Cystitis in children

Cystitis is an inflammation of the bladder, usually caused by a bladder infection. This is a common type of urinary tract infection (UTI), especially in girls, and is usually more troublesome than a major concern.

Mild cases often go away on their own within a few days. But some children have frequent episodes of cystitis and may need regular or long-term treatment.

There is also the possibility that cystitis can lead to a more serious kidney infection in some cases, so it is important to seek medical attention if your symptoms do not improve.

Urinary tract infections (UTIs) are a common cause of acute illness in infants and children. Guidelines and guidelines for the management of UTIs were last published by the Canadian Society of Pediatrics (CPS) in 2004. [1]Since then, meta-analytic reviews have been published examining the usefulness of diagnostic tests, radiological evaluation, and randomized treatment trials. [2],  [3]In 2011, the American Academy of Pediatrics significantly revised its clinical practice guideline on the diagnosis and management of initial febrile UTI in young children. [4]

Epidemiology

In a 2008 systematic review, approximately 7% of children aged 2 to 24 months with no source fever and 8% of children aged 2 to 19 years with possible urinary symptoms were diagnosed with a UTI. [5]The incidence varied widely with age, gender and race. The rate for uncircumcised boys with fever under 3 months of age was 20.7%, compared with 2.4% for circumcised boys, and decreased to 7.3% and 0.3%, respectively, for boys aged from 6 to 12 months. However, contamination is very common when a urine sample is obtained from a man, when the foreskin cannot be retracted, and uncircumcised men are clearly overestimated. Among febrile girls, approximately 7.5% before 3 months, 5.7% between 3 and 6 months, 8.3% between 6 and 12 months, and 2.1% between 12 and 24 months had a UTI as a causes of fever.

Causes of the cystitis in a child

In the etiology of cystitis in children, infectious factors (bacterial, viral, mycotic), chemical, toxic, medicinal and others play a role.

Bladder infection can occur in the descending, ascending, hematogenous and lymphoid pathways; the latter two pathways are of particular importance in newborns, infants and young children. However, in most cases, bladder infections occur ascending.

The mucous membrane of the bladder of a healthy child is sufficiently resistant to the development of infection. Normal urine flow helps to cleanse the bladder mucosa and urethra from microorganisms. In addition, the mucus covering the epithelium of the urethra has a bactericidal effect and prevents the ascending spread of infection. Factors of local immunity (secretory immunoglobulin A, lysozyme, interferon, etc.) are of great importance in protecting the mucous membrane of the bladder.

The development of the microbial-inflammatory process in the bladder mucosa fundamentally depends on two factors: the type of pathogen and its virulence and morpho-functional changes in the bladder. By itself, the ingress of a microorganism into the bladder is not enough for the occurrence of inflammation, since in order to realize its pathogenic effect, it is necessary to adhere to the surface of the mucous membrane, begin to multiply and colonize the epithelium. Such colonization is possible only under certain prerequisites on the part of the macroorganism.

Risk factors

The predisposing factors for the development of cystitis from the side of the macroorganism are:

1. violation of the urodynamics of the lower urinary tract (irregular and incomplete emptying of the bladder);
2. violation of the integrity of the epithelial layer of the bladder (due to toxic or mechanical damage, circulatory disorders, etc.);
3. decrease in local immunological protection (with a decrease in the general reactivity of the child's body, hypothermia, circulatory disorders in the small pelvis, etc.)

Among microorganisms, the leading role in the development of cystitis belongs to bacteria. The most common causative agent of cystitis is Escherichia coli (about 80% of cases). Other pathogens are saprophytic staphylococcus, enterococcus, Klebsiela, Proteus. Perhaps "hospital" infection with Pseudomonas aeruginosa (when carrying out instrumental manipulations in the hospital). With immunodeficiencies, fungi can be the cause of cystitis.

The role of viruses in the development of hemorrhagic cystitis is generally recognized, while in other forms, viral infection obviously plays the role of a predisposing factor.

Non-infectious cystitis can develop as a result of metabolic disorders (crystalluria in dysmetabolic nephropathy), drug damage (sulfonamides, radiopaque substances, cytostatics, etc.), allergic reactions, etc.

Symptoms of the cystitis in a child

The leading syndromes in cystitis are dysuria and urinary syndrome (neutrophilic bacterial leukocyturia and hematuria, usually terminal)

The characteristic symptoms of acute cystitis and exacerbation of chronic are frequent (pollakiuria) painful urination, pain in the bladder, urinary incontinence is possible, and in children of the first months of life - urinary retention.

Due to the fact that cystitis is a local inflammatory process, general symptoms of intoxication are usually absent, but they can be observed in infants.

Chronic cystitis without exacerbations usually proceeds with little or no symptoms, possibly with leukocyturia, and only during an exacerbation a characteristic clinical picture appears.

