Differential diagnosis of cystitis. Pyelonephritis and cystitis differential diagnosis Acute cystitis differential diagnosis

It is expressed by a triad of symptoms: pain, pollakiuria and pyuria. In the hemorrhagic form, macrohematuria comes first. Pain in the lower abdomen appears either when the bladder is filling, or during urination, especially at the end of it. Little boys complain of pain in the head of the penis. Pain at the end of urination is characteristic of the predominant localization of cystitis in the area of ​​\u200b\u200bthe exit from the bladder (cervical cystitis, trigonitis).

Pollakiuria occurs around the clock. Its degree depends on the form of cystitis: relatively moderate in catarrhal forms, it becomes unbearable in the ulcerative process, when an imperative urge to urinate appears, reaching the point of incontinence. These disorders reach their culminating point in patients with a wrinkled bladder. In young boys, a paradoxical phenomenon can be observed - acute cystitis is manifested not by pollakiuria, but by acute urinary retention. The child begins to strain, a few drops of urine appear, the child screams, and urination stops. This situation is explained by sphincter spasm, which occurs as a result of severe pain caused by the passage of urine through the neck of the bladder and the urethra.

With severe pyuria, cloudy urine is macroscopically determined. Less severe pyuria can only be determined microscopically.

The temperature in patients with various forms of cystitis (with the exception of gangrenous) remains normal. An increase in temperature, if there is no other infectious focus located outside the urinary apparatus, indicates an ascending infection of the kidney, the addition of pyelonephritis. In rare cases, an increase in temperature depends on the spread of infection to the peri-vesical tissue (paracystitis).

Diagnostics Acute cystitis is based on the triad of the listed symptoms, as well as on data from physical, laboratory, and, where indicated, endoscopic and x-ray studies.

In patients with acute cystitis, there is pain when palpating the bladder area above the pubis or during vaginal examination in women. In addition to leukocyturia and bacteriuria, a laboratory test of urine can detect a small amount of protein (albuminuria is false in these cases) and a larger or smaller number of red blood cells. Total macrohematuria is characteristic of the hemorrhagic form of cystitis, terminal hematuria is characteristic of cervical cystitis.

Endoscopic examination is contraindicated in acute cystitis, as it causes severe pain and can lead to an exacerbation of the process; it should be performed only in cases of prolonged cystitis. The exception is the hemorrhagic form of cystitis with severe total hematuria, when it is necessary to establish the cause of the latter. Cystoscopy in patients with acute protracted uncomplicated cystitis reveals changes in the mucous membrane of varying intensity and extent: hyperemia, edema, fibrinous deposits, ulcerations. In case of complicated and secondary cystitis, the primary disease of the bladder is determined; violation of the release of indigo carmine from the mouths of the ureters makes it possible to determine the spread of infection towards the kidney. X-ray examination makes it possible to diagnose a calculus, bladder diverticulum, and vesicoureteral reflux. Acute cystitis causes relapses in 12-17% of cases.

Chronic cystitis is mainly a secondary disease. Some authors deny the possibility of primary chronic cystitis. An exception is the so-called cystic cystitis, which occurs without other damage to the bladder. The appearance of small cysts is not always accompanied by signs of cystitis. In some patients, these cysts are discovered accidentally during an examination undertaken for another disease. The symptoms of chronic cystitis are the same as acute ones, but the duration of the disease is longer.

Cystoscopy and x-ray examination are mandatory components of diagnosis. In most cases, they allow us to find out the secondary nature of the disease. It is clear that at the same time a general examination of the patient should be carried out, the condition of the kidneys, ureters, urethra, and reproductive organs should be determined. Trigonitis is characterized by severe dysuria, chronic course and mild pyuria.

During cystoscopy, loosening and hyperemia of the mucous membrane is limited to the area of ​​Lieto's triangle. Cystoscopy image of various forms of cystitis - see color. table, fig. 1-12.

Rice. 1. Acute cystitis, vascular injection. Rice. 2 and 3. Hemorrhagic cystitis. Rice. 4 and 5. Chronic cystitis. Rice. 6. Follicular cystitis. Rice. 7. Fibrinous cystitis. Rice. 8. Cystic cystitis. Rice. 9. Encrusting cystitis. Rice. 10. Bullous cystitis. Rice. 11. Interstitial cystitis. Rice. 12. Polypous cystitis.

Differential diagnosis of cystitis in most cases is not difficult. To avoid diagnostic errors, it is necessary to keep in mind the following rules: without pyuria there is no cystitis; pollakiuria and pyuria may be manifestations of pyelonephritis with secondary changes in the bladder. Primary is rare. Therefore, if cystitis persists, it is necessary to exclude the possibility of secondary cystitis, find out the root cause, and also make sure that there is no tuberculosis of the urinary apparatus. In each case of persistent cystitis, a thorough examination of the pelvic organs is indicated.

With bladder neurosis, isolated pollakiuria is noted. Vola and pollakiuria without pyuria are characteristic of a polyetiological disease, with a pathogenesis that has not yet been clarified - the so-called cystalgia. Cystalgia is observed only in women; with it, pain and pollakiuria occur mainly during the day and disappear during sleep; there are no pathological elements in the urine. During cystoscopic examination, the mucous membrane in the vast majority of cases appears unchanged. In a number of patients, in the area of ​​Lieto's triangle, lighter islands of epithelium are detected, histologically similar to the vaginal epithelium. The occurrence of cystalgia is associated with endocrine disorders, uric acid diathesis, congestion in the pelvis, and a trace reaction after previous cystitis. Abroad, persistent forms of cystalgia are sometimes classified as psychosomatics. Treatment should be aimed at eliminating the suspected causes and normalizing the neuromuscular tone of the bladder (various types of novocaine blockade, physiotherapeutic procedures). Endovesical manipulation should be avoided.

A detailed laboratory, endoscopic and x-ray examination of the condition of the urinary apparatus as a whole makes it possible to make a differential diagnosis between cystitis and tuberculosis, between cystitis and pyelonephritis complicated by cystitis, as well as to establish the cause of secondary cystitis. A gynecological examination allows us to exclude damage to the female genital organs as a cause of secondary cystitis. In men, digital rectal examination can identify the primary source of infection in the prostate gland.

With polypous forms of cystitis, there is a need for a differential diagnosis with a tumor. Often it is not possible to make a correct diagnosis based solely on the cystoscopic picture. Cytological examination of urine sediment and biopsy are helpful. There are certain difficulties in the differential diagnosis between limited encrusting cystitis and encrusting surface of a small neoplasm. The issue is resolved by surgical intervention.

