Chronic cystitis: causes, signs, prevention

If the infection of the bladder is constantly repeated, that is, there are periodic recurrences of its inflammation, a chronic cystitis having ICB-10 code - N30.1-N30.2 can be diagnosed.

Urologists believe that if the inflammation of the bladder happens either at least three times a year or twice in six months, the patient is likely to have a chronic recurrent cystitis.

[1], [2], [3], [4]

Epidemiology

Every year, with infections of the bladder and urinary tract, according to WHO, nearly 150 million people face. For example, in the US, about 8-10 million people turn to urologists annually.

As clinical statistics show, chronic forms of cystitis are more often diagnosed in women 30-50 years old, but women in the post-menopausal period - up to 5% (among residents of North America - up to 20%) are most affected by this disease.

According to experts from the International Urogynecological Association, half of all women experience symptoms of bladder inflammation, and 20-30% have relapses, that is, repeated infection.

Among elderly European men, chronic prostatitis and cystitis occurs in almost a quarter of urological patients.

Chronic cystitis in a child often occurs before the age of two; In boys and young men, this pathology is diagnosed in rare cases. More in the material -  Chronic cystitis in children

Causes of the chronic cystitis

The predominant causes of chronic cystitis are infectious. For example, when the Escherichia coli (colibacillus) that enter the colon enter the urethra and migrate into the bladder, they begin to multiply there and cause inflammation. In addition, chronic bacterial cystitis may result from persistent infection, including Enterobacter (E. Cloacae and E. Agglomerans), Proteus mirabilis, Klebsiella sp., Pseudomonas aeruginosa, Chlamydia trachomatis, Streptococcus faecalis, Staphylococcus saprophyticus.

In connection with a shorter urethra, chronic cystitis in women is much more common than in the male population. Often in women, chronic inflammation of the bladder is combined with bacterial vaginosis. Also possible cystitis against a background of chronic ureaplasmosis - lesions of the urethra, mucous membranes of the cervix or vagina by the bacteria Ureaplasma urealyticum and Ureaplasma parvum. It is significant that in all cases there is a decrease in the level of intravaginal acidity, which facilitates the activation of microorganisms. And physiologically conditioned immunosuppression (overwhelming embryo rejection) explains why chronic cystitis and pregnancy are associated. This topic is devoted to a separate publication -  Cystitis during pregnancy

One of the causes of chronic cystitis in women localized in the neck of the bladder may be a violation of trophism of its mucous tissues due to poor blood supply associated with changes in the position of the vagina and / or uterus after childbirth or with gynecological pathologies.

Infection can be descending: in inflammatory processes in the kidneys, it enters the bladder cavity with urine, which provokes a simultaneous course of such urological diseases as chronic cystitis and pyelonephritis.

Repeated infections of the bladder - chronic cystitis in men - is detected ten times less often than in women. Among the reasons for the development of this pathology are sexually transmitted infections, especially chlamydia, as well as benign enlargement of the prostate gland or its inflammation - prostatitis. Chronic prostatitis and cystitis usually appear in men after 50 years. In addition, infections often develop first in the urethra (which can be the result of frequent placement of catheters), and then affect the bladder, so chronic urethritis and cystitis are associated with a common pathogenesis. In any case, stasis of urine with prostatitis or urethritis creates conditions for chronic inflammation of the bladder in men.

The chronic form of  hemorrhagic cystitis is  induced by radiation or chemotherapy of oncological diseases of the pelvic organs, but may be a consequence of urolithiasis or activation of polyomavirus (BKV and JCV).

[5], [6], [7], [8]

Risk factors

To the risk factors for the development of chronic inflammation of the urinary bladder, urologists include:

• weakening of immunity;
• long-term treatment with antibacterial drugs that suppress the protective obligate intestinal microbiota;
• chronic inflammation of the kidneys (pyelitis, pyelonephritis);
• gynecological diseases (vaginal and cervical inflammatory processes);
• changes in hormone levels in women due to pregnancy and menopause;
• chronic form of prostatitis, adenoma of the prostate gland in men;
• stones of the bladder or kidney;
• the presence of congenital anomalies of the urinary tract or bladder that interfere with its complete emptying;
• metabolic diseases such as diabetes or urine acid diathesis;
• scars and diverticula in the bladder;
• any urological manipulations and surgical interventions (including the installation of cystostomic drainage);
• autoimmune diseases in the anamnesis;
• a tumor of the bladder.

