{"id":61663,"date":"2026-05-13T13:47:00","date_gmt":"2026-05-13T11:47:00","guid":{"rendered":"https:\/\/www.dimann.com\/?page_id=61663"},"modified":"2026-05-22T12:42:45","modified_gmt":"2026-05-22T10:42:45","slug":"white-paper-2026-r02-full-text","status":"publish","type":"page","link":"https:\/\/www.dimann.com\/en\/eco\/white-paper-2026-r02-full-text\/","title":{"rendered":"White Paper 2026-r02 \u2014 Full text [EN]"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"61663\" class=\"elementor elementor-61663 elementor-61640\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-745cfd2a e-flex e-con-boxed e-con e-parent\" data-id=\"745cfd2a\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-635edbe elementor-widget__width-inherit elementor-widget elementor-widget-html\" data-id=\"635edbe\" 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 .paper2-hero-title__text,\r\n  .eco-paper .paper2-hero-title__text,\r\n  .eco-paper #paper2-hero-title > span {\r\n    font-size: 22px !important;\r\n    line-height: 1.18 !important;\r\n    letter-spacing: -0.012em !important;\r\n  }\r\n\r\n  .eco-paper__subtitle {\r\n    margin-top: 18px;\r\n    font-size: 17px;\r\n    line-height: 1.35;\r\n  }\r\n\r\n  .eco-paper__actions {\r\n    display: grid;\r\n    margin-top: 24px;\r\n  }\r\n\r\n  .eco-paper__btn {\r\n    width: 100%;\r\n    min-height: 46px;\r\n    font-size: 13px !important;\r\n    letter-spacing: .03em;\r\n  }\r\n}\r\n<\/style>\r\n<header class=\"eco-paper__hero\" aria-labelledby=\"paper2-hero-title\">\r\n  <div class=\"eco-paper__hero-inner\">\r\n    <div>\r\n      <div class=\"eco-paper__eyebrow-row\"><span class=\"eco-paper__eyebrow\">White paper<\/span><span>2026<\/span><\/div>\r\n      <h1 id=\"paper2-hero-title\" class=\"paper2-hero-title\" style=\"margin:0!important;padding:0!important;max-width:900px!important;line-height:1!important;font-size:0!important;font-family:Lora,Georgia,serif!important;color:#111111!important;text-transform:none!important;\">\r\n        <span class=\"paper2-hero-title__text\" style=\"display:block!important;font-family:Lora,Georgia,serif!important;font-size:38px!important;line-height:1.08!important;font-weight:800!important;letter-spacing:-0.026em!important;color:#111111!important;text-transform:none!important;\">Understanding Recurrent and Chronic Cystitis. The Role of Diet and Hydration in Different Manifestations of Cystitis<\/span>\r\n      <\/h1>\r\n      <p class=\"eco-paper__subtitle\">Understanding Recurrent and Chronic Cystitis Series.<\/p>\r\n      <div class=\"eco-paper__actions\" aria-label=\"Main actions\"><a class=\"eco-paper__btn eco-paper__btn--primary\" href=\"#\">Download the white paper<\/a><a class=\"eco-paper__btn eco-paper__btn--secondary\" href=\"#references\">Go to references<\/a><\/div>\r\n    <\/div>\r\n    <aside class=\"eco-paper__side-tools\" aria-label=\"Paper information\">\r\n      <nav class=\"eco-paper__lang\" aria-label=\"Language\"><a href=\"#\"><img decoding=\"async\" class=\"eco-paper__flag lazyload\" data-src=\"https:\/\/www.dimann.com\/wp-content\/uploads\/2026\/04\/IT.svg\" alt=\"\" width=\"22\" height=\"22\" src=\"data:image\/svg+xml;base64,PHN2ZyB3aWR0aD0iMSIgaGVpZ2h0PSIxIiB4bWxucz0iaHR0cDovL3d3dy53My5vcmcvMjAwMC9zdmciPjwvc3ZnPg==\" style=\"--smush-placeholder-width: 22px; --smush-placeholder-aspect-ratio: 22\/22;\">IT<\/a><a class=\"is-active\" href=\"#\"><img decoding=\"async\" class=\"eco-paper__flag lazyload\" data-src=\"https:\/\/www.dimann.com\/wp-content\/uploads\/2026\/04\/EN.svg\" alt=\"\" width=\"22\" height=\"22\" src=\"data:image\/svg+xml;base64,PHN2ZyB3aWR0aD0iMSIgaGVpZ2h0PSIxIiB4bWxucz0iaHR0cDovL3d3dy53My5vcmcvMjAwMC9zdmciPjwvc3ZnPg==\" style=\"--smush-placeholder-width: 22px; --smush-placeholder-aspect-ratio: 22\/22;\">EN<\/a><\/nav>\r\n      <div class=\"eco-paper__meta-card\"><dl><div><dt>Series<\/dt><dd>Understanding Recurrent and Chronic Cystitis Series<\/dd><\/div><div><dt>By<\/dt><dd>European Cystitis Observatory (ECO)<\/dd><\/div><div><dt>Version<\/dt><dd>V1 \u00b7 2026<br><small>[TO BE VERIFIED]<\/small><\/dd><\/div><div><dt>DOI<\/dt><dd>[TO BE DEFINED]<\/dd><\/div><div><dt>License<\/dt><dd>[TO BE DEFINED]<\/dd><\/div><\/dl><\/div>\r\n    <\/aside>\r\n  <\/div>\r\n<\/header>\r\n<div class=\"eco-paper__layout\">\r\n<nav class=\"eco-paper__toc\" aria-label=\"Table of contents\"><h2>Index<\/h2><ol>\r\n<li><a href=\"#foreword\">Foreword<\/a><\/li>\r\n<li><a href=\"#executive-summary\">Executive Summary<\/a><\/li>\r\n<li><a href=\"#why-discuss-diet-in-relation-to-cystitis\">Why discuss diet in\r\nrelation to cystitis?<\/a><\/li>\r\n<li><a href=\"#the-role-of-proper-hydration-in-cystitis\">The role of proper\r\nhydration in cystitis.<\/a><\/li>\r\n<li><a href=\"#the-role-of-food-intolerances-and-bowel-regularity-in-cystitis\">The\r\nrole of food intolerances and bowel regularity in cystitis.<\/a><\/li>\r\n<li><a href=\"#the-dimann-dataset\">The Dimann Dataset<\/a><\/li>\r\n<li><a href=\"#the-dimann-dataset-dietary-habits-intolerances-and-bowel-regularity\">The\r\nDimann Dataset: dietary habits, intolerances and bowel regularity<\/a><\/li>\r\n<li><a href=\"#diet-and-nutrition\">Diet and nutrition<\/a><\/li>\r\n<li><a href=\"#daily-water-intake\">Daily water intake<\/a><\/li>\r\n<li><a href=\"#food-intolerances\">Food intolerances<\/a><\/li>\r\n<li><a href=\"#bowel-regularity\">Bowel regularity<\/a><\/li>\r\n<li><a href=\"#the-dimann-dataset-cystitis-type-and-symptoms\">The Dimann\r\nDataset: cystitis type and symptoms<\/a><\/li>\r\n<li><a href=\"#type-of-cystitis\">Type of cystitis<\/a><\/li>\r\n<li><a href=\"#cystitis-symptoms\">Cystitis symptoms<\/a><\/li>\r\n<li><a href=\"#results\">Results<\/a><\/li>\r\n<li><a href=\"#type-of-cystitis-1\">Type of cystitis<\/a><\/li>\r\n<li><a href=\"#cystitis-symptoms-1\">Cystitis symptoms<\/a><\/li>\r\n<li><a href=\"#highlights\">Highlights<\/a><\/li>\r\n<li><a href=\"#methodological-note\">Methodological note<\/a><\/li>\r\n<li><a href=\"#limitations\">Limitations<\/a><\/li>\r\n<li><a href=\"#frequently-asked-questions\">Frequently Asked Questions<\/a><\/li>\r\n<li><a href=\"#references\">References<\/a><\/li>\r\n<\/ol><\/nav>\r\n<article class=\"eco-paper__content\">\r\n<section class=\"eco-paper__section eco-paper__section--soft\" id=\"paper-metadata\">\r\n<h2><span>Paper metadata<\/span><\/h2>\r\n<p>Title: The Role of Diet and Hydration in Different Manifestations of Cystitis.<\/p>\r\n<p>Subtitle: [TO BE DEFINED]<\/p>\r\n<p>Series: Understanding Recurrent and Chronic Cystitis Series.<\/p>\r\n<p>By: European Cystitis Observatory (ECO).<\/p>\r\n<p>Prepared by: Nami - Data Intelligence.<\/p>\r\n<p>Contributors: Erica Ravarelli; Alessio Fabbricatore.<\/p>\r\n<p>Funding acknowledgment: Supported by Yellow People Lab Srl.<\/p>\r\n<p>Version: V1 \u00b7 2026 [TO BE VERIFIED]<\/p>\r\n<p>Publication date: May 2026 [TO BE VERIFIED]<\/p>\r\n<p>DOI: [TO BE DEFINED]<\/p>\r\n<p>License: [TO BE DEFINED]<\/p>\r\n<p>Language: English<\/p>\r\n<p>PDF URL: [TO BE DEFINED]<\/p>\r\n<p>Italian page URL: [TO BE DEFINED]<\/p>\r\n<p>English page URL: [TO BE DEFINED]<\/p>\r\n<h3><span>Credits and citation<\/span><\/h3>\r\n<p>\u00a92026 Yellow People Lab Srl<\/p>\r\n<p>Via Privata del Gonfalone 3<\/p>\r\n<p>20123, Milano (MI), Italy<\/p>\r\n<p>VAT no. 08594800966<\/p>\r\n<p>European Cystitis Observatory (ECO). (2026, March). Understanding recurrent and chronic cystitis series: The Role of Diet and Hydration in Different Types and Symptoms of Cystitis (White Paper). ECO https:\/\/www.dimann.com\/european-cystitis-observatory\/<\/p>\r\n<\/section>\r\n<section class=\"eco-paper__section\" id=\"foreword\">\r\n<h2><span>Foreword<\/span><\/h2>\r\n<p>The relationship between diet and cystitis is one of the most widely\r\ndiscussed topics and, at the same time, one of the least supported by\r\nclear evidence in the day-to-day management of the condition. Many\r\npeople living with recurrent or chronic cystitis spontaneously modify\r\ntheir diet in an attempt to reduce symptoms, often relying on fragmented\r\nor research-unvalidated information.<\/p>\r\n<p>With this white paper, <strong>the second in the series\r\n\u201cUnderstanding Recurrent and Chronic Cystitis\u201d, the ECO Observatory aims\r\nto open new avenues of investigation<\/strong> into the social and\r\nbehavioural dynamics surrounding cystitis, with the goal of providing\r\nconcrete impetus for the emergence and development of further studies on\r\nthe topic., with the aim of providing concrete impetus for the emergence\r\nand development of further studies on the topic.<\/p>\r\n<p>The analyses presented are based on data collected during the Dimann\r\nproduct assignment process, and were therefore not originally structured\r\nwith the intent of answering specific research questions. It follows\r\nthat the results make no claim to exhaustivity: rather, this represents\r\n<strong>a first exploration of an as yet little-investigated\r\narea<\/strong>, conducted with the tools currently available. In this\r\nsense, the <strong>main value of this work lies in its goal of bringing\r\nthis topic to the attention of public decision-makers, institutions and\r\nresearchers<\/strong>, so that they may recognise its potential and the\r\nopportunity for new research initiatives.<\/p>\r\n<\/section>\r\n<section class=\"eco-paper__section eco-paper__section--soft eco-paper__section--pink\" id=\"executive-summary\">\r\n<h2><span>Executive Summary<\/span><\/h2>\r\n<p><strong>Cystitis is one of the most common urological\r\nconditions<\/strong> and, when caused by bacterial infection, contributes\r\nsignificantly to <strong>overall antibiotic consumption<\/strong>. This\r\nhas direct implications for the growing spread of antimicrobial\r\nresistance, today recognised as one of the leading public health\r\nchallenges worldwide. The problem takes on even greater significance in\r\nrecurrent forms of cystitis, which affect a considerable proportion of\r\npatients and have a substantial impact on quality of life.<\/p>\r\n<p>In this context, the search for non-pharmacological preventive\r\nstrategies and the identification of modifiable lifestyle factors are\r\nplaying an increasingly central role. Several studies suggest that\r\n<strong>specific dietary patterns, adequate daily fluid intake and bowel\r\nregularity<\/strong> may influence the risk of inflammation, symptom\r\nseverity and their tendency to recur. These factors are particularly\r\nrelevant from a clinical standpoint because, unlike many non-modifiable\r\npredisposing conditions, they can be addressed through intentional and\r\nsustainable lifestyle changes.<\/p>\r\n<p>*relative to symptomatic bacterial cystitis.<\/p>\r\n<\/section>\r\n<section class=\"eco-paper__section\" id=\"why-discuss-diet-in-relation-to-cystitis\">\r\n<h2><span>Why discuss diet in\r\nrelation to cystitis?<\/span><\/h2>\r\n<p class=\"eco-paper__lead\"><em>Diet plays a relevant role in urinary tract health, influencing\r\nurine composition, urothelial inflammation and the balance of the\r\nurinary and intestinal microbiota. Through metabolites produced by diet\r\nand microbiota, nutrients can modulate the chemical environment of the\r\nbladder, bacterial growth and the local immune response. Diets rich in\r\nfibre, phytonutrients and quality fats appear to support a more stable\r\nurinary ecosystem, whereas diets high in refined sugars and saturated\r\nfats may promote dysbiosis and inflammation. From this perspective, diet\r\nemerges as an important modifiable factor in the prevention and\r\nmanagement ofcystitis.<\/em><\/p>\r\n<p>In recent years, scientific research has progressively shown that\r\n<strong>diet<\/strong> does not only affect the domains traditionally\r\nassociated with nutritional habits, such as general metabolism and\r\ncardiovascular health, but also <strong>plays a significant role in\r\nmaintaining the balance and proper functioning of the urinary\r\nsystem<\/strong>. It is now clear that what we eat contributes to shaping\r\nthe biological environment of the bladder, influencing urine\r\ncomposition, urothelial inflammation and the balance of the urinary\r\nmicrobiota [1]. <strong>Diet therefore acts as a kind of biochemical\r\ncontrol panel for the urinary ecosystem<\/strong>. Through ingested\r\nnutrients, our body produces metabolites that are filtered by the\r\nkidneys and eliminated in the urine. These molecules modify fundamental\r\nparameters such as urinary pH, the availability of nutrients for\r\nbacteria and the inflammatory state of urothelial cells [2]. At the same\r\ntime, diet profoundly modulates the <strong>gut microbiota<\/strong>,\r\nwhich represents one of the main microbial reservoirs <strong>from which\r\nthe bacteria responsible for urinary tract infections can\r\noriginate<\/strong> [3].<\/p>\r\n<p>One of the key concepts emerging from the most recent literature is\r\nthat <strong>the intestine acts as a true \u201c<em>microbiological\r\nnursery<\/em>\" for many of the bacteria that subsequently colonise the\r\nbladder<\/strong>. Numerous uropathogens, including uropathogenic\r\nEscherichia coli (UPEC), originate in the intestinal microbiota and can\r\nmigrate to the urethra and bladder through perineal contamination\r\nmechanisms. [1, 2]<\/p>\r\n<p>In this complex picture, <strong>urine represents the final product\r\nof the metabolism of ingested food<\/strong> e and its chemical\r\ncomposition <strong>determines<\/strong> to a large extent <strong>which\r\nmicroorganisms can survive and proliferate in the bladder<\/strong>.<\/p>\r\n<p><strong>Diet therefore plays a fundamental role<\/strong> in\r\ndetermining which bacterial species predominate in the intestine. For\r\nexample, according to the literature, <strong>a diet rich in plant fibre\r\npromotes the growth of symbiotic bacteria<\/strong>, such as\r\n<em>Bifidobacterium<\/em> and other beneficial commensals that compete\r\nwith pathogens for available resources and help reduce the intestinal\r\nload of potentially uropathogenic bacteria. <strong>high consumption of\r\nrefined sugars, saturated fats and low fibre intake, tends to promote\r\nconditions of intestinal dysbiosis<\/strong>. In this context, bacterial\r\nstrains endowed with adhesion structures that facilitate their migration\r\nand colonisation of the urinary tract can proliferate. [4]<\/p>\r\n<p>Also, the <strong>quality of dietary fats and the presence of\r\nadditives<\/strong> typical of ultra-processed foods, such as emulsifiers\r\nor artificial sweeteners, can affect the health of the intestinal\r\nbarrier. Excessive exposure to these compounds can damage the so-called\r\n<em>tight junctions<\/em> between intestinal cells, promoting a condition\r\nknown as increased intestinal permeability (<em>leaky gut<\/em>). In this\r\nsituation, bacterial fragments such as lipopolysaccharides (LPS) and\r\nother microbial components can enter the bloodstream or lymphatic\r\nsystem, <strong>contributing to a state of systemic inflammation that\r\ncan also involve pelvic tissues and the bladder<\/strong>.