What is acute cystitis? The causes of occurrence, the diagnosis and the treatment methods will be analyzed in detail in this article.
Definition of disease. Causes of disease
CystitisIt is an infectious and inflammatory process in the bladder wall, located 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 outer 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 in their lifetime, and more than 30 million new cases of cystitis are reported each year. Most of the time, the disease affects women between the ages of 25 and 30 or over 55.
Acute cystitis is a condition that occurs mainly in non-pregnant women of pre-menopausal age, who do not have anatomical and functional disorders of the urinary tract, and also in the context of full health. In older women, genitourinary symptoms are not necessarily caused by 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 health status 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 frequently staphylococcus - 10-20%;
There is a small group of cystitis that develops after using medications. A typical example of the onset of acute cystitis is the intravesical injection of BCG vaccine (live mycobacterium strain of the Bacillus Calmette-Guerin vaccine) into the bladder during immunotherapy of non-invasive bladder cancer.
The triggering 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, venous blood stagnation;
- hormonal imbalance in the body;
- general hypothermia;
- sexually transmitted infections;
- urolithiasis disease;
- abnormal structure of the urinary tract;
- prolonged position 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 for the bladder to empty, which leads to its increase and stagnation of urine. During pregnancy, the amount of blood that passes through the kidney filters increases every minute. The glucose load in 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, creating a favorable environment 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 encounter similar symptoms, consult your doctor. Don't self-medicate - it's dangerous to your health!
Symptoms of acute cystitis
The onset of symptoms of acute cystitis is sudden, the disease can develop within a few hours. Often, patients notice the presence of a triggering factor, such as general hypothermia or sexual activity. If two or more acute episodes occur within six months, then, in these cases, they speak of recurrent cystitis.
The most common manifestations of acute cystitis:
- frequent painful urination (more than 6-8 times a day);
- urinating in small portions;
- false urge to urinate;
- cramps when urinating;
- pain in the lower abdomen, above the sinus in the projection of the bladder, occasionally radiating to the perineum;
- rarely / sometimes blood in the urine;
- rarely / sometimes an increase in body temperature of 37-37, 5 degrees.
- turbidity of the urine with an unpleasant odor.
Often, in young women, 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 frequent way in which uropathogens penetrate the urethra from the surface of the skin of the perineum, vaginal mucosa, tissues surrounding the urethra and intestine, and then ascend along the mucous membrane of the urethra into thebladder;
- descendant of the kidneys - with inflammatory kidney diseases (pyelonephritis and its terminal phase - pyrophrosis);
- with lymphatic flow from Organs genitals - with salpingo-oophoritis, endometritis, parametritis (inflammation, respectively, of the fallopian tubes and ovaries, of the mucous membrane of the uterus, and of the connective tissue surrounding the uterus);
- hematogenous (with blood) - it is rare, possible with recent infectious diseases;
- direct - in the presence of urinary fistulas, bladder catheterization and cystoscopy (endoscopic method for diagnosing bladder diseases).
After the uropathogens reach the bladder mucosa, they are fixed and the pathogen "confronts" the protective cells of the organ's mucosa. The attachment of uropathogens to the mucous membrane occurs through the so-called adhesins - villi, among which types 1, P and S. The most studied, and type 1 sensitive to mannose. Subsequently, uropathogens attached to the mucous membrane of the bladder begin to form a protective biofilm on top of themselves. Thanks to biofilms, uropathogens can remain invulnerable for a long time and periodically cause cystitis exacerbations.
Prolonged residence and multiplication of bacteria lead to inadequate bladder emptying, urine stagnation, decomposition and accumulation of toxic substances, including bacterial waste.
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, local increase in the temperature of the bladder and violation of its functions. With the penetration of the bacteria in the submucosal layer, destruction of the microvasculature is possible with the development of hemorrhagic cystitis, in which the blood from small injured vessels flows into the bladder, due to which impurities in the blood 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.
