Cystitis in children

Cystitis is an inflammation of the bladder, usually caused by a bladder infection. It is a common type of urinary tract infection (UTI), especially in girls, and is usually more of a nuisance than a cause for serious concern.

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

There's also a chance that in some cases, cystitis can lead to a more serious kidney infection, so it's important to seek medical attention if your symptoms don't improve.

Urinary tract infections (UTIs) are a common cause of acute illness in infants and children. Guidelines and recommendations for the management of UTIs were last published by the Canadian Paediatric Society (CPS) in 2004. [ 1 ] Since then, meta-analytic reviews have been published examining the utility of diagnostic tests, radiologic evaluation, and randomized control trials of treatments. [ 2 ], [ 3 ] In 2011, the American Academy of Pediatrics significantly revised its clinical practice guidelines for 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 fever without a source and 8% of children aged 2 to 19 years with possible urinary symptoms were diagnosed with UTI.[ 5 ] The incidence varied widely by age, sex, and race. The rate in uncircumcised boys with fever under 3 months of age was 20.7% compared with 2.4% in circumcised boys, and decreased to 7.3% and 0.3%, respectively, in boys aged 6 to 12 months. However, contamination is very common when obtaining a urine specimen from a male when the foreskin cannot be retracted, and rates in uncircumcised men are certainly overestimated. Among girls with fever, approximately 7.5% of those aged <3 months, 5.7% of those aged 3 to 6 months, 8.3% of those aged 6 to 12 months, and 2.1% of those aged 12 to 24 months had a UTI as the cause of fever.

Causes cystitis in a child

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

Infection of the bladder can occur by descending, ascending, hematogenous and lymphoid routes; the last two routes are of particular importance in newborns, infants and young children. However, in most cases, infection of the bladder occurs by ascending route.

The mucous membrane of the urinary bladder of a healthy child is sufficiently resistant to the development of infection. Normal urine flow helps cleanse the mucous membrane of the urinary bladder 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. Of no small importance in protecting the mucous membrane of the urinary bladder are factors of local immunity (secretory immunoglobulin A, lysozyme, interferon, etc.).

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

Risk factors

Predisposing factors for the development of cystitis from the macroorganism are:

1. violation of 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. decreased local immunological protection (with decreased overall reactivity of the child's body, hypothermia, impaired blood circulation in the 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 causative agents are saprophytic staphylococcus, enterococci, Klebsiella, Proteus. "Hospital" infection with Pseudomonas aeruginosa is possible (during instrumental manipulations in a hospital). In case of immunodeficiency, fungi may be the cause of cystitis.

The role of viruses in the development of hemorrhagic cystitis is generally recognized, whereas 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-induced damage (sulfonamides, radiocontrast agents, cytostatics, etc.), allergic reactions, etc.

Symptoms cystitis in a child

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

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

Since cystitis is a local inflammatory process, general symptoms of intoxication are usually absent, but they may be observed in infants.

Chronic cystitis outside of exacerbations usually proceeds with few or no symptoms, possibly with leukocyturia, and only during an exacerbation does a characteristic clinical picture appear.

Forms

Depending on the cause, primary and secondary cystitis are distinguished. Primary cystitis occurs in the absence of morpho-functional changes in the bladder. The leading role in the genesis of primary cystitis is played by a decrease in local resistance of the mucosa 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 anomalies, malformations, metabolic disorders, etc.

Depending on the course, cystitis can be acute or chronic. Acute cystitis is often primary and is characterized in most cases by shallow (superficial) damage to the bladder wall with involvement of the mucous membrane and submucous layer. Chronic cystitis, as a rule, occurs against the background of other disorders and is secondary, and is morphologically characterized by deeper damage to the bladder wall (mucous, submucous and muscular membranes).

Classification of cystitis in children

By form	With the flow	By the nature of changes in the mucous membrane	By prevalence	Presence of complications
Primary	Spicy	Catarrhal	Focal:	Without complications
Secondary	Chronic:	Bullous	- cervical	With complications:
	- latent	Granular	- trigonite	- PMR
	- recurrent	Bullous-fibrinous Hemorrhagic Phlegmonous Gangrenous Necrotic Inlaying Interstitial Polypous	Diffuse	- pyelonephritis - urethral stenosis - sclerosis of the bladder neck - urethritis - paracystitis - peritonitis

Acute cystitis is morphologically more often catarrhal (the mucosa is hyperemic, vascular permeability is increased) 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 pronounced infiltration of the bladder wall, up to the formation of purulent infiltrates.

Complications and consequences

If treatment is not timely, the therapy is ineffective, and there are structural abnormalities in the urinary system, complications may develop in the form of pyelonephritis, vesicoureteral reflux, sclerosis of the bladder neck, perforation of the bladder wall, and peritonitis.

Diagnostics cystitis in a child

A general urine analysis reveals leukocyturia and erythrocyturia (usually unchanged erythrocytes) of varying degrees of severity, and bacteriuria.

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

The main method for diagnosing cystitis is cystoscopy, the results of which can be used to determine the nature of changes in the bladder mucosa. Cystoscopy is performed when urine tests are normalized and painful symptoms during urination are eliminated.

Micturition cystography is also performed after the inflammatory process has subsided and allows for the identification of anatomical and functional prerequisites for the development of chronic cystitis, as well as for a differential diagnosis.