<\/p>\r\n<p>A further perspective is the classification of foods according to\r\ntheir potential renal acid load (<em>Potential Renal Acid Load<\/em>,\r\nPRAL). Diets characterised by a high PRAL, typically rich in <strong>red\r\nmeat, aged dairy and refined cereals<\/strong>, <strong>tend to produce\r\nmore acidic urine<\/strong> [5]. Although acidity can inhibit certain\r\nbacteria, an excessively acidic urinary environment can irritate the\r\nnerve endings in the bladder, exacerbating symptoms such as\r\n<strong>pain, burning and urinary urgency<\/strong>. Conversely,\r\n<strong>diets rich in fruit, vegetables and legumes<\/strong> generally\r\nhave a low PRAL and promote the production of citrates and malates,\r\nwhich are excreted as bicarbonates <strong>thereby moderately alkalising\r\nthe urine<\/strong> [5]. Furthermore, a less acidic urinary environment\r\nis often less irritating for an inflamed urothelium and can favour the\r\ngrowth of protective bacteria, such as <em>Lactobacilli<\/em> [6].<\/p>\r\n<p>Beyond macronutrients, several bioactive compounds in foods can\r\ndirectly influence the ability of bacteria to adhere to the bladder wall\r\nor form biofilms. Among these, polyphenols and anthocyanins found in\r\n<strong>berries, pomegranate and green tea<\/strong> are of particular\r\ninterest. Part of these compounds is not completely absorbed in the\r\nintestine but is transformed by the microbiota into metabolites that\r\nreach the bladder through the renal filtrate. Here they can\r\n<strong>interfere with bacterial adhesion mechanisms<\/strong>, hindering\r\nthe anchoring of fimbriae to urothelial cells. A similar mechanism has\r\nbeen observed for <strong>D-mannose<\/strong>, a sugar naturally present\r\nin various fruits, including apples and peaches. This molecule acts as a\r\nkind of \u201cmolecular bait\u201d: <strong>E. coli bacteria preferentially bind\r\nto mannose molecules present in urine rather than to receptors on the\r\nbladder wall, and are then eliminated through urination<\/strong>\r\n[7].<\/p>\r\n<p>Other nutrients instead help modulate the inflammatory response or\r\nlocal immune defences. Omega-3 fatty acids, found in <strong>oily fish\r\nand flaxseeds, reduce the production of inflammatory mediators such as\r\nprostaglandins<\/strong>, while <strong>vitamin D stimulates the\r\nsynthesis of antimicrobial peptides in the urothelium<\/strong>, such as\r\ncathelicidin [8].<\/p>\r\n<p>Micronutrients such as <strong>vitamin A and zinc are also\r\nfundamental for maintaining the integrity of the urothelial mucosa and\r\nfor the production of defensins<\/strong>, molecules that help control\r\nthe density of the urinary microbiota. The latter, in turn, does not\r\nrepresent an isolated system but a dynamic microbial community\r\ninfluenced by diet and intestinal physiology: under balanced conditions,\r\nthe urinary microbiota in women is often dominated\r\nby<em>Lactobacillus<\/em>, while in men a more mixed community is\r\nobserved comprising genera such as <em>Corynebacterium<\/em> e\r\n<em>Streptococcus<\/em> [8].<\/p>\r\n<p>Some dietary patterns, however, can alter this balance. Recent\r\nstudies indicate that diets rich in saturated fats and refined sugars\r\nalso tend to reduce the diversity of the urinary microbiota\r\n(<em>alpha-diversity<\/em>), favouring colonisation by opportunistic\r\nspecies such as <em>Klebsiella<\/em> o <em>Proteus<\/em>. Conversely,\r\n<strong>regular intake of fermented foods, such as yogurt, kefir or\r\nsauerkraut<\/strong>, does not necessarily bring live bacteria to the\r\nbladder, but <strong>contributes to modulating the intestinal and\r\nvaginal microbiota<\/strong>, indirectly reducing the migratory pressure\r\nof pathogens towards the urethra [6].<\/p>\r\n<p>Finally, <strong>substances such as caffeine, alcohol, spicy foods\r\nand certain food additives can pass through the renal filter and reach\r\nthe bladder in a relatively intact form<\/strong> [5, 6], exerting a\r\ndirect irritating action on urothelial cells and stimulating the release\r\nof inflammatory mediators, including histamine [4]. Conversely,\r\ncompounds such as polyphenols, antioxidants and flavonoids (including\r\nquercetin, found in foods such as apples and onions) can help stabilise\r\nthe immune cells involved in the inflammatory response and reduce\r\noxidative damage induced by bacterial infection.<\/p>\r\n<p>The most recent scientific evidence [8], accumulated between 2020 and\r\n2026, suggests that <strong>the ideal diet to support a balanced urinary\r\nmicrobiota<\/strong> should prioritise a few fundamental principles:<\/p>\r\n<ul>\r\n<li><p>un <strong>high intake of soluble fibre<\/strong>, useful for\r\npromoting the production of anti-inflammatory metabolites such as\r\nbutyrate;<\/p><\/li>\r\n<li><p>a <strong>moderate protein intake<\/strong>, preferably from\r\nvegetable or lean sources, to avoid excessive urea load;<\/p><\/li>\r\n<li><p>a <strong>diet rich in phytonutrients<\/strong>, such as\r\nflavonoids and anthocyanins, capable of hindering bacterial\r\nadhesion;<\/p><\/li>\r\n<li><p>a <strong>adequate hydration<\/strong>, essential for diluting\r\nurine and promoting the mechanical elimination of pathogens.<\/p><\/li>\r\n<\/ul>\r\n<\/section>\r\n<section class=\"eco-paper__section\" id=\"the-role-of-proper-hydration-in-cystitis\">\r\n<h2><span>The role of proper\r\nhydration in cystitis.<\/span><\/h2>\r\n<p class=\"eco-paper__lead\"><em>Proper hydration is one of the simplest and most effective\r\nbehavioural factors in the prevention and management ofcystitis.\r\nAdequate fluid intake promotes urine dilution, voiding frequency and the\r\nso-called mechanical bacterial \u201cwash-out\u201d, limiting bacterial adhesion\r\nto the bladder mucosa. It also helps reduce urothelial irritation,\r\nmaintain the balance of the urinary microbiota and support bowel\r\nregularity, all of which contribute to reducing the risk of cystitis\r\nrecurrence.<\/em><\/p>\r\n<p>Among the modifiable factors influencing urinary tract health,\r\n<strong>hydration is one of the simplest and most effective\r\ninterventions in both the prevention and management ofcystitis<\/strong>.\r\nDrinking adequate amounts of water does not only act as a general\r\nsupport to metabolism, but directly modifies the biochemical and\r\nmicrobiological ecosystem of the bladder, influencing urine\r\nconcentration, voiding frequency, urothelial integrity and the ability\r\nof bacteria to colonise the urinary tract.<\/p>\r\n<p>To understand this mechanism, it can be helpful to imagine\r\n<strong>the bladder<\/strong> as a <strong>biological reservoir<\/strong>\r\nin which bacteria attempt to establish themselves and multiply [6]. The\r\nmain agent responsible for cystitis, E. coli, possesses specialised\r\nprotein structures called fimbriae, which function as small molecular\r\n\u201chooks\u201d through which bacteria are able to adhere to the inner wall of\r\nthe bladder.<strong>If urine remains stagnant in the bladder for a long\r\ntime, these microorganisms have the time needed to multiply rapidly and\r\nestablish colonisation of the urothelial mucosa<\/strong> [9], with\r\ndoubling times of approximately 20 minutes.<\/p>\r\n<p>Conversely, adequate fluid intake radically alters this dynamic. The\r\nincrease in fluid intake stimulates greater urine production and more\r\nfrequent urination, generating a continuous flow that exerts a true\r\nmechanical \u201c<em>wash-out<\/em>\" [10]. In other words, the passage of\r\nliquid helps to detach bacteria that have not yet become firmly attached\r\nto the mucosa and to eliminate them through urination, reducing the\r\nprobability that the infection will develop or consolidate.fissati\r\nfirmly to the mucosa and eliminate them through urination, reducing the\r\nlikelihood that the infection will develop or consolidate.<\/p>\r\n<p>Beyond the mechanical effect, <strong>hydration also acts through\r\nimportant chemical and metabolic mechanisms<\/strong>. Urine is composed\r\nnot only of water, but contains a mixture of salts, acids and metabolic\r\nwaste products [10]. Under conditions of <strong>dehydration<\/strong>\r\nthese substances become highly concentrated: a phenomenon easily\r\nrecognisable from the <strong>darker colour and a stronger odour of the\r\nurine<\/strong>.<\/p>\r\n<p>Highly concentrated urine can be chemically irritating to the bladder\r\nmucosa, especially when the urothelium is already inflamed. In these\r\nconditions, the <strong>high concentration of metabolites can act as a\r\ndirect irritant<\/strong>, exacerbating typical cystitis symptoms such as\r\n<strong>burning sensation, pain and urinary urgency<\/strong>.\r\nConversely, proper hydration dilutes these substances, making urine less\r\naggressive to bladder tissue and helping to reduce local inflammatory\r\nstatus. Urine dilution also affects bacterial density and the\r\navailability of nutrients for microorganisms. In a larger volume of\r\nfluid, bacteria are more dispersed and have a lower likelihood of coming\r\ninto contact with the bladder wall. At the same time, a more dilute\r\nurine is relatively poor in metabolic nutrients, making rapid bacterial\r\nproliferation more difficult and giving the immune system the time\r\nneeded to intervene.<\/p>\r\n<p><strong>A further benefit<\/strong> of hydration concerns the\r\nprotection of the <strong>glycosaminoglycan (GAG) layer lining the\r\nurothelium<\/strong> [11], i.e. the inner lining of the bladder. This\r\nlayer represents a <strong>fundamental barrier against bacterial\r\nadhesion<\/strong> and the irritating action of substances present in the\r\nurine. When the body is dehydrated, urine becomes more concentrated,\r\nacidic and rich in salts. This mixture can have an erosive effect on the\r\nbladder mucosa, creating micro-irritations that weaken the protective\r\nlayer and facilitate bacterial adhesion. Maintaining clear and dilute\r\nurine, on the other hand, helps preserve the integrity of this\r\n\u201cbiological shield\u201d, reducing both the risk of bacterial colonisation\r\nand the intensity of irritative symptoms.<\/p>\r\n<p><strong>The importance of hydration<\/strong> becomes particularly\r\nevident <strong>in recurrent cystitis<\/strong>, a condition in which\r\nepisodes recur frequently over time. In many cases, even when acute\r\nsymptoms have resolved, the urinary environment may remain favourable to\r\nthe persistence of small bacterial foci or rapid recolonisation.\r\nMaintaining <strong>good long-term hydration<\/strong> contributes to\r\n<strong>stably modifying the ecosystem of the urinary tract<\/strong>\r\n[7], reducing opportunities for bacteria to re-colonise the bladder.\r\nStudies on bacterial growth in urine have already shown that hanno\r\nvoiding frequency and the rate of renal filtration represent fundamental\r\nfactors in limiting microbial proliferation [9]. Consistently with these\r\nobservations, the European Association of Urology (EAU) guidelines\r\nrecommend increasing fluid intake as a first-line behavioural\r\nintervention in the prevention of urinary tract infections [7].<\/p>\r\n<p>Regarding the impact on the <strong>urinary microbiota<\/strong>,\r\nproper hydration also helps maintain favourable conditions in this\r\nregard. Recent studies suggest that less concentrated urine favours the\r\n<strong>survival of protective commensal bacteria<\/strong> [8], while\r\noverly dense urinary environments rich in toxic metabolites may hinder\r\nthese beneficial species and favour the growth of opportunistic\r\nbacteria. Hydration also affects<strong>urinary pH<\/strong>, a parameter\r\nthat conditions microbial growth and the tolerability of urine by the\r\nurothelium. As highlighted in several review papers on the physiology of\r\nhydration [10], adequate fluid availability contributes to maintaining a\r\nmore stable chemical balance in the urine and to preserving the health\r\nof urothelial tissue.10], adequate fluid availability contributes to\r\nmaintaining a more stable chemical balance in the urine and to\r\npreserving the health of urothelial tissues.<\/p>\r\n<p>Hydration also plays a relevant role in the context of the so-called\r\n<strong>gut\u2013bladder axis<\/strong> [12], espression used to indicate\r\n<strong>the set of functional, microbiological and immunological\r\ninteractions that connect the intestine and the urinary tract<\/strong>.\r\nThe two districts are indeed closely connected: they share anatomical\r\nproximity, part of the sacral nervous control and, above all, a\r\nrelationship mediated by the intestinal microbiota, which represents one\r\nof the main sources of bacteria involved in urinary tract infections.\r\nConsequently, conditions that affect intestinal function \u2013 such as\r\nhydration, transit regularity or microbiota balance \u2013 can also have\r\nrepercussions on the urinary environment and susceptibility to bladder\r\ninfections [8].\u2013 such as hydration, transit regularity or microbiota\r\nbalance \u2013 can also have repercussions on the urinary environment and\r\nsusceptibility to bladder infections [8].<\/p>\r\n<p>Water is indeed essential for the proper functioning of dietary fibre\r\nand for maintaining bowel regularity.<strong>If fluid intake is\r\ninsufficient, even a fibre-rich diet may prove ineffective<\/strong>,\r\nsince fibre tends to absorb water and slow intestinal transit in the\r\nabsence of adequate hydration [13].. <strong>Chronic constipation is a\r\nwell-known risk factor for urinary tract infections<\/strong>, as faecal\r\nstagnation can promote the proliferation of potentially uropathogenic\r\nintestinal bacteria and increase the probability of urinary tract\r\ncontamination [12]. For this reason, proper hydration also indirectly\r\ncontributes to cystitis prevention by improving intestinal function. The\r\nmost recent recommendations suggest that <strong>daily fluid\r\nrequirements<\/strong> can be estimated at approximately <strong>25\u201335 ml\r\nof water per kilogram of body weight<\/strong> [13].