During the inflammatory process, they divide:
- recurrent - occurs at least twice in six months;
- chronic (periods of exacerbation and remission) in the clinical picture, only one symptom is frequently revealed - frequent urination.
Due to the nature of the morphological changes:
- catarrhal (superficial), when inflammation of the bladder is located in the mucous layer;
- fibrinous ulcerative, when there is a deeper lesion of the mucosa with the formation of ulcerative defects in the bladder mucosa up to the muscular layer;
- hemorrhagic - small vessels in the submucosal layer are mainly affected;
- gangrene is a rare form of bladder wall necrosis development.
Taking into account the development of complications, acute schizitis is divided into:
- uncomplicated, when there is no violation of urine flow and, in general, human health is not harmed;
- complicated when cystitis occurs as a result of other diseases (for example, with urolithiasis, tumors or bladder tuberculosis, etc. ).
Community-acquired cystitis and nosocomial cystitis are also distinct. 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 the inflammation spreads to the muscle layer of the bladder. The cause of this form of cystitis is usually an acute violation of the protective mucous layer of the bladder. With the penetration of potassium and other aggressive substances in the urine into the bladder wall, the sensory nerve endings are activated and the smooth muscles are damaged. Over time, there is scarring degeneration of the vesical mucosa, leading to a reduction in its reservoir capacity. As a result, the frequency of urination increases until urinary incontinence, the bladder is not emptied completely, which leads to a closed pathological cycle of the disease's development.
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 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 cause severe poisoning and sepsis. The overwhelming number of cases of acute pyelonephritis is associated with an ascending infection - the migration of microorganisms through the bladder ureters. In acute pyelonephritis, one or both kidneys may be affected. With the development of acute pyelonephritis, hospital treatment is recommended, due to the frequent development of complications and more prolonged 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 necessary.
Hematuria (hemorrhagic cystitis).When bacteria penetrate a deeper layer (submucosa), the microvasculature is destroyed, which is manifested by micro-bleeding in the mucous membrane. Haematuria 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 who take drugs that prevent the formation of thrombi.
With extensive damage to the submucosal layer, a formidable complication can develop -bladder tamponademassive blood clot. In case of illness, the bladder lumen fills with clots, which increase the pressure inside the bladder, ureters, and kidneys. It often manifests as a delay and lack of independent urination with sharp pains above the chest. The complication requires immediate admission to a surgical hospital, as it can lead to acute renal failure.
Diagnosis of acute cystitis
Whenuncomplicated course of 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 analysis of urine. Urine analysis can be performed with a laboratory analyzer and test strips (a positive test for nitrite and leukocyte esterase indicates cystitis).
If within four weeks the symptoms of uncomplicated acute cystitis do not disappear despite treatment, or have passed, but returned after two weeks, then it is indicated.culture of urine with determination of sensitivity to antibiotics.
For sowing, a medium portion of the morning urine is delivered and it is advisable to send it immediately for analysis, if it is not possible, it is advisable to store the urine at a temperature of +2 to +8 before sending.
National clinical guidelines also recommend bacteriological examination of vaginal content and testing for sexually transmitted infections.
Recently, for the diagnosis of recurrent cystitis (as long as there is no growth in conventional culture), analysis of the microbiome by the technique of expanded quantitative urine culture and gene sequencing has been used. It used to be generally accepted that urine was sterile, but this is not the case. Urine is not sterile. It must be remembered that bacteria in urine often cannot be detected, 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 evaluated and the culture is "clean" but there are clinical symptoms of cystitis, urine can be sent for culture to exclude Ureaplasma urealyticum or Mycoplasma hominis.
chair examin patients with a recurrent form of cystitis, it is a mandatory part: vaginal ectopia and / or hypermobility of the external urethral opening, secretion of the external urethral opening, presence of inflammation near the urethral glands are excluded, the condition of the mucous vagina or its prolapse israted, etc. The likelihood of infection increases significantly with vaginal ectopia and / or hypermobility of the external opening of the urethra.
vaginal ectopy- the location of the external opening of the urethra on the edge or on the anterior wall of the vagina.
