This article considers the treatment of recurrent cystitis. It examines the evidence for drinking cranberry juice to prevent recurrent urinary tract infections and discusses the nursing issues raised, drawing conclusions from the evidence presented.
Linda Nazarko, BSc(Hons), RN.
Cystitis is normally treated with antibiotics and usually this treatment is successful. In some cases, however, individuals suffer from repeated urinary tract infections and investigations often fail to determine the cause. Incomplete bladder emptying can lead to a large residual urine  and this can act as a reservoir for infection and lead to recurrent urinary tract infections .
Recurrent urinary tract infections and dysuria are more common in women than men for anatomical reasons  and the incidence of urinary tract infections also rises as people age ,. Many women who suffer from recurrent urinary tract infections are treated with antibiotics but antibiotic therapy alters the pH balance and normal flora of the vagina and can predispose women to oral and vaginal candida infections.
Cranberry juice is increasingly being recommended as an alternative treatment to prevent or reduce the frequency of cystitis attacks. Nurses who wish to recommend the use of cranberry juice should be aware, however, of the available research evidence. By discussing this with the individual suffering from recurrent cystitis, nurses will enable patients to make more informed choices.
Cranberry juice and crushed cranberries were used in treating and preventing urinary tract infections in the US long before the discovery of antibiotics . The first recorded use by orthodox medical practitioners was in 1923 . Researchers suggested that cranberry juice worked by causing changes in urinary pH  but further research indicated that drinking cranberry juice would not alter urinary pH sufficiently to inhibit bacterial activity .
Other researchers postulated that part of the therapeutic effect was caused by increased hippuric acid levels . Hippuric acid is similar in molecular structure to mandelic acid which has been a valued treatment for urinary tract infections for decades . But this theory has also been disproved since cranberry juice does not raise the levels of hippuric acid enough to inhibit bacterial activity . It is now thought that cranberry juice acts by preventing bacterial adherence to mucosal cells . Bacterial adherence to mucosal cells is significant in the development of infection  and preventing this would inhibit colonisation of mucosal surfaces.
It is thought, though not proven, that cranberry juice affects urinary concentrations of Tamm-Horsfall glycoprotein. This is known to prevent adherence of certain strains of E. coli to human kidney cells . Recent research has also confirmed that cranberry juice inhibits bacterial adherence and E. coli reproduction in the bowel and also offers some protection against ascending urinary tract infections in individuals who suffer from ureteric reflux . It has also been found to inhibit a wide range of bacteria and the growth of yeast cells .
Current research therefore indicates that while clinicians report that cranberry juice can benefit patients, the active ingredient or the mode of action is still unknown.
There is a possibility of developing kidney stones if large amounts of cranberry juice (more than 2.5 cartons per day) are drunk . But individuals are normally advised to drink only two mugs a day (about 400ml) and there are no known side effects from drinking this amount.
Ethical, professional and legal issues
It could be argued that nurses have no remit to suggest that a patient drinks cranberry juice. However, the UKCC Code of Professional Conduct states that the nurse should ’work in an open and co-operative manner with patients … foster their independence and recognise and respect their involvement in the planning and delivery of care’ . The use of a client-centred self empowerment model of care allows the patient to make a choice which can bring a positive health benefit .
Cranberry juice is not a well-known home remedy in the UK and there have been few reports of its use even in nursing literature . The role of the nurse is therefore not to dictate to the patient but to present the evidence and listen to the views and wishes of the patient who makes the decision . Many patients are willing to try cranberry juice to see if it prevents or lessens the frequency of recurrent urinary tract infections.
It could be argued that the UKCC guidelines compelling nurses to ‘maintain and improve your professional knowledge and competence’ and ‘ensure that no action or omission on your part … is detrimental to the interests, condition or safety of patients and clients’  would be contravened if a nurse failed to give a patient information which might help improve his/her health condition.
However, one could take the contrary view that by discussing the issue of cranberry juice, the nurse is effectively prescribing it, even though cranberry juice is not listed in the British National Formulary as a medicine  and its active constituent has yet to be identified .
Cranberry juice is a natural substance and it could be argued that nurses who inform patients of the evidence that drinking a certain fluid may help prevent recurrent urinary tract infections are therefore providing dietary information. Nurses, when asked for dietary advice by individuals suffering from constipation, frequently advise them to eat high fibre cereals, prunes and other fruit and vegetables. Such advice is not considered controversial in this case. Indeed, Agenda for Action on Incontinence  states that continence advisers should possess and apply dietary knowledge to their practice.
Cranberry juice can be viewed as an ‘alternative therapy’ and it is important therefore to examine the alternatives to drinking the juice as well. In most cases, individuals have tried to use a number of strategies to prevent recurrent cystitis. These include wearing cotton pants, not wearing tight clothing such as tight jeans or trousers, wearing stockings instead of tights, and drinking more fluids. Women are advised to ensure that they wipe their vulval area from top to bottom after urinating to prevent E. coli being spread from the anal region to the urethra.
Women with recurrent urinary tract infections that appear to be related to sexual intercourse-’honeymoon cystitis’-are advised to pass urine prior to intercourse. While many women find these strategies help, a significant number continue to suffer.
The alternative to drinking cranberry juice is to continue antibiotics and many individuals take more than ten courses of antibiotics in a year. Unfortunately, antibiotics can cause nausea and vomiting which make it difficult to drink copious amounts of fluids. Candida infections can also occur as a direct consequence of the destruction of normal bowel flora by antibiotics  and in many cases antibiotic therapy fails to resolve recurrent urinary tract infections .