 

Forms

Depending on the cause, primary and secondary cystitis is isolated. Primary cystitis occurs in the absence of morpho-functional changes in the bladder. A leading role in the genesis of primary cystitis is played by a decrease in local mucosal resistance due to immunodeficiencies, hypothermia, circulatory disorders, etc. Secondary cystitis occurs against the background of structural and functional disorders of the bladder, leading to obstruction. The most common cause of secondary cystitis in children is neurogenic dysfunction of the bladder, as well as abnormalities, malformations, metabolic disorders, etc.

Along the course, cystitis can be acute and chronic. Acute cystitis is more often primary and is characterized in most cases by a shallow (superficial) lesion of the bladder wall with involvement of the mucous membrane and submucosa. Chronic cystitis, as a rule, occurs against the background of other disorders and is secondary, and morphologically characterized by a deeper lesion of the bladder wall (mucosa, submucosa and muscular membranes).

Classification of cystitis in children

By form	With the flow	By the nature of changes in the mucous membrane	By prevalence	Complications
Primary	Spicy	Catarrhal	Focal:	No complications
Secondary	Chronic:	Bullous	- cervical	With complications:
	- latent	Granular	- trigonitis	- PMR
	- recurrent	Bullous fibrinous Hemorrhagic Phlegmonous Gangrenous Necrotic Inlaid Interstitial Polypoid	Diffuse	- pyelonephritis - urethral stenosis - sclerosis of the bladder neck - urethritis - paracystitis - peritonitis

Acute cystitis is morphologically more often catarrhal (the mucous membrane is hyperemic, increased vascular permeability) or hemorrhagic (areas of hemorrhage with desquamation of the mucous membrane); fibrinous, ulcerative and necrotic cystitis are also observed.

Chronic cystitis can be catarrhal, granular and bullous with severe infiltration of the bladder wall, up to the formation of purulent infiltrates.

Complications and consequences

In case of delayed treatment, ineffectiveness of the therapy, the presence of structural anomalies of the urinary system, complications may form in the form of pyelonephritis, vesicoureteral reflux, sclerosis of the bladder neck, perforation of the bladder wall, peritonitis.

Diagnostics of the cystitis in a child

In the general analysis of urine, leukocyturia and erythrocyturia (usually unchanged erythrocytes) of varying severity, bacteriuria are detected.

According to the ultrasound of the bladder, indirect signs of cystitis can be detected: thickening of the bladder walls, the presence of residual urine.

The main method for diagnosing cystitis is cystoscopy, according to the results of which it is possible to establish the nature of changes in the mucous membrane of the bladder. Cystoscopy is performed with the normalization of urine tests and the elimination of painful manifestations during urination.

Vocal cystography is also performed after the inflammatory process subsides and allows to identify the anatomical and functional prerequisites for the development of chronic cystitis, as well as to carry out a differential diagnosis.

Functional research methods include cystometry and uroflowmetry, which can reveal neurogenic dysfunction of the bladder and determine hydrodynamic parameters.

[6], [7], [8], [9], [10], [11], [12]

 

Differential diagnosis

The differential diagnosis of cystitis is carried out with acute urethritis, appendicitis, paraproctitis, tumors, vascular anomalies, chronic pyelonephritis.

Treatment of the cystitis in a child

Treatment of cystitis is complex and provides for general and local effects. Therapy should be aimed at normalizing urinary disorders, eliminating the pathogen and inflammation, and eliminating pain.

In the acute stage of the disease, bed rest is recommended until the dysuric phenomena subside. The general warming of the patient is shown. Dry heat is applied to the bladder area.

Diet therapy provides for a gentle regimen with the exclusion of spicy, spicy foods, spices and extractives. Shown are dairy products, fruits that promote urine alkalinization. It is advisable to use in the diet of patients with cystitis yoghurts enriched with lactobacilli, which can prevent the recurrence of the microbial-inflammatory process in the urinary tract. After relieving the pain syndrome, it is recommended to drink plenty of water (slightly alkaline mineral waters, fruit drinks, weakly concentrated compotes). An increase in urine output reduces the irritating effect of urine on the inflamed mucous membrane, promotes the flushing of inflammation products from the bladder. Reception of mineral water (Slavyanovskaya, Smirnovskaya, Essentuki) at the rate of 2-3 ml / kg 1 hour before meals has a weak anti-inflammatory and antispasmodic effect, changes the pH of urine.

Drug therapy for cystitis includes the use of antispasmodic, uroseptic and antibacterial agents.

With pain syndrome, the use of age-related doses of no-shpa, papaverine, belladonna, baralgin is indicated.

Antibiotic therapy is usually given empirically pending bacteriological results. When prescribing antimicrobial drugs, they are guided by the following principles: route of administration, sensitivity, optimal pH values of urine, possible side effects, severity of the patient's condition.