<\/p>\r\n<p>Finally, it is important to emphasise that <strong>good\r\nhydration<\/strong> does not depend solely on the total amount of water\r\ningested, but also on the <strong>distribution of intake throughout the\r\nday<\/strong>. Drinking large quantities of water at a single sitting\r\nleads to rapid elimination of fluids [13] without ensuring effective\r\ntissue hydration. Instead,<strong>it is preferable to sip water\r\nregularly<\/strong> throughout the day, maintaining a constant flow of\r\nfluids that promotes stable urine production.<\/p>\r\n<\/section>\r\n<section class=\"eco-paper__section\" id=\"the-role-of-food-intolerances-and-bowel-regularity-in-cystitis\">\r\n<h2><span>The\r\nrole of food intolerances and bowel regularity in cystitis.<\/span><\/h2>\r\n<p class=\"eco-paper__lead\"><em>Scientific evidence indicates that food intolerances and\r\nalterations in bowel regularity can influence the risk of cystitis\r\nthrough the mechanisms of the gut\u2013bladder axis. Inflammation of the\r\nintestinal mucosa, dysbiosis and increased permeability of the\r\nintestinal barrier can promote the proliferation and migration of\r\nuropathogenic bacteria towards the urinary tract. At the same time,\r\nconditions such as chronic constipation increase intestinal bacterial\r\nload and can impede proper bladder emptying, creating an environment\r\nconducive to infections.<\/em><\/p>\r\n<p>In the context of growing attention to the interactions between the\r\nintestine and the urinary tract, <strong>food intolerances and\r\nalterations in bowel regularity<\/strong> are attracting <strong>growing\r\ninterest<\/strong>, as they may contribute to altering the balance of the\r\nintestinal mucosa, microbiota and inflammatory processes, indirectly\r\nfavouring conditions predisposing to the development or persistence of\r\nurinary tract infections. Intolerated foods can promote inflammation of\r\nthe intestinal mucosa, alterations in microbiota composition and\r\nincreased intestinal barrier permeability [12], creating an environment\r\nthat facilitates bacterial proliferation and the spread of potentially\r\npathogenic microorganisms.], creating an environment that facilitates\r\nbacterial proliferation and the spread of potentially pathogenic\r\nmicroorganisms.<\/p>\r\n<p>However, it should be noted that, in the case of known food\r\nintolerances, individuals reasonably tend to<strong>eliminate the\r\nproblematic foods from their diet<\/strong>. Nevertheless, many studies\r\nfind that <strong>the association with cystitis persists<\/strong> for\r\nmultiple reasons. Firstly, the intolerance itself represents a signal of\r\na <strong>heightened systemic sensitivity<\/strong> of the body,\r\nindicative of an intrinsic fragility that goes beyond acute exposure to\r\nthe food, such as an inflammatory predisposition or heightened immune\r\nreactivity [13]. Secondly, dietary elimination may not be complete: it\r\noften occurs partially or intermittently, allowing residual exposure\r\nthat maintains a <strong>subclinical<\/strong> subclinical. Furthermore,\r\nthe discovery of the intolerance may occur after years of prolonged\r\nconsumption, during which <strong>the food has already chronically\r\ncontributed to alterations of the intestinal barrier and\r\nmicrobiota<\/strong>, with persistent effects on the risk of cystitis\r\n[18]. At the same time, dietary modification induced by the elimination\r\nof specific foods may introduce secondary nutritional imbalances, such\r\nas deficiencies or changes in microbial composition, which in turn\r\nindirectly favour the pathogenesis of urinary tract infections.<\/p>\r\n<p>On the other hand, regarding <strong>bowel irregularity<\/strong>,\r\nthis can increase the bacterial load in the colon and promote faecal\r\nstagnation, conditions that increase the likelihood of migration of\r\nuropathogenic bacteria towards the urinary tract [15] and may contribute\r\nto the appearance or recurrence of infections. Among the intestinal\r\nfactors most relevant to recurrent cystitis is <strong>chronic\r\nconstipation<\/strong>. <strong>When intestinal transit is\r\nslowed<\/strong>, faeces stagnate longer in the colon and become a true\r\n<strong>high-density bacterial reservoir, rich in bacteria and\r\nopportunistic microorganisms<\/strong> [16].<\/p>\r\n<p>This stagnation can have consequences at multiple levels: on one\r\nhand, the increased intestinal bacterial load raises the likelihood that\r\npotentially uropathogenic bacteria will migrate to the urethra; on the\r\nother,<strong>the accumulated faecal mass in the rectum can exert\r\nmechanical pressure on the bladder<\/strong> [2], interfering with its\r\nproper emptying and favouring the <strong>persistence of urinary\r\nresiduals<\/strong>, a condition that facilitates bacterial growth.\r\nFurthermore, constipation is often associated with a state of intestinal\r\ninflammation and dysbiosis, which can further compromise the intestinal\r\nbarrier function and favour the spread of pro-inflammatory bacterial\r\ncomponents into the systemic circulation.<\/p>\r\n<p>Among the most relevant functions of the intestine is its role as\r\n<strong>immune regulator of the entire body<\/strong>, modulating\r\nnumerous immunological and inflammatory processes that can also\r\ninfluence urinary tract health. A balanced intestinal microbiota\r\nproduces various bioactive metabolites, including short-chain fatty\r\nacids (SCFAs), such as butyrate. These molecules play a key role in\r\n<strong>regulation of systemic inflammation and maintenance of mucosal\r\nintegrity<\/strong> [8]. Butyrate, in particular, possesses potent\r\nanti-inflammatory and immunomodulatory properties.<\/p>\r\n<p>When a condition of intestinal dysbiosis develops, the production of\r\nthese protective metabolites can decrease significantly. The reduction\r\nin SCFAs, and in particular butyrate, can render the tissues of the\r\npelvic district \u2014 including the bladder \u2014 more vulnerable to\r\ninflammatory processes, increasing susceptibility to infections and the\r\npersistence of urinary symptoms.<\/p>\r\n<p><strong>The relationship between the intestine and the\r\nbladder<\/strong> is not only microbiological or immunological, but\r\n<strong>also has deep anatomical and neurological roots<\/strong>. During\r\nembryonic development, these two organs derive from closely related\r\nanatomical structures and maintain partially shared innervation\r\nthroughout life [17]. The nerves regulating the functioning of the\r\nrectum and the bladder both originate from the sacral segment of the\r\nspinal cord. This neurological connection can generate a phenomenon\r\nknown as <em>cross-sensitization<\/em> [18], i.e. cross-sensitization\r\nbetween the two organs. In practice, <strong>when the intestine is\r\nirritated or inflamed, nerve signals transmitted to the spinal cord can\r\nbe interpreted as alarm signals for the bladder as well<\/strong>. This\r\nmechanism explains why many people affected by irritable bowel syndrome\r\n(IBS) or other inflammatory intestinal conditions also experience\r\nurinary symptoms, such as urinary urgency or increased urinary\r\nfrequency, even in the absence of bladder infection [16, 19].16,\r\n19].<\/p>\r\n<p>A further element of connection between the intestine and the bladder\r\nis the <strong>pelvic floor<\/strong> [12], the set of muscles and\r\nsupporting structures that keep pelvic organs in position and\r\nparticipate in the control of urination and defecation. <strong>When\r\nintestinal function is altered<\/strong>, for example in the presence of\r\nchronic constipation, <strong>these muscles may be subjected to repeated\r\nstrain<\/strong> during defecation, leading to a state of contraction or\r\nmuscular hypertonia. An excessively contracted pelvic floor <strong>can\r\ninterfere with proper bladder emptying<\/strong>[12], favouring the\r\npresence of post-void urinary residual, a condition that increases the\r\nrisk of bacterial proliferation and urinary tract infections.<\/p>\r\n<p>Overall, scientific evidence indicates that urinary tract health is\r\nclosely linked to the balance of the intestinal ecosystem. For this\r\nreason, <strong>in the management of recurrent cystitis it is\r\nincreasingly important to adopt an integrated approach<\/strong>that\r\nconsiders not only the bladder, but also the functioning of the\r\nintestine. Promoting good bowel regularity, maintaining a balanced\r\nmicrobiota and identifying any foods that may cause inflammation or\r\nintolerance is a fundamental step in reducing the risk of infections and\r\nimproving the health of the entire pelvic district.<\/p>\r\n<p>In this perspective, the <strong>prevention of cystitis<\/strong> does\r\nnot concern only the treatment dell\u2019infiammazione when it occurs, but\r\nalso the <strong>maintenance of a physiological balance between the\r\nintestine, microbiota, immune system and urinary tract<\/strong> [7],\r\nelements that together contribute to the stability of the urogenital\r\necosystem.<\/p>\r\n<div class=\"eco-paper__box\">\r\n<span class=\"eco-paper__box-title\">Did you know?<\/span>\r\n<span class=\"eco-paper__box-subtitle\">An ancient kinship between the intestine and the bladder<\/span>\r\n<p>An ancient kinship between the intestine and the\r\nbladder The intestine and bladder are more closely connected than one\r\nmight think. During embryonic development, they form from adjacent\r\nstructures and share part of the same neural network, originating from\r\nthe sacral segment of the spinal cord. For this reason, when the\r\nintestine is irritated or inflamed, nerve signals can also involve the\r\nbladder: this is the phenomenon of cross-sensitization, which explains\r\nwhy those suffering from irritable bowel syndrome often also experience\r\ngreater urinary urgency. The pelvic floor, which supports both organs,\r\nalso plays an important role: if it is too contracted \u2014 for example due\r\nto constipation \u2014 the bladder may empty less effectively, promoting\r\nbacterial proliferation.<\/p>\r\n<\/div>\r\n<\/section>\r\n<section class=\"eco-paper__section eco-paper__section--soft\" id=\"the-dimann-dataset\">\r\n<h2><span>The Dimann Dataset<\/span><\/h2>\r\n<p>The study was conducted using the Dimann dataset, a large collection\r\nof<strong>surveys spontaneously completed by online purchasers of\r\nD-mannose<\/strong>. These questionnaires were designed to support the\r\nformulation of personalised product recommendations, collecting\r\ninformation on aspects such as habits, individual characteristics,\r\nperceived needs and contexts of use. This approach confers a high\r\ninformational value on the dataset and makes it particularly suited to\r\nserve as a solid empirical basis for developing targeted, evidence-based\r\npreventive strategies.<\/p>\r\n<p><strong>The sample analysed comprises over 34,000 anonymised\r\nquestionnaires<\/strong>, compiled in the period between January 2022 and\r\nMay 2025. Currently, the dataset is focused on four main European\r\ncountries \u2014<strong>Italy, France, Germany and Spain<\/strong> \u2014 offering\r\na relevant comparative overview within different but comparable\r\ncontexts. In a perspective of continuous development, an extension of\r\nthe dataset and related analyses is already underway within the ECO\r\nObservatory, with the<strong>inclusion of new countries in the coming\r\nmonths<\/strong>. This expansion will allow the geographic and\r\ndemographic coverage to be broadened, further improving the\r\ngeneralisability of the results and the applicative potential of the\r\nevidence obtained, both in the preventive field and in support of future\r\nstrategic decisions.<\/p>\r\n<div class=\"eco-paper__table-wrap\"><table>\r\n<colgroup>\r\n<col style=\"width: 23%\"\/>\r\n<col style=\"width: 43%\"\/>\r\n<col style=\"width: 33%\"\/>\r\n<\/colgroup>\r\n<tbody>\r\n<tr class=\"odd\">\r\n<td><strong>Country<\/strong><\/td>\r\n<td><strong>Number of observations<\/strong><\/td>\r\n<td><strong>%<\/strong><\/td>\r\n<\/tr>\r\n<tr class=\"even\">\r\n<td><strong>Italy<\/strong><\/td>\r\n<td>32.457<\/td>\r\n<td>94.7%<\/td>\r\n<\/tr>\r\n<tr class=\"odd\">\r\n<td><strong>Spain<\/strong><\/td>\r\n<td>1.036<\/td>\r\n<td>3.0%<\/td>\r\n<\/tr>\r\n<tr class=\"even\">\r\n<td><strong>France<\/strong><\/td>\r\n<td>721<\/td>\r\n<td>2.1%<\/td>\r\n<\/tr>\r\n<tr class=\"odd\">\r\n<td><strong>Germany<\/strong><\/td>\r\n<td>63<\/td>\r\n<td>0.2%<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table><\/div>\r\n<p>The questionnaire, organised into thematic sections, explores key\r\nbehavioural factors related to cystitis, including personal hygiene,\r\ndietary and sexual habits, stress levels and other lifestyle\r\naspects.<strong>With over 30 variables dedicated to the impact and\r\nconsequences of the condition<\/strong> \u2013 such as effects on mood, social\r\nlife and productivity \u2013 <strong>the dataset sheds light on dimensions of\r\nthe condition that are often overlooked<\/strong>.<\/p>\r\n<div class=\"eco-paper__table-wrap\"><table>\r\n<colgroup>\r\n<col style=\"width: 23%\"\/>\r\n<col style=\"width: 43%\"\/>\r\n<col style=\"width: 33%\"\/>\r\n<\/colgroup>\r\n<tbody>\r\n<tr class=\"odd\">\r\n<td><strong>Gender<\/strong><\/td>\r\n<td><strong>Number of observations<\/strong><\/td>\r\n<td><strong>%<\/strong><\/td>\r\n<\/tr>\r\n<tr class=\"even\">\r\n<td><strong>Woman<\/strong><\/td>\r\n<td>33.628<\/td>\r\n<td>98.1%<\/td>\r\n<\/tr>\r\n<tr class=\"odd\">\r\n<td><strong>Man<\/strong><\/td>\r\n<td>628<\/td>\r\n<td>1.8%<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table><\/div>\r\n<p><strong>A marked female predominance emerged in the sample<\/strong>,\r\nwith 98.1% women compared to less than 2% men. This female predominance\r\nis likely related both to the targeting of the products offered by\r\nDimann, primarily aimed at women, and to the strong female prevalence in\r\nthe incidence of cystitis. The remaining 0.1% selected the \u201cother\u201d\r\ncategory, which was excluded from the models.<\/p>\r\n<p><strong>Age distribution<\/strong><\/p>\r\n<p>Regarding age, the individuals included in the sample fall within an\r\nage range of 18 to 99 years; however, participants over 55 years of age\r\nare less represented compared to younger groups. <strong>The mean age is\r\n40 years<\/strong>, with a median of 39, indicating a right-skewed\r\ndistribution. The third quartile, equal to 52 years, shows that 75% of\r\nrespondents are aged 52 or under. These values suggest that the dataset\r\nprimarily represents adults in the young and middle-age bracket.