Complications of cystitis are associated with the spread of infection to the upper urinary tract and surrounding tissues. Ascending pyelonephritis can complicate the course of both acute and chronic cystitis. The infection can spread directly through the lumen of the ureter with vesicoureteral reflux or hematogenously. This is favored by impaired patency of the lower urinary tract (for example, in patients with the prostate gland), exacerbation of chronic cystitis. The occurrence of pyelonephritis is accompanied by a deterioration in general condition, chills, and fever. It is extremely rare that ulcerative and necrotizing cystitis are complicated by purulent peritonitis. More often, these forms of cystitis lead to paracystitis.

Paracystitis - inflammation of the peri-vesical tissue - occurs most often, especially in the conditions of modern antibacterial treatment, in the form of an inflammatory infiltrate with subsequent sclerotic changes in the tissue. A number of patients develop either limited purulent cavities or widespread purulent melting. In cases where the abscess is limited to the reticular space, a protrusion is detected above the pubis in non-obese individuals, which can be mistaken for a full bladder.

Diffuse ulcerative chronic cystitis in rare cases results in the formation of a small, wrinkled bladder. In practice, the detrusor as a whole is replaced by scar connective tissue, the epithelium is preserved only in the area of ​​Lieto's triangle.

Complications of chronic cystitis include leukoplakia of the bladder and malakoplakia. However, in a number of patients with leukoplakia, during cystoscopy the mucous membrane around the circumference of the leukoplakia plaque is not changed.

Treatment Primary acute cystitis consists of a certain regimen, creating “rest” for the bladder, using antibacterial agents, and thermal procedures. For severe forms, bed rest is indicated. In all cases, exclude spicy seasonings from food and alcoholic beverages. A good effect is achieved by presacral novocaine blockade (100 ml of 0.25% novocaine solution) applied on the first day, which significantly relieves spastic contractions of the detrusor. For the same purpose, various antispastic drugs are prescribed: belladonna preparations, papaverine, platifillin, kellin, etc. Antibacterial treatment usually comes down to the use of sulfonamides (etazol, urosulfan) and nitrofuran drugs (furadonin, furazolidone) in normal dosages. If the course is persistent, antibiotics are also indicated, the choice of which should be based on urine culture and antibiogram data. In more than 50% of cases, cystitis can be relieved on the first or second day. If the course is prolonged, a full examination is indicated to determine the cause of such a course. When cystitis lasts more than 5-6 days, you can resort to installing antibiotics, 3% collargol in an oil solution, into the cavity of the bladder.

Treatment of primary chronic cystitis presents significant difficulties due to the persistent course of the disease. Measures are taken to generally strengthen the body, eliminate various possible purulent foci (in the mouth, throat, etc.), and constipation. Antibacterial treatment should be carried out systematically over a period of months with a change of antibiotics every 5-7 days in accordance with the results of repeated antibiograms (during the treatment the type of flora and its sensitivity to antibiotics changes), combining them with sulfonamide and nitrofuran drugs. Local treatment is also indicated in the form of rinsing the bladder with weak solutions of ethacridine, furatsilin, boric acid, followed by the installation of 3% collargol in oil.

For any form of secondary cystitis, the basis of treatment is the elimination of the primary disease: calculus, neoplasm, bladder diverticulum, urethral stricture, prostate adenoma, inflammatory focus in the female genital organs, in the prostate gland.

After eliminating the cause, it is possible to eliminate cystitis using the measures listed above.

Prevention cystitis is based on the prevention and timely elimination of the causes contributing to its occurrence.

Refusal from various endovesical examinations, as well as from catheterization of the bladder, when there are no absolute indications for this, is justified, since in this case the danger of infection of the urinary tract, despite taking the necessary aseptic measures, is very significant.

Acute cystitis should be differentiated from a number of diseases of other organs: kidneys, prostate gland (adenoma), urethra (stricture), bladder stones, cystalgia, diseases of the female genital area, since dysuric disorders, expressed by increased frequency of urination, its pain, difficulty, also occur in the diseases listed above. The pathogenetic mechanisms of dysuria are based on general and local factors. Common factors include various negative emotions and psychogenic reactions. Such dysuria is usually reversible after eliminating the causes that caused it. Local factors include a tumor, the presence of urethral stricture, urinary stones that impede the passage of urine, as well as dynamic disorders of the neuromuscular apparatus of the bladder. One can think of acute cystitis when there is acute painful urination, equally frequent at different times of the day. The patient experiences an imperative urge to urinate, during which he is unable to hold urine in the inflamed bladder.

With cystitis, there is usually no increase in temperature, since the bladder is often emptied and absorption from it is negligible. The exception is necrotic-gangrenous forms of the disease. Suspicion of a bladder tumor may arise when persistent dysuria is combined with hematuria. For acute prostatitis, severe dysuria with an imperative urge to urinate is typical. It is usually accompanied by general symptoms in the form of fever, chills, sweating, tachycardia, which increase with the development of the inflammatory process.

Dysuria in an elderly man makes one suspect most likely a prostate adenoma or a bladder stone. Dysuria caused by adenoma is most pronounced at night and at rest. During the day, with an active lifestyle, it decreases. In the presence of stones in the bladder, the symptoms are very similar to the complaints of patients with cystitis. However, with bladder stones, pain often appears when walking or shaking. It has a characteristic irradiation - to the perineum, testicle or glans penis. The pain intensifies in the presence of thorn-shaped stones - oxalates or in the frequently occurring concomitant cystitis. The pain is caused by the movement of the stone and irritation of the mucous membrane, especially the bladder neck as the richest receptor zone. Urination disorder is manifested by an increased frequency of urges, which intensify when the body moves. During sleep, the pain stops.

A typical symptom of bladder stones is the sudden cessation of urine flow during urination - a symptom<заклинивания>and resumption of urination when the patient’s body position changes. Small stones can become trapped in the posterior urethra and cause acute urinary retention. Often, patients experience urinary incontinence when one part of the stone is placed in the bladder, and the other is in the posterior urethra. In these cases, complete closure of the bladder sphincter is impossible. Prolonged presence of a stone in the neck of the bladder and posterior urethra leads to sclerosis. As a result, urinary incontinence may persist after the stone is removed. Changes in the nature of urine due to bladder stones are characterized by macro- and microhematuria, which is explained by injury to the mucous membrane of the bladder. The appearance of leukocytes and microflora in the urine indicates inflammation of the bladder. Depending on the composition of the stone, the corresponding salts are found in the urine.

Bladder stones can be detected by inserting a metal catheter into the bladder. A more accurate diagnostic method is plain radiography, on the basis of which one can judge the number and size of stones. In the case of X-ray negative stones (cystine, protein, urate), they can be detected by pneumocystography, or cystrography with a contrast agent solution. In these cases, filling defects indicate the presence of stone. The final diagnosis is made based on cystoscopy. However, a stone located in a bladder diverticulum cannot always be detected.

