation | |
|
Is the stinging and burning sensation on urination worse at the end of the urine stream? (cystitis) Are the symptoms of burning pain and increased frequency of urination pain better for a hot bath? (cystitis) Do you experience any pain or blood during or after sexual intercourse?(STD, cancer/infection) |
Marion reports a 28-day cycle with normal bleed pattern and duration. She is not currently taking the oral contraceptive pill.
Marion notices she sometimes gets increased vaginal discharge, particularly after taking antibiotics which she thinks is thrush. The pelvic discomfort usually happens when she has cystitis.
| Analogy: Core of the apple with the seed of ill health | Core: Holistic assessment to understand the client |
| AREAS OF INVESTIGATION AND EXAMPLE QUESTIONS | CLIENT RESPONSES |
| Daily activities | |
| Tell me about your daily routine. | I get up at 6.30 am, have breakfast and get to work by 7.30 am. I finish about 5.30 pm or 6 pm and then go home. Dinner is about 7 pm and then I either go out with Sean or we stay home. I usually go to bed by 11 pm. |
| Occupation | |
| Do you enjoy your work? | I love it, although standing on my feet all day can be tiring. |
| Family and friends Do you have much contact with family and friends? |
Not as much as I did before I started going out with Sean. I try to see my parents every couple of weeks and sometimes Sean and I go out with friends. |
| Education and learning Do you understand why your cystitis keeps returning? |
Not really, but I think it must have something to do with sex. |
| Action needed to heal | |
| What do you think you need to do to get better? | Hopefully not stop having sex! Maybe I need to go to the toilet more during the day and drink more water. |
TABLE 9.4 MARION’S SIGNS AND SYMPTOMS [1–3, 13]
| Pulse | 85 bpm |
| Blood pressure | 120/80 |
| Temperature | 38°C |
| Respiratory rate | 14 resp/min |
| Body mass index | 22 |
| Waist circumference | 77 cm |
| Face | Pale |
| Urinalysis | Cloudy colour; foul odour; alkaline pH; leukocytes detected; microscopic blood detected; positive nitrites; increased specific gravity |
TABLE 9.5 RESULTS OF MEDICAL INVESTIGATIONS
| Marion has not been consistent with contraception recently and had these tests | |
| TEST | RESULT |
| Home urine HGC pregnancy test | Negative |
| Follow up blood HGC pregnancy test | Negative |
TABLE 9.6 UNLIKELY DIAGNOSTIC CONSIDERATIONS [3–8]
| CONDITIONS AND CAUSES | WHY UNLIKELY |
|---|---|
| CANCER AND HEART DISEASE | |
| Congestive heart failure | No protein in Marion’s urine; she does not have high blood pressure, extreme tachycardia or shortness of breath |
| TRAUMA AND PRE-EXISTING ILLNESS | |
| Renal failure | No protein in Marion’s urine |
| OBSTRUCTION AND FOREIGN BODY | |
| Renal calculi: primary hyperoxaluria (oxalate stones); hyperuricaemia and hyperuriosuria (uric acid stones); cysteinuria (results in cystine stones) | Usually presents with acidic urine |
| FUNCTIONAL DISEASE | |
| Female urethral syndrome: irritative bladder symptoms in absence of urologic findings; pain in the urethra; can be a component of interstitial cystitis; pain on urination, increased frequency, pelvic pain, sexually active [43] | Onset of symptoms occurred more than 2–7 days ago; usually does not present with blood in the urine; no bacteria usually detected by urinalysis; level of urinary urgency not noted yet in Marion’s history; usually no fever presents; does not necessarily have nocturia as a symptom |
| INFECTION AND INFLAMMATION | |
| Trigonitis: inflammation of the mouth of bladder; increased urination, pelvic pain | Usually normal urinalysis results |
| Glomerulonephritis (advanced kidney infection) | Would show protein in urine and possible macrocytic blood; low specific gravity |
| ENDOCRINE/REPRODUCTIVE | |
| Causal factor: Ectopic pregnancy | Blood and urine HGC tests negative |
| Causal factor: Pregnancy | Blood and urine HGC tests negative |
| Diabetes: nocturia | No glucose in urinalysis |
Case analysis
| Not ruled out by tests/investigations already done [2–9, 44, 47] | ||
| CONDITIONS AND CAUSES | WHY POSSIBLE | WHY UNLIKELY |
| CANCER AND HEART DISEASE | ||
