Can COVID-19 (Coronavirus Disease 2019) cause interstitial cystitis?

COVID-19 and Interstitial Cystitis: The Connection

COVID-19 can cause urinary symptoms resembling interstitial cystitis, a condition now recognized as COVID-associated cystitis (CAC), which presents as new onset or exacerbated urinary symptoms such as frequency, urgency, and nocturia. 1, 2

Pathophysiology of COVID-Associated Cystitis

• COVID-19 can affect multiple organ systems beyond the respiratory tract, including the genitourinary system 3
• Two primary mechanisms have been proposed for COVID-associated bladder symptoms:
  • Inflammatory mediator theory: COVID-19 inflammation results in elevated proinflammatory cytokines in the urine, similar to what is seen in interstitial cystitis 2, 4
  • ACE-2 receptor theory: SARS-CoV-2 may directly affect bladder urothelium through ACE-2 receptors, which are expressed in urinary tract tissues 4
• The virus can cause a hyperinflammatory state that affects multiple organs, potentially including the bladder 3

Clinical Presentation

• Patients with COVID-associated cystitis typically present with:
  • Urinary frequency (≥13 episodes/24 hours) 2, 5
  • Nocturia (≥4 episodes/night) 2
  • Urgency and sometimes urge incontinence 6
• These symptoms can develop de novo during or after COVID-19 infection or worsen pre-existing urinary symptoms 1, 6
• In one study, 78.6% of patients developed overactive bladder symptoms as new onset after COVID-19 infection, while 21.4% experienced worsening of pre-existing symptoms 6

Diagnosis and Differential Considerations

• COVID-associated cystitis should be considered in patients with:
  • Recent COVID-19 infection 1, 2
  • New onset or worsening urinary symptoms without other clear causes 5
  • Normal urinalysis without signs of bacterial infection 6
• It's important to rule out other causes of similar symptoms:
  • Bacterial urinary tract infection 6
  • Pre-existing overactive bladder or interstitial cystitis 6
  • Medication side effects 3

Management and Prognosis

• Most patients with COVID-associated cystitis show improvement with conservative management:
  • Behavioral modifications 1
  • Standard overactive bladder medications 1, 6
• Trospium chloride (30 mg daily) has been suggested as a preferred medication due to its lack of central nervous system effects, which is important given the potential neurotoxicity of SARS-CoV-2 6
• Long-term prognosis appears favorable:
  • In a study following patients for 21-28 months, 87% reported symptom improvement 1
  • Patients with new-onset symptoms showed better outcomes (95.4% improvement) compared to those with pre-existing symptoms (60.7% improvement) 1

Clinical Implications

• Urinary frequency should be considered as a potential symptom of COVID-19, which could help with early identification of cases 5
• Healthcare providers should be aware of this association to avoid misdiagnosis as simple urinary tract infection or primary interstitial cystitis 5, 4
• Patients with persistent urinary symptoms after COVID-19 should be evaluated for COVID-associated cystitis 1, 4
• The condition appears to respond well to standard treatments for overactive bladder, providing reassurance to affected patients 1, 6

Special Considerations

• Patients with pre-existing urological conditions may be at higher risk for more severe or persistent symptoms 6, 4
• Immunocompromised patients may also experience more pronounced urinary symptoms with COVID-19 4
• The condition should be monitored as part of post-COVID follow-up, especially in patients reporting urinary symptoms 1