Deakos
Efficacy of N-acetylcysteine, D-mannose and Morinda citrifolia to Treat Recurrent Cystitis in Breast
DEBORA MARCHIORI1 and PIER PAOLO ZANELLO2
1Villa Erbosa Hospital – San Donato University and research Group, Bologna, Italy;
2Department of Microbiology and Virology of Parma, Parma, Italy
Abstract. Background/Aim: Breast cancer survivors in
adjuvant therapy, frequently experience the estrogen
deficiency with genitourinary symptoms mostly represented
by recurrent bacterial cystitis. The objective of the present
study was to evaluate the effectiveness of N-acetylcysteine,
D-mannose and Morinda citrifolia fruit extract (NDM), when
associated to antibiotic therapy, in reducing the persistence
of recurrent cystitis in this risk population. Patients and
Methods: Sixty breast cancer survived women with recurrent
cystitis were retrospectively examined. Group 1, comprised
of 40 patients treated with antibiotic therapy associated with
NDM lasting for six months, Group 2 comprised of 20
patients treated with antibiotics alone. Results: The use of
NDM in combination with antibiotic therapy showed a
significant reduction in positive urine cultures, compared to
antibiotics alone. Subjects of Group 1 rather than those of
Group 2, showed improvement in symptoms score of urgency,
frequency, urge incontinence, recurrent cystitis, bladder and
urethral pain. Conclusion: In breast cancer survived women
affected by genitourinary discomfort, the combination of
NDM and antibiotic therapy showed a greater efficacy in
reducing urinary tract infections and urinary discomfort with
respect to antibiotic use only.
Every day worldwide women are diagnosed with malignant
breast cancer with aggressiveness related to the age of
patients (1). Today life expectancy of breast cancer patients
is very high, but is often affected by the long-term side
effects of oncological treatments. Breast tumors are often
hormone-sensitive, and among the therapeutic options,
endocrine therapy is currently used and includes tamoxifen,
aromatase inhibitors and LHRH analogues (2). The
decreased level of circulating estrogens due to the abovementioned
therapy, in addition to the menopause condition,
are responsible for atrophic vaginitis and urinary disorders.
The latter are characterized by symptoms ranging from
moderate to severe. Today an increasing interest on patient’s
quality of life is taken by physicians, especially medical
oncologists, by focusing both on the most effective treatment
and on minimizing the treatments’ side-effects, including
those of uro-gynecological nature. Estrogen deficiency due
to the oncological treatments, chemotherapy and endocrine
therapy, induces the uro-genital syndrome as much as is the
case of postmenopausal women. The genitourinary postmenopausal
syndrome is defined as a set of signs and
symptoms associated with the reduction of circulating
estrogens that determines changes in the vagina, vulva,
bladder and urethra and that severely impairs women’s
quality of life. Women with breast cancer in endocrine adjuvant
treatment, if not yet in physiological menopause,
experience a temporary estrogen deficiency induced by the
treatment itself. Similarly, to the aggressiveness of the
tumor, the symptoms and signs of uro-genital syndrome
may be more debilitating the younger the women are (3).
The uro-genital symptoms of estrogen deficiency are
vaginal dryness, burning and irritation, sexual symptoms
such as the lack of lubrication and dyspareunia and urinary
symptoms such as urgency, frequency, incontinence and
recurrent urinary tract infections. The genitourinary
syndrome, that is accompanied by atrophy of the urological
mucosa, is characterized by recurrent bacterial cystitis and
post-coital cystitis mostly incurred from gram-negative
bacteria (4). The most bothersome urinary symptoms
associated with bacteriuria are urgency, increasing voiding
frequency, pain and urinary incontinence. Bacteria that
colonize the bladder are mostly gram negative and of
intestinal origin. They have a specific pathogenesis activity
underlying the chronicity of the phenomenon which hardly
allows conventional antibiotic therapies to be effective
acute and chronically. Usually the time interval between an
infection and is within three to six months after the initial
infection.