Patients undergoing therapy with suppression of the immune system are at risk of hemorrhagic cystitis due to direct exposure to cytotoxic anti-cancer drugs or the activation of persistent infection in the organs of the urinary system, including the bladder.

It is also known that seizures of chronic cystitis can occur with prolonged hypothermia of the body and frequent sexual contacts.

[9], [10], [11], [12]

Pathogenesis

The pathogenesis of inflammation in the case of a bladder infection penetrated into its cavity of E. Coli is explained by the fact that this bacterium can bind to glycolipids of the cell membrane and be introduced into the cells of the urothelium. Because of the multiplication of the microorganism, accompanied by the release of toxins, protein synthesis ceases, which leads to the destruction of the cells of the mucous membrane of the bladder and the development of an inflammatory reaction.

The pathogenesis of cystitis associated with ureaplasma is well studied. Without causing symptoms, these bacteria live extracellularly in the urogenital tract of sexually active women and men and rarely enter cells, except in cases of immunosuppression. With the weakening of the immunity of U. Urealyticum, the cells of the mucosal epithelium are damaged, causing their morphological changes and increasing the activity of pro-inflammatory cytokines, leukocytes and prostaglandins, as well as the expression of tumor necrosis factor (TNF-α).

Hypotheses about the etiology and pathogenesis of a rare inlaid chronic cystitis are controversial, but the most popular of them suggest the involvement of the gram-positive rod Corynebacterium urealyticum. This commensal skin bacterium with strong urease activity cleaves urea, creating an alkaline environment in the bladder, favorable for the deposition of inorganic salts (struvite crystals and calcium phosphate crystals) on its mucous membranes.

The role of reduced estrogen production in the pathophysiology of urinary tract infections and chronic cystitis in women of the older age category has been determined. Female sex hormone stimulates the proliferation of Lactobacillus cells in the vaginal epithelium, while lactobacilli reduce the pH and prevents microbial contamination of the vagina. In addition, in the absence of estrogen, the volume of vaginal muscles and the elasticity of ligaments supporting the bottom of the uterus decrease, and the prolapse of the internal genital organs causes compression of the bladder and stagnation of urine.

[13], [14], [15], [16], [17], [18], [19]

Symptoms of the chronic cystitis

According to urologists, how often or how much the symptoms of chronic cystitis manifest themselves depend on a number of factors. But the first signs in 80% of cases are associated with an increase in urination (pollakiuria) and small volumes of excreted urine at each exercise.

As a rule, the course of chronic cystitis passes in several stages, but some types of this disease proceed continuously.

Infection usually manifests itself as a gradual onset of the inflammatory process and worsening for months - with one or more symptoms, including:

• uncomfortable sensations in the bladder;
• imperative urge to urinate (both during the day and at night);
• pain and burning when urinating;
• spasms of the bladder;
• fever.

According to clinical observations, in 60% of patients in the acute stage there are drawing pains in chronic cystitis, felt in the lower abdomen (above the pubic bone), in the perineum and pelvis, in women - also in the uterus and appendages. Another symptom is dyspareunia, that is, sex with chronic cystitis can be painful for women.

Sharp cooling, as well as the season from late autumn to early spring - the main time when there may be an exacerbation of chronic cystitis. And, as it turned out, chronic bacterial cystitis in 90% of cases is aggravated due to a new infection that occurs after a break more than two weeks after the previous inflammation.

After the stage of abating, when the intensity of symptoms decreases significantly, there are asymptomatic periods perceived as a remission of chronic cystitis, after which after a while relapse occurs.

In most patients, urine in chronic cystitis is turbid, and analyzes indicate a marked bacteriuria. Some may have an admixture of pus in the urine or the presence of blood ( hematuria ) in it .

[20], [21]

Forms

First of all, they separate chronic bacterial cystitis and much more rare non-bacterial.

Defining chronic latent cystitis, that is, not manifesting itself with obvious symptoms, mean latent, that is, latent periods, in which the course of chronic cystitis differs in many patients.

In the presence of blood in the secreted urine determine chronic hemorrhagic cystitis. In cases of localization of the inflammatory process in the neck of the bladder (cervix vesicae) - the area of its narrowing and transition to the urethra - is diagnosed chronic  cervical cystitis of the bladder in women and men.