Hypermobility- increased mobility of the external opening and distal urethra in women due to the presence of urethroginal adhesions. With each intercourse, the external opening from the urethra to 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 lower urinary tract infection. This type of cystitis is calledpostcoital cystitis.
Kidney and Bladder Ultrasound Examit 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 in the absence of the effect of therapy, with frequent relapses associated with bacterial infection and / or in the presence of predisposing risk factors (abnormalities of the urinary tract, calculi, 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:
- drink plenty of fluids at least 1, 5 liters a day;
- exclude sexual intercourse during the entire period of the illness;
- antibiotic therapy.
If cystitis is recurrent, the antibiotic is selected based on the results of the urine culture.
- Broad-spectrum antibiotics that have high activity against most bacteria.
- An alternative is drugs from the nitrofuran group. The drugs are effective against various bacteria, in addition to Candida genus fungi. Resistance to nitrofurans rarely develops.
- Less commonly, they resort to prescribing systemic oral antibiotics. Antibiotics from 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 relapses of acute cystitis, bacteriophage preparations - drugs based on viruses, selectively, such as sniper shooting, destroying bacteria - have been increasingly used lately. Most of the time, bacteriophages multiply within bacteria and cause them to divide into fragments.
Treatment with bacteriophages is safer than antibiotics, but it should be noted that for targeted bacterial destruction, a bacteriological study of the 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 an external opening deeply located in the urethra, surgical treatment is used. Operations aimed at displacing (transposing) the urethra have a high success rate.
Pathogenic treatment (aimed at eliminating or suppressing disease development mechanisms)
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 cell phagocytosis). When prescribing a vaccine, it must be kept in mind that the effectiveness remains with the repeated course of administration of the drug.
Monosaccharideafter absorption of the intestine with urine into the bladder, where it blocks the fixation of the bacterial pili (growth of filamentous bacteria). As a result, bacteria leave the body along with urine. This is a dietary supplement, not a medication, but it has proven effectiveness and is recommended by the European Association of Urology.
Hormone replacement therapy.In the post-menopausal period in women, the estrogen level dramatically decreases. 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,having anti-inflammatory, weak diuretic and antiseptic effects.
With severe hematuria, it is possible to prescribe hemostatic medications. The most effective in this group are antifibrinolytics.
If the cause of acute cystitis is obstructive uropathy (difficulty urinating associated with narrowing of the urethral lumen), then, after relief from the acute period and elimination of the infectious agent, surgical correction is performed - installation of a cystostomy (special tube drainage), 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 daily urine output (eg cranberries), as well as enough liquid to maintain daily urination in the amount of 2, 000-2500 ml.
In the overwhelming majority of cases, acute cystitis (in the absence of disturbances in urinary excretion, concomitant diseases, a standard pathogen and its sensitivity to antibacterial drugs, rational antibiotic therapy) passes without consequences. With recurrent cystitis, treatment requires more in-depth laboratory and instrumental diagnostics and can be effective only if the principles of pathogenic therapy and active prevention of disease recurrence are observed.
Prevention consists of:
- Follow proper hygiene of the external genitalia 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 night, 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 perform antibacterial prophylaxis for invasive urological interventions - inject a single dose of an antibacterial medication 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 your 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 medication (fosfomycin or nitrofuran).
- Do not use spermicides and vaginal diaphragms for contraception.
- Perform immunological prophylaxis (after two months, the duration of treatment is determined by the doctor).
So far, recommendations for the use of various medications, such as: cranberries, vaginal estrogens, probiotics in the form of vaginal suppositories, intravesical administration of hyaluronic acid and other injections to restore the protective surface layer of the bladder mucosa may have a resultpositive effect, however, its use has a poorly proven effect. . .