Often, pain in the bladder area can be referred and be associated with diseases of the kidneys, prostate gland and urethra. Therefore, if the cause of pain cannot be explained by direct damage to the bladder, it should be sought in a possible disease of the listed organs. In acute urinary retention, which occurs with prostate adenoma, urethral stricture, due to a stone getting stuck in the lumen of the urethra, pain in the bladder area is unbearable and causes the patient to rush about in bed. A distended bladder is detected above the pubis.

Constant pain in the bladder area can be caused by the infiltrating growth of a malignant tumor. These pains can intensify when the tumor disintegrates with the occurrence of secondary cystitis. The first manifestation of prostate cancer is also characterized by an increased urge to urinate, especially at night. Many patients experience difficulty urinating with straining or a sluggish thin stream of urine intermittently, sometimes urine is released in drops, and this is accompanied by a feeling of incomplete emptying of the bladder. Often the patient complains of pain when urinating at the beginning or throughout the act of urination.

Quite often, a symptom of prostate cancer is dissatisfaction with the act of urination. Pain associated with the act of urination also occurs with cystalgia. Cystalgia can develop in women during puberty and menopause. In this case, the patient complains of frequent urination, pain during urination, as well as pain in the perineum, sacrum, and lower abdomen. Sometimes the pain is insignificant. The severity of painful symptoms may vary. With long-term processes, neuroticization of the personality develops.

Along with complaints, a clinical examination of a patient with cystalgia does not reveal organic changes in the bladder. Pyuria is also absent. However, pain with cystalgia can be very pronounced. Diagnosis<цисталгия>diagnosed on the basis of complaints typical of cystitis, in the absence of pyuria and microflora in the urine, as well as changes in the mucous membrane of the bladder characteristic of cystitis, detected during cystoscopy. With cystalgia, morphological signs of chronic urethritis are often found.

Pain from cervical cancer may be misinterpreted as tumor growth into the bladder. The correct diagnosis can only be made by cystoscopic examination.

Often acute pain in the bladder area, accompanied by impaired urination, occurs as a result of pathological processes in the female genital organs. This occurs with adnexitis, para- and perimetritis. Moreover, inflammatory changes in the mucous membrane of the bladder are often detected, caused by the spread of infection from the female genital area.

In case of gangrenous cystitis, before carrying out instrumental research methods, there may be suspicions of the presence of a stone in the bladder or a tumor of the bladder. Urosepsis and chronic cystitis should be excluded.

Externally, cystitis, depending on the pathogen, its virulence, and complications, may manifest itself atypically. To identify the source of leukocyturia, it is necessary to conduct a two- or three-glass test. It is typical for cystitis if the urine contains leukocytes in both or all three glasses, especially if the sediment in the second portion contains more leukocytes than in the first.

With cystitis, pus usually quickly settles to the bottom, and the layer of urine above the sediment becomes significantly clearer and sometimes becomes transparent. With pyelonephritis, the urine is diffusely cloudy, grayish; when standing in the vessel at the bottom, a sediment of varying thickness is formed, consisting of pus and mucus. The layer of urine above the sediment does not clear at all and remains cloudy. With cystitis, the amount of protein corresponds to the pus in the urine. With pyelonephritis, proteinuria is more pronounced. If the amount of protein in purulent urine exceeds 1% or the number of leukocytes, while the protein content is less than 50,000, then kidney damage can be assumed.

A.V. Ayvazyan proposed a method for studying daily diuresis, in which the absolute number of leukocytes, protein, relative density of urine and transparency are examined in four portions of urine. This allows for a more reliable differential diagnosis of cystitis and pyelonephritis.

In acute cystitis, cystoscopy, as a rule, cannot be performed due to the small capacity of the bladder and severe pain when it is filled. In addition, during this period of illness, cystoscopy can cause complications. If there is a need for cystoscopy, it is performed under anesthesia. At the same time, cystoscopy for chronic cystitis is absolutely indicated; it is given great, decisive importance, since it allows not only to identify the form of cystitis, but also to carry out differential diagnosis. The differential diagnosis of chronic cystitis is carried out mainly with urethritis. The presence of pathological changes only in the first portion of urine during a two-glass test indicates urethritis. In the differential diagnosis of chronic cystitis that occurs with the formation of ulcers, a bladder tumor should be excluded. Endovesical biopsy is of decisive importance.

Epidemiology. Cystitis is one of the most common urological diseases. Women get sick more often, which is due to the anatomical, morphological and hormonal characteristics of their body.

Etiology and pathogenesis. There are cystitis of infectious and non-infectious nature. Non-infectious cystitis is much less common.

In case of cystitis of an infectious nature, the causative agents are Escherichia coli (70-80%), staphylococcus, enterococcus and streptococci of other species, Proteus, and sometimes gas-producing microorganisms. In urine with cystitis of an infectious nature, mycelium of fungi of the genus can be found Candida or drusen of actinomycetes, Trichomonas vaginalis. Every year the frequency of cystitis, which is caused by chlamydia, mycoplasma and viruses (herpes), increases.

The causative agents of specific cystitis are tuberculous mycobacteria, and occasionally Treponema pallidum.

With infectious cystitis, the following routes of penetration of microorganisms into the bladder are possible: ascending, descending, hematogenous, lymphogenous and contact. Most often, microorganisms enter the bladder through the ascending route through the urethra.

The mucous membrane of the bladder has significant resistance to infection, so infection alone is not enough for the development of cystitis. In addition to infection, additional predisposing factors play an important role in the development of cystitis. These include a decrease in the body's resistance caused by hypothermia, fatigue, vitamin deficiencies, exhaustion, previous diseases, secondary immunodeficiency, hormonal disorders, and surgical interventions. Disturbance in the outflow of urine from the bladder in patients with BPH, urethral stricture, bladder stone, and bladder dysfunction is very significant. The predisposing factor is a circulatory disorder in the wall of the bladder or pelvis.

The more frequent occurrence of cystitis in women is associated with the proximity of the anus, vagina and urethra, as well as the fact that a short and wide urethra leads to relatively easier penetration of bacteria found in vaginal secretions or entering with feces from the rectum into the urethra and then into bladder.

Dryness and atrophy of the mucous membranes of the vagina and urethra, often occurring in postmenopausal women as a result of decreased estrogen levels in the blood, increase the risk of bladder infection.

Cystitis of non-infectious origin occurs when a concentrated solution of a chemical substance is introduced into the bladder (chemical cystitis), during radiation therapy for tumors of the pelvic organs (radiation cystitis), when the mucous membrane of the bladder is irritated by drugs during their long-term use in large doses (during chemotherapy), when damage to the mucous membrane of the bladder by a foreign body, bladder stone, during endoscopic examination, during radiation therapy for tumors of the female genital organs, rectum, bladder (radiation cystitis). In most cases, an infection soon joins the initially aseptic inflammatory process.

