What is acute cystitis? The causes of occurrence, diagnosis and treatment methods will be discussed in detail in this article.
Definition of disease. Causes of the disease
CystitisIt is an infectious and inflammatory process in the bladder wall, located mainly in the mucosa.
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 closer to the rectum than men. Half of the world's women have had at least one episode of cystitis in 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 older than 55.
Acute cystitis is a condition that occurs mainly in non-pregnant women of premenopausal age who do not have anatomical and functional disorders of the urinary tract, and also in the context 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:
- pain in the lower abdominal area;
- frequent and 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 the onset of acute cystitis is the intravesical injection of BCG (live mycobacterium from the Bacillus Calmette-Guerin vaccine strain) vaccine into the bladder during non-invasive bladder cancer immunotherapy.
The factors that cause the appearance 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 the compression of the ureters by the uterus make it difficult to empty the bladder, which leads to its enlargement and urine stagnation. During pregnancy, the amount of blood that passes through the kidney filters increases every minute. The glucose load 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, thus 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 a prostate adenoma.
If you find similar symptoms, see 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 within a few hours. Often times, 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, in such cases it is referred to as recurrent cystitis.
The most common manifestations of acute cystitis:
- frequent and 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 chest in the projection of the bladder, occasionally radiating to the perineum;
- rarely / sometimes blood in the urine;
- rarely / sometimes an increase in body temperature from 37 to 37. 5 degrees.
- cloudy urine with an unpleasant odor.
Often in young women, the symptoms of acute cystitis can be associated with sexual 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 through the urethra: the most common way in which uropathogens enter 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 ascend toalong the mucous membrane of the urethra towards the bladder;
- descending from the kidneys - with inflammatory diseases of the kidneys (pyelonephritis and its terminal stage - pyonephrosis);
- with lymphatic 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 (bloody) - rare, possible with recent infectious diseases;
- direct: in the presence of urinary fistulas, bladder catheterization and cystoscopy (endoscopic method to diagnose bladder diseases).
After the uropathogens hit the mucosa of the bladder, they become attached and the pathogen "faces" the protective cells of the mucosa of the organs. The fixation of uropathogens to the mucosa is carried out due to the so-called adhesins - villi, among which the most studied are type 1, P and S. Type 1 is a type sensitive to mannose. Subsequently, the uropathogens attached to the mucous membrane of the bladder begin to form a protective biofilm on themselves. Thanks to biofilms, uropathogens can remain invulnerable for a long time and periodically provoke exacerbations of cystitis.
Prolonged residence and multiplication of bacteria leads to improper bladder emptying, urine stagnation, breakdown, and accumulation of toxic substances, including bacterial waste products.
Signs of an inflammatory process appear in the bladder: pain due to irritation of pain receptors in the submucous 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 submucous layer, destruction of the microvasculature with the development of hemorrhagic cystitis is possible, 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, radioactive, toxic, chemical, parasitic, allergic.
In the course of the inflammatory process, they are divided:
- recurrent - occurs at least twice in six months;
- chronic (periods of exacerbation and remission) in the clinical picture, often only one symptom is revealed - frequent urination.
By the nature of morphological changes:
- catarrhal (superficial), when the inflammation of the bladder is located within the mucous layer;
- ulcerative fibrinous, when a deeper lesion of the mucous membrane occurs with the formation of ulcerative defects in the mucous membrane of the bladder to the muscle layer;
- hemorrhagic - small vessels in the submucosal 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 is not affected;
- complicated when cystitis occurs as a consequence of other diseases (for example, with urolithiasis, tumors or tuberculosis of the bladder, etc. ).
Community-acquired and nosocomial cystitis are 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 strong violation of the protective mucous layer of the bladder. With the deep penetration of potassium and other aggressive substances from urine into the bladder wall, sensory nerve endings are activated and smooth muscles are damaged. Over time, scarring of the bladder mucosa occurs, leading to a decrease in its reservoir capacity. As a result, the frequency of urination increases until urinary incontinence, the bladder does not empty completely, which leads to a closed pathological 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-It is an inflammation of the kidneys caused by an infectious agent that damages 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 poisoning 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 may be affected. With the development of acute pyelonephritis, hospital 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 ainfectious agent, so antibiotic therapy is not always necessary.
Hematuria (hemorrhagic cystitis).When bacteria penetrate a deeper layer (submucosa), the microvasculature is destroyed, 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 people taking drugs that prevent thrombus formation.
With extensive damage to the submucosal layer, a formidable complication can develop:bladder tamponademassive blood clot. In disease, the lumen of the bladder fills with clots, as a result of which pressure increases within the bladder, on the ureters and kidneys. It often manifests as a delay and lack of independent urination with sharp pains above the chest. The complication requires immediate hospitalization in a surgical hospital, as it can lead to acute kidney failure.
Diagnosis of 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, and proteins are found in the general urine analysis. Urinalysis can be performed with either a laboratory analyzer or test strips (a positive test for nitrite and leukocyte esterase indicates cystitis).
If in four weeks the symptoms of uncomplicated acute cystitis have not disappeared despite treatment, or have passed, but return after two weeks, then it is indicated to performurine culture with determination of sensitivity to antibiotics.
