Cystitis

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• Cystitis describes a clinical syndrome of dysuria, frequency, urgency, and occasionally suprapubic pain

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Reduced Urine Flow Outflow obstruction, prostatic hyperplasia, prostatic carcinoma, urethral stricture, foreign body (calculus)

Neurogenic bladder Inadequate fluid uptake (dehydration)

Promote Colonization Sexual activity—increased inoculation

Antimicrobial agents—decreased indigenous flora

Facilitate Ascent Catheterization Urinary incontinence Fecal incontinence Residual urine with ischemia of bladder wall

Risk Factors for UTIs

Laboratory Diagnosis

• The presumptive laboratory diagnosis of acute cystitis is based on microscopic urinalysis, which indicates microscopic pyuria, bacteriuria, and hematuria

• presence of 102 cfu/mL or more of urine usually indicates infection

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Tubercular cystitis

• Never primary

Treatment– Medical: ATT– Surgical:

• failure of medical treatment• Nephroureterectomy to remove the source of infection

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Abacterial cystitis

• Presence of pus in urine but without any accompanying bacteria

Aetiology• Mycoplasma• Chlamydia• Adenovirus

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Pathology

• Inflammation of the bladder

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Clinical features

• Urethral discharge

• Abrupt onset features of cystitis

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Investigations

• All investigations should be done to exclude tuberculous cystitis

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Treatment

• Spontaneous resolution

• Analgesics, antispasmodic & bladder sedatives

• Antibiotics: tetracycline, chloramphenicol

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Interstitial cystitis

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Interstitial cystitis

• Painful bladder syndrome

Epidemiology• prevalence: ~20/100,000• 90% of cases are in females• mean age at onset is 40 years• higher prevalence in Jews

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Etiology: unknown

• theories: increased epithelial permeability; autoimmune; neurogenic• associations: severe allergies; IBS, fibromyalgia

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Hypothesis for etiologic cascade of painful bladder syndrome/interstitial cystitis

❏ Classification

• non-ulcerative (more common) - younger to middle-aged• ulcerative – middle-aged to older

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Hunner's ulcer in interstitial cystitis nonulcerative interstitial cystitis

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❏ diagnosis (not usually adhered to)• NIDDK required criteria

1) glomerulations (submucosal petechiae) or Hunner’s ulcers on cystoscopic examination, AND

2) pain associated with the bladder or urinary urgency

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❏ differential diagnoses• UTI• vaginitis• bladder tumour• radiation/ chemical cystitis• eosinophilic/TB cystitis

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❏ treatment• symptomatic only (no cure)• bladder hydrodistension (also diagnostic)• intravesical dimethylsulfoxide (DMSO)• intravesical hyaluronic acid or heparin• amitriptyline• pentosan polysulfate (Elmiron)• surgery is last resort

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Complicated Cystitis

• Complicated UTIs are those that occur in a patient with a compromised urinary tract or that are caused by a very resistant pathogen

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Functional/structural abnormalities of urinary tract Recent urinary tract instrumentation

Recent antimicrobial agent use

Diabetes mellitus Immunosuppression Pregnancy Hospital-acquired infection

Complicating Host Factors

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Common Pathogens

Mitigating Circumstances

Recommended Empirical Treatment

E. coli, Proteus species, Klebsiella species, Pseudomonas species,

Mild-to-moderate illness, no nausea or vomiting—outpatient therapy

Oral norfloxacin, ciprofloxacin, or ofloxacin for 10-14 days

Serratia species, enterococci, staphylococci

Severe illness or possible urosepsis—hospitalization required

Parenteral ampicillin and gentamicin, ciprofloxacin, levofloxacin, ceftriaxone, aztreonam, ticarcillin-clavulanate or imipenem-cilastin until fever gone; then oral trimethoprim-sulfamethoxazole, norfloxacin, ciprofloxacin, or levofloxacin for 14-21 days

Treatment of Complicated UTIs trimethoprim-sulfamethoxazole, 160 to 800 mg 12h; norfloxacin, 400 mg 12h; ciprofloxacin, 500 mg 12h; levofloxacin, 500 mg/day.

ciprofloxacin, 400 mg 12h; levofloxacin, 500 mg/day; gentamicin, 1 mg/kg 8h; ceftriaxone, 1 to 2 g/day; ampicillin, 1 g 6h; imipenem-cilastin, 250 to 500 mg 6-8h; ticarcillin-clavulanate, 3.1 g 6h; and aztreonam, 1 g 8-12h

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