What is Acute Cystitis? The causes of occurrence, diagnosis and treatment methods will be analyzed in detail in this article.
Definition of disease. Causes of the disease
CystitisIs an infectious and inflammatory process in the wall of the bladder, localized mainly in the mucous membrane.
Acute cystitis mainly affects women. This is due to the anatomical and physiological structure of the female body - women have a short urethra, the external opening of the urethra is located closer to the rectum than men. Half of the world's women have had at least one episode of cystitis during their lifetime, and more than 30 million new cases of cystitis are reported each year. Most often, the disease affects women between the ages of 25 and 30 or over 55.
Acute cystitis is a condition that primarily occurs in non-pregnant women of premenopausal age who do not have anatomical and functional disorders of the urinary tract, and also against the background of complete health. In older women, genitourinary symptoms are not necessarily due to cystitis.
There are rare non-infectious forms of acute cystitis associated with physical effects. For example, ionizing radiation during radiation therapy is often the cause of acute radiation cystitis.
The main symptoms are:
- lower abdominal pain;
- frequent painful urination;
- blood in the urine;
- darkening and clouding of urine.
With the typical development of acute cystitis, the general state of health remains at a satisfactory level, many patients continue to lead their normal daily lives.
In most cases, vital activity leads to the development of acute cystitis. bacteria:
- Escherichia coli - 70-95%;
- less often staphylococcus - 10-20%;
There is a small group of cystitis that develops after the use of medications. A typical example of acute cystitis is the intravesical injection of BCG vaccine (live mycobacterium of the Calmette-Guerin bacillus vaccine strain) into the bladder during immunotherapy of non-invasive bladder cancer.
The provoking factors for the onset of acute cystitis are:
- damage to the mucous membrane of the bladder;
- varicose veins of the pelvis and, as a result, stagnation of venous blood;
- hormonal imbalance in the body;
- general hypothermia;
- sexually transmitted infections;
- urolithiasis disease;
- abnormal structure of the urinary tract;
- prolonged standing of the urinary catheter.
Pregnancy also predisposes to the development of acute cystitis - the influence of the hormone progesterone and compression of the ureters by the uterus make it difficult to empty the bladder, which leads to its enlargement and stagnation of urine. During pregnancy, the amount of blood passing through the filters in the kidneys increases every minute. The load of glucose on the renal tubules becomes excessive, its reabsorption worsens (transport of glucose from the urine back to the blood). As a result, the concentration of glucose in the urine increases, the pH level of the urine changes, thereby creating a favorable background for the growth of bacteria.
In men, acute cystitis is rare and is usually a complication of another medical condition, such as urethritis or prostatitis, or as a consequence of prostate adenoma.
If you find similar symptoms, consult your doctor. Do not self-medicate - it is dangerous for your health!
Symptoms of acute cystitis
The onset of symptoms of acute cystitis is sudden, the disease can develop in a few hours. Often, patients note the presence of a provoking factor, such as general hypothermia or sexual activity. If two or more acute episodes occur within six months, then in such cases they speak of recurrent cystitis.
The most common manifestations of acute cystitis:
- frequent painful urination (more than 6-8 times a day);
- urination in small portions;
- false urge to urinate;
- cramps when urinating;
- pain in the lower abdomen, above the bosom in the projection of the bladder, occasionally radiating to the perineum;
- rarely / sometimes blood in the urine;
- rarely / sometimes a rise in body temperature of 37-37. 5 degrees.
- clouding of urine with an unpleasant odor.
Often in young women, symptoms of acute cystitis can be associated with intercourse, the appearance of a new sexual partner, the use of spermicides, the presence of kidney stones or urinary tract abnormalities, diabetes mellitus, etc.
Pathogenesis of acute cystitis
The penetration of pathogenic microorganisms into the bladder is possible in the following ways:
- ascending along the urethra - the most frequent way in which uropathogens penetrate into the urethra from the surface of the skin of the perineum, from the vaginal mucosa, from the tissues surrounding the urethra and from the intestine, and then rise along the mucous membrane of the urethra into the bladder;
- descending from the kidneys - with inflammatory diseases of the kidneys (pyelonephritis and its terminal stage - pyonephrosis);
- with lymph flow from the genitals - with salpingo-oophoritis, endometritis, parametritis (inflammation, respectively, of the fallopian tubes and ovaries, the mucous membrane of the uterus and the connective tissue surrounding the uterus);
- hematogenous (with blood) - is rare, possible with recent infectious diseases;
- direct - in the presence of urinary fistulas, bladder catheterization and cystoscopy (endoscopic method for diagnosing diseases of the bladder).
