CYSTITIS.pptx

cystitis

1. CYSTITIS DR POTNURU SRINIVASA SUDHAKAR

2. AETIOLOGY Cystitis is much more common in women than in men probably due to short urelhra through which the bacteria ascend. Cystitis also accompanies haematogenous renal infection in rare cases. Lymphatic spread from infected cervix is also a probable cause of cystitis though rare. Bowel infections e.g. appendicular abscess, diverticulitis etc. may cause cystitis by involving bladder by contiguity.

3. In men, cystitis is almost always secondary to some other causes e.g. infection of the prostate, enlarged prostate associated with residual urine, presence of vesical calculus or an ulcerated vesical neoplasm.

4. PREDISPOSING CAUSES The various predisposing causes which may indulge to cause cystitis are being mentioned here — 1. Presence of a calculus, foreign body or neoplasm in the bladder 2. Obstruction in the urethra due to urethral stricture or enlargement of prostate or prostatic carcinoma or stenosis of the external urinary meatus may lead to stasis and formation of residual urine in the urinary bladder which initiate cystitis.

5. PREDISPOSING CAUSES 3. Presence of diverticulum in the bladder may cause cystitis due to residual urine inside the diverticulum . 4. Injuries or diseases of the spinal cord which hinders proper evacuation of the bladder may lead to cystitis. 5. Presence of vesicoureteral reflux may incite cystitis. 6. Malnutrition with lowered general resistance and particularly avitaminosis may lead to cystitis.

6. Routes of infection 1. Ascending infection from the urethra is the commonest. That is why cystitis is very common in females who possess short urethra. E. coli which originate in the bowel, contaminate the vulva and perineal region. From these regions they get easy access to the bladder in case of females. Passage of urethral instruments may cause cystitis in either sex. 2. Haematogenous infection from kidney may cause cystitis, but rare. 3. Lymphatic spread from neighbouring viscera has also been noticed. These viscera are mostly infected cervix, fallopian tube, vagina, sigmoid colon etc.

7. CAUSATIVE ORGANISMS The most common infecting agent is E. coli. This is followed by Proteus mirabilis, particularly in young women, Staphylococcus aureus . Staphylococcus albus . Various Streptococci, Pseudomonas and Klebsiella . Schistosoma haematobium produces cystitis which may be complicated by stone formation and high incidence of cancer. Mycotic infection ofthe bladder is rare. Monilial vaginitis may secondarily infect bladder.

8. CAUSATIVE ORGANISMS Very rarely actino -mycosis may involve the bladder by direct extension from lesions in the bowel. Tuberculous cystitis is a specific form of cystitis. The students must remember that in this condition there will be plenty of pus cells without any organisms found with ordinary staining ( abacterial pyuria ). But besides tuberculous cystitis, abacterial pyuria is also seen in abacterial cystitis or in an ulcerative bladder carcinoma.

9. PATHOLOGY MACROSCOPIC FEATURES In acute cystitis : the mucous membrane of the bladder is swollen, intensely red and congested. The normal glistening appearance of the mucous membrane is lost. Multiple foci of submucosal haemorrhage are noticed. The mucosa is oedematous and its surface is covered with purulent membrane. Superficial ulcers are occasionally seen. In the trigone there may be tiny clear cyst, known as ‘ bullous oedema ’. The muscularis is usually not involved.

10. PATHOLOGY MACROSCOPIC FEATURES In chronic cystitis: the bladder may show thickening of its wall with corresponding reduction in the size of the cavity. There may be hypertrophy of the muscular tissue. The mucous membrane is dull, rough and mottled with the brown remains of old haemorrhages . In places it may be ulcerated. The mucous membrane is firmly attached to the muscle coat owing to fibrosis of the submucosa .

11. PATHOLOGY MICROSCOPIC FEATURES In acute cystitis: it is the submucous coat which shows major changes. There is much congestion and dilatation of capillaries. There is infiltration with the cells of acute inflammation. The superficial layers of the epithelium may be desquamated, but the deeper layer remains intact. Leucocytic infiltration may extend into the muscle, but otherwise the muscle layer remains unaltered.

