Cystitis is a bladder inflammation. Usually the onset is acute. Bladder inflammation causes irritative symptoms, including increased urinary frequency, suprapubic pain or burden feeling, urinary burning sensation, at times with the strong desire to void. Fever is possible. The urine can smell unpleasantly. It is not rare to have haematuria (blood in the urine). In elder patients the symptoms can be mild, or vague, with mental confusion, fever, dizziness.
It usually affects female patients. About 20-40% of women have at least one episode of cystitis during life.
Urine is secreted by the kidney through blood selective filtration, and it is sterile. Cystitis is often due to bacteria, that reach the bladder from outside environment. Commonly the bacteria come from the vaginal mucosa. In the majority of cases of cystitis, Escherichia Coli is the bacterium involved.
Since the female urethra is a short channel (4 cm), microorganisms can easily ascend from the vagina to the bladder. The vagina is a cavity open to the external end. In such anatomical conditions, it can´t be sterile, but it always hosts germs; these germs are generally not pathogenic
for the genito-urinary tract, like lactobacilli. However, the anus is anatomically so close to the vagina, that it is not rare that bacteria coming from the bowel can easily reach the vagina.
Some factors may contribute to increase the risk of cystitis. An excess of local hygiene may mechanically wash out the resident bacteria, and leave the field open to the infection of new bacteria, for lack of biological competitors. The vagina and anus should be washed separately, with the water flowing in the direction from the vagina to the anus, and not in the opposite direction, to decrease the risk of contamination.
The menopause is related to a decreased estrogens concentration and to a subsequent poor metabolism of vaginal mucosa, with greater infection risk.
Intercourse may be a risk factor for cystitis. In fact, there is an increased chance of carrying inside the vagina bacteria from the genital skin. The massage exerted by intercourse on the urethra may facilitate the bacteria of the vaginal mucosa entering the bladder. Besides, the male semen itself is potentially infective in case of recurrent vaginal infections.
Congenital malformations of the lower genito-urinary tract my also be a risk factor for cystitis..
In male patients, cystitis is more rare than in women, though with aging the difference of incidence according to gender is smaller. Major risk factors in male are incomplete bladder voiding, due to obstructing prostate enlargement, or bladder stones.
Of course an indwelling catheter is a source of bladder infection.
In some Northern Africa and Middle East countries, some urinary parasites (Bilharzia and Schistosoma) may be a cause of cystitis.
The diagnosis is based upon symptoms, urinalysis, and urine culture. In case of repeated or haemorrhagic cystitis, a bladder ultrasound and a vaginal swab are advisable.
Uncomplicated cystitis may heal spontaneously within 3 days. However, in case of severe symptoms or recurrent cystitis, the acute treatment is based upon antibiotic therapy, according to urine culture results. Antibiotic treatment must be continued for 3 days, but it can last up to7 day for complicated cystitis (haemorrhagic or with fever) or even 7 days in case of very weak or very ill patients.
The prevention is based upon removal or reduction of risk factors.
When there is an estrogens deficiency, vaginal administration of estrogens-based creams may be a reasonable option, unless oncological contraindications subsist.
Interstitial cystitis is a particular condition with suprapubic and/or pelvic pain, with increased urinary frequency and voiding urgency. The incidence is between 2 and 7 cases per 100,000, according to the diagnostic criteria used. It occurs mainly in women (9 cases out of 10), with a peak of incidence at 40 years.
The diagnostic criteria are not standard, and the diagnosis is often made when other possible underlying causes of the symptoms have been excluded.
Though initial diagnosis criteria included ulcers at cystoscopy and bleeding after bladder distension, today the criteria are mainly based upon symptoms.
Altered bladder sensitivity may be involved in the disease.
In 75% of patients the symptoms are triggered by the potassium test (instillation of a potassium solution in the bladder)
The diagnostic role of bladder biopsy is controversial.
Medical therapy includes drugs that might protect the integrity of the bladder wall, such as Pentosan polysulfate sodium, heparin, ialuronic acid, or endovesical instillation of DMSO (dimethyl sulfoxide). Some tricyclic antidepressants (amitriptyline), antihistamines., or narcotic analgesic have been proposed, with debatable symptom improvement.
Some authors have related interstitial cystitis to chronic prostatitis, and chronic pelvic pain syndrome, and altered potassium metabolism might be involved.
Experimental treatments with vitamin D3 analogues, endovesical BCG, bladder, submucosal injection of botulinum toxin have been all tried.
Transcutaneous Electrical Nerve Stimulation has been proposed to relieve the pelvic pain. Mild electric tension is applied on the pubic area or on the lower back. It may help to decrease pain and urinary frequency. Often at least 3 months of treatment are needed to obtain some benefit. Also sacral nerve root stimulation, with permanently implanted electrodes, has been experimented.
Invasive procedures can go from simple bladder distension, under anaesthesia, to increase bladder capacity, to bladder augmentation with a bowel segment, for patients with severely contracted bladder.