After the uropathogens hit the bladder mucosa, they are fixed and the pathogen "confronts" the protective cells of the organ mucosa. The fixation of uropathogens to the mucous membrane is carried out due to the so-called adhesins - villi, among which type 1, P and S are the most studied. Type 1 is a mannose-sensitive type. Subsequently, the fixed uropathogens on the mucous membrane of the bladder begin to form a protective biofilm over themselves. Thanks to biofilms, uropathogens can remain invulnerable for a long time and periodically cause exacerbations of cystitis.
Prolonged residence and multiplication of bacteria leads to inadequate emptying of the bladder, stagnation of urine, decomposition and accumulation of toxic substances, including waste products of bacteria.
Signs of an inflammatory process appear in the bladder - pain due to irritation of pain receptors in the submucosal layer, edema and redness of the mucous membrane, a local increase in temperature in the bladder and a violation of its functions. With the penetration of bacteria into the submucosal layer, the destruction of the microvasculature is possible with the development of hemorrhagic cystitis, in which blood from damaged small vessels flows into the bladder, due to which blood impurities appear in the urine.
Classification and stages of development of acute cystitis
By etiology, there are:
- infectious - bacterial, viral, caused by fungi;
- non-infectious - medicinal, radiation, toxic, chemical, parasitic, allergic.
In the course of the inflammatory process, they divide:
- recurrent - occurs at least twice within six months;
- chronic (periods of exacerbation and remission) in the clinical picture, only one symptom is often revealed - frequent urination.
By the nature of morphological changes:
- catarrhal (superficial), when inflammation in the bladder is localized within the mucous layer;
- ulcerative fibrinous, when a deeper lesion of the mucous membrane occurs with the formation of ulcerative defects on the mucous membrane of the bladder up to the muscle layer;
- hemorrhagic - small vessels in the submucous layer are mainly affected;
- gangrenous is a rare form in which necrosis of the bladder wall develops.
Taking into account the development of complications, acute cisitis is divided into:
- uncomplicated, when there is no violation of the outflow of urine and, in general, human health does not suffer;
- complicated when cystitis occurs as a result of other diseases (for example, with urolithiasis, tumors or tuberculosis of the bladder, etc. ).
Community-acquired and nosocomial cystitis is also distinguished. Nosocomial cystitis is characterized by the presence of bacteria resistant to certain antibiotics.
There is a separate form of acute cystitis - interstitial cystitis. It occurs when inflammation spreads to the muscular layer of the bladder. The cause of this form of cystitis is often a sharp violation of the protective mucous layer of the bladder. With the penetration of potassium and other aggressive substances from urine deep into the bladder wall, sensory nerve endings are activated and smooth muscles are damaged. Over time, cicatricial degeneration of the bladder mucosa occurs, leading to a decrease in its reservoir capacity. As a result, the frequency of urination increases up to urinary incontinence, the bladder is not emptied completely, which leads to a pathological closed cycle of the development of the disease.
Complications of acute cystitis
The main complications of acute cystitis include acute pyelonephritis, chronic cystitis, and hematuria.
Acute pyelonephritis-This is an inflammation of the kidneys caused by an infectious agent with damage to the parenchyma, the calyx-pelvis complex and the fibrous connective tissue of the kidney.
Acute pyelonephritis is a more formidable disease than cystitis, which can lead to severe intoxication and sepsis. The overwhelming number of cases of acute pyelonephritis is associated with an ascending infection - the migration of microorganisms through the ureters from the bladder. In acute pyelonephritis, one or both kidneys can be affected. With the development of acute pyelonephritis, inpatient treatment is recommended, this is due to the frequent development of complications and longer therapy than in acute cystitis.
Chronic cystitis-the clinical picture during exacerbation corresponds to acute cystitis, but the symptoms are less pronounced, the temperature often does not rise above 37. 5 ° C. Often, in chronic cystitis, it is not possible to identify the relationship with an infectious agent, therefore, antibiotic therapy is not always needed.
Hematuria (hemorrhagic cystitis).When bacteria penetrate into a deeper layer (submucosal), the microvasculature is destroyed, which is manifested by microbleeds in the mucous membrane. Hematuria in acute cystitis is relatively benign and rarely leads to serious consequences such as anemia, collapse and shock. A more malignant course of hematuria is acquired in persons taking drugs that prevent thrombus formation.
