The three major nonspecific infections of the bladder are: Acute cystitis, chronic cystitis and Acute urethral syndrome in women. But before we go into these three diseases in details, we need to get familiar with some terminologies. You might have come across them in my other urological related hubs, but for the sake of those reading this as their first urological article from me, here are some major terminologies we will come across as we try to discuss this matter.
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Hyperemia-This is an increase of blood flow to different tissues of the body. A very good indicative sign is redness in the part of body where such increase is experienced.
Edema-this is fluid accumulation in some parts of the body. It is a strong indicative sign of pathology of some diseases. Edema, usually occurs on the leg, but sometimes the eyes and hands, lower back etc.
Neutrophils-these are a part of white blood cells responsible for fighting against bacteria infection in the human body.
Dysuria-In a lay man’s language dysuria is always defined as painful and difficult urination. But clinically speaking, its a lot more than that. Dysuria is always associated with blood in Urine (hematuria) and increased frequency of urination (up to 7-8-9 times in a day).
Leukocytosis-This is the increase in Leukocytes (white blood cells) which are responsible for the body immune system, fighting against infection. In most cases, leukocytosis suggest infection in a patient.
Urinalysis- this is the laboratory analysis of the Urine.
Pyuria-This is urine containing pus. In clinical terms, it is the presence of 4 or more neutrophils per high power field of unspun, voided midstream urine.
bacteriuria-From the name, its very clear it means bacteria pathogens in Urine.
Hematuria-Blood in Urine
Serum creatinine-Measuring serum creatinine is a useful and inexpensive method of evaluating renal dysfunction. Creatinine is a non-protein waste product of creatine phosphate metabolism by skeletal muscle tissue. Creatinine production is continuous and is proportional to muscle mass.
Hemorrhage-this simply means loss of blood (bleeding).
Exudate- Any fluid that filters from the blood circulatory system into any lesion or area of inflammation.
Nocturia-The need to wake up at night to urinate, thereby interrupting sleep. Usually occurs with the elderly or individuals taking high level of fluid during the day. Asides these two common causes, Nocturia is pathologic.
Urethra diverticulum-Urethral diverticulum (UD) is a condition in which a variably sized “pocket” or outpouching forms next to the urethra. Because it most often connects to the urethra, this outpouching repeatedly gets filled with urine during the act of urination thus causing symptoms.
Now that we are acquainted with these technical words, we can go through the diseases in question.
Acute bacterial cystitis is an infection of the Urinary bladder caused mainly by Coliform bacteria (usually strains of E.Coli) and less often by gram-positive aerobic bacteria (especially staphylococcus sapro-phyticus and enterococci). The infection usually ascends to the bladder from the urethra. The incidence of acute cystitis is much greater in girls and women than in boys and men. Adenovirus infection may lead to hemorrhagic cystitis in children, however, viral cystitis rarely is found in Adults.
Let’s have a brief and quick look at the bladder wall. When we study the bladder wall microscopically from its inner wall to its external part, we will find out that its wall is in layers: Mucosa, Submucosa, Muscular, Serous, Adventitia and perivesical fats. In the early stages of acute cystitis, the bladder mucous layer shows hyperemia, edema, infiltration by neutrophils. As the process advances, the mucous layer is replaced by a friable, hemorrhagic, granular surface focally pitted with shallow ulcers containing exudate. The muscular layer generally remains un-involved.
Signs and symptoms
Irritative voiding symptoms prevail: frequency, urgency, nocturia, burning on urination and dysuria. Low back and suprapubic pain and discomfort are common complaints. Urge incontinence and hematuria occur commonly, but significant fever is unusual. The onset in women frequently follows sexual intercourse (“honeymoon cystitis”). Although suprapubic tenderness is sometimes elicited, physical signs are characteristic. Possible associated contributing factors should be sought. Vaginal, introital, or urethral abnormalities (e.g, Urethral diverticulum) or Vaginal discharge in female patients, urethral discharge or a swollen, tender prostate or epididymis in male patients. The hemogram may be normal or show mild leucocytosis. Urinalysis typically shows pyuria and bacteriuria; gross or microscopic hematuria is seen on occasion. The infecting pathogen will be found on Urine culture. Unless the patient has associated urologic disorders, the serum creatinine and blood urea nitrogen values are normal. Radiographic evaluation is warranted only if renal infection or genitourinary tract abnormalities are suspected in patients with proteus infections that do not respond promptly to therapy or that replapse, X-rays should be taken to investigate the possibility of infected struvite calculi.