The uropathogenic bacteria in patients affected by estrogen
deficiency syndrome are usually Enterobacteriaceae
(Escherichia coli, Klebsiella, Shigella, Pseudomonas) and
they are able to generate biofilms, a complex of
mucopolysaccharide matrix created by bacterial secretions
which represent a strategic and effective weapon of defense
against antibiotics and immune defenses. Inside the bacterial
biofilm, frequently of polymicrobial nature (bacterial and
fungal), the microorganisms are protected from the immune
system cells and from the action of antibiotics, which are
unlikely to penetrate the urothelium deeper layers (5). The
persistence of bacteria within the biofilm favors the onset of
phenomena of both genetic and phenotypical resistance to
antibiotics, caused by a metabolic slowdown that allows the
development of multi-resistant quiescent cells, called
persistent cells. Even if in quiescent status, the persistent cells
are always able to be reactivated, if necessary, by developing
a new infection locally or at distant sites from the biofilm
source as well (6).
Recently, this theory has allowed us to change our
therapeutic approach to cure these women affected by estrogen
deficiency with recurrent bacterial cystitis. In order to minimize
the chronicity of an infection and improving the efficacy of
antibiotics, the current prophylaxis in uroginecology has been
previously demonstrated by urodynamic and is based on Dmannose,
N-acetylcysteine (NAC) and Morinda citrifolia fruit
extract (NDM) with antibacterial, anti-inflammatory, analgesic
and immunomodulatory activity (7). D-Mannose has a binding
affinity to the E. coli surface adhesins in order to reduce the
adhesion between the bacteria and urothelium (8, 9). NAC has
the ability to disrupt the pathogen polymicrobial biofilm and
Morinda citrifolia fruit extract is a natural strong antiinflammatory,
immunostimulating, antimicrobial and cancer
chemopreventive phytotherapeutic product (7, 10-12). In
particular, literature has shown an increase in the efficacy of
phosphomycin, nitrofurantoin or quinolones when associated
with NAC in disrupting biofilm and reducing the number of
vital bacterial forms, respectively, against Staphylococcus
aureus, Escherichia coli and Pseudomonaceae. These last
findings support the therapeutic perspective of the association
antibiotics/NAC, opening new and important therapeutic
solutions in chronic infectious diseases of the respiratory and
urinary tract, both supported by forming biofilm
microorganisms (13-15).
Even if there is no discussion on the efficacy of antibiotics
in terms of bactericidal activity, we believe that in this
population of patients it is possible to increase the
therapeutic efficacy of the antibiotic
Objectives of this study are represented by two end-points:
i) to verify if a product containing NAC, D-Mannose and
Morinda citrifolia added to antibiotics therapy was able to
eliminate both bacterial urinary infection with no recurrent
cystitis episodes within six months from the first visit, and
ii) to reduce urinary discomfort such as urgency, increasing
voiding frequency, bladder and urethral pain and urinary
incontinence in cancer patients.
Patients and Methods
This observational retrospective clinical study was conducted on 60
patients with recurrent cystitis, both in physiological menopause and
in childbearing age affected by breast cancer. All patients observed
in this study were submitted to a uro-gynecological visit, since they
complained uro-genital discomfort, in the period between March
2015 and January 2017. A total of 58 of the 60 patients were in
adjuvant hormonal treatment. The 60 patients observed were divided
into two groups. Group 1 included 40 patients treated with Dmannose
500 mg, N-acetylcysteine 100 mg and Morinda citrifolia
fruit extract 200 mg (NDM) for two months with the following
regimen: NDM 1 vial every 12 h after emptying the bladder for 60
days and then 1 vial every 24 h after emptying the bladder for 4
months, associated with variable antibiotic therapy, depending on
microbial sensitivity. The antibiotics used were fosfomycin, a sachet
of 3 grams per day for two days, to be repeated every 15 days for a
total of three cycles, nitrofurantoin 1cprs 100 mg three time a day
for 6 days and ciprofloxacin 1,000 RM or prulifloxacin 600 mg 1
cps/day for 6 days.
The group 2 included 20 patients treated only with antibiotic
therapy following the treatment regimens described for group 1.
All patients went at the first visit (before treatment), and repeated
the visit at 2 months. After six months from first visit only patients
from group 1 and those of group 2 with negative urine cultures at
second visit were evaluated to measure symptoms’ intensity and urine
culture. At a second visit all patients had repeated urine cultures at
least 10 days after the last intake of antibiotics to verify appropriate
and rapid bacterial killing effect. All women were asked to report their
symptoms intensity through a verbal rating scale (VRS) created
specifically to explore the following 5 urological domains: urge
incontinence, urgency, voiding frequency, episodes of recurrent
cystitis, bladder and urethral pain The symptomatology related to each
domain was measured at every visit associating a degree of intensity
to the symptoms ranked from 0 (absence of symptoms) to 4 (severe
symptom), depending on the discomfort felt by the patient (Figure 1).
