HEALTH / Second Opinion

READERS of fiction or biography from the first half of this century come into frequent contact with infectious diseases: tuberculosis, typhoid fever, diphtheria, dysentery, pneumonia, meningitis and rheumatic fever might strike down anyone in the prime of life. Most of these have disappeared from technically advanced countries as a result of immunisation and high standards of nutrition, sanitation and housing. Our freedom from infections - few adults nowadays have major infectious illnesses - is such that the few remaining ones are naturally resented. Among these is cystitis, inflammation of the bladder from bacterial infection.

A million women visit their doctors every year in Britain complaining a frequent need to empty the bladder and pain on passing urine (dysuria). Why has this common complaint proved so difficult to control?

Part of the answer is that dysuria may be due to several other diseases apart from cystitis. It may be caused by a vaginal infection irritating the urethra, the outflow tube from the bladder. Or it may arise from a sexually transmitted infection of the urethra with chlamydia, gonorrhoea or the herpes virus. In most cases dysuria is due to infection of the bladder with a bacterium, Escherichia coli, which is a normal inhabitant of the bowel. In engineering terms, there is a design problem: the urethra is much shorter in women than in men (who rarely suffer from cystitis before the age of 50) and bacteria from the bowel seem able to pass easily from the exit of the urethra to reach the bladder.

Treatment of a single attack is usually straightforward: there are several well tried antibiotics. The vexing aspect of the illness is that all too often the symptoms return within a few weeks. Research has shown that the recurrence is a genuine fresh attack due to the same process as before, bacteria getting into the bladder from outside.

The risks of recurrence are known to be increased by several factors, most important of which is sexual intercourse. Another is the use of a diaphragm and spermicide for contraception, apparently because this encourages the growth of the E coli bacterium within the vagina. The association of sex and cystitis has been known for many years, and so has the protection given by emptying the bladder shortly after sex, which washes any bacteria out of the urethra.

Women who have recurrent attacks of cystitis are bombarded with advice about their choice of underclothes, washing before and after sex, choosing a diet that affects the acidity of the urine, and so on. Many choose to rely on antibiotics. There are three choices: taking an antibiotic all the time, taking a single dose after sex, or waiting and then taking a course of antibiotics at the first sign of symptoms. A review in the New England Journal of Medicine concluded recently that the bacteria rarely become resistant to the antibiotics and that women who are willing to follow the policy of early treatment on their own initiative have a 'safer, inexpensive and effective management strategy'.

This treatment has been used by millions of women in the past 20 years or so; had there been complications from the repeated use of antibiotic drugs we should have heard of them by now.