Cystoscopy usually is indicated when hematuria is prominent; however, the procedure should be delayed until the acute phase is over and the infection has been treated adequately.
In female patients, acute bacterial cystitis, must be distinguished from several other infectious processes. Vulvovaginitis may mimic the symptoms of cyctitis but can be diagnosed accurately by pelvic examination coupled with proper examination of vaginal discharge for pathogens. Acute Urethral syndrome causes frequency and dysuria, but urine cultures show low counts or no growth of bacteria. Acute pyelonephritis often causes symptoms of vesical irritabiblity but typically produces loin pain and significant fever. In children, vulval and urethral irritation caused by detergents in bubble bath or by pinworms may mimic the symptoms of cystitis.
In male patients, acute bacterial cystitis must be distinguished mainly from infections of the urethra, prostate, and kidney. Appropriate physical examination and laboratory tests usually enable the physician to make a specific diagnosis. Noninfectious types of cystitis produce symptoms that exactly mimic those of bacterial cyctitis. Some of these conditions include cystitis resulting from anticancer therapy (e.g, irradiation, cyclophosphamide), interstitial cystitis, esosinophilic cystitis (“allergic” cystitis), bladder carcinoma (especially carcinoma in situ), and psychosomatic disorders.
The main complication of acute cyctitis is infection that ascends to the kidneys. Children with vesico-ureteral reflux and pregnant women are especially prone to this complication. Patients prone to recurrent bouts of acute cystitis should be evaluated for factors that may contribute to enhanced susceptibility, and these should be corrected whenever possible. Failing this, antimicrobial prophylaxis may prove necessary.
Specific measures-Although its efficacy has not been prove in men, the use of short-term antimicrobial therapy (1-3 days or even a single does) is effective in acute uncomplicated cystitis in women. Ideally, an antimicrobial agent should be selected on the basis of culture and sensitivity testing. Since most uncomplicated infections occurring outside the hospital environment are due to stains of E.Coli, sensitive to may antibiotics, sulfonamides, trimethoprim-sulfamethoxazole, nitrofurantoin, or ampicillin usually is effective. Urologic evaluation is warranted when the response is unsatisfactory.
General measures-Due to the fact that acute uncomplicated cystitis responds rapidly to proper antimicrobial therapy, additional measures usually are unnecessary. Hot sitz baths, anticholinergics (eg, propantheline bromide), and urinary analgesics (e.g, phenazopyridine hydrochloride) are occasionally warranted for relief of symptoms. Acute uncomplicated bacterial cystitis usually resolves rapidly in response to appropriate antimicrobial therapy. Permanent bladder injury is unusual.
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ACUTE URETHRAL SYNDROME IN WOMEN
Acute urethral syndrome consists of dysuria and frequency (plus variable other bladder or urethral symptoms) in women whose bladder urine shows ‘no growth’ or low bacterial counts on culture. Gallagher, Montgomerie, and North (1965) found that, in a general practice setting, 41% of women with such irritative voiding symptoms had urine cultures deemed nondiagnostic of bacterial cystitis; however, documented bacteriuria of significance occurred in about a third of these women within the ensuing few months. Fihn and Stamm (1983) were able to categorize acutely dysuric women into groups with specific therapeutic implications, as follows:
- Vaginitis (32%)
- Typical cystitis, with growth of bacteria to the power of 108 bacteria per milliliter of midstream urine (32%)
- Acute urethral syndrome (36%)
- Pyuria present (22%) (bladder bacteriuria in 15%, and chlamydial infection in 7%).