Classification. Cystitis is classified: according to its course (primary, secondary), according to the etiological factor (infectious, non-infectious), according to the activity of the inflammatory process (acute, chronic), according to the localization and prevalence of the inflammatory process (total, cervical, trigonitis), according to the presence of complications (complicated, uncomplicated), according to the nature of the morphological changes (catarrhal, hemorrhagic, ulcerative, gangrenous, interstitial, etc.).

Symptoms and clinical course. Acute cystitis has a sudden onset. The main symptoms of acute cystitis are frequent painful urination, pain in the lower abdomen, and terminal hematuria. Pain during urination occurs at the beginning, at the end or throughout the entire act of urination. The intensity of pain during urination increases with the development of the disease. Due to increased urgency to urinate, patients are sometimes unable to hold urine. Pain above the pubis may not be associated with the act of urination and becomes almost constant.

The severity of clinical signs in acute cystitis varies. In milder cases, patients feel only heaviness in the lower abdomen. Moderate pollakiuria is accompanied by slight pain at the end of urination. Sometimes these phenomena are observed within two to three days and pass without special treatment. However, more often acute cystitis, even with timely treatment, lasts 6-8, and sometimes 10-15 days. A longer course indicates the presence of a concomitant disease that supports the inflammatory process and requires additional examination.

The general condition of patients with cystitis, as a rule, is not disturbed. Body temperature remains normal or may be low-grade. This is explained by the weak resorptive ability of the bladder mucosa.

In addition to pyuria (leukocyturia), in acute cystitis, macro- and microhematuria is possible, usually terminal, which is associated with trauma to the inflamed mucous membrane of the bladder neck and Lieto’s triangle at the end of urination. Erythrocyturia is observed as often as leukocyturia.

Severe forms of acute cystitis (hemorrhagic, gangrenous, phlegmonous) are characterized by severe intoxication, high body temperature, and oliguria. The urine is cloudy with a putrid odor, contains fibrin flakes, sometimes layers of necrotic mucous membrane, and an admixture of blood. The duration of the disease in these cases increases significantly, and severe complications may develop.

Hemorrhagic cystitis develops with intense diapedesis of red blood cells from blood vessels. This occurs with any exudative inflammation, but not in such a pronounced form. The released red blood cells give the urine the color of blood, and the affected tissue itself takes on a bloody tint. Hemorrhagic character can be observed in both serous and purulent inflammation. Its basis is greater permeability of the vascular walls than with ordinary inflammation. The latter may be due either to the previous condition of the vascular walls, or to the peculiarity of the cause that caused the inflammation. Hemorrhagic inflammation can develop with some streptococcal infections. It can also be observed in persons suffering from anemia and other blood diseases with degenerative changes in the vascular walls, with vitamin deficiency, especially with a lack of ascorbic acid and rutin, and with disorders of the blood coagulation system.

Gangrenous cystitis is relatively rare and is the result of impaired blood circulation in the bladder, damage to the nervous system due to diabetes mellitus, or the unintentional introduction of substances into the bladder cavity that damage the mucous membrane.

The clinical picture of bladder gangrene consists of complaints of difficult painful urination, up to complete urinary retention (more often in men), pain in the sacrum, weakness, and high body temperature.

In some cases, acute gangrenous cystitis can develop suddenly and simulate an “acute abdomen,” especially since perforation of the bladder wall, its contents can enter the abdominal cavity, causing peritonitis. Due to the melting of the mucous and submucosal membranes, the urine becomes fetid, with an alkaline reaction. The process is characterized by persistent progression of purulent necrotic lesions of the bladder.

Postpartum cystitis occurs due to the peculiarities of the course of labor and the transfer of infection from the genitals to the bladder. It develops when E. coli enters the bladder, less commonly staphylococcus and streptococcus. The development of the disease is caused by predisposing factors, the main of which are changes in the mucous membrane of the bladder wall during prolonged labor and trauma. Symptoms of postpartum cystitis are urinary retention, pain at the end of urination, cloudiness of the last portion of urine. The number of leukocytes in the urine is moderate. Body temperature is usually normal. The general condition of the patients changes little.

The clinical picture of chronic cystitis is varied and depends on the activity of the inflammatory process, the etiological factor, and the general condition of the patient. Chronic cystitis either occurs as a continuous process with constant, more or less pronounced complaints and changes in the urine (leukocyturia, bacteriuria), or has a recurrent course with exacerbations similar to those of acute cystitis, and remissions, during which all signs of cystitis are missing.

In chronic cystitis, the urine reaction may be alkaline. It contains an increased amount of mucus. An acidic urine reaction is observed in cystitis caused by Escherichia coli and tuberculosis bacilli.

With interstitial cystitis, urination is sharply increased (up to 100-150 times a day) due to a pronounced decrease in bladder capacity. The etiology of the non-infectious inflammatory process is unclear; general analysis and urine culture do not reveal abnormalities. Interstitial cystitis is characterized by complaints of severe pain over the pubis when filling the bladder and its disappearance after urination. As the disease progresses, the bladder sharply decreases in volume. A condition in which the bladder volume is 50 ml or less is called microcystis.

Clinical manifestations and changes in urine with radiation cystitis are the same as with ordinary chronic cystitis. With tuberculosis infection, the course of cystitis is always chronic.

Diagnostics. In most cases, recognizing cystitis is not difficult. Acute and chronic cystitis in the acute stage are accompanied by characteristic complaints of frequent painful urination with stinging and pain in the suprapubic region.

The diagnosis is confirmed by the results of a general urine test, which reveals leukocyturia and hematuria.

In the diagnosis of chronic cystitis and identifying the causes that support inflammation, cystoscopy plays a crucial role (performed without exacerbation of the inflammatory process). At the same time, the degree of damage to the bladder, the form of cystitis, the presence of a tumor, urinary stone, foreign body, diverticulum, fistula, and ulcers are determined.

A biopsy of the bladder mucosa is performed in patients with chronic cystitis for differential diagnosis with interstitial cystitis, tumors and specific lesions of the bladder, etc.

Urine collection for microbiological examination is carried out before the start of antibacterial therapy. First, a thorough toilet of the external genitalia is performed. Then 3-5 ml of an average portion of freely released urine is collected in a sterile container. In acute cystitis, a monoculture of Escherichia coli, Proteus, staphylococci and streptococci is more often isolated in an amount of more than 10 5 CFU/ml of urine. Associations of microorganisms are more common in chronic processes.

Differential diagnosis. Cystitis should be differentiated from a number of diseases of other organs accompanied by dysuria: kidneys, prostate gland (BPH and cancer, acute and chronic prostatitis), urethra (stricture, urethritis), bladder stones, overactive bladder, diseases of the female genital organs.

Treatment for acute cystitis consists of prescribing antibacterial agents and herbal medicine. Hospitalization is indicated for patients with the most common complication of acute cystitis - pyelonephritis, hemorrhagic and necrotizing forms of cystitis, acute urinary retention.