12. PATHOLOGY MICROSCOPIC FEATURES In chronic cystitis: all coats are involved. There is diffuse fibrosis which is most evident in the submucosa . The mucosa is ulcerated in places. There may be abundant formation of granulation tissue covered by epithelium giving rise to polypoid excrescences.

13. CLINICAL FEATURES SYMPTOMS Severity of the symptoms depends on severity of the disease. ( i ) Increased frequency of urine both in day and at night is the most important symptom. This may disturb sleep of the patient at night which may make the patient drawn and tired. (ii) Urgency is also a very characteristic symptom of this condition. At times the desire to micturate becomes so urgent that incontinence may result.

14. CLINICAL FEATURES (iii) Pain, though often associated with, is not a major symptom. Pain varies from mild to agonising in severe cystitis. When the superior surface of the bladder is involved pain is referred to the suprapubic region. When the trigone is involved pain is referred to the tip of the penis or the labia majora .

15. CLINICAL FEATURES (iv) Haematuria .— It should be remembered that cystitis is the commonest cause of haematuria . Such haematuria is usually terminal that means at the end of micturition Later on as severity increases, the whole urine may be blood stained, but it will be more so at the end of micturition . (v) Pyuria .— This is often seen in cases of cystitis.

16. PHYSICAL SIGNS Examination of the abdomen is usually normal. Tenderness may be elicited at the suprapubic region. Rectal examination should always be performed It may reveal an enlarged prostate (benign enlargement of prostate) which is the cause of cystitis. It may reveal an enlarged firm and tender prostate (acute prostatitis as the cause of cystitis). It may reveal presence of residual urine.

17. PHYSICAL SIGNS In female, pelvic examination is highly important to exclude any pathology in the genital system as the cause of cystitis.

18. SPECIAL INVESTIGATIONS 1. Blood examination.— White blood count is usually elevated. E.S.R. is also increased. 2. Urine examination usually shows pus cells, bacteria and red blood cells. In case of presence of associated prostatitis threads may be seen in the initial specimen, so midstream urine specimen should be taken for culture and sensitivity test.

19. SPECIAL INVESTIGATIONS 3. X-rays are not indicated unless stasis or renal infection is suspected. X-ray is also required if the patient fails to respond to adequate antibiotic treatment for cystitis or the infection is recurrent and there is presence of obstruction, vesicoureteral reflux, tuberculosis or calculus.

20. SPECIAL INVESTIGATIONS 4. Cystoscopy is contraindicated in acute phase. But it should be done 10 days later when haematuria is continuing to exclude presence of vesical neoplasm or stone or foreign body.

21. TREATMENT A. GENERAL MEASURES B. SPECIFIC TREATMENT

22. GENERAL MEASURES 1. The patient is urged to drink plenty. 2. Alkalinisation of the urine should be achieved. This provides symptomatic relief. By raising the pH of the urine, it counteracts the burning sensation of acidic urine which normally accompanies infection. 60 to 20 g of sodium bicarbonate may be given for this. 3. Antispasmodics.— Various antispasmodics e.g. baralgan , buscopan , atropine with phenobarbital or tincture of belladonna may be used. This relieves muscular spasm and provides considerablerelief to the patient.

23. GENERAL MEASURES 4. Urinary tract analgesic.— Phenazopyridine is an urinary tract analgesic. 100 mg tablets of phcnazopyridine ( pyridium ) may be used in the dosage of 2 tablets thrice daily after meals provides considerable relief. 5. Local heat.— Hot sitz baths may ease severe pain and spasm.

24. SPECIFIC TREATMENT Antibiotics are prescribed according to the sensitivity test report. A few antibiotics are particularly effective in cystitis. These are nalidixic acid 500 mg, nitrofurantoin 100 mg tablets, amoxycillin , trimethoprin and sulphamethoxazole , chloramphenicol , ampicillin etc.