<\/p>\r\n<\/section>\r\n<section class=\"eco-paper__section\" id=\"the-dimann-dataset-dietary-habits-intolerances-and-bowel-regularity\">\r\n<h2><span>The\r\nDimann Dataset: dietary habits, intolerances and bowel regularity<\/span><\/h2>\r\n<p>To systematically analyse the possible role of behavioural and\r\nnutritional factors in the modulation of cystitis, the variables\r\nincluded in the study were specifically considered in relation to two\r\ncentral clinical dimensions: the type of the condition and the perceived\r\nsymptomatology.<\/p>\r\n<p><strong>The variables relating to dietary regimen, hydration habits,\r\nthe presence of food intolerances and bowel regularity<\/strong> were\r\ntherefore treated as indirect indicators of physiological and\r\nbehavioural contexts that <strong>may influence metabolic, intestinal,\r\nimmune and urinary balance<\/strong>.<\/p>\r\n<p>In this perspective, each of these dimensions was not analysed as an\r\nisolated element, but as part of a system of factors that may contribute\r\nto defining specific risk profiles. Dietary habits help define the type\r\nof foods consumed daily and their potential impact on inflammation, the\r\nintestinal microbiota and urine composition; hydration directly affects\r\nurinary dilution and bladder voiding dynamics; food intolerances can\r\ninfluence food choices and the functioning of the digestive system;\r\nbowel regularity is a key indicator of gastrointestinal tract balance,\r\nknown for its interconnections with the urinary system.<\/p>\r\n<p>An this integrated interpretive framework, behavioural variables can\r\ntherefore be read as elements potentially associable with specific types\r\nof cystitis and different levels of symptom intensity, facilitating the\r\nemergence of clinically significant correlations in subsequent\r\nanalyses.<\/p>\r\n<p>In other words, this approach helps to read <strong>daily habits as\r\nfactors that may help explain why cystitis manifests in different ways\r\nand with symptoms of varying intensity<\/strong>, facilitating the\r\nidentification of clinically useful correlations.<\/p>\r\n<h3 id=\"diet-and-nutrition\"><span>Diet and nutrition<\/span><\/h3>\r\n<p>To investigate the dietary habits of people affected by cystitis,\r\nincluding daily water intake and the possible presence of food\r\nintolerances, responses to a Dimann questionnaire question about daily\r\nnutritional habits were used.<\/p>\r\n<div class=\"eco-paper__box\">\r\n<span class=\"eco-paper__box-title\">Your diet is...*<\/span>\r\n<ul>\r\n<li><p>you do not follow a specific diet;<\/p><\/li>\r\n<li><p>you follow a vegetarian diet;<\/p><\/li>\r\n<li><p>you follow a vegan diet;<\/p><\/li>\r\n<li><p>you follow a paleo diet;<\/p><\/li>\r\n<li><p>you follow a macrobiotic diet;<\/p><\/li>\r\n<li><p>other.<\/p><\/li>\r\n<\/ul>\r\n<p><em>*Single-answer question<\/em><\/p>\r\n<\/div>\r\n<p><strong>The \u201cother\u201d option in the questionnaire allows participants\r\nto manually enter text responses<\/strong> not covered by the predefined\r\noptions, favouring more detailed and personalised data. During the data\r\npreparation and cleaning phase, these textual responses were subjected\r\nto a systematic recoding process: <strong>the most frequent responses\r\nwere aggregated into additional categories<\/strong>, enhancing the\r\ninformation collected and more accurately representing actual dietary\r\nhabits.<\/p>\r\n<p>As a result, <strong>three new categories<\/strong>, drastically\r\nreducing the use of the residual \u201cother\u201d option. This enhanced the\r\ndescriptive capacity of the variable and the precision of subsequent\r\nanalyses.<\/p>\r\n<div class=\"eco-paper__box\">\r\n<span class=\"eco-paper__box-title\">Additional categories<\/span>\r\n<ul>\r\n<li><p>lactose-free diet;<\/p><\/li>\r\n<li><p>gluten-free diet;<\/p><\/li>\r\n<li><p>low-carb diet.<\/p><\/li>\r\n<\/ul>\r\n<\/div>\r\n<p>The final distribution thus obtained is illustrated in the donut\r\nchart in Figure 2. The option \u201c<strong>you do not follow a specific\r\ndiet<\/strong>\u201d emerges as the most frequent response. This category\r\nprimarily includes omnivorous dietary regimens attributable to an\r\nordinary Mediterranean model, characterised by variety and the absence\r\nof formal restrictions or codified dietary structures.<\/p>\r\n<p>The second most common response is <strong>vegetarian diet<\/strong>,\r\nindicating a significant presence of nutritional choices oriented\r\ntowards models that differ from traditional omnivorous eating. It should\r\nbe noted that this option is distinguished from the vegan diet by the\r\ninclusion of animal products such as dairy and eggs, while still\r\nexcluding meat and fish.<\/p>\r\n<p><strong>Your diet is...<\/strong><\/p>\r\n<p>The <strong>vegan diet (0.9%)<\/strong>, although less frequent than\r\nvegetarian (5.5%), highlights a proportion of respondents who adopt a\r\nmore selective dietary regimen, characterised by the total exclusion of\r\nanimal products. This figure signals the existence of subgroups with\r\nhighly structured dietary choices guided by ethical, environmental or\r\nhealth motivations that could influence the incidence and symptomatology\r\nof cystitis.<\/p>\r\n<p>The third most frequent category is the <strong>macrobiotic\r\ndiet<\/strong>. This finding is particularly relevant, as it is a\r\nstructured dietary regimen based on principles of food balance,\r\nseasonality and a prevalence of whole grains, vegetables and legumes.\r\nIts prevalence in the sample suggests the presence of a subgroup of\r\nrespondents who adopt dietary choices strongly oriented towards specific\r\nand codified nutritional models.<\/p>\r\n<p>The remaining categories \u2013 including gluten-free, paleo, low-carb and\r\nlactose-free diets \u2013 show progressively lower frequencies. These\r\nregimens, often associated with specific needs or targeted nutritional\r\norientations, concern more limited portions of the population\r\nconsidered. Their presence, although minority, is nonetheless relevant\r\nfrom an exploratory analysis perspective, as it may be indicative of\r\nparticular dietary needs or associated clinical conditions.<\/p>\r\n<h3 id=\"daily-water-intake\"><span>Daily water intake<\/span><\/h3>\r\n<p>The second key variable analysed is daily water intake, measured\r\nthrough a single-answer question with predefined categorical options.\r\nThis metric is crucial in discussions relating to cystitis, as adequate\r\nhydration promotes urinary flow, reducing bacterial concentration in the\r\nbladder and the risk of pathogen adhesion to urethral walls\r\n[15].15].<\/p>\r\n<p>Similarly to the diet distribution, this variable allows correlation\r\nof fluid intake with cystitis type and symptom severity, highlighting\r\npotential behavioural influences.<\/p>\r\n<div class=\"eco-paper__box\">\r\n<span class=\"eco-paper__box-title\">How much water do you drink per day?*<\/span>\r\n<ul>\r\n<li><p>you have to force yourself to drink;<\/p><\/li>\r\n<li><p>one litre or less;<\/p><\/li>\r\n<li><p>approximately two litres or more;<\/p><\/li>\r\n<li><p>when you have cystitis you drink a lot, when it passes you drink\r\nlittle;<\/p><\/li>\r\n<li><p>you don\u2019t pay attention.<\/p><\/li>\r\n<\/ul>\r\n<p><em>*Single-answer question<\/em><\/p>\r\n<\/div>\r\n<p>Particularly relevant to the analysis is the presence of the response\r\noption \"<strong>when you have cystitis you drink a lot, when it passes\r\nyou drink little<\/strong>\u201d, which reflects a very common behaviour among\r\npatients: increasing fluid intake as a reactive strategy during the\r\nacute phase, followed by a reduction in hydration during the\r\nasymptomatic phase.<strong>This option makes it possible to\r\ncapture<\/strong> not only the average level of water consumption, but\r\nalso <strong>the behavioural variability linked to the progression of\r\ndell\u2019infiammazione<\/strong>.<\/p>\r\n<p><strong>How much water do you drink per day?<\/strong><\/p>\r\n<p>The distribution of responses provides an articulated picture of\r\nhydration habits among participants. As shown in Figure 3, the most\r\nfrequent response is<strong>approximately two litres or more<\/strong>\u201d,\r\nindicated by 34% of the sample, confirming the presence of a significant\r\nproportion of respondents who report water consumption in line with\r\ngeneral recommendations. In second place is the option \u201c<strong>when you\r\nhave cystitis you drink a lot, when it passes you drink\r\nlittle<\/strong>\u201d, chosen by 26% of respondents. This finding is\r\nparticularly noteworthy as it highlights a <strong>reactive hydration\r\nbehaviour<\/strong>, closely linked to the appearance of symptoms rather\r\nthan to a stable daily habit.<\/p>\r\n<p>20% of respondents report instead drinking \u201c<strong>one litre or\r\nless<\/strong>\" per day, indicating a potentially insufficient level of\r\nhydration. In addition to this,<strong>doversi imporre di\r\nbere<\/strong>\u201d, signalling a structural difficulty in maintaining\r\nadequate fluid intake during the day. Finally, a minority proportion,\r\nequal to 6%, states \u201c<strong>don\u2019t pay attention<\/strong>\u201d, highlighting\r\nlimited awareness of their own water consumption habits.<\/p>\r\n<p>However, it should be noted that some of these responses do not allow\r\na clear assessment of whether daily fluid intake<strong>is actually\r\nadequate relative to individual needs<\/strong>. In particular, in the\r\ncase of \u201creactive\u201d hydration, fluid intake appears discontinuous and not\r\nnecessarily sufficient during asymptomatic periods, which actually\r\nrepresent a crucial phase for relapse prevention. Similarly, the\r\nresponses \u201chave to force yourself to drink\u201d and \u201cdon\u2019t pay attention\u201d\r\nsuggest a lack of structure and awareness around hydration habits,\r\nmaking it difficult to establish whether daily intake is in line with\r\nrecommendations. In these cases, fluid intake may be variable, sporadic\r\nor insufficient, without any real monitoring of the quantity\r\nconsumed.<\/p>\r\n<p>Overall, this evidence highlights a marked heterogeneity in\r\nhydration-related behaviours. The variable as constructed\r\nproves<strong>useful in distinguishing different consumption profiles,\r\npotentially associable with different modes of management and\r\nprogression of cystitis symptomatology<\/strong> in subsequent\r\nanalyses.<\/p>\r\n<h3 id=\"food-intolerances\"><span>Food intolerances<\/span><\/h3>\r\n<p>A further relevant variable is that concerning food intolerances,\r\nwhich acts as a crucial bridge between nutritional habits, bowel\r\nregularity and cystitis dynamics. Alterations of the intestinal\r\nmicrobiota, often induced by intolerances such as lactose or gluten, can\r\npromote dysbiosis, increasing intestinal permeability and bacterial\r\ntranslocation towards the urinary tract.<\/p>\r\n<p>Participants were asked the following multiple-answer question (i.e.,\r\nwith the possibility of selecting one or more options).<\/p>\r\n<div class=\"eco-paper__box\">\r\n<span class=\"eco-paper__box-title\">Do you have any food intolerances?<\/span>\r\n<ul>\r\n<li><p>no intolerance;<\/p><\/li>\r\n<li><p>lactose;<\/p><\/li>\r\n<li><p>milk proteins;<\/p><\/li>\r\n<li><p>gluten;<\/p><\/li>\r\n<li><p>crustaceans;<\/p><\/li>\r\n<li><p>other.<\/p><\/li>\r\n<\/ul>\r\n<\/div>\r\n<p>Similarly to the approach taken for the dietary regimen variable, in\r\nthis case too the open-ended responses entered under the \u201cother\u201d\r\ncategory were subjected to a recoding process. Analysis of frequencies\r\nmade it possible to identify further particularly recurring\r\nintolerances, which were converted into independent categories:<\/p>\r\n<ul>\r\n<li><p>nickel;<\/p><\/li>\r\n<li><p>frutta;<\/p><\/li>\r\n<li><p>dried fruit\/nuts;<\/p><\/li>\r\n<li><p>solanaceae;<\/p><\/li>\r\n<li><p>yeasts;<\/p><\/li>\r\n<li><p>eggs;<\/p><\/li>\r\n<li><p>fish;<\/p><\/li>\r\n<li><p>medications;<\/p><\/li>\r\n<li><p>respiratory allergies;*<\/p><\/li>\r\n<li><p>legumes\/soya;<\/p><\/li>\r\n<li><p>sugars\/carbohydrates;<\/p><\/li>\r\n<li><p>histamine;<\/p><\/li>\r\n<li><p>coffee\/cocoa.<\/p><\/li>\r\n<\/ul>\r\n<p>This operation made it possible to more fully enhance the information\r\ncontained in the questionnaire and to reduce the proportion of cases\r\ngenerically classified as \u201cother\u201d, improving the descriptive and\r\nanalytical capacity of the variable.<\/p>\r\n<p><strong>The vast majority of participants \u2013 equal to 70% of the\r\nsample \u2013 report having no specific intolerance<\/strong>. This finding\r\nsuggests that, for a considerable proportion of people with cystitis,\r\nany gastrointestinal disturbances or dietary changes are not linked to\r\ndiagnosed or perceived intolerance conditions.<\/p>\r\n<div class=\"eco-paper__note\"><span class=\"eco-paper__note-title\">Footnote<\/span><p>*Although respiratory allergies do not constitute a food intolerance,\r\nit was decided to keep them among the categories analysed as a\r\nnon-negligible number of participants reported them in the open-ended\r\nresponses. This inclusion therefore responds to a descriptive criterion\r\nand one of completeness in the recoding of spontaneous responses. In\r\nsubsequent analyses, however, this variable showed no associations or\r\nstatistically significant results.<\/p><\/div>\r\n<div class=\"eco-paper__box\">\r\n<span class=\"eco-paper__box-title\">Do you have any food intolerances?<\/span>\r\n<\/div>\r\n<p><em>Note: 70% of respondents reported no intolerance.<\/em><\/p>\r\n<p>The distribution of responses relating to food intolerances, shown in\r\nFigure 4, reveals that, among those reporting at least one intolerance,\r\nthe most frequent is<strong>lactose<\/strong> (19%), followed by\r\nintolerance to <strong>milk proteins<\/strong> (8%) e al\r\n<strong>gluten<\/strong> (7%).<\/p>\r\n<p>In practical terms, <strong>the first two categories refer primarily\r\nto the consumption of milk and dairy products<\/strong>: in the case of\r\nlactose, a milk sugar, in addition to milk, yogurt, cream, ice cream and\r\nvarious cheeses are often included, while milk protein intolerance is\r\nlinked to components such as caseins and whey proteins, also present in\r\nmany industrial preparations where milk or whey may appear among the\r\ningredients.<\/p>\r\n<p>Gluten intolerance, on the other hand, is primarily associated with\r\nthe <strong>cereals<\/strong> that contain it, such as wheat (and related\r\nvarieties), barley and rye, and therefore products widely consumed such\r\nas bread and pasta.