As antibacterial treatment for acute cystitis, nitrofurans (furagin 0.1 g 2-3 times a day), pipemidic acid (palin 0.4 g 2 times a day), fluoroquinolones - norfloxacin (nolitsin), pefloxacin ( abactal), ciprofloxacin (ciprolet, tsiprinol, tsiprobay), etc. One of the listed drugs is used for 5-10 days, even after the disappearance of dysuria, which leads to eradication of the pathogen.

In case of acute cystitis, drink plenty of fluids, a diet excluding spicy foods, pickles, sauces, seasonings, canned food is prescribed, and the consumption of alcoholic beverages is prohibited. Vegetables, fruits, and dairy products are recommended. Thermal procedures are prescribed only if the cause of dysuria is established. They should be avoided if the diagnosis is unknown, especially with gross hematuria, since heat increases bleeding. To reduce pain, warm baths are prescribed. For severe dysuria, M-anticholinergics (oxybutynin, trospium) and antispasmodics are symptomatically prescribed.

Treatment of chronic cystitis consists of eliminating the causes that caused chronic inflammation. It is aimed at restoring impaired urodynamics, eliminating foci of reinfection, removing urinary stones, etc. Antibacterial therapy for chronic cystitis is carried out only after bacteriological examination and determination of the sensitivity of microflora to antibiotics.

In this case, the use of antibacterial drugs should be combined with immunomodulatory therapy. It is necessary to use herbal medicine (decoctions from birch buds, bearberry, bear's ears, lingonberries, half-pol, etc.).

For chronic cystitis, instillation into the bladder of solutions of silver nitrate (0.25-0.5%, 20-40 ml) or collargol (1-3%, 20-40 ml), 20-30 ml 0.5-1% is prescribed dioxidine solution, rosehip seed oil, sea buckthorn, antibiotic emulsion.

To improve blood supply to the bladder wall, laser radiation treatment, inductothermy, and mud applications are used.

For radiation cystitis, in addition to symptomatic and antibacterial treatment, agents that enhance regeneration (actovegin), instillations of methyluracil, corticosteroids, sea buckthorn and rosehip oils are used.

The effectiveness of treatment for interstitial cystitis is currently not high enough, which is largely due to the incompletely clear etiology and pathogenesis of the disease. Antidepressants, tranquilizers, mast cell stabilizers, kinin antagonists, non-steroidal anti-inflammatory drugs, angioprotectors, instillation of hydrocortisone into the bladder in combination with antibiotics and anesthetics, presacral novocaine blockades, physiotherapy, hydrobougation of the bladder, endoscopic surgical interventions (TUR of the bladder neck or ulcers, endoscopic circular denervation, photocoagulation of the bladder mucosa using a laser). Improvement can only occur with intensive treatment started in the early stages of the lesion. The progression of the disease leads to very severe pain syndrome and microcystis. In this regard, there is a need for intestinal plastic surgery of the bladder.

In the treatment of gangrenous cystitis, along with powerful and adequate antibacterial therapy, according to indications, a revision of the bladder with urine diversion (cystostomy) and release of the bladder from necrotic tissue is performed. These measures limit the area of ​​tissue necrosis and save the patient from fatal complications.

Forecast generally favorable; in chronic cystitis it is less favorable than in acute cystitis. Good results in the treatment of chronic cystitis can only be obtained with persistent complex treatment and the elimination of predisposing factors. With secondary cystitis, the prognosis is determined by the course and outcome of the underlying disease.

The bladder is a hollow organ; it has several parts: the bottom, the body and the neck. The neck of the bladder passes into the urethra. At the bottom of the bladder, the ureters open into the bladder. The bladder is located on the urogenital diaphragm. In women, the uterus and upper part of the vagina are adjacent to it. In men, behind the bladder are the seminal vesicles, the ampulla of the vas deferens, and the rectum. The prostate gland is located below the neck of the bladder.

The functions of the bladder are determined by its morphological structure. The wall of the bladder consists of four layers. From the inside it is lined by the mucous membrane, which lies on the submucosa, followed by the muscular and outer adventitia. The serosa covers only the bottom of the bladder. The emptied bladder has a thick wall, the mucous membrane is collected in numerous folds. In a stretched state, the mucous membrane becomes thinner and has no folds. The structure of the mucous membrane ensures its ability to remain intact even if there is quite a liquid in the cavity of the bladder - urine.

The transitional epithelium lining the inside of the bladder cavity in a stretched state resembles stratified squamous non-keratinizing epithelium. The cells do not move apart, as they are connected by tight junctions and desmosomes, which prevent urine from penetrating through the wall of the bladder, even despite the difference in osmotic and hydrostatic pressure. In the normal state, the epithelial cells of the surface layers are rounded. The lamina propria of the mucous membrane of the bladder, fused with the submucosa, is richly supplied with blood and lymphatic vessels, and small vessels come so close to the epithelium that they seem to penetrate it. As a result, the healthy mucous membrane of the bladder has a pink color.

The mucous membrane in the place where the ureters open into the bladder does not have folds, even with a collapsed bladder. This area has the shape of a triangle and, after the name of the author who first described it, is called Lieto’s triangle. The apex of Lieto's triangle is directed towards the internal opening of the urethra, and at the corners of its base are the openings of the ureters. In the submucosa of the triangle, glands similar to those found in the lower part of the ureter are found.

Following the main submucosa is the muscular layer, consisting of smooth muscle tissue. In the muscular layer, three vaguely limited layers are distinguished, intertwined with each other. The inner and outer layers have longitudinally arranged muscle fibers. In the middle, the most developed layer of the muscular layer, the muscle fibers run circularly and form the sphincter of the bladder neck in the area of ​​the internal opening of the urethra. Layers of loose fibrous connective tissue that separate the individual muscle bundles and layers of the muscular layer pass into the outer adventitia of the bladder.

There are quite a lot of nerve ganglia and scattered neurons of the autonomic nervous system in the wall of the bladder. The latter are especially numerous in the area of ​​Lieto's triangle, where the ureters enter the bladder. There are many receptor nerve endings in all membranes of the bladder.

The bladder is adapted to perform two functions. The first of these is that the bladder is a reservoir for urine, which periodically enters it from the kidneys through the ureters. The amount of incoming urine depends on the volume of fluid drunk, the filtration function of the kidneys, and various mental phenomena. The bladder is capable of holding urine for some time, and the retention time will depend to a greater extent not on the amount of incoming urine, but on the speed of its inflow. The bladder can hold urine that flows slowly for a longer period of time than urine that flows quickly. This feature is due to the muscular lining of the bladder. The latter can stretch quite strongly without stimulating the urge to urinate.

