Sex-induced cystitis: An epidemiological study in female populations of three district of rural Thebes, Greece

G Georgakopoulos; K Stamatiou; G Ilias; V Karanasiou; M Christakis; M Matsagoura; V Papadimitriou; J Heretis; G Daskalopoulos

doi:10.4103/0253-7184.39009

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ORIGINAL ARTICLE

Year : 2007 \| Volume : 28 \| Issue : 2 \| Page : 79-82

Sex-induced cystitis: An epidemiological study in female populations of three district of rural Thebes, Greece

G Georgakopoulos¹, K Stamatiou¹, G Ilias¹, V Karanasiou¹, M Christakis¹, M Matsagoura¹, V Papadimitriou², J Heretis², G Daskalopoulos²
¹ Urology & Surgery Department, General Hospital of Thebes, Thebes, Greece
² Urology Department, University Hospital of Heraclion, Crete, Greece

Correspondence Address:
G Georgakopoulos
General Hospital of Thebes, Koumerki Point, Thebes
Greece

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/0253-7184.39009

Abstract

The aim of our study was to examine the frequency and characteristics of recurrent lower urinary tract infections (LUTIs) due to sexual intercourse (sex-induced cystitis - SIC) in female population of three districts of the rural Thebes targeted to investigate the influence of age and culture on its epidemiology. We examined 432 women between 15 and 65 years of age in female populations of three district of the rural areas of Thebes between May 2006 and January 2007 with symptoms of recurrent LUTIs. Women who reported a sexual intercourse 24-72 h before the onset of symptoms were evaluated as possible cases of SIC. Urinalysis was done during therapy, 10 days after completion of treatment and within 24 weeks after the initial therapy. Women with a positive urine culture were evaluated by an ultrasound examination of their urinary tract and those having abnormality of urinary tract were excluded from the study, while the remaining completed a simple questionnaire querying on several risk factors that could be possibly associated with SIC. The SIC, accounted for almost 40% of the recurrent cases, was the most frequent in non-menopausal women of age between 23-27 years and 40-47 years and affected almost equally women of all three groups (local, immigrants and rom). There were no statistically significant differences between the cultural groups in the frequency rate of SIC; however, the immigrant women study group showed a slightly lower frequency of SIC when compared to the other groups. Frequency of SIC was slightly higher during summer in all populations studied. The SIC being a neglected and often misdiagnosed disorder, represents a challenging and significant healthcare issue affecting mainly young women of lower socioeconomic groups independent of the ethnicity, behavioural and ethical issues.

Keywords: Recurrence, sex-induced cystitis, socioeconomic status, urinary tract infection

How to cite this article:
Georgakopoulos G, Stamatiou K, Ilias G, Karanasiou V, Christakis M, Matsagoura M, Papadimitriou V, Heretis J, Daskalopoulos G. Sex-induced cystitis: An epidemiological study in female populations of three district of rural Thebes, Greece. Indian J Sex Transm Dis 2007;28:79-82

How to cite this URL:
Georgakopoulos G, Stamatiou K, Ilias G, Karanasiou V, Christakis M, Matsagoura M, Papadimitriou V, Heretis J, Daskalopoulos G. Sex-induced cystitis: An epidemiological study in female populations of three district of rural Thebes, Greece. Indian J Sex Transm Dis [serial online] 2007 [cited 2023 Nov 28];28:79-82. Available from: https://ijstd.org/text.asp?2007/28/2/79/39009

Introduction

Lower urinary tract infection (LUTI) is the most common bacterial infection, with half of all women experiencing at least one LUTI in their lifetime.^[1],[2] Between 10 and 20% of them experience a recurrent uncomplicated LUTI.^[3] Risk factors for recurrence are both genetic and behavioural. Many of these recurrent cases are facilitated by sexual intercourse (sex-induced infections). General consideration about sex-induced infections is that they are caused by several pathogens, are recurrent (while caused by a new pathogen each time) and sometimes occur at short intervals. The exact rate of recurrent infections associated with sexual intercourse (sex-induced cystitis, SIC) is not known. Furthermore, it is not known if women having recurrent sex-induced infections represent a separate population, compared to those who present an isolated infection. As cases of fast relapse are not infrequent (since cultures of the urine are not usually obtained during treatment of simple uncomplicated LUTIs), they represent a problem of differential diagnosis between bacterial persistence and re-infection from another pathogen. In addition, because of the high frequency of recurrent LUTIs and of the additional laboratory tests and therapy required to treat them, they represent a significant cost burden to healthcare system.