For sowing, an average portion of morning urine is delivered and it is advisable to send it immediately for analysis, if this is not possible then it is advisable to store the urine at a temperature of +2 to +8 before sending it.
National clinical guidelines also recommend bacteriological examination of vaginal contents and testing for sexually transmitted infections.
Recently, for the diagnosis of recurrent cystitis (as long as there is no growth in conventional culture), the analysis of the microbiome using the expanded quantitative urine culture technique and gene sequencing has been used. It was generally accepted that urine was sterile, but this is not the case. Urine is not sterile. It should be remembered that bacteria can often not be detected in urine, because sometimes bacteria can penetrate the cells of the mucous layer of the bladder with the formation of protective films.
If the microbiome cannot be assessed and the culture was "clean", but there are clinical symptoms of cystitis, then urine can be submitted for culture to exclude Ureaplasma urealyticum or Mycoplasma hominis.
Chair examin patients with a recurrent form of cystitis, it is an obligatory part: vaginal ectopy and / or hypermobility of the external urethral opening, discharge from the external urethral opening, the presence of inflammation near the urethral glands, the condition of the vagina is excludedthe mucosa or its prolapse, etc. are evaluated. The probability of infection increases significantly with vaginal ectopia and / or hypermobility of the external opening of the urethra.
Vaginal ectopia- the location of the external opening of the urethra at the edge or anterior wall of the vagina.
Hypermobility- increased mobility of the external opening and distal urethra in women due to the presence of urethroginous adhesions. With each intercourse, the external opening of the urethra into the vagina shifts, resulting in a continuous retrograde reflux of the vaginal microflora into the urethra, which in turn is a constant source of lower urinary tract infection. This type of cystitis is calledpostcoital cystitis.
Ultrasound examination of the kidneys and bladder.It is performed for all patients with recurrent cystitis, taking into account the safety of the method and its potential usefulness.
Cystoscopyit is recommended to perform it in the absence of the effect of therapy, with frequent relapses associated with a bacterial infection and / or in the presence of predisposing risk factors (urinary tract abnormalities, stones, tumors). Cystoscopy is an endoscopic exam 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:
- drink 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, the antibiotic is selected based on the results of the urine culture.
- Broad spectrum antibiotics that show high activity against most bacteria.
- An alternative is drugs from the group of nitrofurans. The drugs are effective against various bacteria and fungi of the genus Candida. Resistance to nitrofurans rarely develops.
- Less frequently, they resort to the prescription of 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 uncomplicated acute cystitis.
Etiological treatment (aimed at eliminating the cause and conditions for the development of the disease)
With the relapses of acute cystitis, bacteriophage preparations (virus-based drugs, selectively, such as sniper fire, which kill bacteria) have been used more and more lately. Very often, bacteriophages multiply within bacteria and cause them to break down into fragments.
Bacteriophage treatment is safer than antibiotics, but it should be noted that for targeted killing 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 sexual intercourse (postcoital cystitis) and in the presence of a deep 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 ingestion). The agent has an immunobiological property that protects against the effects of Escherichia coli and triggers an immune response of a non-specific 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, the bacteria leave the body along with the urine. This is a dietary supplement, not a drug, 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 drops dramatically. Estrogens are one of the protective factors of the bladder mucosa, with a decrease, the protective mechanisms of the mucous membrane are weakened. Perhaps the introduction through the urethra or vagina of hormonal preparations containing estrogens.
As adjuvants for the treatment of acute cystitis are usedphytopreparations,It has 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 urinating associated with a narrowing of the urethral lumen), then after relief of the acute period and removal of the infectious agent, a surgical correction is performed: installation of a cystostomy (drainagespecial tube), plastic urethra, etc.
Symptomatic treatment (reducing the manifestations of the disease)
NSAIDs (non-steroidal anti-inflammatory drugs)- a large group of drugs 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 the daily production of urine (for example, blueberries), as well as a sufficient amount of liquid to maintain daily urination in the amount of 2000-2500 ml.
In the vast 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. With recurrent cystitis, treatment requires deeper instrumental and laboratory diagnoses and can be effective only if the principles of pathogenetic therapy and active prevention of disease recurrence are observed.
Prevention consists of:
- Observe 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, only twice a day, in the morning and in the evening, under running water.
- If indicated, correct infantile lower urinary tract abnormalities.
- Treat gynecological diseases in a timely and appropriate manner.
- Avoid hypothermia.
- Observe sexual hygiene (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 medicine before or immediately after the procedure.
- Correct urological pathology that leads to alteration of urinary excretion, such as prostate adenoma and urethral structure.
- Drink a sufficient amount of liquid (2 liters) and empty your bladder in a timely manner.
- Women with recurrent attacks of acute cystitis should urinate immediately after intercourse and use a single dose of an antibacterial drug (fosfomycin or nitrofuran).
- Do not use spermicides or vaginal diaphragms for birth control.
- Carry out 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: blueberries, vaginal estrogens, probiotics in the form of vaginal suppositories, intravesical administration of hyaluronic acid and other injections to restore the protective layer on the surface of the mucosa of the bladder may havea positive effect. effect, however, its use has a poorly proven effect. . .