The second function of the bladder is evacuation. In a healthy person, the bladder can hold from 200 to 400 ml of urine. The volume of urine retained depends on the gender and age of the individual. Women have a smaller bladder capacity than men. In old age, the ability of the bladder muscles to contract decreases. As a result, the capacity of the organ increases.

A healthy person urinates about five times a day. Frequent urination (polyuria) can occur either from an increase in the daily amount of urine due to increased drinking or cold weather, or from some metabolic disease (diabetes mellitus or diabetes insipidus), or from a disease of the kidneys, renal pelvis, or bladder. Frequent urination in some cases occurs the same day and night. In other cases, it appears only at night, waking a person several times a night and thereby depriving him of sleep.

The normal daily amount of urine for men is approximately 1.5 liters, for women - 1.2 liters. With polyuria it can reach up to 7 liters and even up to 15 liters with diabetes insipidus. A decrease in the amount of urine can occur with increased sweating, vomiting, diarrhea, a sharp weakening of cardiac activity, and especially with acute inflammation of the kidneys, when the amount of urine can decrease to 50-100 ml.

In the normal state of the lower urinary tract, urine flows in a strong and full stream. In many diseases, the patient's urine stream becomes weak, thin and intermittent. The process of holding urine in the bladder may depend on the muscles of the genitourinary diaphragm, the condition of the anterior abdominal wall, and the muscles of the urethra. Thus, in elderly women with flabby muscles, slight straining when coughing, sneezing, or emotional manifestations is accompanied by involuntary urination of small portions of urine. The urine that is removed from a healthy bladder remains the same as that entering it, i.e., water, mineral and organic substances are not absorbed in it.

The development of the bladder occurs from blind outgrowths, which are formed at the junction of both Wolffian ducts into the cloaca. By the seventh week, the anlage is lined with multirow epithelium containing glycogen and nonspecific phosphatases. In the third month of embryogenesis, all three membranes of the bladder are already formed.

The bladder in newborns and young children is located high and has a spindle shape. In the second year of life, this shape smoothes out and it becomes round, taking on the shape of an adult by 15-17 years.

Microscopically, the ratio of tissue components is recorded, different from that of an adult. In newborns and infants, the epithelium already has a definitive structure.

In the area of ​​the bladder triangle there are several tubular unbranched glands. The longitudinal muscle layer of the bladder walls is more developed than the circular one. The development of the muscular membrane is weaker than in an adult, which obviously determines the shape of the bladder during the neonatal period. With the development of the circular layer, the shape of the bladder changes. The connective tissue is well expressed and occupies most of the bladder wall. It is poor in elastic fibers, the number of which increases at the border with the muscle layer.

The study of the bladder of children of different ages on serial sections made it possible to detect glands. They are found in the lower parts of the triangle in the form of dense epithelial strands in the mucous membrane or small secretion-filled cavities in the epithelium. There are also transitional forms between these formations. In adults, glands are not always detected.

The bladder muscles actively grow from the age of 6. The sphincter reaches its development by 12 years.

CYSTISTS

Cystitis is the name given to acute or chronic inflammatory processes in the mucous membrane of the bladder. Sometimes the entire wall of the bladder is involved in the pathological process. Cystitis is the most common urological disease, for which patients turn to emergency and emergency doctors, therapists, urologists, gynecologists, and sometimes surgeons. Women get sick more often, which is due to the anatomical, morphological and hormonal characteristics of their body.

Cystitis can be primary, that is, it occurs initially in a healthy body, and secondary, that is, it can be a complication of a pre-existing disease of the bladder or other organs. According to the course and nature of morphological changes, acute and chronic cystitis are distinguished. Primary cystitis most often affects young women. Secondary cystitis mainly affects older men, who usually develop prostate adenoma. As a consequence of this, urinary retention occurs, and then instrumental studies, catheterization, and cystoscopy are performed. In this case, trauma to the mucous membrane of the bladder and its infection are possible.

Depending on the prevalence of the process, focal and diffuse cystitis are distinguished. When only the bladder neck is involved in the inflammatory process, cervical cystitis develops, and trigonitis develops in the bladder triangle. There is also a special form of chronic cystitis - interstitial.

Classifications of cystitis

G.I. Goldin proposed the following classification of cystitis.

O.L. Tiktinsky proposed his own classification of cystitis.

There are cystitis of infectious and non-infectious nature. Cystitis of non-infectious origin occurs when the mucous membrane of the bladder is irritated by chemicals released in the urine, including drugs when used for a long time in large doses, with burns of the mucous membrane, for example, in the case of a concentrated solution of a chemical substance being introduced into the bladder, as a result of rinsing bladder with a solution whose temperature exceeds 45°C (burn cystitis), in case of damage to the mucous membrane by a foreign body, urinary stone, as well as during endoscopic examination, during radiation therapy for tumors of the female genital organs, rectum, bladder (radiation cystitis ).

In most cases, an infection soon joins the initially aseptic inflammatory process. In case of cystitis of an infectious nature, which occurs much more often than cystitis of a non-infectious origin, the causative agents are often E. coli, staphylococcus, streptococcus, enterococcus and Proteus vulgaris, sometimes gas-producing microorganisms.

In the urine of cystitis of an infectious nature, drusen of actinomycetes, causing mycotic cystitis, and Trichomonas vaginalis, the causative agents of trichomonas cystitis, can be found. Every year the epidemiological significance of cystitis, which is caused by some representatives of chlamydia - the causative agents of urogenital chlamydia and mycoplasma, is growing. Currently, they account for more than 50% of all non-gonococcal diseases. Chlamydia and mycoplasma can cause acute and chronic forms of cystitis.

The causative agents of cystitis can be tuberculous mycobacteria and rarely - Treponema pallidum - the etiological factor of syphilis.

PATHOGENESIS AND PATHOLOGICAL ANATOMY OF CYSTITIS

Infectious cystitis can occur by ascending, descending, hematogenous, lymphogenous and contact routes.

Infectious agents can enter the bladder through the ascending route in inflammatory diseases of the urethra, prostate gland, seminal vesicles, testicle and its appendages. The descending route of infection most often occurs with tuberculosis of the kidney. The hematogenous path of damage to the mucous membrane of the bladder occurs in infectious diseases or the presence of a purulent focus in the body: tonsillitis, pulpitis, furunculosis. The lymphogenous route of infection occurs in diseases of the genital organs: endometritis, salpingo-oophoritis, parametritis. Infection of the bladder can occur during catheterization or during cystoscopy. Direct infection of the bladder can occur when there are fistulas connecting the vagina to the bladder or the vagina to the rectum.

The mucous membrane of the bladder has significant resistance to infection, so infection alone is not enough for the development of cystitis. In addition to infection, additional predisposing factors play an important role in the development of cystitis. These include a decrease in the body's resistance caused by hypothermia, fatigue, vitamin deficiencies, exhaustion, previous diseases, secondary immunodeficiency, hormonal disorders, and surgical interventions.