Results
Only 10 of the 60 patients were not in menopause at the time
of diagnosis. Among the patients enrolled in the study 28/60
(46.6%) were in treatment with aromatase inhibitors, 20/60
(33.3%) with tamoxifen therapy, 10/60 (16.6%) with
tamoxifen and LHRH analogue, 2/60 (3.3%) with an
aromatase inhibitor and tamoxifen, and 2/60 (3.3%) did not
assume any adjuvant therapy (Table I). All patients subjected
to a first visit had a history of recurrent cystitis and showed
positive urine cultures with bacterial prevalence of
Escherichia coli and Klebsiella (Figure 2).

Figure 1. Verbal evaluation sheet to be completed at the first and at the
second visit by patients, for quantifying the intensity of urinary
symptoms.
Table I. Characteristics of recruited population patients for the clinical
study.
Characteristics of the recruited patients Number of patients
Total 60
Middle age 57
Menopausal status 50
Aromatase inhibitor 28
Tamoxifen 20
Tamoxifen and LHRH 10
Aromatase inhibitor and Tamoxifen 2
No treatment 2
At the second visit, two months from the first visit, only
5 patients (12.5%) of group 1 had positive urino-culture, two
of which were diabetics, two had a rectocele, and one had a
neurological bladder. No difference was found in this group
regarding the type of antibiotic taken: 2 patients took
fosfomycin, 1 patient took nitrofurantoin and 2 patients took
ciprofloxacin according to dosage indicated in Materials and
Methods.
In patients of group 2, treated with antibiotic therapy
alone, after two months positive urine cultures were
observed in 18 patients (90%), in the absence of other
significant comorbidities. In both groups the distribution of
the various antibiotic therapies was quite random. From the
analysis of urine cultures after two months, group 1 showed
an important reduction of 87.5% (from 40 to 5) of patients
with positive urine cultures, as compared to group 2, which
showed a reduction of only 10% of positive urine cultures
(20 to 18) (Figure 2). Patients of group 1 and group 2 with
persistence of positive urine cultures at second visit were not
evaluated at 6 months because they were subjected to other
than antibiotic therapies, and no comparison was possible

Figure 2. Number of Group 1 (antibiotic associated at NDM) and Group
2 (antibiotic only) patients, positive for E. coli in urinary tract
registered at the first (before treatment) and at the second visit (two
months later).
between the two groups: at 6 months only 35 patients of
Group 1 and Group 2 were evaluated. The 2 patients of
Group 2 that showed negative urine cultures at second visit,
showed positive urine cultures at six months, while the 35
patients of Group 1 showed persistence of negative urine
culture after treatment with 1 vial of NDM every 24 h, after
emptying the bladder, for 4 months.
Looking at the symptoms by using the verbal rating scale
(VRS) for the 5 explored urological domains: urge
incontinence, urgency, voiding frequency, recurrent cystitis,
bladder and urethral pain, it is possible to observe a
significant reduction in symptoms score registered at the
second visit after two months, in patients of Group 1, treated
with antibiotics associated at NDM, if compared to Group 2,
treated with antibiotics alone (Figure 3).
Table II shows the intensity of the perceived symptoms
reported at the first and at the second visit of the two groups:
urgency incontinence, imperious urination, increasing
voiding frequency, bladder and urethral pain, and the
intensity of symptoms is referred to as mild, medium or
severe. The results allow to observe that patients of Group 1

Figure 3. distribution of experienced discomfort in the five urological domains investigated in Group 1 (Antibiotic associated at NDM) and Group
2 (Antibiotic only) patients before and after treatment and at 1st and at the 2nd visit respectively.
Table II. Intensity of the symptoms experienced by patients in Group 1 (antibiotic and NDM) and Group 2 (antibiotic) before and after treatment,
reported at the first and second visit.
Group 1 symptoms Mild Moderate Severe
1st visit 2nd visit 1st visit 2nd visit 1st visit 2nd visit
Urgency incontinence 5 0 5 0 10 0
Imperious urination 0 2 6 1 1 0
Increasing voiding frequency 5 0 10 2 15 0
Bladder and urethral pain 2 0 6 3 7 7
Group 2 symptoms Mild Moderate Severe
1st visit 2nd visit 1st visit 2nd visit 1st visit 2nd visit
Urgency incontinence 3 1 2 0 2 1
Imperious urination 5 7 3 8 2 2
Increasing voiding frequency 13 17 5 3 2 2
Bladder and urethral pain 4 4 8 8 2 1
reported an improvement in perceived symptoms, especially
for those affected by severe urinary bothersome; while for
patients of Group 2 there was no improvement at clinical
investigation carried out during the second visit.
At the second visit only 15 patients in Group 1 showed
mild to severe symptoms as follows: 2 mild, 6 moderate and
7 severe, while at 6 months, only 8 patients of group 1
showed persistent symptoms (3 mild, 4 moderate and 1
severe). At six months, the 2 patients of Group 2 with
positive urine culture showed also the recurrence of severe
urinary bothersome.
Discussion
The genitourinary syndrome of menopause (physiologically
as well as the one hormonally induced), especially in women
with breast cancer, is accompanied by atrophy of the genital
mucosa and episodes of recurrent cystitis, with a strong
emotional and physical impact on women’s health. In
addition, the indiscriminate use of antibiotics often worsens
the severity of symptoms and creates a chronicity of the
recurrence increasing the frustration of the persistent failing
of the antibacterial therapies (5). At the origin of the
recurrence there is the possibility that the uropathogenic
bacteria will create a biofilm, a mucopolysaccharide complex
structure which tends to generate a chronic site of infection
with the consequent developing of antibiotic resistance (14,
15). The results obtained in this study suggest that the
integration of NDM to the antibiotic therapy, here evaluated
in women who had breast cancer, could be an effective
available tool to reduce bacteriuria, recurrent cystitis and
urinary symptoms represented by the five urological domains
explored.
Despite the small number of patients involved in the two
study groups and the difference in the number of patients
recruited in the two groups, the results are promising for even
large-scale assessment. In Group 1, the persistence of
symptoms after 6 months, though mild, in 8 women, is
probably justified by the presence of various comorbidities
and the different response of our immune system to
inflammation. In fact, in group 1 were included 5 patients with
persistent positive urinary culture, and those who, regardless
of bacterial positivity, had a hypersensitive bladder as they
suffered from genitourinary postmenopausal syndrome, which
further complicates the effects of endocrine treatment on the
genitourinary tract. The duration and the schedule of antibiotic
therapy in recurrent cystitis is currently unknown because it
is not possible to predict the time lead between a bladder
infection to another in this risk population. It’s very important
to consider that the uro-genital syndrome severely impacts
quality of life of patients both in their social relationships and
in their daily work.
The results obtained demonstrate that the association of
N-acetylcysteine, D-mannose and Morinda citrifolia fruit
extract, with conventional antibacterial therapy, could reduce
the need of antibiotic therapies responsible for chronic
systemic resistances, that when used alone can often cause
precarious vaginal and intestinal environments, favoring the
phenomenon of infectious recurrence. In this sample of sixty
women affected by breast cancer, the risk of recurrent
urinary tract infections is very high due to tissue atrophy
induced both by hormonal therapies used in the treatment of
hormone-sensitive tumors, and by the effects of
physiological estrogen deficiency if the cancer has been
generated post-menopausaly. Therefore, antibiotic therapy
associated with NDM allows to give more effectiveness to
the antibiotics in reducing both the infection at the time and
the risk of its recurrence. In addition, the above-mentioned
therapy regimen provides a benefit in terms of reduced
toxicity associated with prolonged antibiotic therapy, that
may add further disadvantages to breast cancer survivors,
already physically and psychologically affected by the sideeffect
of common anticancer drugs.
In conclusion, in selected patients, the association of NAC
D-mannose, and Morinda citrifolia fruit extract, allow to
improve the effectiveness of antibiotic therapy maintaining
the result over time in fighting the pathogenic effect and
resistance of uropathogenic bacteria. It is also very important
to point out how the therapeutic efficacy is associated with a
reduction in urogenital discomfort that in women with longlife
expectancy impacts their intimate and daily sphere.
Conflicts of Interest
Dr. Pier Paolo Zanello and Dr. Debora Marchiori are Deakos
scientific consultants.
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Received May 31, 2017
Revised June 19, 2017
Accepted June 20, 2017
in vivo 31: 931-936 (2017)
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