The Encyclopedia of Natural Medicine, 3rd Ed.

Cystitis and Interstitial Cystitis/Painful Bladder

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• One or more of the following signs or symptoms:

  images Increased urinary frequency, urgency, nocturia (waking up to urinate at night)

  images Burning pain on urination

  images Turbid, foul-smelling, or dark urine

  images Lower abdominal pain

  images Chronic pelvic pain

  images A persistent, urgent need to urinate

  images Pain during sexual intercourse

Irritation of the bladder (cystitis) is a very common condition, especially in women. It is estimated that 10 to 20% of all women have urinary tract discomfort at least once a year, 37.5% of women with no history of urinary tract infection (UTI) will have one within 10 years, and 2% to 4% of apparently healthy women have elevated levels of bacteria in their urine, indicative of an unrecognized UTI. Women with a history of recurrent UTIs will typically have an episode at least once a year. Recurrent bladder infections can be a significant problem for some women because 55% will eventually involve the kidneys, and recurrent kidney infection can have serious consequences, including abscess formation, chronic progressive kidney damage, and kidney failure.

UTIs are much less common in males than females, except infants, and in general indicate an anatomical abnormality, a prostate infection, or rectal intercourse.

Chronic interstitial cystitis or painful bladder syndrome (IC/PBS) is a persistent form of bladder irritation not due to infection. In addition to the general measures given below, the therapeutic focus is on enhancing the integrity of the tissue (interstitium) along with the lining of the bladder wall. The symptoms of IC/PBS can overlap with such conditions as endometriosis, recurrent urinary tract infection, chronic pelvic pain, overactive bladder, and vulvodynia. Studies have indicated that interstitial cystitis affects 52 to 67 per 100,000 people in the United States.1 Some investigators believe these numbers are vastly underestimated owing to lack of proper diagnosis.

Diagnostic Considerations

The diagnosis is usually made according to signs and symptoms and urinary findings. Microscopic examination of the infected urine shows high levels of white blood cells (WBCs) and bacteria. Culturing the urine determines the quantity and type of bacteria involved. The bacteria Escherichia coli is by far the most common. The presence of fever, chills, and low back pain can indicate involvement of the kidneys.2

IC/PBS can also be difficult to diagnose, as the symptoms overlap with a variety of other disorders, including endometriosis, UTI, chronic pelvic pain, overactive bladder, and vulvodynia. Because there is no definitive diagnostic test, IC/PBS remains a diagnosis of exclusion. The presence of additional symptoms caused by other conditions can confuse the diagnosis even further. Patients may not receive an accurate diagnosis for years. The average time between the development of IC/PBS symptoms and the diagnosis is approximately five years.3

Therapeutic Considerations

Although most bladder infections are not serious, it is important that you be properly diagnosed, treated, and monitored. If you have symptoms suggestive of a bladder infection, consult a physician. That is especially true if you are also experiencing fever, abdominal or flank pain, or nausea and vomiting. If a urine culture indicates the presence of bacteria, it is appropriate to follow up with another culture 7 to 14 days after treatment is started to ensure it has been resolved. Most physicians will want to prescribe antibiotics. However, please discuss your desire to utilize a more natural approach. Notify your physician if any change occurs in your condition (fever, more painful urination, low back pain, etc.).

For most bladder infections, especially those that are chronic or recurrent, the best treatment appears to be the natural approach. There is a growing concern that antibiotic therapy actually promotes recurrent bladder infection by disturbing the bacterial flora of the vagina and by giving rise to antibiotic-resistant strains of E. coli. One of the body’s most important defenses against bacterial colonization of the bladder is a protective shield of healthful bacteria that line and protect the external portion of the urethra. When antibiotics are used, this normal protective shield can be stripped away or replaced by less effective organisms.

If a woman tends to suffer from recurrent bladder infections, or if antibiotics have been used, it is appropriate to reintroduce friendly bacteria into the vagina. The best way to do this is to use commercially available Lactobacillus acidophilus products. Use a product that is a capsule or tablet, and simply place one or two in the vagina before going to bed, every other night for two weeks. In addition, oral supplementation with a probiotic is recommended (5 billion to 10 billion live bacteria per day).