Disturbances in the outflow and stagnation of urine in patients with prostate adenoma, urethral stricture, bladder stones, and neurogenic bladder dysfunction are important. The predisposing factor is a circulatory disorder in the wall of the bladder or pelvis. Changes in the mucous membrane of the bladder during cystitis are recorded during cystoscopic examination, which is especially indicated for chronic cystitis. In the early stages of acute cystitis, cystoscopy should not be performed so as not to cause additional harm to the patient.

The literature describes quite fully the cystoscopic picture that develops with cystitis of various etiologies. In cystitis, where the etiological factors are coccal flora, E. coli, chlamydia, Trichomonas, changes in the mucous membrane will be quite uniform, devoid of any specificity. The situation is different with specific damage to the bladder by tuberculous mycobacteria, Treponema pallidum and actinomycetes. In these cases, cystoscopic and morphological studies will reveal typical changes.

Due to the above reasons, it is advisable to consider separately nonspecific and specific changes in the bladder wall during cystitis. Cystoscopy examination of acute cystitis of nonspecific origin usually reveals a swollen, full-blooded mucous membrane, injection of blood vessels, their dilation, various sizes and forms of hemorrhage into the mucous membrane. Damaged areas may be covered with mucus, purulent or fibrinous-purulent deposits.

A postmortem examination reveals catarrhal inflammation, i.e., mucus is mixed with the exudate that comes to the surface. Exudate drains from the inflamed surface. Under a microscope, leukocytes, fallen cells of the integumentary epithelium, and sometimes fibrin are visible in varying quantities. In the tissue of the mucous membrane of the bladder, the usual signs of exudative inflammation are noticeable: hyperemia, edema, infiltration. Depending on the nature of the exudate, catarrhal inflammation can take the forms of serous catarrh, mucous catarrh, and purulent catarrh.

Serous catarrh is characterized by the release of a clear liquid exudate with a small admixture of leukocytes and falling epithelium. This form often represents the initial stage of other forms of catarrhal inflammation. With mucous catarrh, mucus is mixed with the exudate, which is why it takes the form of a thick, viscous mass. In addition, more significant desquamation of epithelial cells is characteristic. With pronounced desquamation, inflammation is called desquamative.

Purulent catarrh is based on the release of purulent exudate mixed with mucus. This exudate looks like a viscous, cloudy mass of yellowish-gray or greenish-gray color. The mucous membrane of the bladder with purulent catarrh is often subject to superficial destruction over a limited extent, which leads to the formation of small ulcers called erosions. The course of catarrhal inflammation is often acute.

During recovery, exudation and mucus secretion gradually cease. A special form of purulent cystitis is interstitial, phlegmonous cystitis, in which there is a continuous diffuse purulent impregnation of the submucosal layer with a huge number of leukocytes. When the process spreads to the surrounding tissue, purulent pericystitis (inflammation of the serous membrane of the bladder) or purulent paracystitis (inflammation of all tissues surrounding the bladder) develops.

In essence, paracystitis can be considered a form of peritonitis. Acute purulent paracystitis can occur as a consequence of pericystitis. In this case, one or more ulcers appear in the edematous tissues around the bladder, causing acute diffuse inflammation of the entire tissue. With pericystitis and paracystitis of intestinal origin, the purulent process often takes on a putrefactive character and is complicated by the formation of vesico-intestinal fistulas.

With interstitial cystitis, a bladder ulcer occurs as a result of damage to the subepithelial tissue, and then the mucous membrane and other layers. Ulceration of the mucous membrane is usually linear in shape. As a result of interstitial cystitis, the bladder shrinks and its capacity decreases. Sometimes catarrh takes a long-term chronic course. In chronic cystitis, the entire mucous membrane of the bladder is usually involved in the pathological process. It is infiltrated, swollen, thickened, and its elasticity is reduced. The area of ​​the vesical triangle suffers to a greater extent, especially in women. The mucous membrane in the affected areas is moderately hyperemic, loosened with areas of easily bleeding granulation tissue.

In some cases, microabscesses occur in the wall of the bladder, and after their opening, ulcers appear. Ulcers of the mucous membrane in chronic cystitis have different sizes, depths and configurations, and can be single or multiple. Long-term ulcers are subject to encrustation with uric acid salts, resulting in encrusting cystitis. With the predominance of proliferative processes, the development of granulation tissue is noted with the formation of warty, polypous and granular growths, which leads to the occurrence of polypous or granular cystitis.

The pathoanatomical feature of chronic catarrh is a weakening of hyperemia, a change in the cellular composition of the exudate with an admixture of lymphocytes, and sometimes plasma cells. The tissues are infiltrated with small lymphocytes, and brown pigmentation of the tissue may be observed. It is the result of the deposition of hemosiderin in the tissue from destroyed red blood cells emerging through diapedesis from dilated congested vessels.

Along with pigmentation, atrophy of the mucous membrane is often observed, which becomes thin and smooth. Atrophic catarrh develops. In some cases, hypertrophic catarrh can also be observed, in which the mucous membrane grows, proliferation and infiltration of the submucosal membrane occurs. Usually the mucous membrane thickens unevenly. In this case, retraction alternates with bulging, i.e., a combination of atrophic and hypertrophic manifestations on the part of the mucous membrane is possible.

The influence of thermal and chemical factors is important only as a predisposing factor that weakens the resistance of the mucous membrane, but the main cause of inflammation is microorganisms.

Hemorrhagic inflammation in the mucous membrane of the bladder develops in cases where there is an abundant release of red blood cells from the blood vessels, which occurs with any exudative inflammation, but not in such a pronounced form. The released red blood cells give the exudate the color of blood, and the affected tissue itself takes on a bloody tint. Hemorrhagic character can be observed in both serous and purulent inflammation. Its basis is greater permeability of the vascular walls than in ordinary inflammation. The latter may be due either to the previous condition of the vascular walls, or to the peculiarity of the cause that caused the inflammation.

Hemorrhagic inflammation can develop with some streptococcal infections. It can also be observed in persons suffering from anemia and other blood diseases with degenerative changes in the vascular walls, with vitamin deficiency, especially with a lack of ascorbic acid and rutin, with congenital hemophilia.

In our opinion, the description of the picture of specific tuberculous lesions of the bladder deserves special attention, since tuberculosis has now become a very common disease. Moreover, the strains of microbes found are very resistant to traditional methods of therapeutic influence, and this explains the wariness of doctors towards tuberculosis, which has now emerged from the category of social diseases.