<\/p>\r\n<p>Smaller proportions concern intolerance to\r\n<strong>crustaceans<\/strong> (3%), typically referring to\r\n<strong>shrimps, scampi, crabs<\/strong> and preparations that include\r\nthem, followed by more heterogeneous and less frequent conditions, such\r\nas sensitivity to <strong>nickel<\/strong> (often associated, depending\r\non individual cases, with legumes, cocoa\/chocolate, certain\r\nvegetables),<\/p>\r\n<p>In the <strong>solanaceae<\/strong> are grouped the intolerances\r\nattributed to foods belonging to this family, in\r\nparticular<strong>tomato, potato, pepper and aubergine<\/strong>, in\r\npractice also including many everyday derivatives such as tomato passata\r\nand sauces, potato-based products or paprika-derived spices.<strong>The\r\nremaining categories are less represented and more fragmented<\/strong>;\r\namong these, at the bottom, residual reports appear such as yeasts, eggs\r\nor legumes.<\/p>\r\n<h3 id=\"bowel-regularity\"><span>Bowel regularity<\/span><\/h3>\r\n<p>Closely connected to food intolerances, a dedicated variable on bowel\r\nregularity investigates evacuation frequency. Chronic constipation can\r\nin fact alter the intestinal microbiota, favouring the proliferation of\r\nuropathogens and their migration to the lower urinary tract.<\/p>\r\n<div class=\"eco-paper__box\">\r\n<span class=\"eco-paper__box-title\">How often do you go to the toilet?*<\/span>\r\n<ul>\r\n<li><p>with the following predefined and exclusive options:<\/p><\/li>\r\n<li><p>every day;<\/p><\/li>\r\n<li><p>three to five times per week;<\/p><\/li>\r\n<li><p>fewer than three times per week.<\/p><\/li>\r\n<\/ul>\r\n<p><em>* Single-answer question<\/em><\/p>\r\n<\/div>\r\n<p><strong>How often do you go to the toilet?<\/strong><\/p>\r\n<p>The figure shows that the predominant category is \u201c<strong>Every\r\nday<\/strong>\u201d, selected by 58% of participants, indicating\r\n<strong>optimal bowel regularity<\/strong> reflecting a balanced\r\nmicrobiota and effective digestive function \u2014 both protective factors\r\nagainst dysbiosis and potential bacterial translocation towards the\r\nurinary tract. This prevalence suggests the majority of participants\r\nenjoy an intestinal function profile that is favourable to reduced\r\ncystitis risk.<\/p>\r\n<p>The second most common response, \u201c<strong>Three to five times per\r\nweek<\/strong>\u201d (29%), represents a range still within physiological\r\nlimits for many adults, but <strong>signals suboptimal regularity that\r\ncould benefit from nutritional optimisation<\/strong> to minimise\r\ninflammatory risks. Finally, \u201c<strong>Fewer than three times per\r\nweek<\/strong>\" (13%) highlights subclinical constipation in a\r\nsignificant minority, correlated in the medical literature with an\r\naltered intestinal barrier, proliferation of uropathogens and an\r\n<strong>increased incidence of relapses.<\/strong><\/p>\r\n<p>Overall, <strong>over 40% of the sample shows non-ideal\r\nregularity<\/strong>\", opening opportunities for personalised behavioural\r\ninterventions such as the integration of prebiotic fibre, specific\r\nprobiotics or dietary corrections, in synergy with non-antibiotic\r\napproaches to the long-term management of the condition.<\/p>\r\n<div class=\"eco-paper__note\"><span class=\"eco-paper__note-title\">Footnote<\/span><p>For detailed information on the procedures adopted, please refer to\r\nthe <strong>Methodological note<\/strong> at the end of this white paper,\r\nin which the statistical models implemented are described in detail,\r\ntogether with the data processing criteria and validation\r\nprocedures.<\/p><\/div>\r\n<\/section>\r\n<section class=\"eco-paper__section\" id=\"the-dimann-dataset-cystitis-type-and-symptoms\">\r\n<h2><span>The Dimann\r\nDataset: cystitis type and symptoms<\/span><\/h2>\r\n<p>To assess the impact of the behavioural and nutritional variables\r\nexamined thus far, we adopted <strong>two complementary and fundamental\r\ndimensions: the type of condition and the perceived\r\nsymptomatology<\/strong>. This multidimensional approach allows a\r\nmultifaceted and clinically relevant representation of the\r\ncondition.<\/p>\r\n<p>The first dimension, cystitis type, classifies the condition based on\r\nits<strong>clinical presentation<\/strong>: distinguishing, for example,\r\nuncomplicated bacterial forms from post-coital, interstitial forms or\r\nthose associated with anatomical\/hormonal factors. This distinction is\r\nessential for identifying differential risk patterns.<\/p>\r\n<p>The second dimension, relating to perceived symptomatology,\r\nquantifies <strong>the intensity of the most common and debilitating\r\nsymptoms<\/strong>. These include, for example, dysuria, urgency,\r\nfrequency, pelvic pain and mild incontinence, each of which can be\r\ninformative of the specific type of cystitis.<\/p>\r\n<p>The integration of these dimensions generates a <strong>disease\r\nmapping<\/strong>, not limited to the mere presence of cystitis but\r\nextended to its severity and its daily manifestations,<strong>enabling\r\nprecise correlations between behavioural and nutritional risk factors\r\nand specific clinical profiles<\/strong>.<\/p>\r\n<p>However, we deliberately excluded episodic frequency, despite it\r\nbeing a key marker for recurrent or chronic cystitis, deferring it to a\r\nsubsequent dedicated ECO Observatory analysis, in which the impact of\r\ndietary habits on inflammation frequency will be explored..<\/p>\r\n<h3 id=\"type-of-cystitis\"><span>Type of cystitis<\/span><\/h3>\r\n<p>To characterise the type of cystitis, a specific single-answer\r\nquestion was used, designed to identify the prevalent form of the\r\ncondition as identified by respondents.<\/p>\r\n<p><strong>Can you tell us what type of cystitis you suffer\r\nfrom?*<\/strong><\/p>\r\n<ul>\r\n<li><p>cystitis caused by bacteria;<\/p><\/li>\r\n<li><p>cystitis triggered by sexual intercourse;<\/p><\/li>\r\n<li><p>cystitis without bacteria but with symptoms;<\/p><\/li>\r\n<li><p>cystitis that never goes away;<\/p><\/li>\r\n<li><p>cystitis with bacteria but without symptoms;<\/p><\/li>\r\n<li><p>you don\u2019t know.<\/p><\/li>\r\n<\/ul>\r\n<p>*Single-answer question<\/p>\r\n<p>This question makes it possible to capture different clinical\r\nmanifestations of cystitis as understood and reported by patients. The\r\noption<strong>cystitis caused by bacteria<\/strong>\" identifies\r\n<strong>classic infectious forms, generally confirmed by diagnostic\r\ntests<\/strong>.<\/p>\r\n<p>The response \"<strong>cystitis triggered by sexual\r\nintercourse<\/strong>\" allows the identification of the so-called\r\n<strong>post-coital cystitis<\/strong>, frequently reported in clinical\r\npractice and characterised by specific behavioural risk factors.<\/p>\r\n<p>The option \"<strong>cystitis without bacteria but with\r\nsymptoms<\/strong>\u201d captures situations in which symptomatology is\r\npresent in the absence of infectious evidence, as occurs for example in\r\n<strong>irritative or interstitial forms<\/strong>.<\/p>\r\n<p>The category \"<strong>cystitis that never goes away<\/strong>\u201d was\r\nincluded to represent conditions perceived <strong>as chronic or\r\npersistent<\/strong>, with continuous symptoms over time.<\/p>\r\n<p>The option \"<strong>with bacteria but without symptoms<\/strong>\"\r\nfinally allows the detection of cases of <strong>asymptomatic\r\nbacteriuria<\/strong>, while the option \"<strong>you don\u2019t know<\/strong>\u201d\r\nallows the identification of respondents who do not have a clear\r\ndiagnosis or are unable to classify their condition precisely.<\/p>\r\n<div class=\"eco-paper__placeholder\"><strong>Image 1<\/strong><span>[IMAGE TO BE PRODUCED]<\/span><\/div>\r\n<p>The distribution of cystitis types shows that the most frequent\r\ncategory is<strong>cystitis triggered by sexual intercourse<\/strong>,\r\nindicated by 33% of the sample. This figure underlines the relevant\r\nweight of the mechanical and behavioural factor in the genesis of\r\nepisodes, confirming that the post-coital dimension represents a central\r\ncomponent in the clinical experience of many women.<\/p>\r\n<p>This is followed by <strong>cystitis caused by bacteria<\/strong>\r\n(28%), which refers to the classic infectious form, generally associated\r\nwith the proliferation of microorganisms \u2013 most frequently E. coli \u2013 at\r\nthe level of the urinary tract. The relevance of this category confirms\r\nthe presence of a significant proportion of episodes attributable to an\r\ninfectious aetiology, documented or presumed. This dimension was also\r\nexplored in the first paper of the ECO Observatory, \u201c<em>Psychological\r\nimpact of the fight against cystitis. Evidence from Italy<\/em>\u201d, in\r\nwhich the clinical and psychosocial implications of the bacterial forms\r\nof the condition were analysed.<\/p>\r\n<p>Smaller proportions concern <strong>cystitis without bacteria but\r\nwith symptoms<\/strong> (10%), which may suggest non-infectious\r\ninflammatory pictures or forms similar to interstitial\r\ncystitis;<strong>cystitis that never goes away<\/strong> (6%), an\r\nexpression referring to a perception of chronicity or persistence of\r\nsymptoms; and finally<strong>cystitis with bacteria but without\r\nsymptoms<\/strong> (2%), compatible with pictures of asymptomatic\r\nbacteriuria.<\/p>\r\n<p>Finally, the third most frequent response is \u201c<strong>You don\u2019t\r\nknow<\/strong>\u201d, indicating that a substantial proportion of respondents\r\nreport not knowing what type of cystitis they have. This element\r\nhighlights a possible<strong>informational or diagnostic gap<\/strong>,\r\nsuggesting the presence of clinical pathways that are not always clearly\r\ndefined or fully understood by patients. Sometimes this lack stems from\r\nthe diagnostic complexity of cystitis, especially in interstitial or\r\nchronic variants where restrictive criteria lead to missed or delayed\r\ndiagnoses of up to 12 months, with patients often labelled as\r\n\u201cpsychosomatic\u201d.<\/p>\r\n<h3 id=\"cystitis-symptoms\"><span>Cystitis symptoms<\/span><\/h3>\r\n<p>Regarding the symptomatology reported by affected women, the question\r\nwas structured to allow the indication of multiple simultaneous\r\nsymptoms. Consequently, the sum of percentages does not correspond to\r\n100%, as many women report<strong>different combinations of\r\nsymptoms<\/strong> in the same episode of cystitis.<\/p>\r\n<div class=\"eco-paper__box\">\r\n<span class=\"eco-paper__box-title\">When you have cystitis, you feel...<\/span>\r\n<ul>\r\n<li><p>Discomfort when urinating<\/p><\/li>\r\n<li><p>Fire in the bladder<\/p><\/li>\r\n<li><p>Needles and pins<\/p><\/li>\r\n<li><p>Chills<\/p><\/li>\r\n<li><p>Broken glass in the bladder<\/p><\/li>\r\n<\/ul>\r\n<\/div>\r\n<p>In general, the distribution of symptoms reported by respondents\r\nreveals a picture characterised by high perceived intensity and marked\r\nheterogeneity in the pain experience.<\/p>\r\n<p>The most frequent symptom by far is \u201c<strong>discomfort when\r\nurinating<\/strong>\" (83%), which represents the most common\r\nmanifestation, occurring across cystitis episodes. This data confirms\r\nthat dysuria constitutes the main symptomatological core of the\r\ncondition, present in the vast majority of cases regardless of clinical\r\ntype. This is followed by<strong>fire in the bladder<\/strong>\" (44%), an\r\nexpression commonly used by individuals who suffer from cystitis. This\r\nsymptomatology refers to<strong>a sensation of intense, diffuse\r\nburning<\/strong>, indicating more marked inflammation of the bladder\r\nmucosa.<\/p>\r\n<p>Similar percentages are observed for \u201c<strong>needles and\r\npins<\/strong>\u201d (40%) e \u201c<strong>\"chills\"<\/strong>\u201d (39%). <strong>The\r\nformer describes an acute, punctiform pain<\/strong>, often associated\r\nwith spasms or bladder overactivity; <strong>the latter introduces a\r\nsystemic dimension to the disorder<\/strong>, suggesting broader\r\ninflammatory involvement or a general response of the organism.<\/p>\r\n<p>The symptom \"<strong>broken glass in the bladder<\/strong>\u201d (24%),\r\nalthough less frequent, represents one of the most evocative and severe\r\ndescriptions of perceived pain. Its presence in almost a quarter of the\r\nsample indicates that a significant proportion of respondents experience\r\nepisodes with high and potentially debilitating pain intensity.<\/p>\r\n<\/section>\r\n<section class=\"eco-paper__section\" id=\"results\">\r\n<h2><span>Results<\/span><\/h2>\r\n<p><em>This section summarises the statistically significant outcomes\r\nemerging from the analyses, with the aim of deepening the relationships\r\nbetween the <strong>behavioural and nutritional variables<\/strong>\r\nconsidered and the two main clinical dimensions under study: the\r\n<strong>reported cystitis type<\/strong> e la <strong>perceived\r\nsymptomatology<\/strong>.<\/em><\/p>\r\n<p>In order to isolate the specific contribution of behavioural and\r\nnutritional factors, the main objective of the study, the analysis model\r\nwas integrated with the main available socio-demographic variables, so\r\nas to control for any confounding factors.<\/p>\r\n<p>The following sections present the statistically significant results\r\nshowing the relationships between the behavioural and nutritional\r\nvariables analysed and the two main clinical dimensions of the study:\r\ncystitis type and perceived symptoms.<\/p>\r\n<h3 id=\"type-of-cystitis-1\"><span>Type of cystitis<\/span><\/h3>\r\n<p>The analyses revealed <strong>statistically significant differences\r\nbetween men and women<\/strong> in the presentation of cystitis.<\/p>\r\n<p>In particular, compared to women, <strong>men are slightly less\r\nlikely to report cystitis with bacteria but without symptoms than a\r\nsymptomatic bacterial form<\/strong>: the relative risk is approximately\r\n9% lower. This suggests that, in comparison with the \u201cclassical\u201d\r\nbacterial form, the asymptomatic variant is relatively less frequent\r\namong men. Conversely, <strong>men show an almost twice as high\r\nlikelihood of reporting cystitis without bacteria but with symptoms\r\ncompared to the bacterial form<\/strong>, representing the most marked\r\nassociation observed for gender.<\/p>\r\n<p>Regarding post-coital cystitis, <strong>men show a relative risk\r\n16.5% higher than women of reporting a form triggered by sexual\r\nintercourse compared to the bacterial form<\/strong>.<\/p>\r\n<p>Finally, regarding diagnostic awareness, men are slightly more\r\n<strong>likely to not know their own type<\/strong> of cystitis (+15%\r\ncompared to women) relative to the bacterial form.<\/p>\r\n<p>More nuanced results emerge when considering <strong>l\u2019et\u00e0<\/strong>.\r\nAs age increases, a slight <strong>reduction in the relative risk of\r\nreporting chronic cystitis<\/strong> compared to the bacterial form\r\n(-3.4% per additional year). Conversely, age is associated with a\r\n<strong>significant increase in the relative risk of reporting\r\nasymptomatic bacterial cystitis<\/strong> compared to the bacterial form\r\n(+36% per unit increase in age, according to the scale used in the\r\nmodel). Finally, consistently with expectations, as age increases\r\n<strong>the relative likelihood of not knowing one\u2019s own type of\r\ncystitis also decreases<\/strong>(-27% per additional year of age). This\r\nfinding can be interpreted as a signal of greater awareness or a greater\r\nlikelihood of having received a diagnosis over the years.<\/p>\r\n<p>Turning to the central variables of the study, the presence and type\r\nof intolerance show relevant associations with the reported type of\r\ncystitis.<\/p>\r\n<p>A first result concerns the theme of convergence between different\r\ninformational gaps: a significant association emerged between being\r\nuncertain about one\u2019s intolerance and not knowing the type of cystitis\r\none has. In other words,<strong>those who have not investigated their\r\ncondition in one area have more than double the likelihood (+104.7%) of\r\nnot having done so in the other<\/strong>. This finding suggests a\r\npossible common profile of lower recourse to diagnostic tests or lower\r\nclinical awareness. This is therefore not only an association between\r\nbiological variables, but a coherent behavioural pattern: uncertainty\r\nappears to cut across the different health dimensions considered.<\/p>\r\n<p>A particularly interesting result concerns <strong>solanaceae\r\nintolerance<\/strong>. People reporting this intolerance show an\r\napproximately <strong>67% higher likelihood of reporting cystitis\r\nwithout bacteria but with symptoms<\/strong> compared to the bacterial\r\nform. Conversely, those reporting this intolerance are slightly\r\n<strong>less likely (-13%) to report cystitis with bacteria but without\r\nsymptoms<\/strong>, again in comparison with the bacterial form. Overall,\r\nthis suggests that solanaceae intolerance is not simply associated with\r\nan increase or general reduction in risk, but rather with a different\r\nrelative profile of the reported cystitis types. In particular, it\r\nappears to be more frequently associated with symptomatic non-bacterial\r\nforms compared to the \u201cclassical\u201d bacterial form.<\/p>\r\n<p>Regarding <strong>nickel intolerance<\/strong>, a slight increase in\r\nthe relative risk of reporting chronic cystitis compared to the\r\nbacterial form (+2.4%) is observed. This is a statistically significant\r\nassociation, but of limited magnitude.<\/p>\r\n<p>Other intolerances instead appear to be associated with a lower\r\nrelative likelihood of certain specific forms.<strong>fruit\r\nintolerance<\/strong> are, for example, much less likely to report\r\ncystitis triggered by sexual intercourse compared to the bacterial form\r\n(-74%).<strong>tree nut intolerance<\/strong> shows a lower likelihood of\r\nreporting cystitis with bacteria but without symptoms (-37% compared to\r\nthe bacterial form).<\/p>\r\n<p>Overall, these results suggest that intolerances are not simply\r\nassociated with a general increase or reduction in risk, but rather with\r\na different relative distribution of reported cystitis types.<\/p>\r\n<p>Regarding the analysis of <strong>dietary habits<\/strong>,\r\ninteresting associations with the reported type of cystitis were\r\nidentified, although not always homogeneous.<strong>vegetarian and vegan\r\ndiets<\/strong> are associated with a lower relative likelihood of\r\nreporting cystitis triggered by sexual intercourse compared to the\r\nbacterial form.<strong>the bacterial form is relatively more frequent\r\nthan the post-coital form.<\/strong><\/p>\r\n<p>A similar pattern emerges for some restrictive diets in relation to\r\nother types. Those who follow a<strong>lactose-free diet<\/strong>\r\n<strong>shows a lower likelihood of reporting asymptomatic\r\ncystitis<\/strong> (-54%), while for those following a low-carb diet the\r\nreduction is more limited (-15%). Similarly, <strong>a gluten-free diet\r\nis associated with a lower likelihood (-46%) of reporting non-bacterial\r\ncystitis compared to the bacterial form<\/strong>.<\/p>\r\n<p>A partially different result is observed instead among\r\n<strong>vegani<\/strong> regarding the form <strong>with bacteria but\r\nwithout symptoms<\/strong>: in this case the relative risk <strong>more\r\nthan doubled<\/strong> compared to those who do not follow a specific\r\ndiet.<\/p>\r\n<p>Overall, <strong>dietary habits do not appear to be associated with a\r\ngeneral increase or reduction in risk, but rather with a different\r\nrelative distribution of cystitis types<\/strong> compared to the\r\nbacterial form. Restrictive diets, in particular, appear to be\r\ncorrelated with specific symptomatological profiles rather than a\r\nuniform effect.<\/p>\r\n<p>Regarding the two dimensions of <strong>hydration habits and bowel\r\nregularity<\/strong>, the analyses <strong>did not show statistically\r\nsignificant relationships with the types of cystitis<\/strong>\r\nconsidered. In other words, in the data analysed no systematic pattern\r\nemerges linking these behaviours to a greater or lesser relative\r\nlikelihood of the different forms of inflammation. This finding is\r\nrelevant because it suggests that, at least in the observed sample,\r\nthese factors do not appear to represent distinguishing elements in the\r\ndistribution of cystitis types. Although they are variables often cited\r\nin clinical and popular debate, no robust associations are observed here\r\nthat would indicate a differential role compared to the other\r\nbehavioural and nutritional dimensions analysed. Thus, while diet and\r\nintolerances appear to be selectively associated with specific clinical\r\nprofiles and the distribution of different cystitis\r\ntypes,<strong>hydration and bowel regularity<\/strong> do not show\r\nsignificant associations with the classification of the reported form.\r\nConversely, as illustrated in the following paragraph, these dimensions\r\nemerge as <strong>particularly relevant in the modulation of\r\nsymptomatology<\/strong>, exerting a more marked influence on the\r\nintensity and perception of disorders.<\/p>\r\n<h3 id=\"cystitis-symptoms-1\"><span>Cystitis symptoms<\/span><\/h3>\r\n<p>Moving on to perceived symptomatology, the picture differs markedly\r\nfrom the cystitis type analysis. Here, <strong>significant associations\r\nemerge between hydration habits, bowel regularity and<\/strong>, such as\r\ndysuria and urgency. This suggests distinct mechanisms for the two\r\naspects of cystitis: <strong>nutritional factors shape the risk of\r\nurinary tract inflammation, while hydration and intestinal function\r\nmodulate the daily symptom burden<\/strong>, with more immediate effects\r\non perceived wellbeing.<\/p>\r\n<p>Unlike the cystitis type analysis, the evaluation of symptomatology\r\nwas conducted by treating each symptom as an independent binary outcome,\r\nas participants could <strong>report multiple manifestations\r\nsimultaneously<\/strong>. The associations are therefore interpreted as\r\nvariations in the likelihood of reporting a specific symptom in relation\r\nto the variables considered.<\/p>\r\n<p>Regarding the gender of respondents, a systematic difference emerges\r\nin the symptomatology reported by men and women. In all manifestations\r\nconsidered, the male gender is associated with a lower likelihood of\r\nreporting a single symptom compared to women. This result reflects a\r\nreal difference in the observed percentages: for each symptom analysed,\r\nthe proportion of women reporting it is substantially higher than that\r\nof men. The overall symptom burden analysis confirms this pattern:\r\n<strong>women report an average of more than two symptoms per episode,\r\nwhile men report fewer than one and a half<\/strong>. Since each\r\nparticipant could select multiple symptoms simultaneously, this\r\ndifference in the average number of symptoms coherently explains the\r\nlower male likelihood observed in the models for each individual\r\nmanifestation.<\/p>\r\n<p>Considering the different average symptom burden between men and\r\nwomen, it is nonetheless possible to observe some differences in the\r\nrelative distribution of individual symptoms.<strong>among men the\r\nrelatively most frequent symptom is \u201cdiscomfort when\r\nurinating\u201d<\/strong>, which shows the least marked gap <strong>compared\r\nto women<\/strong> (-24%). This means that, although less likely in men\r\nthan in women, this symptom represents the most \u201cshared\u201d manifestation\r\nbetween the two genders and the one with the smallest divide.\r\nConversely, <strong>the most marked difference is observed for symptoms\r\nsuch as \u201cchills\u201d and \u201cfire in the bladder\u201d, for which women show an\r\napproximately twice as high likelihood compared to men<\/strong>,\r\nsuggesting that more intense or systemic manifestations are more\r\nfrequently reported by the female gender.<\/p>\r\n<p>Overall, these results seem to indicate that men not only report an\r\naverage lower number of symptoms, but also tend to concentrate more on\r\nmanifestations that are more \u201clocal\u201d and directly related to urination,\r\nwhile women show a more articulate symptomatological profile\r\ncharacterised by a greater presence of painful or systemic symptoms.<\/p>\r\n<p>Also <strong>age<\/strong> shows a systematic association with\r\nreported symptomatology. In all manifestations considered,\r\n<strong>increasing age is associated with a reduction in the likelihood\r\nof reporting a single symptom<\/strong>. Although the annual effect is\r\nlimited (in the order of 1\u20132.5% per year depending on the symptom), the\r\ncumulative impact over larger age intervals becomes relevant. This trend\r\nindicates a progressive increase in average symptom burden at more\r\nadvanced ages.<\/p>\r\n<p>Moving on to the behavioural and nutritional factors, the focus of\r\nthis study, the analysis of <strong>hydration habits<\/strong> yields\r\nparticularly interesting results in relation to symptomatology, unlike\r\nthe cystitis type analysis, where no relevant associations emerged.<\/p>\r\n<p>Compared to those who <strong>increases fluid intake only during an\r\nacute cystitis episode<\/strong>, people who report a constant intake of\r\n<strong>approximately two litres or more per day show a lower likelihood\r\nof reporting \u201cdiscomfort when urinating\u201d<\/strong> (-19%) <strong>and\r\n\"chills\"<\/strong> (-9%), suggesting a possible <strong>favourable effect\r\nof hydration<\/strong> on some manifestations typically associated with\r\nurinary disorders and the systemic component. At the same time, in the\r\nsame group a slightly higher likelihood of reporting symptoms such as\r\n\u201cneedles and pins\u201d (+7%) and \u201cbroken glass in the bladder\u201d (+11%) is\r\nobserved, which describe a more localised and punctiform pain component.\r\nAlthough the magnitude of the increase is limited, the finding suggests\r\nthat habitual high hydration may be associated not so much with a\r\nuniform reduction in symptomatology, as with a different qualitative\r\nexpression of pain. However, a particularly relevant element emerges\r\nwhen considering the other hydration patterns: compared to the\r\n\u201creactive\u201d group \u2014 i.e. those who drink a lot only during the episode\r\n\u2014<strong>all other habits are associated with a lower likelihood of\r\nreporting the main symptoms analysed<\/strong>, with reductions of\r\nbetween 23% and 34% for manifestations such as \u201cchills\u201d and \u201cdiscomfort\r\nwhen urinating\u201d. This pattern suggests that reactive behaviour does not\r\nrepresent a protective factor, but perhaps rather an <strong>indirect\r\nindicator of greater symptom intensity<\/strong>. It is plausible that\r\npeople who experience more marked symptoms tend to increase their fluid\r\nintake in response to discomfort, thus outlining a reactive behavioural\r\nmechanism. Overall, hydration therefore appears closely connected to\r\nsymptom management rather than prevention.<\/p>\r\n<p>Regarding <strong>bowel regularity<\/strong>, significant and coherent\r\nassociations emerge with the hypothesis of a possible worsening of\r\nsymptomatology in the presence of irregularity. Compared to those who\r\nreport daily evacuation, people reporting going to the\r\ntoilet<strong>fewer than three times per week show a greater\r\nlikelihood<\/strong> of reporting certain symptoms, in particular\r\n<strong>\u201cneedles and pins\u201d<\/strong> (+11%) e <strong>\"chills\"<\/strong>\r\n(+28%). This suggests that marked bowel irregularity may be associated\r\nwith greater intensity or perception of painful and systemic\r\nmanifestations.<\/p>\r\n<p>A similar trend, although of more limited magnitude, is also observed\r\namong those who go to the toilet <strong>three to five times per\r\nweek<\/strong>. In this group, an <strong>increase in the likelihood of\r\nreporting \u201cchills\u201d<\/strong> (+13%) e <strong>\u201cbroken glass in the\r\nbladder\u201d<\/strong> (+9%). Overall, the results delineate a possible\r\ngradient: as bowel regularity decreases, the likelihood of symptomatic\r\nmanifestations increases, particularly those that are painful or have a\r\nsystemic component.<\/p>\r\n<p>Regarding <strong>food intolerances<\/strong>, selective associations\r\nemerge with certain symptomatological manifestations. In particular,\r\nsubjects reporting <strong>lactose<\/strong> show a <strong>higher\r\nlikelihood of reporting painful and localised symptoms: +20% for\r\n\u201cdiscomfort when urinating\u201d<\/strong>, <strong>+14% for \u201cfire in the\r\nbladder\u201d<\/strong> e +17% <strong>for \u201cbroken glass in the\r\nbladder\u201d<\/strong>. These are moderate but consistent increases,\r\nsuggesting an association with greater expression of the non-systemic\r\npain component.<\/p>\r\n<p>Also noteworthy is the finding regarding those who report <strong>no\r\nintolerance<\/strong>, which shows a <strong>greater likelihood only of\r\nreporting \u201cdiscomfort when urinating\u201d<\/strong> (+25%). Overall,\r\nintolerances do not appear to uniformly influence all symptoms, but are\r\nassociated in particular with certain manifestations.