The primary goal in the natural approach to treating infectious cystitis is enhancing normal host protective measures against UTI. Specifically, this refers to enhancing the flow of urine by achieving and maintaining proper hydration, promoting a pH that inhibits the growth of infectious organisms, preventing bacterial adherence to the endothelial cells of the bladder, and enhancing the immune system. In addition, several botanical medicines with antimicrobial activity can be employed.

In IC/PCP the therapeutic focus is also on enhancing the integrity of the tissue along with the lining of the bladder wall—the interstitial tissue. Eliminating food allergens appears to be a valid goal, as food allergies have been shown to produce cystitis in some patients. Repeated ingestion of a food allergen could easily explain the chronic nature of interstitial cystitis. In addition, certain foods are notorious for producing symptoms.4 For example, one study found that 90% of IC patients experience an increase in symptoms when they consume certain foods and beverages, especially coffee, tea, soda, alcoholic beverages, citrus fruits and juices, artificial sweeteners, and hot peppers.5

The herbs gotu kola (Centella asiatica) and aloe vera appear to address some of the other features of chronic IC. Specifically, gotu kola extracts have been shown to heal ulcerations of the bladder and to improve the integrity of the connective tissue that lines the bladder wall.6,7 Aloe vera may also be of benefit.

Pentosan polysulfate sodium (PPS), sold under the name Elmiron, is an FDA-approved drug that is thought to replenish the defective bladder lining. It is very similar to natural hyaluronic acid (HA), a key component of the interstitial tissue. Supplementation with HA (100 to 200 mg per day) may be of similar value, as it has been shown to improve the connective tissue matrix of the interstitium of the skin.

Increasing Urine Flow

Increasing urine flow can be easily achieved by increasing the amount of liquids consumed. Ideally, the liquids should be in the form of water, herbal teas, and fresh fruit and vegetable juices diluted with at least an equal amount of water. Drink at least 64 fl oz from this group, with at least half of this amount being water. Avoid soft drinks, concentrated fruit drinks, coffee, and alcoholic beverages.

Acidify or Alkalinize?

Although many practitioners believe acidifying the urine is the best approach in addressing cystitis, several arguments can be made for alkalinizing the urine. First, it is often difficult to acidify the urine. Many popular methods of attempting to acidify the urine, such as vitamin C supplementation and cranberry juice, have little effect on pH at commonly prescribed doses.

Alkalinizing the urine is easily achieved with the use of citrate salts (e.g., potassium citrate, sodium citrate). These salts are rapidly absorbed and metabolized without affecting gastric pH or producing a laxative effect. They are excreted partly as carbonate, thus raising the pH of the urine.

Potassium citrate and sodium citrate have long been employed in the treatment of lower UTIs. They are often used for temporary relief until the results of a urine culture are available. Some clinical studies support this practice. For example, in one study, women presenting with symptoms of a UTI were given 4 g sodium citrate every 8 hours for 48 hours.8 Of the 64 women evaluated, 80% of the women had relief of symptoms, 12% had deterioration of symptoms, and 91.8% of the women rated the treatment as acceptable. Of the 64 women, 19 were shown to have positive bacterial cultures. There was more variation in response to treatment in the group of women with proven bacterial infection, with those having symptoms of urethral pain (7 of 10) and dysuria (13 of 18) improving more than those with symptoms of frequency (9 of 17) and urgency (6 of 13). These results were similar to those of a previous study that demonstrated significant symptomatic relief in 80% of the 159 women who did not have bacteria in their urine.9

One more possible advantage to alkalizing rather than acidifying the urine is that many herbs used to treat UTIs, such as Hydrastis canadensis and Arctostaphylos uva ursi, contain antibacterial components that work most effectively in an alkaline environment.

Botanical Medicines

Cranberry

Based on extensive experimental research and positive clinical results, cranberry (Vaccinium macrocarpon) has gained a lot of attention as a possible alternative to antibiotics in the prevention and treatment of UTIs.10 For many years it was thought that the action of cranberry juice was due to acidifying the urine and to the antibacterial effects of a cranberry component, hippuric acid. However, these are probably not the major mechanisms of action. Rather than its action as an antibiotic or acidifying the urine, the most likely explanation for cranberry’s beneficial effects are that components known as proanthocyanidins interfere with the adherence of bacteria to the cells that line the urinary tract. In order to cause an infection in the urinary tract, bacteria must first attach to these cells. So when the bacteria are blocked from attaching, an infection can be prevented. And, in the case of an active infection, the proanthocyanidins can make it too “slippery” for the bacteria to maintain their hold. In the studies looking at cranberry and bacterial adherence, cranberry was found to decrease adherence in more than 60% of the strains of bacteria tested.1114