- Pyuria absent; sterile urine (12%)
- other pathogens, including herpes simplex and N.gonorrhoeae (2%
In evaluating an acutely dysuria woman, the physician should check routinely for the presence of vaginitis, obtain vaginal specimens for diagnosis, and treat any recognized infection. Women in whom dense bacteriuria is found on culture clearly have bacterial cystitis that usually responds promptly to appropriate antimicrobial therapy. Acutely dysuric women without vaginitis or classic bacterial cystitis generally have acute urethral syndrome. Acute urethral syndrome itself is not a homogenous group. Many women with pyuria and ‘low-count’ bacteriuria actually have bacterial ure-throcystitis and should be treated appropriately with the usual antimicrobial agent of choice. In a second group, cultures are positive for organisms that may be sexually transmitted. These women and their sexual partners should be treated with an appropriate antibiotic: a tetracycline or erythromycin for C trachomatis infection; a penicillin or tetracycline for gonorrhea. In a third group, no causative pathogen is identifiable, but, curiously, the dysuria will respond to antimicrobial therapy. A small group of women with no pyuria or identifiable pathogen will respond poorly to antimicrobial therapy; some clinicians believe that these women may suffer from some type of functional voiding dysfunction.
The term “Chronic cystitis” is confusing, just like ‘chronic pyelonephritis”, because it means different things to different people. Some physicians use this term exclusively to mean unresolved or persistent bladder infection. Whereas others use it to mean 3 or more bouts of bladder infection occurring in the course of 1 year. Chronic infectious cystitis is caused by the same pathogens causing acute cystitis and acute and chronic pyelonephritis.
Persistence of bladder infection beyond the acute stage leads to chronic cystitis, which differs from the acute form mainly in the character of the inflammatory infiltrate. In the early stages of chronic cystitis, the bladder mucosa becomes progressively more edematous, erythematous and friable; it may ulcerate. In the later stages of chronic infection, the submucosa is infiltrated by fibroblasts, plasma cells and lymphocytes, the bladder wall eventually becomes thickened, fibrotic and inelastic.
Patients with chronic cystitis are asymptomatic or have variable symptoms of vesical irritability. If the bladder infection is caused by a persistent source of infection in the Kidneys or Prostate, there may also be symptoms associated with the primary infection. Pneumaturia suggests an enterovesical fistula or infection caused by a gas-forming pathogen (usually a coliform organism). The latter is seen most often in diabetics. Physical findings often are absent and usually are sparse and nonspecific. Unless chronic cystitis is associated with serious primary genitourinary tract disorder, the hemogram and renal function studies usually are normal. Urinalysis typically shows significant bacteriuria but may show surprisingly little pyuria. Urine culture generally is positive.
Unless chronic cystitis is associated with other genitourinary tract disease, radiographic studies usually are normal. Excretory and retrograde urograms and voiding cystograms may demonstrate associated conditions (e.g, obstructive uropathy, vesicoureteral reflux, atrophic pyelonephritis, vesico-enteric or vesico-vaginal fistulas). Urethral calibration, catheterization and urethrocystoscopy may be indicated to evaluate whether contributing conditions (eg, urethral stricture, prostatic obstruction) exist.
Infectious types of chronic cystitis must be distinguished from other infectious diseases of the genitourinary tract in men and women. Sometimes, these conditions mimic cystitis; sometimes, they are associated with or contribute to chronic cystitis. Examples include infectious vaginitis, prostatitis, and urethritis and renal infections. Tuberculosis of the Kidney or bladder must be considered in the differential diagnosis of chronic cystitis characterized by ‘sterile’ pyuria. Non-infentious conditions that must be considered in the differential diagnosis include senile vaginitis and urethritis relate to hormonal deficiency. Non-infectious urethral disease, nonbacterial forms of prostatitis, interstitial cystitis, “allergic” cystitis, radiation cystitis, cystitis secondary to the use of chemotherapeutic (including anticancer) agents, and various psychosomatic syndromes. Chronic bladder infections may lead to ascending infection of the Kidneys, the development of infected calculi in the upper urinary tract and bladder, or secondary infection of the prostate or epididymis. The prevention of chronic cystitis depends upon the identification of causative and contributing factors and the relative success of correcting these factors.
The causative organism should be identified by culture, and the infection should be treated with appropriate antimicrobial therapy based upon susceptibility testing. Long-term preventive therapy or suppressive therapy with gents such as nitrofurantoin, trimetho-prim-sulfamethoxazole, or methenamine plus an acidifier may prove necessary. The most important aspect of treatment is thorough evaluation for underlying causes and appropriate correction of contributing factors when possible. Uncomplicated chronic cystitis may produce annoying illness but seldom leads to serious sequels unless infection ascends to the Kidney. The outlook varies considerably with the nature and severity of underlying causes and contributing factors.
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