| Bladder carcinoma | Blood in urine; pelvic discomfort; increased frequency of urination (need to determine if the volume is decreased) | Pain on urination is not a common symptom |
| Cervical cancer | Vaginal discharge, symptoms worse with sexual intercourse | Need to determine if pain/blood is experienced on intercourse |
| TRAUMA AND PRE-EXISTING ILLNESS | ||
| Causal factor: Mechanical urethritis/honeymoon cystitis/trauma | Pain on urination, increased frequency; sexually active | Urine is usually sterile and urinalysis does not indicate the presence of bacteria or other abnormalities |
| OBSTRUCTION AND FOREIGN BODY | ||
TABLE 9.8 DECISION TABLE FOR REFERRAL [1, 3–6, 8, 12]
| COMPLAINT | CONTEXT | CORE |
|---|---|---|
| Referral for presenting complaint | Referral for all associated physical, dietary and lifestyle concerns | Referral for contributing emotional, mental, spiritual, metaphysical, lifestyle and constitutional factors |
| REFERRAL FLAGS | REFERRAL FLAGS | REFERRAL FLAGS |
| ISSUES OF SIGNIFICANCE | ISSUES OF SIGNIFICANCE | ISSUES OF SIGNIFICANCE |
| Nil | Nil | |
| REFERRAL | REFERRAL | REFERRAL |
TABLE 9.9 FURTHER INVESTIGATIONS THAT MAY BE NECESSARY [1–8, 42, 45]
| TEST/INVESTIGATION | REASON FOR TEST/INVESTIGATION |
|---|---|
| FIRST-LINE INVESTIGATIONS: | |
| Urinalysis – repeat test [42, 46, 49–51] | UTI, kidney infection, stones, diabetes, blood |
| Abdominal examination | Suprapubic tenderness on palpation and percussion |
| Pelvic examination | Appearance of labia, vulva, entire vagina, cervix, vaginal discharge should be inspected; cervical manipulation for masses or points of tenderness; scabies, contact dermatitis; bulky uterus indicates uterine cancer; vulval inflammation more often in Candida than in bacterial vaginosis; vaginal discharge visible with vaginitis |
| Pap smear (cervical smear) [42, 46] | Check for signs of STIs |
| Full blood count | Check for infections and/or anaemia |
| ESR/CRP blood test | Check for inflammation, tumour detection, bacteria and viral detection |
| Urea, creatinine and electrolytes (sodium, potassium, chloride, bicarbonate) blood test | Gives an indicator of renal excretory function as urea and blood creatinine is excreted entirely by the kidneys; this will show in renal abnormalities and diabetes |
| Gram stain and culture of urethral discharge [48] | Chlamydia and gonorrhoea |
| Potassium hyroxide/saline wet mount | Candida albicans, Trichomonas |
| Urine microscopy | To eliminate the possibility of renal disease; will give information about specific white blood cells (indicates an inflammatory reaction in urinary tract), red blood cells, casts (clumps of materials or cells and can indicate renal disease) and crystals (indicate renal stone formation is imminent) |
| IF NECESSARY: | |
| Calcium, phosphate and serum alkaline phosphatase | Metabolic bone disease and renal calculi due to calcium excess, renal infarction; calcium excretion can be monitored |
| TSH (thyroid-stimulating hormone) suppressed in hyperthyroidism; thyroid-specific antibodies, to confirm auto-immune cause of hyperthyroidism (Graves’) | |
| Estimated glomerular filtration rate (eGFR) | Kidney function |
| Renal ultrasound/x-ray | If renal disease is suspected; ultrasound/x-ray will give information about renal size, failure, stones, mass formation, lesions |
| Pelvic x-ray | Osteoporosis |
| Cystoscopy: bladder | Direct visualisation of urethra and bladder; check for interstitial cystitis; evaluate blood in urine, bladder cancer, trigonitis |
| HLA-B27 antigen: human lymphocyte antigen B-27 | Reiter’s syndrome |
Confirmed diagnosis
Prescribed medication
TABLE 9.10 DECISION TABLE FOR TREATMENT (ONCE DIAGNOSIS IS CONFIRMED)
• Lifestyle recommendations to help prevent a recurrence of symptoms and improve urinary hygiene
• Physical therapy recommendations to help prevent a recurrence of symptoms
• Dietary recommendations to improve general health and immunity
• Dietary supplements to boost immunity, support bowel flora and prevent a recurrence of cystitis
Treatment aims
• Prevent or reduce frequency of UTIs by reducing urinary stasis [16] and increasing urine flow to aid expulsion of bacteria [14, 16, 18].