Recent research has demonstrated that while 15 per cent of older women suffer from repeated urinary tract infections, less than half seek medical help. Also, many of the women treated with antibiotic therapy find it ineffective . Research indicates that many older adults suffer from asymptomatic bacteriuria  and Mollander et al’s research  may make one wonder if older adults with bacteriuria are genuinely asymptomatic or if they merely fail to seek medical treatment.
There has been considerable controversy within the medical profession about the desirability and effectiveness of treating ‘asymptomatic’ bacteriuria in older adults. Doctors have acknowledged the limitations of antibiotic therapy and the side effects such as nausea and vomiting which can render them hazardous to older adults, who find it more difficult to maintain homeostasis than younger people .
Researchers acknowledge that health education, hygiene and preventative measures are vitally important if the cycle of infection and re-infection is to be broken .
Those who are advised to drink cranberry juice must buy it. It costs approximately 92p per litre and the usual recommended dose of 400ml will cost around 37p per day. This may be too expensive for some individuals. Cranberry juice is also only available from larger supermarkets, so people without access to a car may find it difficult to obtain or to carry the juice home. Cranberry juice capsules can now be purchased in health food shops, but there is little research available on how they compare with drinking the juice.
Cranberry juice has been proven to reduce the frequency of urinary tract infections. It is seen to be effective in inhibiting bacterial adherence to mucosa and inhibiting the growth of yeast . Unlike antibiotic therapy, it has no known side effects at normal doses, is a natural substance and is not licensed as a medicine. But its mode of action and its long-term effects are not known.
So, while many questions about the role of cranberry juice remain unanswered, nurses and other health professionals will have to maintain a sensitive stance when deciding if they should recommend its use.
© Linda Nazarko BSc(Hons), RN.; Nursing Standard; (1995); 9; 34; 33-35.
- Brocklehurst JC et al. The prevalence and symptomatology of urinary infection in an aged population. Gerontologia Clinica. 1968. 10, 242-253.
- Mollander U et al. An epidemiological study of urinary incontinence and related urogenital symptoms in elderly women. Maturitas. 1990. 12, 51-60.
- Brocklehurst JC et al. Dysuria in old age. Journal of the American Geriatric Society. 1971. 19, 582-590.
- Milne JS et al. Urinary symptoms in older people. Modern Geriatrics. 1972. 3, 198-212.
- Moen DV. Observations on the effectiveness of cranberry juice in urinary tract infections. Wisconsin Medical Journal. 1962. 61, 282-283.
- Blatherwick NR, Long ML. Studies on urinary acidity. The increased acidity produced by eating prunes and cranberries. Journal of Biological Chemistry. 1923. 57, 815.
- Fellers CR et al. Effect of cranberries on urinary acidity and blood alkali reserve. Journal of Nutrition. 1933. 6, 455.
- Sobota AE. Inhibition of bacterial adherence by cranberry juice: potential use for the treatment of urinary tract infections. The Journal of Urology. 1984. 131, 1013-1016.
- Bodel PT et al. Cranberry juice and the antibacterial action of hippuric acid. Journal of Laboratory and Clinical Medicine. 1959. 54, 6, 881-888.
- Rosenheim ML. Mandelic acid in the treatment of urinary tract infections. The Lancet. 1935. 1, 1032.
- Beachy EH. Bacterial adherence; adhesion receptor inter-actions mediating the attachment of bacteria to mucosal surfaces. Journal of Infectious Diseases. 1981. 143, 325-345.
- Svanberg EC et al. Adhesiveness to urinary tract epithelial cells of fecal and urinary Escheria coli isolates from patients with symptomatic urinary tract infections or asymptomatic bacteriuria of varying duration. Journal of Urology. 1979. 122, 185.
- Dulawa J et al. Tamm-Horsfall glycoprotein interferes with bacterial adherence to human kidney cells. European Journal of Clinical Investigations. 1988. 18, 87-91.
- Sternlieb P. Cranberry juice in renal disease. New England Journal of Medicine. 1963. 268, 57.
- Zafriri D et al. Inhibitory activity of cranberry juice on adherence type 1 and type P fimbriated Escheria coli to eurcaryotic cells. Antimicrobial Agents and Chemotherapy. 1989. 33, 1, 92-98.
- Kahn HD et al. Effect of cranberry juice on urine. Journal of American Dietetic Association. 1967. 51, 251-286.
- United Kingdom Central Council. The Code of Professional Conduct for the Nurse, Midwife and Health Visitor. Third edition. London, UKCC. 1992.
- Ewles L, Simnett I. Promoting Health-A Practical Guide. Philosophical Issues in Health Promotion. Harrow, Scutari Press. 1992.
- Rodgers J. Pass the cranberry juice. Nursing Times. 1992. 87, 48, 36-37.
- Wright S, Kershaw B. Using a Model of Nursing. Edinburgh, Churchill Livingstone. 1991.
- British Medical Association & Royal Pharmaceutical Society of Great Britain. British National Formulary. London, The Pharmaceutical Press. 1993.
- Department of Health. An Agenda for Action on Continence Services. London, HMSO. 1991.
- Moody M. Incontinence: Patient Problems and Nursing Care. Oxford, Heinemann. 1990.
- Dontas AS et al. Bacteriuria and survival in old age. New England Journal of Medicine. 1981. 304, 39.
- Boscia JA et al. Asymptomatic bacteriuria in elderly persons; to treat or not to treat? Annals of Internal Medicine, 1987. 106, 764-766.
- Iosif C, Bekassy Z. Prevalence of genito-urinary symptoms in late menopause. Acta Obstetrics Gynecologica Scandinavia. 1984. 63, 257-260.