Frequently Asked QUestions

COVID-Associated Cystitis (CAC) is the result of the COVID-19 infection affecting the urinary tract, resulting in the symptoms of urinary frequency, urgency, pressure and/or pain. Many patients have no history of bladder or urinary tract disease or dysfunction. Symptoms range from mild to severe, with some patients struggling with symptoms for several months or longer. 

HOW WAS IT DISCOVERED? 

In the earliest days of the pandemic, urologists in Germany were the first describe the sudden onset of urinary symptoms in patients struggling with COVID-19.(1) They shared an unusual case study of a patient who was admitted to a hospital reporting fever, shivering, pain, urgency and increased urinary symptoms though there were no signs of a typical bacterial urinary tract infection. A swab taken the same day revealed COVID-19 infection.  They sought to determine if this was occurring in other patients, and found a small but significant number of patients admitted  for COVID had increased urinary symptoms. 

Shortly thereafter, researchers at several medical centers in Michigan initially found 39 COVID-19 patients (32 men, 7 women) who had also developed urinary symptoms in which urine cultures revealed no bacterial infection. 85% of these patients struggled with increased urinary frequency and night time urination greater than 4 times per night.(2) They completed a larger study which identified 350 patients with de novo (new) or worsening OAB symptoms 10 to 14 weeks after their hospitalization with COVID, suggesting that this could be the result of "long haul covid." (3). Urologists and researchers around the world continue to identify new cases of Covid Associated cystitis. Patients with pre-existing bladder (interstitial cystitis, bladder pain syndrome, overactive bladder) or prostate conditions may also struggle with intensified symptoms during and after COVID infection. 

WHAT IS HAPPENING IN THE BLADDER?

Researchers have a few theories: 

A. An unusually high inflammatory response (aka cytokine storm syndrome) has been found in severe cases of COVID-19. Not surprisingly, these increased inflammatory markers (cytokines) have also been found throughout the body, including in the urine and bladder of some COVID-19 patients. Cytokines can damage to the bladder lining (urothelium) triggering the classic symptoms of urinary frequency, urgency, pressure and/or pain.  Unfortunately, some clinicians have mistakenly assumed that these patients were struggling with a routine bacterial infection.(3) 

B. In the most severe patients, there is concern that COVID-19 could also be infecting the bladder wall. Though uncommon, other viral infections (HIV, HTLV and polyoma BK) have been known to cause urinary symptoms.(4,5,6) Fourteen studies have found active COVID-19 virus in urine samples, more commonly in patients with moderate or severe disease.(7)

C. COVID virus may be triggering a peripheral neurological effects, perhaps due to to the nervous system trauma. (8)

D. COVID-19 infection may be disrupting the immune system which could then allow other pathogens to grow, such as the polyoma bk virus in patients who have had kidney transplant. (9)

WHAT IS THE PROGNOSIS?

More research is needed to understand exactly what is happening the bladder. That said, some patients have shared their symptoms lasted for several months before gradually improving.  We have no long-term data at this time. 

References: 

1. Mumm JN, et al. Urinary Frequency as a Possibly Overlooked Symptom in COVID-19 Patients: Does SARS-CoV-2 Cause Viral Cystitis? Eur Urol. 2020 Oct; 78(4): 624–628.
2. Dhar N, et al. De Novo Urinary Symptoms Associated with COVID 19: COVID-19-Associated Cystitis. J Clin Med Res . 2020 Oct;12(10):681-682.
3. Lamb L, et al. Long COVID and COVID-19-associated cystitis (CAC). Int Urol Nephrol. 2021 Nov 17 : 1–5.
4.  Breyer BN, et al. HIV status is an independent risk factor for reporting lower urinary tract symptoms. J Urol 2011;185(5):1710–5. 
5. Castro NM, et al. Urinary symptoms associated with human T-cell lymphotropic virus type I infection: evidence of urinary manifestations in large group of HTLV-I carriers. Urology 2007; 69(5):813–8. 
6. Imlay H, et al. Presentation of BK polyomavirus–associated hemorrhagic cystitis after allogeneic hematopoietic cell transplantation. Blood Adv 2020;4(4):617–28.  
7. Kashi A, et al. Urinary Viral Shedding of COVID-19 and its Clinical Associations: Systematic Review and Meta-analysis of Observational Studies. Urol J 2020 Sep 5;17(5):433-441
8. Praschan N, et al. Implications of COVID-19 sequelae for health-care personnel. Lancet Respir Med. 2021 Mar; 9(3): 230–231.
9. Masset C, et al. Resurgence of BK Virus following COVID-19 in kidney transplant recipients. Transpl Infect Dis . 2021 Feb;23(1):e13465