Depending on the morphological features of the damage to the tissues of the inner membrane of the bladder, revealed in cystoscopy, the following types of this disease are distinguished:

• chronic catarrhal cystitis (superficial, affecting the upper layers of the mucous epithelium, accompanied by exudation).
• chronic follicular cystitis - a rare nonspecific inflammation of the bladder of uncertain etiology; characterized by the presence in its mucous membrane of infiltrates of lymphoid follicular tissue. Usually, pathological changes with edema and hyperemia are localized in the basal membrane of the trigonal zone (the urinary bladder) or at the base of the bladder.
• chronic cystic cystitis is a rare form of the disease with formations (the so-called Brunn's nests), which grow into the basal membrane (lamina propria) of the bladder mucosa and in the urothelial wall of the bladder are transformed into cystic cavities (often with liquid contents).
• chronic polyposis cystitis also refers to the rare forms of nonspecific mucosal reaction with polypoid lesions and edema. In 75% of cases it appears in men with frequent catheterization of the bladder.
• chronic bullous cystitis - reversible inflammation with extensive submucosal edema of the bladder, simulating tumor formations. The variant of polyposis cystitis, but with larger lesions. It can have an asymptomatic form, but acute attacks of chronic cystitis are also possible.
• chronic granular cystitis - diffuse inflammation of the mucosa of the bladder with multiple small focal infiltrates in the form of granules.

Some specialists distinguish chronic glandular cystitis that affects lamina propria with granular epithelium cell formations, as well as chronic glandular cystitis (also called intestinal metaplasia), which looks like papillary formations from cells similar to the intestinal epithelium, and localizes in the neck of the bladder and trigonal zone.

In clinical urology, chronic interstitial cystitis or painful bladder syndrome is prominent. Its etiology, pathogenesis, symptoms and methods of treatment is devoted to the publication -  Interstitial cystitis.

[22]

Complications and consequences

Chronic disease, including urological, always has certain consequences and complications.

What is dangerous for chronic cystitis? The defeat of the deep layers of the wall of the bladder and its deformation, leading to a decrease in the capacity of the bladder and its partial dysfunction. As a consequence, there are problems with the excretion of urine - up to enuresis.

Infection can spread to the pelvic organs; in women it is fraught with a violation of the monthly cycle and inflammation of the reproductive organs, so they often ask whether it is possible to become pregnant with chronic cystitis. Indeed, problems can arise if the inflammatory process has affected the appendages and / or uterus.

In addition, possible complications of chronic cystitis include urine flow in the opposite direction (vesico-ureteral reflux), pyelitis, pyelonephritis.

The threat of ureteral obstruction of the ureter with a blood clot in chronic hemorrhagic cystitis (with a bladder rupture) or urethra in chronic bullous cystitis (when the inflammatory focus is in the trigonal or periurethral zones of the bladder) is not ruled out.

In patients with chronic polyposis cystitis, the risk of developing bladder tumors (urothelial carcinoma) is increased.

[23], [24], [25], [26], [27], [28], [29]

Diagnostics of the chronic cystitis

For laboratory tests, tests are submitted:

• general blood analysis;
• blood test for STDs;
• general urine analysis;
• urine tests for the content of leukocytes, erythrocytes, protein;
• sow urine on bacteria.

Instrumental diagnostics is carried out:

• contrast cystography (X-ray of the bladder);
• visualization of the bladder and urinary tract by ultrasound scanning; chronic cystitis on ultrasound - see in detail  ultrasound of the bladder
• Mikrotsionnaya cystourethrography (X-ray examination during urination);
• cystoscopy with biopsy (endoscopic examination is performed exclusively at the stage of remission of the disease).

[30], [31], [32], [33]

Differential diagnosis

Only differential diagnosis can exclude all pathologies in which there is a violation of urination. For example, a bladder infection with a hyperactive bladder, chronic prostatitis, urethritis, or pain in the pelvic area with endometriosis is mistakenly diagnosed .

Chronic recurrent cystitis can also be a sign of bladder cancer, especially in elderly patients with hematuria and a urinary tract infection (therefore a biopsy is required).

Treatment of the chronic cystitis

About effective schemes of treatment of chronic cystitis read in this article.

Prevention

Prevention of bladder infection is not always possible. What can you do to minimize risk? Urologists advise:

• drink more water;
• to observe hygiene (general and intimate);
• do not wear tight underwear;
• increase the number of vegetables and fruits in the diet. This will give the body more vitamins that increase immunity, and the intestines - more fibers that promote the work of useful lactobacilli, which suppress the growth of pathogenic microorganisms;
• daily do at least 10-minute charge;
• do not smoke and do not abuse alcohol.

[34], [35], [36], [37]

Forecast

It is difficult to predict the development of chronic forms of diseases, and chronic cystitis is proof. There are kinds of inflammations that are difficult to cure because they are associated with other pathologies.

[38], [39], [40]