• Enhance Marion’s immune function [14, 18].
• Improve Marion’s urinary hygiene [16, 17].
• Adjust Marion’s urinary pH to assist in preventing growth of pathogenic bacteria [14, 15].
• Inhibit adherence of pathogenic bacteria to the urinary bladder wall [14].
• Deal with underlying causative or aggravating factors such as lifestyle and diet [14, 18].
Lifestyle alterations/considerations
• Marion can improve urinary hygiene by emptying her bladder completely before going to bed [16] and by drinking at least 2½ L of water daily [14, 16, 17].
• Encourage Marion to should minimise exposure of the urethra to E. coli by ensuring she wipes from front to back when she has a bowel motion and wearing cotton underpants rather than nylon underpants and/or pantyhose [17].
• Encourage Marion to empty her bladder as soon as she feels the urge [17].
• Marion’s partner should wear condoms during intercourse [17] and avoid the use of spermicides [16].
• Encourage Marion to urinate after intercourse [14, 17] and can wash her labia and urethra with a strong tea of golden seal (2 tsp/cup) both before and after intercourse [14].
• During acute episodes of cystitis Marion can reduce the sensation of burning and stinging by pouring warm water over her labia and urethral opening while urinating to dilute the urine.
• Weekly vaginal insertion of a pessary containing Lactobacillus rhamnosus and Lactobacillus gasseri may be helpful to prevent recurrence [16, 28].
Dietary suggestions
• Encourage Marion to drink at least 2½ litres of water each day [14–18].
• Drinking 250 mL of unsweetened cranberry or fresh berry juice [14, 15, 33] and eating a cup of cranberries daily can help prevent recurrence [17, 21, 33].
• Barley water (30 g barley in 1 L of water, reduced by boiling it down to 500 mL) can help alleviate symptoms [16].
• Encourage Marion to avoid refined carbohydrates and simple sugars [14].
• Identify and manage food allergies or intolerances [14].
• Encourage Marion to consume of garlic and onions [14] and eat unsweetened yoghurt with live lactobacilli several times per week [14, 33].
• Encourage Marion to have an antioxidant and flavanoid-rich whole-food diet [30, 31].
Physical treatment suggestions
• Hydrotherapy: a hot shallow bath several times a day or hot foot baths in the acute stage [36]. Apply a hot Epsom salt compress on the bladder, covered with wool and kept warm by a heating pad/hot water bottle [37]. Alternate hot compress with neutral sitz bath [35, 37]. Note: ice packs or ice compresses are contraindicated over the bladder in cystitis.
• Myofascial trigger point therapy on pelvic floor trigger points may help alleviate symptoms of urgency and frequency [26].
• Acupuncture may help reduce the severity and frequency of symptoms [27].
• Marion may benefit from massage to help reduce stress [38, 39].
| HERB | FORMULA | RATIONALE |
|---|---|---|
Cranberry
Vaccinium oxycoccus, Vaccinium macrocarpon
Cranberry is bacteriostatic [21]; antioxidant [21]; prevents bacterial adhesion [15, 23, 25] and deodorises urine [16]
