CYSTITIS

AETIOLOGY.—

 Cystitis is much more common in women than in men probably due to short urethra through
which the bacteria ascend.
 Cystitis also accompanies haematogenous renal infection in rare cases.
 Lymphatic spread from infected cervix is also a probable cause of cystitis though rare.
 Bowel infections e.g. appendicular abscess, diverticulitis etc. may cause cystitis by involving
bladder by contiguity.
 In men, cystitis is almost always secondary to some other causes e.g. infection of the prostate,
enlarged prostate associated with residual urine, presence of vesical calculus or an ulcerated
vesical neoplasm.
PREDISPOSING CAUSES.—
The various predisposing causes which may indulge to cause cystitis are being mentioned here —
1. Presence of a calculus, foreign body or neoplasm in the bladder
2. Obstruction in the urethra due to urethral stricture or enlargement of prostate or prostatic carcinoma
or stenosis of the external urinary meatus may lead to stasis and formation of residual urine in the
urinary bladder which initiate cystitis.
3. Presence of diverticulum in the bladder may cause cystitis due to residual urine inside the
diverticulum.
4. Injuries or diseases of the spinal cord which hinders proper evacuation of the bladder may lead to
cystitis.
5. Presence of vesicoureteral reflux may incite cystitis.
6. Malnutrition with lowered general resistance and particularly avitaminosis may lead to cystitis.

Routes of infection —
1. Ascending infection from the urethra is the commonest. That is why cystitis is very common in
females who possess short urethra. E. coli which originates in the bowel, contaminate the vulva and
perineal region. From these regions they get easy access to the bladder in case of females. Passage of
urethral instruments may cause cystitis in either sex.
2.Haematogenous infection from kidney may cause cystitis, but rare.
3.Lymphatic spread from neighbouring viscera has also been noticed. These viscera are mostly
infected cervix, fallopian tube, vagina, sigmoid colon etc. This is also comparatively rare.

CAUSATIVE ORGANISMS.-

 The most common infecting agent is E. coli.

  This is followed by Proteus mirabilis, particularly in young women, Staphylococcus aureus.
Staphylococcus albus. various Streptococci, Pseudomonas and Klebsiella.
 Schistosoma haematobium produces cystitis which may be complicated by stone formation
and high incidence of cancer.
 Mycotic infection of the bladder is rare. Monilial vaginitis may secondarily infect bladder.
 Very rarely actinomycosis may involve the bladder by direct extension from lesions in the
bowel.
PATHOLOGY —

MACROSCOPIC FEATURES:—

 In acute cystitis, the mucous membrane of the bladder is swollen, intensely red and
congested.
 The normal glistening appearance of the mucous membrane is lost.
 Multiple foci of submucosal haemorrhage are noticed.
 The mucosa is oedematous and its surface is covered with purulent membrane.
 Superficial ulcers are occasionally seen.
 In the trigone there may be tiny clear cyst, known as ‘bullous oedema’. The muscularis is
usually not involved.
In chronic cystitis,

 the bladder may show thickening of its wall with corresponding reduction in the size
of the cavity.
 There may be hypertrophy of the muscular tissue. The mucous membrane is dull,
rough and mottled with the brown remains of old haemorrhages.
 In places it may be ulcerated.
 The mucous membrane is firmly attached to the muscle coat owing to fibrosis of the
submucosa.
MICROSCOPIC FEATURES:—

 In acute cystitis, it is the submucous coat which shows major changes. There is much
congestion and dilatation of capillaries. There is infiltration with the cells of acute
inflammation.
 The superficial layers of the epithelium may be desquamated, but the deeper layer remains
intact.
 Leucocytic infiltration may extend into the muscle, but otherwise the muscle layer remains
unaltered.
 In chronic cystitis, all coats are involved.
 There is diffuse fibrosis which is most evident in the submucosa.
 The mucosa is ulcerated in places.
 There may be abundant formation of granulation tissue covered by epithelium giving rise to
polypoid excrescences.
CLINICAL FEATURES —

SYMPTOMS:—

 Severity of the symptoms depends on severity of the disease.

 (i) Increased frequency of urine both in day and at night is the most important symptom. This
may disturb sleep of the patient at night which may make the patient drawn and tired.
(ii) Urgency is also a very characteristic symptom of this condition. At times the desire to
micturate becomes so urgent that incontinence may result.
(iii) Pain, though often associated with, is not a major symptom. Pain varies from mild to
agonising in severe cystitis. When the superior surface of the bladder is involved pain is
referred to the suprapubic region. When the trigone is involved pain is referred to the tip of
the penis or the labia majora.
(iv) Haematuria.— It should be remembered that cystitis is the commonest cause of
haematuria. Such haematuria is usually terminal that means at the end of micturition Later on
as severity increases, the whole urine may be blood stained, but it will be more so at the end
of micturition.
(v) Pyuria.— This is often seen in cases of cystitis.
PHYSICAL SIGNS.—
Examination of the abdomen is usually normal.

 Tenderness may be elicited at the suprapubic region.

 Rectal examination should always be performed It may reveal an enlarged prostate
(benign enlargement of prostate) which is the cause of cystitis.
 It may reveal an enlarged firm and tender prostate (acute prostatitis as the cause of
cystitis).
 It may reveal presence of residual urine. In female, pelvic examination is highly
important to exclude any pathology in the genital system as the cause of cystitis.
Special Investigations.—

1. Blood examination.— White blood count is usually elevated. E.S.R increased.

2. Urine examination usually shows pus cells, bacteria and red blood cells. In case of presence of
associated prostatitis threads may be seen in the initial specimen, so midstream urine specimen should
be taken for culture and sensitivity test.
3. X-rays are not indicated unless stasis or renal infection is suspected. X-ray is also required if the
patient fails to respond to adequate antibiotic treatment for cystitis or the infection is recurrent and
there is presence of obstruction, vesicoureteral reflux, tuberculosis or calculus.
4.Cystoscopy is contraindicated in acute phase. But it should be done 10 days later when haematuria
is continuing to exclude presence of vesical neoplasm or stone or foreign body.
TREATMENT.—

A. GENERAL MEASURES—
1. The patient is urged to drink plenty.
2. Alkalinisation of the urine should be achieved. This provides symptomatic relief. By raising the pH
of the urine, it counteracts the burning sensation of acidic urine which normally accompanies
infection. 60 to 20 g of sodium bicarbonate may be given for this.
3. Antispasmodics.— Various antispasmodics relieves muscular spasm and provides consider able
relief to the patient.
4. Urinary tract analgesic.
SPECIFIC TREATMENT — Antibiotics are prescribed according to the sensitivity test report.