Urinary tract infection is common among the general population and it is mainly caused by bacterial pathogens. Viruses are usually considered an uncommon cause of UTI. But nowadays, various types of viruses are being found related to UTI especially in the immunocompromised group of people. In this article, we are going to discuss the causes, symptoms, and management (treatment) of viral cystitis.
What is viral cystitis?
The answer is simple. It is a viral infection of the urinary bladder. Various parts of the lower urinary tract like the bladder, prostate, seminal vesicle, etc may be infected by viruses. Different viruses like herpes simplex virus ( HSV type 1 &2), BK virus, adenovirus, cytomegalovirus, etc can cause viral cystitis.
Who is more prone to viral cystitis?
Viral infection of the urinary bladder is uncommon in immunocompetent persons. It is usually found in people with an altered or suppressed immune system. Some important examples of such conditions are mentioned below:
- Conditions with abnormal immune function
- Diabetes mellitus
- Pregnancy
- Liver cirrhosis
- Alcoholism
- Severe malnutrition
- Immunosuppressive disorders
- AIDS
- Blood cancers
- Congenital immunodeficiency disorders
- Treatment procedures causing immunosuppression
- Chemotherapy for cancer
- Bone marrow transplantation
- Solid-organ transplantation(e.g. kidney)
Have a look at this list and think about yourself. Do you have any of these risk factors? Any of these conditions will make you prone to viral infections including cystitis.
The prevalence of diabetes mellitus is increasing day by day. If you look around, you will definitely find someone with diabetes among your friends and family. One of the long-term complications of diabetes is that it will weaken your immunity.
In western society, alcoholism is a very common trend. Excessive alcohol intake will damage your liver and impair immune function. Severe malnutrition is found in third world countries especially among women and children. These conditions increase the risk of viral cystitis.
One of the well-known causes of immune dysfunction all over the world is HIV infection or AIDS. This incurable viral infection will kill your protective white blood cells( helper T-cells).
The prevalence of different kinds of blood cancers and the use of chemotherapy and bone marrow transplantation as treatment purposes is rising. All of these make the immune system too weak to kill the viruses. So, the incidence of complicated viral cystitis is increasing day by day.
What are the symptoms of viral cystitis?
Regardless of the cause, cystitis has some common clinical features. Such as,
- Fever
- Lower abdominal pain
- Pain during urination
- Frequency
- Urgency
- Haematuria or blood in the urine
In viral cystitis, these symptoms may be present as well. But in the case of immunocompetent (healthy) individuals, viral cystitis may be totally asymptomatic. In immunocompromised patients, symptoms may be altered due to an impaired immune function. But fever and malaise are commonly found.
The fever is usually of low grade unless there is a secondary bacterial infection. An important point is that the symptoms do not respond to antibiotic therapy. So, if you have the risk factors( of immunodeficiency) mentioned above and your symptoms are not improving despite treatment, think of viral UTI (cystitis).
Patients who have gone through bone marrow transplantation may experience gross haematuria due to adenovirus or BK-virus infection. This is called viral hemorrhagic cystitis. We will discuss it later.
How to diagnose viral cystitis?
The diagnosis of viral cystitis is different from other types of urinary tract infections. The presence of cystitis can be confirmed by urine microscopy and ultrasonography like other types, but it is not possible through these methods to know which type of cystitis it is.
You may find inflammatory cells and red blood cells in the urine and ultrasonography will show a thickened bladder wall. Unluckily, in mild cases, there may be no significant findings at all. Even if you find those signs, you can’t call it viral cystitis, unless the presence of viruses in urine is proved.
Viruses are too small to be detected under a light microscope. Culturing the virus requires special techniques and different types of culture media. Because viruses do not grow out of living cells. The process is complex, time-consuming, and expensive. So this method is not used in clinical laboratories.
Most laboratories use antibody-based methods( e.g. ELISA) to detect the presence of viruses in urine. The antigen or parts of the viral molecules can be detected by using a specific antibody. The presence of viral antigen in the urine indicates viral UTI.
Another method to diagnose viral cystitis is polymerase chain reaction or PCR. You must have heard this term as PCR is being widely used to diagnose coronavirus infection all over the world. It is a method to amplify the genome( DNA or RNA) of the virus and then identify it using a special technique.
The advantage is that a minute amount of viral load is enough for the diagnosis. But the problem is different viruses have different kinds of antigens or genomes. So, one type of antibody can’t detect another type of virus.
For example, in the ELISA method, if you use an antibody against BK-virus to detect it, but the sample contains adenovirus, the result will be negative. To detect adenovirus, you must use an antibody against adenovirus antigen. The same is true for the PCR technique. In PCR, specific primers are used to detect the viral genome. The primers are special nucleotide sequence which binds with specific DNA fragments. You will need different primers to identify the BK-virus or adenovirus.
So what are you thinking? There is a lot of viruses related to cystitis. And different lab techniques will be required to differentiate the types of viruses. Diagnosis of viral cystitis is a bit difficult indeed. So, what can we do to make an early diagnosis of viral cystitis?
In this case, your doctor will evaluate your condition and test for the most common organisms accordingly. For example, the BK virus is most common in immunodeficient persons, especially after organ transplantation. Gross haematuria with kidney involvement within 1 to 6 months of transplantation is common with the BK virus.
On the other hand, hemorrhagic cystitis in immunocompromised patients and within 12 months of transplantation is exclusively caused by adenovirus. Herpes simplex viruses usually cause genital ulcers. But may cause cystitis in diabetic and rheumatoid arthritis patients.
So, talk to your doctor. He will choose the most suitable test for you.
How to treat viral cystitis?