Tuberculosis of the bladder is always a secondary process that occurs as a result of tuberculosis of the kidney. Less commonly, the infection spreads from the primary foci of genital tuberculosis. With kidney tuberculosis, the process in the bladder begins with focal hyperemia in the area of ​​the mouth of the ureter, rash of tuberculous tubercles, followed by their ulceration and the formation of deep ulcers and scars. With tuberculous inflammation, tissue damage first occurs - alteration, which is expressed in the form of necrosis of tissue elements. This is followed by the development of an exudative reaction with the release of fluid, leukocytes and lymphocytes from the vessels. Soon, cells of local origin begin to multiply, resulting in focal proliferation of granulation tissue.

To the naked eye, such growth is perceived as a gray nodule the size of a barely noticeable dot to the size of a millet seed. Such nodules are called tubercles, or tubercles. During a microscopic examination of the tubercles, the presence of alteration, exudation, and proliferation is noted, depending on the reactive state of the body. Most often, the tubercle is built from granulation tissue, represented by epithelioid cells - supermature macrophages. In shape, these cells resemble the integumentary squamous epithelium - lamellar cells with a pale-colored vesicular nucleus. Among the epithelioid cells, delicate argyrophilic fibers or a granular mass of coagulated proteinaceous exudate are usually visible. In addition, lymphoid cells, macrophages and polymorphonuclear leukocytes are found in the tubercle.

A characteristic feature of the tuberculous tubercle is the presence of giant cells with numerous nuclei among the cellular elements. The nuclei are usually located in a ring along the periphery of the cell body.

At the beginning of the development of the tubercle, giant cells lie closer to the center, and with cheesy necrosis of the center they appear in the peripheral parts of the tubercle. With developed epithelioid tubercles, their constituent granulation tissue usually does not contain blood vessels. It should be noted that epithelioid tubercles correspond to the proliferative phase of development and represent a predominantly productive form of tuberculosis.

There are lymphoid tubercles that differ from those described above in that epithelioid cells are not found in them, but there are cells of the lymphoid series with an admixture of macrophages and leukocytes, which are located among the protein mass of the exudate. These tubercles belong to the exudative phase of tubercle development and are designated as the exudative form of tuberculosis.

The third type of tubercles can be represented by focal necrosis of organ tissue. These are necrotic tubercles, which are a consequence of the predominance of alterative changes. Necrotic tubercles are observed in individuals with a sharp decline in nutrition, cachexia, and in the elderly. The gray translucent appearance of epithelioid and lymphoid tubercles remains relatively short-lived. Soon the central part of the tubercle loses its translucency and becomes opaque, dry and yellowish. In appearance it resembles boiled cottage cheese. This process is called cheesy, or caseous, degeneration. The cells of such a tubercle undergo karyopyknosis, karyorrhexis, and then, in the area of ​​the disintegrated cells, fine-grained, dust-like detritus remains, containing the remains of the disintegrated nuclei. In epithelioid tubercles, cheesy degeneration occurs more slowly than in lymphoid tubercles, spreading from the center to the periphery.

The granular nature of the periphery persists for a long time in the presence of a caseous altered center. In lymphoid tubercles, necrosis develops very quickly and in a short time covers the entire tubercle.

Epithelioid tubercles can undergo not only caseous, but also fibrous transformation. In the latter case, fibroblasts accumulate in the tubercle, producing collagen fibers that gradually replace cellular elements.

Fibrous connective tissue develops at the site of the tubercle or along its periphery. If fibrous transformations take place in a tuberculous tubercle in which cheesy degeneration has already occurred, then in this case the dead cheesy mass is surrounded by a sheath of connective tissue and encapsulation occurs. Subsequently, uric acid salts may be deposited in the curdled mass.

With special staining for tuberculosis microbes, the latter are found between epithelioid cells, in their cytoplasm, and also inside giant cells. In epithelioid tubercles, tuberculous mycobacteria are found in small numbers and are sometimes difficult to detect. In lymphoid tubercles they are found in much greater quantities, especially with cheesy degeneration of the tubercles. A lot of microorganisms are present in necrotic tubercles. When the tuberculosis process spreads, often simultaneously with the formation of tubercles, there is a diffuse proliferation of granulation tissue, which, when examined with the naked eye, appears as a gray-pink translucent soft mass. Its microscopic structure may not differ in any particular way from banal granulation tissue, especially at the beginning of the process. Only by the presence of tubercle bacilli in it can one determine its nature.

A feature of tuberculous exudates is the predominance of lymphocytes over polymorphonuclear leukocytes. If the tubercle does not undergo fibrous transformation, then due to cheesy transformation and disintegration, its tuberculosis bacilli penetrate into the adjacent tissue, where new tubercles appear. Subsequently, they merge with each other, which gives the formation of larger tuberculosis foci. In this case, extensive fields of ulceration sometimes occupy the entire inner surface of the bladder. In some cases, the tuberculosis focus is steadily increasing and constantly shows a tendency to cheesy degeneration and decay. Reaching the surface, the tuberculous focus is opened, and the cheesy mass is separated, which gives the formation of a tuberculous ulcer.

In some cases, swelling of the mucous membrane, formation of papillomatous outgrowths of the epithelium and deposition of uric acid salts in ulcerated areas are noted. As a result of the disease, sclerosis of the bladder wall and peri-vesical tissue may develop. Adhesions with nearby organs form, fistulas and cold abscesses appear. The walls of the bladder thicken, are replaced by scar tissue, the bladder shrinks, and the closure mechanism of the ureteric orifice is disrupted with the occurrence of vesicoureteral reflux.

With syphilitic lesions of the bladder, which is rare, no changes in it are recorded in the primary period. In the secondary period of syphilis, damage to the bladder is characterized by a papular rash and papillomatous growths, small ulcerations of the mucous membrane. In the tertiary period, typical gummas and gummous infiltrates can be found in the bladder. Gummas can be small in size and appear to the naked eye as gray dots or nodules, similar to gray milliary tubercles.

In the case of solitary gumma, the nodes range in size from a pea to a chicken egg. In a fresh state, solitary gum is a soft gray-pink node. Gumma milliaria appears as a gray dot or is so small that it can only be detected under a microscope. Subsequently, necrobiotic changes begin in the gum, leading its tissue to necrosis. In some cases, the necrotizing tissue undergoes decomposition, turning into a gelatinous, translucent, glue-like mass. More often, necrosis of gum tissue follows the path of dry necrosis and is expressed in a picture of cheesy degeneration, similar in appearance to what occurs during the development of a tuberculous focus. Usually, simultaneously with necrosis of the gum tissue, scar-connective tissue develops along its periphery. In this period, gumma is one or several adjacent foci of a dry yellowish cheesy mass, surrounded by a thin translucent grayish layer, which passes along the periphery into a powerful development of scar connective tissue. Cheesy degeneration and necrotic liquefaction of the gum located on the surface of the mucous membrane are accompanied by the separation of dead mass and the formation of a gummous ulcer.

On microscopic examination, gummas turn out to consist of granulation tissue containing vessels and built from epithelioid, lymphoid and plasma cells. