• Deakos

Efficacy of N-acetylcysteine, D-mannose and Morinda citrifolia to Treat Recurrent Cystitis in Breast


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


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).


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


Table I. Characteristics of recruited population patients for the clinical


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


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.


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


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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