<\/p>\r\n<p>Finally, some <strong>dietary habits<\/strong> show associations with\r\nspecific symptomatological manifestations. In particular, those who\r\nfollow <strong>a paleo diet<\/strong> <strong>show a lower likelihood of\r\nreporting \u201cchills\u201d<\/strong> (-43%), suggesting a lower presence of the\r\nsystemic component of the disorder. Conversely, among those who follow a\r\n<strong>vegetarian diet a greater likelihood of reporting the symptom\r\n\u201cbroken glass in the bladder\u201d is observed<\/strong> (+16%), indicative of\r\na more localised and punctiform pain component.<\/p>\r\n<p>Overall, these results indicate that <strong>diet does not appear to\r\nuniformly affect the overall symptom burden<\/strong>, but rather on the\r\nqualitative mode of symptom expression, contributing to delineating\r\ndifferent profiles for specific manifestations.<\/p>\r\n<\/section>\r\n<section class=\"eco-paper__section\" id=\"highlights\">\r\n<h2><span>Highlights<\/span><\/h2>\r\n<ol type=\"1\">\r\n<li><p>Results show clear differences between men and women. Men tend to\r\nmore frequently report cystitis with symptoms but without bacterial\r\ninfection, and more frequently linked to sexual intercourse. Women, on\r\nthe other hand, describe episodes with a greater number of symptoms and\r\nwith more intense or systemic manifestations.<\/p><\/li>\r\n<li><p>With advancing age, there is an increased risk of symptomatic\r\nnon-bacterial cystitis and a general worsening of the reported\r\nsymptomatological picture. In fact, as age increases, the likelihood of\r\nreporting only one symptom decreases.<\/p><\/li>\r\n<li><p>People reporting specific food intolerances, such as nickel,\r\nsolanaceae, fruit and nuts, show different types of cystitis compared to\r\nthose without intolerances. Furthermore, those intolerant to lactose\r\ntend to more frequently report localised pain symptoms. Those who report\r\nno intolerance, on the other hand, show a greater likelihood of the most\r\nlocalised and least painful symptom, i.e. discomfort during\r\nurination.<\/p><\/li>\r\n<li><p>In the observed sample, nutritional factors are more strongly\r\nassociated with the type of cystitis, while hydration and intestinal\r\nfunction modulate the daily symptom burden, with more immediate effects\r\non perceived wellbeing.<\/p><\/li>\r\n<li><p>Vegetarian, vegan, lactose-free and gluten-free diets appear to\r\nbe correlated with specific inflammation profiles rather than a uniform\r\neffect.<\/p><\/li>\r\n<li><p>Drinking more does not seem to clearly change the type of\r\ncystitis, but may influence symptoms. Those who maintain a constant\r\nfluid intake tend to report fewer complaints compared to those who drink\r\na lot only when symptoms appear. However, this association may simply\r\nindicate more intense episodes.<\/p><\/li>\r\n<li><p>Bowel regularity does not seem to determine the type of cystitis,\r\nbut is linked to symptom intensity. Those with less regular bowel\r\nfunction tend to more frequently report painful symptoms and more marked\r\nmanifestations. Overall, as bowel regularity decreases, the likelihood\r\nof symptomatic manifestations increases, particularly those that are\r\npainful or have a systemic component.<\/p><\/li>\r\n<\/ol>\r\n<\/section>\r\n<section class=\"eco-paper__section\" id=\"methodological-note\">\r\n<h2><span>Methodological note<\/span><\/h2>\r\n<p>Prior to the analyses, a preliminary data cleaning phase was\r\nconducted to ensure the quality and reliability of the sample. In this\r\nphase, 30 observations were removed that presented incomplete,\r\ninconsistent or manifestly erroneous information. The exclusion mainly\r\nconcerned questionnaires with missing responses in key variables or with\r\ninvalid completion patterns.<\/p>\r\n<p>The final dataset used for the analyses therefore consists of N =\r\n34,277 valid observations, selected on the basis of criteria for\r\ncompleteness and consistency of the reported information.<\/p>\r\n<p>The information collected allows analysis of a broad set of factors\r\npotentially associated with the onset and management of cystitis,\r\nincluding dietary habits, hydration levels, bowel regularity, the\r\npresence of food intolerances and other lifestyle-related elements.\r\nThese dimensions are recognised in the literature as relevant components\r\nfor defining personalised preventive strategies and for reducing the\r\nrisk of relapse.<\/p>\r\n<p>For the purposes of this study, specific thematic variables were\r\nselected, identified in accordance with the analytical objectives and\r\nresearch hypotheses. Among the main thematic variables considered\r\nare:<\/p>\r\n<ul>\r\n<li><p>dietary habits and dietary regimen adopted;<\/p><\/li>\r\n<li><p>any food intolerances;<\/p><\/li>\r\n<li><p>average daily water intake;<\/p><\/li>\r\n<li><p>regularity of bowel movements;<\/p><\/li>\r\n<li><p>type and symptomatology of cystitis reported.<\/p><\/li>\r\n<\/ul>\r\n<p>These variables were selected as they are considered central to\r\nsystematically exploring the role of diet and hydration in the\r\nmanagement of the condition and its clinical course.<\/p>\r\n<div class=\"eco-paper__placeholder\"><strong>Image 2<\/strong><span>[IMAGE TO BE PRODUCED]<\/span><\/div>\r\n<p><strong>Example:<\/strong> Do you have any food intolerances?\r\n<em>Other<\/em>.<\/p>\r\n<div class=\"eco-paper__table-wrap\"><table>\r\n<colgroup>\r\n<col style=\"width: 100%\"\/>\r\n<\/colgroup>\r\n<tbody>\r\n<tr class=\"odd\">\r\n<td>YES NICKEL<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table><\/div>\r\n<p>Nickel<\/p>\r\n<div class=\"eco-paper__table-wrap\"><table>\r\n<colgroup>\r\n<col style=\"width: 100%\"\/>\r\n<\/colgroup>\r\n<tbody>\r\n<tr class=\"odd\">\r\n<td>Nickel<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table><\/div>\r\n<div class=\"eco-paper__table-wrap\"><table>\r\n<colgroup>\r\n<col style=\"width: 100%\"\/>\r\n<\/colgroup>\r\n<tbody>\r\n<tr class=\"odd\">\r\n<td>Intolerant to nickel<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table><\/div>\r\n<p>Subsequently, in cases where some open-ended responses contained\r\nrecurring content clearly attributable to the same substantive meaning,\r\nthey were aggregated into homogeneous categories. This procedure was\r\napplied with particular care to responses that, although expressed\r\nfreely by respondents, referred to conditions, habits or dietary\r\nprofiles already observable with a certain frequency in the sample. In\r\nsuch cases, the information was brought back to common classes based on\r\npredominant semantic content, so as to avoid excessive fragmentation of\r\nthe data.<\/p>\r\n<p>The following control variables also considered relevant to the\r\nanalysis were included:<\/p>\r\n<ul>\r\n<li><p>age;<\/p><\/li>\r\n<li><p>gender;<\/p><\/li>\r\n<li><p>country of residence.<\/p><\/li>\r\n<\/ul>\r\n<p>The inclusion of these variables made it possible to take into\r\naccount possible confounding factors and to improve the robustness of\r\nthe estimates.<\/p>\r\n<p>In the case of the gender variable, the \u201cother\u201d category, selected by\r\n0.1% of respondents during questionnaire completion, was excluded from\r\nthe models in order to simplify the interpretation of results, setting\r\nthe female gender as the reference category and comparing it with the\r\nmale gender. Furthermore, the extremely small size of this category\r\nleads to the conclusion that its exclusion does not entail a loss of\r\nrelevant information for the purposes of the analysis.<\/p>\r\n<p>Furthermore, a specific check was conducted by calculating the\r\nVariance Inflation Factors (VIF) for the set of regressors considered.\r\nThe results of the analysis did not reveal any relevant criticalities in\r\nthis regard. The VIF values observed were in fact limited: the highest\r\nvalue was found for some variables relating to food intolerances (None,\r\nlactose). All other coefficients showed lower values, in most cases very\r\nclose to 1, indicating a very low level of linear association with the\r\nother regressors.<\/p>\r\n<p>Regarding the two variables with the highest VIF, the values recorded\r\nnevertheless remain within thresholds generally considered acceptable in\r\nthe literature and not such as to suggest problematic multicollinearity\r\n(No intolerance = 4.504795, Intolerant to lactose = 2.815882). This\r\ntrend also appears plausible in light of the nature of these variables,\r\nwhich belong to the same informational block relating to food\r\nintolerances and may therefore share some variability with other\r\ncovariates in the same domain. Overall, it can therefore be considered\r\nthat the inclusion of the control variables improved the model\r\nspecification without compromising the stability and interpretability of\r\nthe estimates.<\/p>\r\n<p>The variables analysed are largely categorical or ordinal in nature,\r\nas they derive from a structured questionnaire with single-choice or\r\nmultiple-choice response options from a defined set of options. The main\r\nreference categories used in the models were:<\/p>\r\n<ul>\r\n<li><p>\u201cYou do not follow a specific diet\u201d for the variable relating to\r\ndietary regimen;<\/p><\/li>\r\n<li><p>\u201cWhen you have cystitis you drink a lot, when it passes you drink\r\nlittle\u201d for the quantity of water intake;<\/p><\/li>\r\n<li><p>\u201cEvery day\u201d for regularity of bowel movements;<\/p><\/li>\r\n<li><p>\u201cItaly\u201d for country of residence;<\/p><\/li>\r\n<li><p>\u201cWoman\u201d for the gender variable;<\/p><\/li>\r\n<li><p>\u201cCystitis caused by bacteria\u201d for cystitis type.<\/p><\/li>\r\n<\/ul>\r\n<p>For all variables the most frequent category was selected, except for\r\nwater consumption. In this case, the \u2018reactive\u2019 category was compared\r\nwith all options that reported specific quantities or indirectly\r\ndeducible ones, although defined in less precise terms as in the case of\r\nthe option \u201chave to force yourself to drink\u201d.<\/p>\r\n<p>Regarding food intolerances, participants could indicate more than\r\none option simultaneously. For this reason, each intolerance was treated\r\nas an independent binary variable (presence\/absence), making it possible\r\nto model the possible coexistence of multiple conditions in the same\r\nindividual. The same approach was adopted for the dependent variable\r\nrelating to cystitis symptoms, treating each symptom as a dichotomous\r\nvariable (presence\/absence) analysed individually.<\/p>\r\n<p>For the statistical analysis, logistic regression models were used,\r\nselected based on the type of dependent variables considered. In\r\nparticular:<\/p>\r\n<ol type=\"1\">\r\n<li><p>to analyse the association between the explanatory variables and\r\ncystitis type, a multinomial logistic regression model was estimated,\r\nwhich allows the modelling of categorical outcomes with multiple\r\ncategories;<\/p><\/li>\r\n<li><p>for the analysis of reported symptoms, separate binary logistic\r\nregression models were estimated, one for each symptom considered, in\r\norder to assess the factors associated with the likelihood of reporting\r\na specific symptom.<\/p><\/li>\r\n<\/ol>\r\n<p>The analyses were conducted using the Python language and the\r\nstatistical libraries pandas, NumPy, SciPy and scikit-learn.<\/p>\r\n<\/section>\r\n<section class=\"eco-paper__section\" id=\"limitations\">\r\n<h2><span>Limitations<\/span><\/h2>\r\n<p>As in any investigation based on self-reported data collected through\r\nquestionnaires, this study also entails certain limitations that must be\r\nconsidered when interpreting the results.<\/p>\r\n<p>A first limitation concerns the <strong>non-probabilistic nature of\r\nthe sample<\/strong>. The data analysed derive from a questionnaire\r\nvoluntarily completed by users, potential purchasers of Dimann products,\r\nand not from a random sampling design.<\/p>\r\n<p>A second critical point concerns the <strong>uneven distribution of\r\ncertain socio-demographic variables<\/strong>. In particular, a strong\r\ndisparity is observed in the frequency of observations between different\r\ncountries of residence, between genders and between certain age groups.\r\nFor example, most of the observations come from a limited number of\r\ncountries and the sample is predominantly composed of female subjects,\r\npartly reflecting the higher incidence of the condition in this\r\npopulation but at the same time reducing the possibility of balanced\r\ncomparisons between groups. Similarly, some age classes are\r\nunderrepresented, which may limit the precision of the estimates\r\nrelating to these groups.<\/p>\r\n<p>A further limitation is linked to the <strong>self-reported nature of\r\nthe information collected<\/strong>. The responses provided by\r\nparticipants may be subject to memory errors, subjective interpretations\r\nof the questions or inaccuracies in the classification of their clinical\r\ncondition. This aspect is particularly relevant in the case of the\r\nvariable relating to <strong>cystitis type<\/strong>, for which a portion\r\nof the observations derives from self-diagnosis and not from certified\r\nmedical diagnosis.<\/p>\r\n<p>A further critical element concerns the <strong>structure of the\r\nquestionnaire itself<\/strong>. Some questions required the selection of\r\na single response from options that, from a clinical standpoint, are not\r\nnecessarily mutually exclusive.<strong>classification errors<\/strong>\r\nand generate an excessive simplification of potentially more complex\r\nclinical situations.<\/p>\r\n<p>Further limitations arise from the <strong>presence of categories\r\nwith small sizes<\/strong> in some categorical variables. Similarly to\r\nwhat was specified for the socio-demographic variables, some response\r\noptions are in fact less frequent than others, with a consequent\r\nreduction in the statistical precision of the estimates associated with\r\nthese categories. In some cases, this may make model estimates less\r\nstable or limit the ability to identify statistically significant\r\nassociations.<\/p>\r\n<p>It should also be considered that the study adopts an\r\n<strong>observational approach<\/strong>, based on the analysis of\r\nassociations between variables. Consequently, the results do not allow\r\ncausal relationships to be established between the factors analysed and\r\nthe type or manifestation of cystitis symptoms. The relationships\r\nobserved must therefore be interpreted as statistical associations and\r\nnot as causal effects.