Functional research methods include cystometry and uroflowmetry, which allow us to identify neurogenic dysfunction of the bladder and determine hydrodynamic parameters.

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

Differential diagnosis

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

Treatment cystitis in a child

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

In the acute stage of the disease, bed rest is recommended until the dysuric symptoms subside. General warming of the patient is indicated. Dry heat is applied to the bladder area.

Diet therapy involves a gentle regimen with the exclusion of spicy, hot dishes, spices and extractive substances. Dairy and vegetable products, fruits that promote alkalization of urine are indicated. It is advisable to use yoghurts enriched with lactobacilli in the diet of patients with cystitis, which can prevent a relapse of the microbial inflammatory process in the urinary tract. After the pain syndrome has been relieved, it is recommended to drink plenty of fluids (weakly alkaline mineral waters, fruit drinks, low-concentration compotes). An increase in diuresis reduces the irritating effect of urine on the inflamed mucous membrane, promotes the washing out of inflammation products from the bladder. Taking mineral water (Slavyanovskaya, Smirnovskaya, Essentuki) at a rate of 2-3 ml / kg 1 hour before meals has a weak anti-inflammatory and antispasmodic effect, changes the pH of the urine.

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

In case of pain syndrome, the use of age-appropriate doses of no-shpa, papaverine, belladonna, and baralgin is indicated.

Antibacterial therapy is usually prescribed empirically until the results of bacteriological examination are received. When prescribing antimicrobial drugs, the following principles are followed: route of administration, sensitivity, optimal urine pH values, possible side effects, severity of the patient's condition.

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

In acute uncomplicated cystitis, it is advisable to use oral antimicrobial drugs that are excreted primarily by the kidneys and create the maximum concentration in the bladder. The initial drugs for the therapy of acute uncomplicated cystitis can be "protected" penicillins based on amoxicillin with clavulanic acid. Oral cephalosporins of the 2nd-3rd generation or co-trimoxazole can be used as an alternative. However, the use of the latter should be limited to those cases where there is bacteriological confirmation of sensitivity. When atypical flora is detected, macrolides are used, and fungi - antimycotic drugs.

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

Uroseptic therapy includes the use of nitrofuran series drugs (furagin), non-fluorinated quinolones (drugs of nalidixic and pipemidic acids, 8-oxyquinoline derivatives). However, low efficiency 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 broad antimicrobial spectrum of action.

In the acute period of the disease, phytotherapy with antimicrobial, tanning, regenerating and anti-inflammatory effects is carried out. The composition of herbal infusions 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, nettle, coltsfoot, plantain, chamomile, blueberries, etc. are used as anti-inflammatory agents. Barley, nettle, lingonberry leaf have a regenerating effect.

Antibacterial therapy of chronic cystitis is long-term 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. In catarrhal cystitis, an aqueous solution of furacilin, sea buckthorn and rosehip oil, and syntomycin emulsion are used. Instillations of antibiotics and uroseptics are used in hemorrhagic cystitis. In the treatment of bullous and granular forms, a solution of collargol and silver nitrate is used. The course duration is 8-10 procedures with a volume of 15-20 ml, catarrhal cystitis requires 1-2 courses of instillations, granular and bullous - 2-3 courses, the interval between courses is 3 months. Along with instillations, it is recommended to perform microclysters of warm solutions of eucalyptus and chamomile to improve microcirculation in the pelvic organs.

In case of frequent relapses, it is possible to use immunomodulatory drugs. Tomicide instillations (a product of the vital activity of non-pathogenic streptococcus), which also has a bactericidal effect, can be used. Tomicide increases the content of slgA in the mucous membrane of the urinary bladder.

Physiotherapy is mandatory. Electrophoresis, ultra-high frequency electric field, azokerite or paraffin applications are used. Physiotherapy treatment is recommended to be performed every 3-4 months.

After eliminating bacteriuria in chronic cystitis, preventive herbal preparations are used.

Treatment regimen for cystitis

Instillation of the bladder with a 0.1% solution of AgNO3 _- 10.0 ml or a 1% solution of dioxidine - 10.0 ml once a 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.

Antibacterial therapy during exacerbations.

During the period of subsidence of the inflammatory process in the bladder, herbal therapy is recommended: herbs and infusions with anti-inflammatory and antiseptic properties.

One month after the 3rd course of bladder instillations and physiotherapy, a control examination is recommended, including, in addition to general and biochemical blood and urine tests, ultrasound of the kidneys and bladder, cystography and cystoscopy. If there are no pathological changes based on the results of these studies, the child is removed from the dispensary register.

As a drug that enhances the effectiveness of antibacterial therapy, in some cases replacing it, it is necessary to consider the new immunostimulant Uro-Vaxom, which contains a bacterial lysate of 18 strains of E. coli. The therapeutic effect of Uro-Vaxom is due to the stimulation of T-cell immunity, increased production of endogenous interferon and the creation of a high level of IgA in the urine. Due to the stimulation of the specific and non-specific immune system, Uro-Vaxom allows to reduce the frequency of exacerbations of urinary tract infections, relieve 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 for acute cystitis, and for the prevention of subsequent exacerbations - for 3 months.

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

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