Materials and Methods

Study was carried out to detect the frequency and to investigate the impact of possible cultural risk factors for SIC in cultural female populations of three districts in rural area of Thebes in the Viotia region (Greece). We examined 432 women (153 local, 135 rom and 144 immigrant women) who were referred to our institution between May 2006 and January 2007, with symptoms of LUTI. Women receiving antimicrobial treatment (on a regular or temporary basis) for any medical reason were excluded. In addition, cases of neurogenic bladder dysfunction, fistula, manipulation of the urinary tract and/or diseases such as diabetes mellitus, as well as women under immune suppressing therapies, were excluded. All patients were between 15 and 65 years of age and were divided in three study groups [local, rom (term Rom is officially used for Romani people, a distinct ethnic and cultural group) and immigrant]. Women of foreign nationalities were considered as immigrants.

Participants were enrolled if they had a previous history of symptomatic cystitis in past 6 months with urinalysis positive for pyuria and/or two or more signs or symptoms indicative of an acute uncomplicated LUTI (e.g., dysuria, frequency and urgency for urination, suprapubic pain, etc.), with an onset of symptoms within the last 72 h. A clean-catch midstream urine specimen was obtained for microscopic examination and culture for common and non-common pathogens. Cultures were performed on Mc Conkey and B agar culture medium. A positive culture was defined as isolation of an uropathogen in quantities >10⁵ colony-forming units (CFU)/mL urine. All infected patients received antimicrobial therapy.

Women who had active sexual life and reported a sexual intercourse 24-72 h before the onset of symptoms were evaluated as possible cases of SIC. Urinalysis was done during therapy, 10 days after completion of treatment and within 24 weeks after the initial therapy. An isolation of a uropathogen in quantities >10⁵ CFU/mL urine within 24 weeks after the initial therapy in patients with a negative urinalysis during therapy and 10 days after completion of treatment were considered as recurrent LUTI and a possible SIC case. Women with a positive culture were further subjected to ultrasound examination of their urinary tract. Women with abnormalities of urinary tract (dilatation of uretero-pelvic junction, renal calculi, etc.) were excluded from the study. The remaining patients completed a simple questionnaire querying several risk factors that could be possibly associated with SIC.

Patients were asked to fill the study's questionnaire. Patients were asked to report the quality, intensity and duration of symptoms, namely, vaginal discharge, pain during urination, frequent urination, urgency to urinate, flank pain, incontinence and feeling of incomplete urination. Questions gathering information on several factors considered to be related with an increased risk of SIC such as the frequency of sexual intercourse per week, marital status, stable sexual partner and the use of non-pharmaceutical contraceptive methods were also asked.

For statistical analysis, three study groups were divided according to age (post- and pre-menopausal status). Statistical analysis was performed using the SPSS programme. The associations were subjected to parametric and non-parametric statistical methods. The research protocol was approved by the locally appointed ethics committee and informed consent of all subjects was taken.

Results

Seven out of the 432 women who initially presented with LUTI were excluded from the study since LUTI was not confirmed. A total of 145 out of the remaining 425 women did not report a sexual intercourse 24-72 h before the onset of symptoms and were not evaluated as possible cases of SIC. A total of 44 patients with a negative urinalysis during therapy and 10 days after completion of treatment had a new positive urine culture within 24 weeks after initial therapy [Table - 1].

According to the aforementioned data, SIC was found responsible for LUTI (after adjustment for all confounding factors mentioned in the "Material and Methods" section), in 12% of the rom study group, in 11.2% of the local study group and in 7.8% of the immigrant study group.

Among 425 patients, the signs and symptoms of SIC episodes were identical in quality, intensity and duration with those of common LUTI. More precisely, each episode of SIC was associated with 3-6 days of symptoms and 1-3 days of restricted activity. Most commonly reported symptoms were frequency and urgency of urination in both isolated infections and sex-induced re-infections. Other commonly documented symptoms were pain during urination and inability to completely empty the bladder. Most women with SIC-reported vaginal discharge before the onset of other symptoms. Escherichia ^{More Details} coli was the most common cause of SIC accounting for 94.5% (173) cases. Other gram-negative bacteria responsible for the remaining infections were Proteus mirabilis (3.8%) and Staphylococcus saprophyticus (1.6%). An age-specific prevalence in the frequency of SIC was observed: it is more frequent among women of age group 20-30. A worth-mentioning finding was that among women with confirmed SIC, the prior history of more than five LUTIs was found proportional to the high frequency of sexual intercourse (more than four sexual intercourses per week) in all study populations ( P < 0.05).