<\/p>\r\n<p>Finally, although certain relevant control variables were included in\r\nthe models (such as age, gender and country of residence), it is\r\npossible that <strong>other unobserved or unretrieved factors from the\r\nquestionnaire<\/strong> influence the relationships analysed. Variables\r\nsuch as pre-existing medical conditions, pharmacological therapies,\r\ngenetic factors or other lifestyle components could in fact contribute\r\nto explaining part of the variability observed in the data.<\/p>\r\n<p>In light of these limitations, the results of the study must be\r\ninterpreted with caution. However, <strong>the large sample size and the\r\nvariety of information collected<\/strong> nevertheless allow the\r\nidentification of <strong>patterns and associations of interest<\/strong>\r\nthat can contribute to understanding the factors associated with\r\ncystitis and provide useful indications for future, more in-depth\r\ninvestigations.<\/p>\r\n<\/section>\r\n<section class=\"eco-paper__section eco-paper__section--soft\" id=\"frequently-asked-questions\">\r\n<h2><span><br\/>\r\nFrequently Asked Questions<\/span><\/h2>\r\n<p><strong>What is the role of diet in modulating cystitis\r\nsymptoms?<\/strong><\/p>\r\n<p>Diet can influence cystitis symptoms primarily through irritative or\r\nprotective effects on the bladder mucosa. Certain foods, such as\r\ncaffeine, alcohol, spicy foods and highly acidic foods, have been\r\nassociated with a worsening of symptomatology. Conversely, a diet rich\r\nin plant-based foods, fibre and omega-3 fatty acids may help modulate\r\nthe inflammatory response and support the immune system. It is, however,\r\nimportant to highlight that the available evidence is in part\r\nheterogeneous and often based on clinical observations rather than\r\nrandomised controlled trials.<\/p>\r\n<p><strong>How is the intestinal microbiota involved in the pathogenesis\r\nof cystitis?<\/strong><\/p>\r\n<p>The intestinal microbiota plays a central role in the pathogenesis of\r\nurinary tract infections, as it represents the main reservoir of\r\nuropathogenic pathogens, including Escherichia coli. Alterations in\r\nmicrobiota composition (dysbiosis) can promote colonisation and\r\nsubsequent migration of bacteria to the urinary tract. This gut-bladder\r\nlink highlights the importance of strategies aimed at maintaining a\r\nbalanced microbiota, also from a preventive perspective.<\/p>\r\n<p><strong>Can constipation be considered a risk factor for\r\ncystitis?<\/strong><\/p>\r\n<p>Constipation is frequently associated with an increased risk of\r\nurinary tract infections, especially in women and children. Reduced\r\nintestinal motility can lead to a longer permanence of bacteria in the\r\ncolon and facilitate their proliferation. Furthermore, faecal\r\naccumulation can exert mechanical pressure on the bladder, interfering\r\nwith complete urinary emptying and promoting stasis, a further\r\npredisposing factor for inflammation.<\/p>\r\n<p><strong>What nutritional strategies can support intestinal health and\r\nreduce the risk of cystitis?<\/strong><\/p>\r\n<p>The main strategies include:<\/p>\r\n<ul>\r\n<li><p>an adequate intake of dietary fibre, which promotes bowel\r\nregularity<\/p><\/li>\r\n<li><p>proper hydration, essential for intestinal transit<\/p><\/li>\r\n<li><p>the intake of probiotics, which can contribute to maintaining\r\nmicrobiota balance<\/p><\/li>\r\n<\/ul>\r\n<p>These interventions, if maintained over time, can indirectly reduce\r\nthe risk of recurrent urinary tract infections or inflammation.<\/p>\r\n<p><strong>What is the role of probiotics in the prevention of\r\ncystitis?<\/strong><\/p>\r\n<p>Probiotics are the subject of growing interest in the prevention of\r\nurinary tract infections. Certain strains, in particular of the genus\r\n<em>Lactobacillus<\/em>, appear to contribute to restoring a microbial\r\nenvironment unfavourable to colonisation by pathogens [6].<\/p>\r\n<p>However, clinical evidence is still evolving and does not allow\r\ndefinitive recommendations to be formulated. Probiotics can be\r\nconsidered a support, but not an alternative to standard therapies.<\/p>\r\n<p><strong>How can sugar consumption influence cystitis?<\/strong><\/p>\r\n<p>A high intake of simple sugars can promote bacterial growth and\r\ncontribute to a state of intestinal dysbiosis. Furthermore, high glucose\r\nlevels in urine (in pathological conditions) can create an environment\r\nconducive to microbial proliferation. For this reason, moderation of\r\nsugar intake is generally recommended, especially in subjects with\r\nrecurrent infections.<\/p>\r\n<p><strong>Is it possible to prevent cystitis exclusively through diet\r\nand lifestyle?<\/strong><\/p>\r\n<p>Diet and lifestyle represent important tools in prevention, but they\r\nare not sufficient to guarantee the complete absence of episodes,\r\nespecially in predisposed subjects. Effective management of cystitis\r\nrequires an integrated approach that includes:<\/p>\r\n<ul>\r\n<li><p>correct hygiene habits<\/p><\/li>\r\n<li><p>adequate hydration<\/p><\/li>\r\n<li><p>balanced diet<\/p><\/li>\r\n<li><p>pharmacological therapy, where indicated<\/p><\/li>\r\n<\/ul>\r\n<\/section>\r\n<section class=\"eco-paper__section eco-paper__section--bibliography\" id=\"references\">\r\n<h2><span>References<\/span><\/h2>\r\n<ol type=\"1\">\r\n<li><p>Worby, C. J., Schreiber, H. L., 4th, Straub, T. J., van Dijk, L.\r\nR., Bronson, R. A., Olson, B. S., Pinkner, J. S., Obernuefemann, C. L.\r\nP., Mu\u00f1oz, V. L., Paharik, A. E., Azimzadeh, P. N., Walker, B. J.,\r\nDesjardins, C. A., Chou, W. C., Bergeron, K., Chapman, S. B., Klim, A.,\r\nManson, A. L., Hannan, T. J., Hooton, T. M., \u2026 Earl, A. M. (2022).\r\nLongitudinal multi-omics analyses link gut microbiome dysbiosis with\r\nrecurrent urinary tract infections in women. Nature microbiology, 7(5),\r\n630\u2013639. <a href=\"https:\/\/doi.org\/10.1038\/s41564-022-01107-x\"><u>https:\/\/doi.org\/10.1038\/s41564-022-01107-x<\/u><\/a><\/p><\/li>\r\n<li><p>Minardi, D., d'Anzeo, G., Cantoro, D., Conti, A., &amp;\r\nMuzzonigro, G. (2011). Urinary tract infections in women: etiology and\r\ntreatment options. International journal of general medicine, 4,\r\n333\u2013343. <a href=\"https:\/\/doi.org\/10.2147\/IJGM.S11767\"><u>https:\/\/doi.org\/10.2147\/IJGM.S11767<\/u><\/a><\/p><\/li>\r\n<li><p>Magruder, M., Sholi, A.N., Gong, C. et al. Gut uropathogen\r\nabundance is a risk factor for development of bacteriuria and urinary\r\ntract infection. Nat Commun 10, 5521 (2019). <a href=\"https:\/\/doi.org\/10.1038\/s41467-019-13467-w\"><u>https:\/\/doi.org\/10.1038\/s41467-019-13467-w<\/u><\/a><\/p><\/li>\r\n<li><p>Ru\u021ba, F., Avram, C., Mardale, E., Maior, R., Filip, C., &amp;\r\nNemeth, S. (2025). Histamine-Producing Intestinal Dysbiosis and Its Role\r\nin Lower Urinary Tract Infections and Irritable Bowel Syndrome in Young\r\nWomen. Nutrients, 18(1), 16. <a href=\"https:\/\/doi.org\/10.3390\/nu18010016\"><u>https:\/\/doi.org\/10.3390\/nu18010016<\/u><\/a><\/p><\/li>\r\n<li><p>Marinkovic, S. P., Moldwin, R., Gillen, L. M., &amp; Stanton, S.\r\nL. (2009). The management of interstitial cystitis or painful bladder\r\nsyndrome in women. BMJ (Clinical research ed.), 339, b2707. <a href=\"https:\/\/doi.org\/10.1136\/bmj.b2707\"><u>https:\/\/doi.org\/10.1136\/bmj.b2707<\/u><\/a><\/p><\/li>\r\n<li><p>Du, Y., Sui, X., Bai, Y., Shi, Z., Liu, B., Zheng, Z., Zhang, Z.,\r\nZhao, Y., Wang, J., Zhang, Q., Zhu, Y., Liu, Q., Wang, M., Sun, H.,\r\n&amp; Shao, C. (2024). Dietary influences on urinary tract infections:\r\nunraveling the gut microbiota connection. Food &amp; function, 15(19),\r\n10099\u201310109. https:\/\/doi.org\/10.1039\/d4fo03271c<a href=\"https:\/\/doi.org\/10.1039\/d4fo03271c\"><u>https:\/\/doi.org\/10.1039\/d4fo03271c<\/u><\/a><\/p><\/li>\r\n<li><p>EAU Guidelines. Edn. presented at the EAU Annual Congress London,\r\nUnited Kingdom 2026. ISBN 978-94-92671-32-5<\/p><\/li>\r\n<li><p>Yang, H.J.; Kim, D.S.; Lee, K.W.; Kim, Y.H. The Urinary\r\nMicrobiome; Axis Crosstalk and Short-Chain Fatty Acid. Diagnostics 2022,\r\n12, 3119. <a href=\"https:\/\/doi.org\/10.3390\/diagnostics12123119\"><u>https:\/\/doi.org\/10.3390\/diagnostics12123119<\/u><\/a><\/p><\/li>\r\n<li><p>Hakam, N., Guzman Fuentes, J. L., Nabavizadeh, B., Sudhakar, A.,\r\nLi, K. D., Nicholas, C., Lui, J., Tahir, P., Jones, C. P., Bent, S.,\r\n&amp; Breyer, B. N. (2024). Outcomes in Randomized Clinical Trials\r\nTesting Changes in Daily Water Intake: A Systematic Review. JAMA network\r\nopen, 7(11), e2447621. <a href=\"https:\/\/doi.org\/10.1001\/jamanetworkopen.2024.47621\"><u>https:\/\/doi.org\/10.1001\/jamanetworkopen.2024.47621<\/u><\/a><\/p><\/li>\r\n<li><p>Liska, D., Mah, E., Brisbois, T., Barrios, P. L., Baker, L. B.,\r\n&amp; Spriet, L. L. (2019). Narrative Review of Hydration and Selected\r\nHealth Outcomes in the General Population. Nutrients, 11(1), 70.\r\nhttps:\/\/doi.org\/10.3390\/nu11010070<\/p><\/li>\r\n<li><p>Hurst, R.E., Rhodes, S.W., Adamson, P.B., Parsons, C.L., Roy,\r\nJ.B., Functional and Structural Characteristics of the\r\nGlycosaminoglycans of the Bladder Luminal Surface, The Journal of\r\nUrology, Volume 138, Issue 2, 1987, Pages 433-437, ISSN 0022-5347, <a href=\"https:\/\/doi.org\/10.1016\/S0022-5347(17)43180-6\"><u>https:\/\/doi.org\/10.1016\/S0022-5347(17)43180-6<\/u><\/a>.<\/p><\/li>\r\n<li><p>Scott, A. M., Clark, J., Mar, C. D., &amp; Glasziou, P. (2020).\r\nIncreased fluid intake to prevent urinary tract infections: systematic\r\nreview and meta-analysis. The British journal of general practice : the\r\njournal of the Royal College of General Practitioners, 70(692),\r\ne200\u2013e207. <a href=\"https:\/\/doi.org\/10.3399\/bjgp20X708125\"><u>https:\/\/doi.org\/10.3399\/bjgp20X708125<\/u><\/a><\/p><\/li>\r\n<li><p>Fuoco, M. B., Irvine-Bird, K., Curtis, N. J., Multiple\r\nsensitivity phenotype in interstitial cystitis\/bladder pain syndrome.\r\nCan Urol Assoc J. 2014 Nov;8(11-12):E758-61. doi: 10.5489\/cuaj.2031.\r\nPMID: 25485000; PMCID: PMC4250237.<\/p><\/li>\r\n<li><p>EFSA Panel on Dietetic Products, Nutrition, and Allergies (NDA);\r\nScientific Opinion on Dietary reference values for water. EFSA Journal\r\n2010; 8(3):1459. [48 pp.]. doi:10.2903\/j.efsa.2010.1459. Available\r\nonline: www.efsa.europa.eu<a href=\"http:\/\/www.efsa.europa.eu\"><u>www.efsa.europa.eu<\/u><\/a><\/p><\/li>\r\n<li><p>Kontiokari, T., Laitinen, J., J\u00e4rvi, L., Pokka, T., Sundqvist,\r\nK., &amp; Uhari, M. (2003). Dietary factors protecting women from\r\nurinary tract infection. The American journal of clinical nutrition,\r\n77(3), 600\u2013604. https:\/\/doi.org\/10.1093\/ajcn\/77.3.60<a href=\"https:\/\/doi.org\/10.1093\/ajcn\/77.3.60\"><u>https:\/\/doi.org\/10.1093\/ajcn\/77.3.60<\/u><\/a><\/p><\/li>\r\n<li><p>Alagiri, M., Chottiner, S., Ratner, V., Slade, D., &amp; Hanno,\r\nP. M. (1997). Interstitial cystitis: unexplained associations with other\r\nchronic disease and pain syndromes. Urology, 49(5A Suppl), 52\u201357. <a href=\"https:\/\/doi.org\/10.1016\/s0090-4295(99)80332-x\"><u>https:\/\/doi.org\/10.1016\/s0090-4295(99)80332-x<\/u><\/a><\/p><\/li>\r\n<li><p>Panicker, J. N., &amp; Sakakibara, R. (2020). Lower Urinary Tract\r\nand Bowel Dysfunction in Neurologic Disease. Continuum (Minneapolis,\r\nMinn.), 26(1), 178\u2013199. <a href=\"https:\/\/doi.org\/10.1212\/CON.0000000000000824\"><u>https:\/\/doi.org\/10.1212\/CON.0000000000000824<\/u><\/a><\/p><\/li>\r\n<li><p>Malykhina A. P. (2007). Neural mechanisms of pelvic organ\r\ncross-sensitization. Neuroscience, 149(3), 660\u2013672. <a href=\"https:\/\/doi.org\/10.1016\/j.neuroscience.2007.07.053\"><u>https:\/\/doi.org\/10.1016\/j.neuroscience.2007.07.053<\/u><\/a><\/p><\/li>\r\n<li><p>Whitehead, W. E., Palsson, O., &amp; Jones, K. R. (2002).\r\nSystematic review of the comorbidity of irritable bowel syndrome with\r\nother disorders: what are the causes and implications?.\r\nGastroenterology, 122(4), 1140\u20131156. <a href=\"https:\/\/doi.org\/10.1053\/gast.2002.32392\"><u>https:\/\/doi.org\/10.1053\/gast.2002.32392<\/u><\/a><\/p><\/li>\r\n<\/ol>\r\n<\/section>\r\n<section class=\"eco-paper__section eco-paper__section--soft\" id=\"to-complete-before-publication\">\r\n  <h2><span>To complete before publication<\/span><\/h2>\r\n  <div class=\"eco-paper__todo\">\r\n    <ul>\r\n      <li>Complete subtitle, DOI, license, PDF URL, Italian page URL and English page URL.<\/li>\r\n      <li>Verify version V1 \u00b7 2026, publication date and clinical reviewer information.<\/li>\r\n      <li>Insert final English WebP images and update <code>src<\/code>, <code>width<\/code> and <code>height<\/code>.<\/li>\r\n      <li>Review the executive summary graphic and the methodological recoding graphic when they are produced.<\/li>\r\n      <li>Check whether table labels \u201cNumber of observations\u201d and decimal formatting should remain as in the official English file.<\/li>\r\n    <\/ul>\r\n  <\/div>\r\n<\/section>\r\n\r\n<\/article>\r\n<\/div>\r\n<section class=\"eco-paper__cta\" aria-label=\"Download the white paper\">\r\n  <div><h2><span>Interested in the Observatory\u2019s work?<\/span><\/h2><p>Download the White Paper and receive updates from the first European Cystitis Observatory.<\/p><\/div>\r\n  <a class=\"eco-paper__btn eco-paper__btn--primary\" href=\"#\">Download the white paper<\/a>\r\n<\/section>\r\n<\/main>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>&nbsp; White paper2026 Understanding Recurrent and Chronic Cystitis. The Role of Diet and Hydration in Different Manifestations of Cystitis Understanding Recurrent and Chronic Cystitis Series. Download the white paperGo to references ITEN Series Understanding Recurrent and Chronic Cystitis Series By European Cystitis Observatory (ECO) Version V1 \u00b7 2026 [TO BE VERIFIED] DOI [TO BE DEFINED] [&hellip;]<\/p>\n","protected":false},"author":31,"featured_media":61903,"parent":60080,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_canvas","meta":{"footnotes":""},"class_list":["post-61663","page","type-page","status-publish","has-post-thumbnail","hentry"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.6 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>White Paper 2026-r02 \u2014 Full text [EN] | Dimann<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.dimann.com\/en\/eco\/white-paper-2026-r02-full-text\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"White Paper 2026-r02 \u2014 Full text [EN] | Dimann\" \/>\n<meta property=\"og:description\" content=\"&nbsp; White paper2026 Understanding Recurrent and Chronic Cystitis. 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