Many uropathogenic Escherichia coli (UPEC) strains produce both hemolysin (Hly) and cytotoxic necrotizing factor type 1 (CNF1), and the loci for these toxins are often linked. The conclusion that Hly and CNF1 contribute to urovirulence is supported by the results of epidemiological studies associating the severity of urinary tract infections (UTIs) with toxin production by UPEC isolates. Additionally, we previously reported that mouse bladders and rat prostates infected with UPEC strain CP9 exhibit a more profound inflammatory response than the organs from animals challenged with CP9cnf 1 and that CNF1 decreases the antimicrobial activities of polymorphonuclear leukocytes. More recently, we created an Hly mutant, CP9⌬hlyA 1 ::cat, and showed that it was less hemolytic and destructive for cultured bladder cells than CP9 was. Here we evaluated the relative effects of mutations in hlyA 1 or cnf 1 alone or together on the pathogenicity of CP9 in a mouse model of ascending UTI. To do this, we constructed an hlyA 1 -complemented clone of CP9⌬hlyA 1 ::cat and an hlyA 1 cnf 1 CP9 double mutant. We found that Hly had no influence on bacterial colonization of the bladder or kidneys in single or mixed infections with the wild type and CP9⌬hlyA 1 ::cat but that it did provoke sloughing of the uroepithelium and bladder hemorrhage within the first 24 h after challenge. Finally, we confirmed that CNF1 expression induces bladder inflammation and, in particular, as shown in this study, submucosal edema. From these data, we speculate that Hly and CNF1 may be largely responsible for the signs and symptoms of cystitis in humans infected with toxigenic UPEC.Urinary tract infections (UTIs) include infections of the bladder (cystitis) and/or kidney (pyelonephritis) and account for more than 7 million office visits each year by otherwise healthy women (23). Extraintestinal pathogenic Escherichia coli (ExPEC) is the causative agent of at least 80% of all uncomplicated UTIs. ExPEC strains that cause a UTI are called uropathogenic E. coli (UPEC). UPEC strains typically are members of phylogenetic group B2 or D and often exhibit specific O:K:H serotypes, as well as various combinations of virulence factors, including, among others, adhesins or fimbriae, siderophore systems, and toxins. The virulence-associated genes in UPEC are frequently clustered together in "pathogenicity islands" (PAIs) (25), and many UPEC isolates harbor more than one PAI. For instance, the prototypic UPEC clinical strain J96 (O4:K6) carries two PAIs, PAI I J96 and PAI II J96 (58). PAI I J96 is over 170 kb long and contains operons encoding alpha-hemolysin (hly) and Pap fimbriae (pap). PAI II J96 is 110 kb long and also contains an hly operon in addition to genes encoding Prs fimbriae (prs) and cytotoxic necrotizing factor type 1 (CNF1) (cnf 1 ) (6). Here, we hypothesized that the link between PAI II J96 and the urovirulence of E. coli strains may largely reflect the fact that these strains produce both alpha-hemolysin (referred to as hemolysin [Hly] here) and CNF1. ...