Immigrant and local patients reported a systematic use of condoms and diaphragms while the use of contraceptive methods was minimal in the rom group. According to these findings, the use of contraceptive methods does not seem likely to add on SIC risk ( P > 0.05). Frequency of SIC was slightly higher during the summer months, but of no statistical significance ( P > 0.05). The SIC was common among unmarried women in local and immigrant subjects, while almost all affected rom women were married-though in younger ages.

Discussion

Although sexual intercourse has been established as an important risk factor for the uncomplicated urinary tract infections (LUTI) in women,^[2],[3] the exact rate and the characteristics of recurrent LUTI's due to sexual intercourse and its patient burden is unknown. SIC affects several asects of patients' quality of life and has a negative impact on daily activities.^[4] The present study is aimed at imposing further issues regarding symptom burden and epidemiology of SIC in three distinct female populations. A late summer to fall peak has been also reported for the incidence of recurrent LUTI.^[5],[6] Rom patients reported that an interval of 2-5 days elapsed between the onset of LUTI symptoms and the request for medical aid. The actual reasons why women waited this long before consulting a physician were not asked for by our researchers, but may be linked to social reasons. SIC seems to affect mainly women from low and median socioeconomic groups; however, since immigrant and rom study populations consisted mostly of women of low and median socioeconomic groups this finding could be misleading.

According to our findings most characteristics of SIC do not differ from those of LUTI of other aetiology as reported in literature. According to the literature re-infections in women (ordinary non-SIC LUTIs), are mainly associated with increased vaginal mucosal receptivity for uro-pathogens and/or with an eventual ascending colonization from the faecal or external flora.^[2] On the contrary (regarding the predisposing factors and aetiology), SIC is a recurrent LUTI in which although the exact mechanisms of its pathogenesis are not clear, it is probable that sexual intercourse facilitates the colonization of the normally aseptic urethra and bladder by forcing pathogens to move into the urethra. The origin of such pathogens could be multiple: In part they could represent a sufficient number of virulent bacterial populations growing in the vaginal flora, due to the use of vaginal cleaners/antiseptics, antibiotics, foreign bodies or due to hormonal imbalances. Increased frequency of sex-induced re-infections in post-menopausal women caused by E. coli is actually caused by changes in the vaginal microflora (loss of lactobacilli and increased colonization by E. coli).^[7] On the other hand, the causing pathogens could derive from host contamination by the sexual partner and not from disorders of the common vaginal and urethral flora. Sexual transmission of uropathogens has been demonstrated by identifying identical E. coli in the faecal and urinary flora of sexual partners.^[8] According to current literature, the use of diaphragm, spermicides and tampon have been associated with vaginal colonization with E. coli and consequently with an increased risk of LUTI and SIC.^[9],[10] There is an increasing trend for recurrent LUTIs especially in women who frequently use spermicidal agents. Spermicides containing the active ingredient nonoxynol-9, may provide a selective advantage for the colonization of the vagina with pathogens, perhaps by a reduction in the population of vaginal lactobacilli and through enhancement of adherence of E. coli to epithelial cells.^[11] In addition, some authors suggested that diaphragm users are supposed to have a significantly greater risk of recurrent LUTI than women who use other contraceptive methods. It is also known that foreign bodies are considered as factors encouraging the colonization of the vaginal area with pathogens. Such considerations cannot explain (at least in part) the almost equal incidence of SIC in the local study group, when compared to the rom group in which the use of contraceptive methods was minimal. The finding that in all three groups, women of age group 20-30 were significantly more likely to develop a re-infection, adds more evidence in the impact of sexual intercourse related factors, in the aetiopathogenesis and definition of SIC as a distinct clinical entity in the heterogeneous group of recurrent LUTIs. Similarly, the finding that in all three groups the frequency of women with SIC progressively decreases with increasing age is possibly due to social reasons.

Conclusion

Social, behavioural and economical factors do not seem to be the main issues that influence the epidemiology of SIC, although larger scale multicentric studies in different populations and various ethnic groups are needed in order to establish more decisive conclusions. The patient burden of this type of LUTI (SIC) is greatly wider, because of its association with an increased number of sickness days than in individual LUTI's. Since additional days of drug therapy (cost increase) and loss of working hours would be required in case of non-prevented recurrences, the importance of appropriate and on time SIC detection and treatment is imperative and represents a challenging and significant healthcare issue.

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