Research is sparse, but a two to four day course of oral antibiotics based on local E coli susceptibility is likely to be effective. [13]

In acute uncomplicated cystitis, it is advisable to use oral antimicrobial drugs, which are excreted mainly by the kidneys and create a maximum concentration in the bladder. The starting drugs for the treatment of acute uncomplicated cystitis can be "protected" penicillins based on amoxicillin with clavulanic acid. Alternatively, oral cephalosporins 2-3 generations or co-trimoxazole can be used. However, the use of the latter should be limited to those cases where there is bacteriological confirmation of sensitivity. When detecting atypical flora, drugs are used - macrolides, fungi - antimycotic drugs.

The criteria for the duration of antibiotic therapy are the patient's standing, the nature of the microbial flora, effectiveness, and the presence of complications of the microbial-inflammatory process. The minimum course of treatment is 7 days. In the absence of urine sanitation against the background of antibiotic therapy, an additional examination of the child is required.

Uroseptic therapy includes the use of drugs of the nitrofuran series (furagin), non-fluorinated quinolones (drugs of nalidixic and pipemidic acids, derivatives of 8-hydroxyquinoline). However, the low efficiency of the use of non-fluorinated quinolones has been described due to their insufficient concentration in the blood (below the maximum plasma concentration of the pathogen).

A promising drug for the treatment of cystitis is monural, which has a wide antimicrobial spectrum of action.

In the acute period of the disease, herbal medicine is carried out with antimicrobial, tanning, regenerating and anti-inflammatory effect. The composition of herbal preparations depends on the severity of clinical symptoms, the period of the disease and the presence or absence of bacteriuria. Lingonberry leaves and fruits, oak bark, St. John's wort, calendula, nettles, coltsfoot, plantain, chamomile, blueberries, and others are used as anti-inflammatory agents. Barley, nettle, and lingonberry leaf have a regenerating effect.

Antibiotic therapy of chronic cystitis is carried out for a long time and should be combined with local treatment in the form of bladder instillations. The drugs used for this purpose are selected depending on the morphological form of cystitis. For catarrhal cystitis, an aqueous solution of furacilin, sea buckthorn and rosehip oil, synthomycin emulsion are used. Instillations of antibiotics and uroseptics are used for hemorrhagic cystitis. In the treatment of bullous and granular forms, a solution of collargol and silver nitrate is used. The duration of the course is 8-10 procedures with a volume of 15-20 ml, with catarrhal cystitis, 1-2 courses of instillations are required, with granular and bullous - 2-3 courses, the interval between courses is 3 months. Simultaneously with instillations, it is recommended to conduct microclysters of warm solutions of eucalyptus, chamomile to improve microcirculation in the pelvic organs.

With frequent relapses, it is possible to use immunomodulatory drugs. Instillations with tomicide (a waste product of a non-pathogenic streptococcus), which also have a bactericidal effect, can be used. Tomicide increases the slgA content in the bladder mucosa.

Physiotherapy is mandatory. Electrophoresis, ultrahigh frequency electric field, applications of azokerite or paraffin are used. Physiotherapy treatment is recommended to conquer every 3-4 months.

After the elimination of bacteriuria in chronic cystitis, preventive phytotherapeutic fees are used.

Cystitis treatment regimen

Instillation of the urinary bladder with 0.1% AgNO ₃ solution  - 10.0 ml or 1% dioxidine solution - 10.0 ml 1 time per day - 3 courses of 10 days with an interval between courses of 2-3 months.

Physiotherapy treatment - 3 courses of 10 sessions with intervals between courses of 2-3 months.

Antibiotic therapy during exacerbations.

During the period when the inflammatory process in the bladder subsides, herbal medicine is recommended: herbs and preparations with anti-inflammatory and antiseptic properties.

After 1 month. After the 3rd course of bladder instillations and physiotherapeutic treatment, a follow-up examination is recommended, including, in addition to general and biochemical blood and urine tests, ultrasound of the kidneys and bladder, cystography and cystoscopy. In the absence of pathological changes according to the results of these studies, the child is removed from the dispensary registration.

A new immunostimulator Uro-Vaxom, which contains bacterial lysate of 18 E.coii strains, should be considered as a drug that enhances the effectiveness of antibacterial therapy, in some cases replacing it. The therapeutic effect of Uro-Vaxom is due to the stimulation of T-cell immunity, an increase in the production of endogenous interferon and the creation of a high level of IgA in the urine. By stimulating the specific and non-specific immune system, Uro-Vaxom allows you to reduce the frequency of exacerbations of urinary tract infections, relieve the symptoms of exacerbations and prevent relapses for a long time.

The drug is compatible with antibiotics and other drugs and can be used in the complex treatment of acute infections. Uro-Vaxom can be used in children from 6 months of age.

Uro-Vax is prescribed 1 capsule daily in the morning on an empty stomach for 10 days with acute cystitis, for the prevention of subsequent exacerbations - within 3 months.

Considering that E.coii is the main causative agent of infectious and inflammatory diseases of the urinary tract, the use of a specifically targeted drug that is not an antibiotic is very promising.

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