Cystitis secondary prevention

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Yazan Daaboul, M.D., Usama Talib, BSc, MD [2]


Secondary prophylaxis of cystitis is useful to prevent recurrent cystitis. It is more beneficial in patients in which cystitis is associated with sexual intercourse, a structural defect or a disease like diabetes that can lead to recurrent infections.

Secondary Prevention

Systematic reviews by the Cochrane Collaboration regarding the prevention of urinary tract infection
Intervention Number of trials Relative risk ratio
(Continuous or postcoital)
10 0.21
Intravaginal estrogen[2] 2 0.25 to 0.64
Cranberry[3] 10 0.65

The secondary prevention of cystitis includes the prophylaxis to prevent recurrent cystitis.

Antimicrobial Prophylaxis

  • Prophylaxis is required in individuals having two or more episodes in 6 months or three or more episodes in 12 months period.[4][5]
  • Prophylactic therapy using antimicrobial agents may be considered as either continuously or postcoital prophylaxis for 6 to 12 months.
  • The following regimens may be used as single doses prior to sexual activity.[6]
  • Prophylactic Therapy:
  • Preferred regimen (1): Fosfomycin tromethamine 3 g PO in a single dose
  • Preferred regimen (2): Nitrofurantoin monohydrate/macrocrystals 100 mg PO in a single dose
  • Preferred regimen (3): Trimethoprim-Sulfamethoxazole 160/800 mg PO double-strength tablet bid in a single dose
  • Preferred regimen (4): Trimethoprim 100 mg PO bid in a single dose
  • Alternative regimen (1): Ciprofloxacin 250 mg PO bid in a single dose
  • Alternative regimen (2): Levofloxacin 250 mg PO qd in a single dose
  • Alternative regimen (3): Norfloxacin 400 mg PO bid in a single dose
  • Alternative regimen (4): Gatifloxacin 200 mg PO qd in a single dose

Other therapies

For women who dring less than 1.5 liters of water per day, adding 1.5 liters of water per day can reduce cystitis[10]. The following are measures that studies suggest may reduce the incidence of urinary tract infections. These may be appropriate for people, especially women, with recurrent infections:

Selected randomized controlled trials of intravaginal estrogen for the prevention of urinary tract infection
Author, year Duration of study change in pH in treatment group Rates of recurrence Relative risk ratio
Raz, 1993[15] 8 months 5.5 to 3.6 Intravaginal estrogen cream:
Eriksen, 1999[16] 9 months 6.7 to 5.3 Intravaginal estrogen via vaginal ring:
No treatment:
Raz, 2003[17] 9 months 5.6 to 5.3 Intravaginal estrogen via pessary:
  • For post-menopausal women, a randomized controlled trial[15] and a meta-analysis[2] by the Cochrane Collaboration has shown that intravaginal estrogen cream can prevent recurrent cystitis. The relative risk of recurrence was 0.25[15] to 0.64[16] in the two trials included in the review. In the original trial in 1993, patients in the experimental group applied 0.5 mg of estriol vaginal cream nightly for two weeks followed by twice-weekly applications for eight months[15].
    • Higher dose of intravaginal estrogen cream (1 mg estriol daily for two weeks then twice a week for two additional weeks) may help premenopausal women for 11 months.[18] However, this study was uncontrolled.
    • Intravaginal estrogen via estriol pessary may not be effective.[17]
    • Intravaginal estrogen may be more effective than continuous oral antibiotics[19]. However, this is not true of the estrogen pessary due to inability to restore normal lactobacilli and lower vaginal pH.[17]


  1. 1.0 1.1 1.2 Albert X, Huertas I, Pereiró II, Sanfélix J, Gosalbes V, Perrota C (2004). "Antibiotics for preventing recurrent urinary tract infection in non-pregnant women". Cochrane Database Syst Rev (3): CD001209. doi:10.1002/14651858.CD001209.pub2. PMID 15266443.
  2. 2.0 2.1 Perrotta C, Aznar M, Mejia R, Albert X, Ng CW (2008). "Oestrogens for preventing recurrent urinary tract infection in postmenopausal women". Cochrane Database Syst Rev (2): CD005131. doi:10.1002/14651858.CD005131.pub2. PMID 18425910.
  3. 3.0 3.1 Jepson RG, Craig JC (2008). "Cranberries for preventing urinary tract infections". Cochrane Database Syst Rev (1): CD001321. doi:10.1002/14651858.CD001321.pub4. PMID 18253990.
  4. Nicolle LE, Ronald AR (1987). "Recurrent urinary tract infection in adult women: diagnosis and treatment". Infect Dis Clin North Am. 1 (4): 793–806. PMID 3333659.
  5. Ronald AR, Conway B (1988). "An approach to urinary tract infections in ambulatory women". Curr Clin Top Infect Dis. 9: 76–125. PMID 3077293.
  6. Gupta K, Hooton TM, Naber KG, Wullt B, Colgan R, Miller LG; et al. (2011). "International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases". Clin Infect Dis. 52 (5): e103–20. doi:10.1093/cid/ciq257. PMID 21292654.
  7. Melekos MD, Asbach HW, Gerharz E, Zarakovitis IE, Weingaertner K, Naber KG (1997). "Post-intercourse versus daily ciprofloxacin prophylaxis for recurrent urinary tract infections in premenopausal women". J Urol. 157 (3): 935–9. PMID 9072603.
  8. Brumfitt W, Hamilton-Miller JM (1998). "Efficacy and safety profile of long-term nitrofurantoin in urinary infections: 18 years' experience". J Antimicrob Chemother. 42 (3): 363–71. PMID 9786476.
  9. Rudenko N, Dorofeyev A (2005). "Prevention of recurrent lower urinary tract infections by long-term administration of fosfomycin trometamol. Double blind, randomized, parallel group, placebo controlled study". Arzneimittelforschung. 55 (7): 420–7. doi:10.1055/s-0031-1296881. PMID 16080282.
  10. Hooton TM, Vecchio M, Iroz A, Tack I, Dornic Q, Seksek I; et al. (2018). "Effect of Increased Daily Water Intake in Premenopausal Women With Recurrent Urinary Tract Infections: A Randomized Clinical Trial". JAMA Intern Med. 178 (11): 1509–1515. doi:10.1001/jamainternmed.2018.4204. PMID 30285042.
  11. Meyhoff H, Nordling J, Gammelgaard P, Vejlsgaard R (1981). "Does antibacterial ointment applied to urethral meatus in women prevent recurrent cystitis?". Scand J Urol Nephrol. 15 (2): 81–3. PMID 7036332.
  12. Brumfitt W, Smith GW, Hamilton-Miller JM, Gargan RA (1985). "A clinical comparison between Macrodantin and trimethoprim for prophylaxis in women with recurrent urinary infections". J. Antimicrob. Chemother. 16 (1): 111–20. PMID 4044461. Unknown parameter |month= ignored (help)
  13. Stamm WE, Counts GW, Wagner KF; et al. (1980). "Antimicrobial prophylaxis of recurrent urinary tract infections: a double-blind, placebo-controlled trial". Ann. Intern. Med. 92 (6): 770–5. PMID 6992677. Unknown parameter |month= ignored (help)
  14. Stapleton A, Latham RH, Johnson C, Stamm WE (1990). "Postcoital antimicrobial prophylaxis for recurrent urinary tract infection. A randomized, double-blind, placebo-controlled trial". JAMA. 264 (6): 703–6. PMID 2197450. Unknown parameter |month= ignored (help)
  15. 15.0 15.1 15.2 15.3 Raz R, Stamm W (1993). "A controlled trial of intravaginal estriol in postmenopausal women with recurrent urinary tract infections". N Engl J Med. 329 (11): 753–6. doi:10.1056/NEJM199309093291102. PMID 8350884.
  16. 16.0 16.1 Eriksen B (1999). "A randomized, open, parallel-group study on the preventive effect of an estradiol-releasing vaginal ring (Estring) on recurrent urinary tract infections in postmenopausal women". Am. J. Obstet. Gynecol. 180 (5): 1072–9. PMID 10329858. Unknown parameter |month= ignored (help)
  17. 17.0 17.1 17.2 Raz R, Colodner R, Rohana Y; et al. (2003). "Effectiveness of estriol-containing vaginal pessaries and nitrofurantoin macrocrystal therapy in the prevention of recurrent urinary tract infection in postmenopausal women". Clin. Infect. Dis. 36 (11): 1362–8. doi:10.1086/374341. PMID 12766829. Unknown parameter |month= ignored (help)
  18. Pinggera GM, Feuchtner G, Frauscher F; et al. (2005). "Effects of local estrogen therapy on recurrent urinary tract infections in young females under oral contraceptives". Eur. Urol. 47 (2): 243–9. doi:10.1016/j.eururo.2004.09.008. PMID 15661421. Unknown parameter |month= ignored (help)
  19. Xu R, Wu Y, Hu Y (2001). "[Prevention and treatment of recurrent urinary system infection with estrogen cream in postmenopausal women]". Zhonghua Fu Chan Ke Za Zhi (in Chinese). 36 (9): 531–3. PMID 11769665. Unknown parameter |month= ignored (help)

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