With extensive damage to the submucosal layer, a formidable complication may develop -bladder tamponademassive blood clot. In case of illness, the lumen of the bladder fills with clots, as a result of which the pressure inside the bladder, in the ureters and kidneys increases. It often manifests itself as a delay and lack of independent urination with sharp pains above the bosom. The complication requires immediate hospitalization in a surgical hospital, as it can lead to acute renal failure.
Diagnostics of the acute cystitis
Whenuncomplicated course of the diseaseenough to make a diagnosisexamination by a urologist, the presence of the above complaints and a general urine test.
In acute cystitis, leukocytes, bacteria, protein are found in the general analysis of urine. Urine analysis can be performed both with a laboratory analyzer and with test strips (a positive test for nitrite and leukocyte esterase indicates cystitis).
If within four weeks the symptoms of acute uncomplicated cystitis did not go away, despite the treatment, or went away, but returned after two weeks, then it is indicated to performculture of urine with determination of sensitivity to antibiotics.
For sowing, an average portion of morning urine is handed over and it is advisable to immediately send it for analysis, if this is not possible, then it is advisable to store the urine at a temperature from +2 to +8 before sending.
National clinical guidelines also recommend bacteriological examination of vaginal contents and testing for sexually transmitted infections.
Recently, for the diagnosis of recurrent cystitis (provided there is no growth on conventional culture), microbiome analysis using the expanded quantitative urine culture and gene sequencing techniques has been used. It used to be generally accepted that urine was sterile, but this is not the case. The urine is not sterile. It should be remembered that often bacteria in the urine can not be detected, because sometimes bacteria can penetrate into the cells of the mucous layer of the bladder with the formation of protective films.
If it is not possible to assess the microbiome, and the culture was "clean", but there are clinical symptoms of cystitis, then urine can be sent for culture to exclude Ureaplasma urealyticum or Mycoplasma hominis.
Chair examinationin patients with a recurrent form of cystitis, it is an obligatory part: vaginal ectopia and / or hypermobility of the external urethral opening, discharge from the external urethral opening, the presence of inflammation near the urethral glands are excluded, the condition of the vaginal mucosa or its prolapse is assessed, etc. The likelihood of infection increases significantly withvaginal ectopia and / or hypermobility of the external opening of the urethra.
Vaginal ectopia- the location of the external opening of the urethra on the border or on the anterior wall of the vagina.
Hypermobility- increased mobility of the external opening and the distal urethra in women due to the presence of urethrogynal adhesions. With each sexual intercourse, the external opening of the urethra into the vagina is displaced, due to which there is a continuous retrograde reflux of the vaginal microflora into the urethra, which in turn is a constant source of infection of the lower urinary tract. This type of cystitis is calledpostcoital cystitis.
Ultrasound examination of the kidneys and bladderis performed for all patients with recurrent cystitis, taking into account the safety of the method and its potential usefulness.
Cystoscopyit is recommended to perform in the absence of the effect of the therapy, with frequent relapses associated with a bacterial infection and / or in the presence of predisposing risk factors (urinary tract anomalies, stones, tumors). Cystoscopy is an endoscopic examination performed with a cystoscope inserted into the urethra to examine the lining of the bladder.
Treatment of acute cystitis
Algorithm for the treatment of acute cystitis:
- drinking plenty of fluids at least 1. 5 liters per day;
- exclude sexual intercourse for the entire period of the disease;
- antibiotic therapy.
If the cystitis is recurrent, then the antibiotic is selected based on the results of urine culture.
- Broad-spectrum antibiotics that show high activity against most bacteria.
- An alternative is drugs from the nitrofuran group. The drugs are effective against various bacteria, as well as fungi of the genus Candida. Resistance to nitrofurans rarely develops.
- Less commonly, they resort to prescribing systemic oral antibacterial drugs. Antibiotics of the fluoroquinolone and cephalosporin groups are associated with a large number of adverse reactions and can lead to the development of resistant bacterial forms, and therefore should not be the first line of treatment for acute uncomplicated cystitis.
Etiological treatment (aimed at eliminating the cause and conditions for the development of the disease)
With relapses of acute cystitis, bacteriophage preparations - drugs based on viruses, selectively, like sniper fire, destroying bacteria - have been increasingly used lately. Most often, bacteriophages multiply inside bacteria and cause them to break down into fragments.