The scientific support for the positive effect of cranberry preparations in the prevention and treatment of UTIs is somewhat inconsistent.10 However, that may be because it does not prevent adhesion of all bacteria to the bladder cells. So while many women (and men) with a history of UTIs will gain benefit from cranberry, some will not. The effectiveness of cranberry may be enhanced by using well-defined preparations standardized for proanthocyanidin content rather than commercial cranberry juice. Most cranberry juices on the market contain one-third cranberry juice mixed with water and sugar. Since sugar has such a detrimental effect on the immune system (see the chapter “Immune System Support”), use of sweetened cranberry juice cannot be recommended. Fresh cranberry juice (sweetened with blueberry juice) or blueberry juice is preferred. For tough cases, we recommend using cranberry extracts instead.

One study did compare the efficacy and cost of taking a cranberry extract (CranMax) in tablet form vs. cranberry juice in the prevention of UTI in 150 women over the course of one year. Both cranberry juice and cranberry tablets significantly decreased the number of patients experiencing at least one symptomatic infection per year (20% and 18%, respectively) compared with a placebo (32%). The average annual cost of cranberry tablets was $624, whereas the juice cost $1,400.15

To illustrate just how effective cranberry juice can be in preventing a bladder infection, in one study 300 ml (about 8 fl oz) of cranberry juice per day dramatically decreased the level of bacteria in the urine and the frequency of recurrence of infection in 153 women (average age 78.5).16 However, in another study, involving 319 college women, no significant effect was seen. In this double-blind study participants were followed up until a second UTI or for 6 months, whichever came first. The study concluded that 8 fl oz low-calorie cranberry juice twice per day gave no greater protection against the risk of recurring UTI among college-age women compared with a placebo juice.17Lack of active compounds is probably not the reason the study failed, as the juice used in the study was standardized to provide 112 mg per day of proanthocyanidins. The possible explanation again is that since cranberry proanthocyanidins do not prevent the adhesion of all types of bacteria to the urinary tract lining, cranberry may not be effective in all cases.

The bottom line is that cranberry is very safe and can be quite effective, so it is worth using. One sure benefit is that cranberry ingestion can significantly reduce strong urinary odor—a common problem in elderly people, especially those in nursing homes or assisted living facilities.18,19

Uva Ursi

Uva ursi (upland cranberry or bearberry, Arctostaphylos uva ursi) is another popular herbal medicine for UTIs. It has been used by women for centuries, with the first recorded use in the thirteenth century. It exerts urinary antiseptic activity by means of its component arbutin, which typically makes up 6.3 to 9.6% of the leaves.20 Once ingested, arbutin is broken down into hydroquinone and excreted into the urine. It is the hydroquinone that prevents bacterial growth, and it is most effective in an alkaline urine. The preventive effect of a standardized uva ursi extract on recurrent cystitis was evaluated in a double-blind study of 57 women.21 At the end of one year, 5 of 27 women in the placebo group had a recurrence, while none of the 30 women receiving the uva ursi extract had a recurrence. No side effects were reported in either group. These impressive results indicate that regular use of uva ursi, like cranberry, may prevent bladder infections. Uva ursi has also been shown to be helpful in increasing the susceptibility of antibiotic-resistant bacteria to antibiotics.

Care must be taken to avoid excessive dosages of uva ursias little as 15 g (0.5 oz) of the dried leaves has been shown to produce toxicity in susceptible individuals. Early signs of toxicity include ringing in the ears, nausea, and vomiting.22

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QUICK REVIEW

• If you have symptoms suggestive of a bladder infection, consult a physician.

• There is a growing concern that antibiotic therapy actually promotes recurrent bladder infections.

• The primary goal in the natural approach to treating infectious cystitis is enhancing normal host protective measures against urinary tract infection.

• Drink at least 64 fl oz water per day.

• Alkalinize the urine with citrate.

• Cranberry juice has been shown to be quite effective in several clinical studies.

• Uva ursi is effective in the acute treatment of bladder infections as well as a preventive measure.

• In interstitial cystitis the therapeutic focus is on enhancing the integrity of the tissue along with the lining of the bladder wall.