As you may know, antibiotics can’t kill viruses, they only kill bacteria. So, the conventional antibiotic regimen, no matter how powerful it is, will fail to cure your cystitis. To kill the viruses, we need anti-viral drugs like acyclovir, valacyclovir, cidofovir, etc.
But the most important part is the general management of the condition. Such as maintaining hydration, taking citrus fruits, eating healthy foods, frequent emptying of the bladder, etc. If you are immunocompetent (meaning that you are a healthy person), only general or non-pharmaceutical measures will be enough to cure viral cystitis. You just need to help your immune system by these measures.
In an immunocompetent host, viral infections are self-limiting, meaning that the immune system overcomes them with time. You will get cured even without any treatment. That’s why antiviral drugs are not usually required in most cases. But your doctor may advise antibiotics to prevent secondary bacterial infection. Because during this period bacteria may take a chance to infect you.
But, if you are suffering from complicated viral cystitis, antiviral drugs will be required. No antiviral drugs are devoid of side effects and none of those are effective against all viruses.
The choice of antiviral agent depends on the suspected virus type, disease severity, general condition, and comorbidity (if any) of the patient.
For the last few years, Cidofovir is becoming a drug of choice in viral cystitis because it is active against the most common viral pathogens that cause UTI. Talk to your doctor. He will assess your condition and advise the antiviral medications if required.
What is viral hemorrhagic cystitis?
Now we are going to discuss a complicated form of viral cystitis which is characterized by severe haematuria( passage of blood in urine).
In any form of urinary tract infection, blood may pass with urine. But usually, that is little in amount and often visible only under microscopic examination. But in the case of viral hemorrhagic cystitis, there is severe haemorrhage from the bladder wall.
It is usually seen in immunocompromised patients like blood cancer patients, following organ transplantation, and after anticancer chemotherapy or radiotherapy. Previously it was thought that hemorrhagic cystitis is related to bladder wall damage due to radiation or drugs. But recent studies established viral infection as an important aetiology.
Adenovirus type-11 is the most common culprit which can be identified by antigen detection in the urine or PCR. Among other viruses, BK-virus can also cause hemorrhagic cystitis.
Treating viral hemorrhagic cystitis is a challenge for the doctor. Intensive treatment under a urologist is required. Maintenance of blood volume and bladder irrigation is essential to reduce complications. You may need blood transfusions to compensate for the loss of blood. Antiviral drugs like cidofovir and gancyclovir can be used. But these drugs are not free from side effects. Your doctor will decide after assessing the drug safety profile and expected benefits.
What is non-bacterial cystitis?
The term non-bacterial cystitis encompasses a group of disorders where patients suffer from symptoms of cystitis, but the exact aetiology can’t be identified in routine investigations. We are going to discuss this topic as viral cystitis is one of the causes of non-bacterial cystitis.
There are both infectious and non-infectious causes of non-bacterial cystitis. For example:
Infectious causes include:
- Viral
- Fungal
- Schistosomiasis
- Mycobacterial
Non-infectious causes of non-bacterial cystitis:
- Radiation-induced
- Chemical injury
- Autoimmune
- Hypersensitivity
You already know about viral cystitis. Among other infectious causes, Mycobacterium is actually a bacteria. But the pattern of mycobacterial infection is different from other bacteria. It can’t be identified in routine urine examination, even by commonly used culture methods. So, it is classified as non-bacterial cystitis. Schistosoma is a parasite that deposits eggs in the bladder wall and produces chronic inflammation.
Radiation-induced and chemical cystitis are usually the adverse effects of radiotherapy and chemotherapy given for different cancers. Autoimmune cystitis may occur in different autoimmune diseases like SLE (Systemic lupus erythematosus). Autoimmune diseases often required immunosuppressive drugs which increase the risk of viral cystitis too.
The diagnosis of non -bacterial cystitis needs evaluation of detailed history and clinical findings. Depending on the clinical features, your doctor may advise some lab investigations to confirm the diagnosis.
Treatment varies according to the causes. If any of the infectious causes are found, alleviation of the infection will cure cystitis. In the case of non-infectious non-bacterial cystitis, a complete cure may be difficult. Because many of the underlying injurious events are sometimes unavoidable.
For example, chemotherapy is an obligatory treatment for cancer patients and autoimmune diseases like SLE can’t be cured completely. Luckily, cystitis in these conditions is usually mild and does not produce severe complications. Symptomatic treatments will provide benefits.
This is just a beautiful intermission between segments. Such views always relax me when I look at them.
Is there any relation between COVID19 and cystitis?
During this current COVID19 pandemic situation, this is one of the most common questions asked by the patients. The COVID19 usually attacks the respiratory system first and causes severe pneumonia and respiratory failure. But in severe cases, it may damage different body parts leading to multi-organ failure.
However many COVID19 patients complain about urinary symptoms like frequency, urgency, lower abdominal pain, nocturia, etc. Initially, it was being overlooked. But recent documentation and studies show that COVID19 patients may suffer from lower urinary symptoms.
This is termed COVID19-associated cystitis.
Increased levels of pro-inflammatory cytokines were detected in the urine samples of COVID19 patients. And it was found that these symptoms are not due to kidney injury or other urological problems. However, coronavirus was not found in the urine of all COVID19 positive patients.
It is not still clearly understood that how coronavirus causes cystitis. We don’t know is it due to an inflammatory response or due to direct invasion of the bladder wall by the virus. Hope future research will discover the fact soon.
we recommend checking the world health organization website for the latest accurate information about COVID-19.
That’s all about the topic now. Hope you have got the answers regarding viral cystitis. If you still have any queries, feel free to ask. We will try our best to help you. Thanks for reading with patience.