Treatment with bacteriophages is safer than antibiotics, but it should be noted that for targeted destruction of bacteria, a bacteriological study of urine is required to determine the pathogen and its sensitivity to phages.
In patients with recurrent cystitis, which is directly related to intercourse (postcoital cystitis) and in the presence of a deeply located external opening of the urethra, surgical treatment is used. Operations aimed at displacement (transposition) of the urethra have a high success rate.
Pathogenetic treatment (aimed at eliminating or suppressing the mechanisms of the development of the disease)
Vaccinetaken orally (by swallowing). The agent has an immunobiological property that protects against the effects of Escherichia coli and triggers an immune response of a nonspecific nature (activates macrophages and cellular phagocytosis). When prescribing a vaccine, it should be borne in mind that the effectiveness remains with the repeated course of taking the drug.
Monosaccharideafter absorption from the intestine with urine into the bladder, where it blocks the attachment of bacterial pili (filamentous outgrowths of bacteria). As a result, bacteria leave the body along with urine. This is a dietary supplement, not a medicine, but this drug has proven efficacy and is recommended by the European Association of Urology.
Hormone replacement therapy.In the postmenopausal period in women, the level of estrogen sharply decreases. Estrogens are one of the factors of protection of the bladder mucosa, with a decrease, the protective mechanisms of the mucous membrane are weakened. Perhaps the introduction through the urethra or through the vagina of hormonal preparations containing estrogens.
As adjuvants for the treatment of acute cystitis are usedphytopreparations,possessing anti-inflammatory, weak diuretic and antiseptic effects.
With severe hematuria, it is possible to prescribe hemostatic drugs. The most effective in this group are antifibrinolytic drugs.
If the cause of acute cystitis is obstructive uropathy (difficulty passing urine associated with narrowing of the urethral lumen), then after the relief of the acute period and elimination of the infectious agent, surgical correction is performed - installation of a cystostomy (special drainage tube), plastic urethra, etc.
Symptomatic treatment (reducing the manifestations of the disease)
NSAIDs (non-steroidal anti-inflammatory drugs)- a large group of medicines that have analgesic, antipyretic and anti-inflammatory effects, reduce pain, fever and inflammation.
In case of illness, it is necessary to observedietwith the exception of spicy dishes. It is advisable to eat foods rich in vitamins and increase daily urine output (for example, cranberries), as well as a sufficient amount of liquid to maintain daily urination in the amount of 2000-2500 ml.
In the overwhelming majority of cases, acute cystitis (in the absence of disturbances in urine excretion, concomitant diseases, a standard pathogen and its sensitivity to antibacterial drugs, rational antibiotic therapy) passes without consequences. In case of recurrent cystitis, treatment requires more in-depth laboratory and instrumental diagnostics and can be effective only if the principles of pathogenetic therapy and active prevention of recurrence of the disease are observed.
Prevention consists of:
- Adhere to proper hygiene of the external genital organs in women and girls to prevent the development of vaginitis, and then urethritis and cystitis. You need to wash the girl from front to back, just twice a day, morning and evening, under running water.
- If indicated, correct anomalies in the development of the lower urinary tract in childhood.
- Timely and adequately treat gynecological diseases.
- Avoid hypothermia.
- Observe sexual hygiene (take a shower before and after intimacy).
- Treat asymptomatic bacteriuria in pregnant women.
- To carry out antibacterial prophylaxis for invasive urological interventions - inject a single dose of an antibacterial drug before or immediately after the procedure.
- Correct urological pathology leading to impaired urinary excretion, such as prostate adenoma and urethral structure.
- Drink a sufficient amount of liquid (from 2 liters) and empty the bladder in a timely manner.
- Women with recurrent attacks of acute cystitis need to urinate immediately after intercourse and use a single dose of an antibacterial drug (fosfomycin or nitrofuran).
- Do not use spermicides and vaginal diaphragms for contraception.
- Conduct immunological prophylaxis (from two months, the duration of treatment is determined by the doctor).
To date, recommendations for the use of various drugs such as: cranberries, vaginal estrogens, probiotics in the form of vaginal suppositories, intravesical administration of hyaluronic acid and other injections in order to restore the surface protective layer of the bladder mucosa may have a positive effect, however, their use has poorly proven effect. . .