• Gotu kola extracts have been shown to heal ulcerations of the bladder and to improve the integrity of the bladder lining.

Goldenseal

Goldenseal (Hydrastis canadensis) is one of the most effective of the herbal antimicrobial agents. Its long history of use by herbalists and naturopathic physicians for the treatment of infections is well documented in the scientific literature. Of particular importance here is its efficacy against E. coliProteus species, Klebsiella species, Staphylococcus spp., Enterobacter aerogenes (requires large dosage), and Pseudomonas species.22,23 Its active ingredient, berberine, like hydroquinone from uva ursi, works better in alkaline urine.

Immune Support

See the chapter “Immune System Support,” for a complete discussion on how to optimize the functioning of your immune system.

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TREATMENT SUMMARY

Although most cases of cystitis are relatively benign, it is extremely important to seek medical care for proper diagnosis and monitoring. Owing to the possibility of a kidney infection, it is imperative to consult a physician if there is fever, low back pain, nausea, or vomiting. Kidney infections (e.g., pyelonephritis) require immediate antibiotic therapy and sometimes hospitalization.

Although the occasional acute bladder infection is easily treated, dealing with chronic cystitis can be a challenge. Long-term success requires determining the underlying cause, such as loss of the probiotic urethral shield, structural abnormalities, excessive sugar consumption, food allergies, nutritional deficiencies, or chronic vaginitis.

General Recommendations

• Drink large quantities of fluids (at least 64 fl oz per day), including at least 16 fl oz unsweetened cranberry juice or 8 fl oz blueberry juice per day. Or, take a clinically proven cranberry extract.

• Urinate after intercourse.

Diet

• Follow the guidelines in the chapter “A Health-Promoting Diet.”

• Avoid all simple sugars, refined carbohydrates, full-strength fruit juice (diluted fruit juice is acceptable), and food allergens.

Nutritional Supplements

• A high-potency multiple vitamin and mineral formula as described in the chapter “Supplementary Measures”

• Key individual nutrients:

  images Vitamin C: 500 to 1,000 mg per day

  images Magnesium (bound to aspartate, citrate, fumarate, malate, or succinate): 200 to 300 mg three times per day

  images Vitamin D3: 2,000 to 4,000 IU per day (ideally, measure blood levels and adjust dosage accordingly)

• Fish oils: 1,000 mg EPA + DHA per day

• One of the following:

  images Grape seed extract (>95% procyanidolic oligomers): 100 to 300 mg per day

  images Pine bark extract (>95% procyanidolic oligomers): 100 to 300 mg per day

• During acute cystitis:

  images Citrate: dosage can be based on the level of elemental mineral such as potassium, magnesium, or calcium; recommendation is 125 to 250 mg three to four times per day

  images Vitamin C: 500 mg every two hours

  images Zinc: 30 mg per day

Botanical Medicines

For symptoms associated with a bladder infection, choose one of the following; dosages can be taken three times per day with a large glass of water. (Neither uva ursi nor goldenseal is recommended during pregnancy.)

• Uva ursi (Arctostaphylos uva ursi):

  images Dried leaves or as a tea: 1.5 to 4.0 g (1 to 2 tsp)

  images Freeze-dried leaves: 500 to 1,000 mg

  images Tincture (1:5): 4 to 6 ml (1 to 1.5 tsp)

  images Fluid extract (1:1): 0.5 to 2.0 ml (1/4 to 1/2 tsp)

  images Powdered solid extract (10% arbutin): 250 to 500 mg

• Goldenseal (Hydrastis canadensis):

  images Dried root (or as tea): 1 to 2 g

  images Freeze-dried root: 500 to 1,000 mg

  images Tincture (1:5): 4 to 6 ml (1 to 1.5 tsp)

  images Fluid extract (1:1): 0.5 to 2.0 ml (1/4 to 1/2 tsp)

  images Powdered solid extract (8% alkaloids): 250 to 500 mg

For symptoms associated more with nonbacterial interstitial cystitis or painful bladder, one of the following:

• Gotu kola (Centella asiatica): 60 to 120 mg per day of an extract standardized to contain 40% asiaticoside, 29 to 30% asiatic acid, 29 to 30% madecassic acid, and 1 to 2% madecassoside

• Aloe vera juice: up to 32 fl oz per day as a beverage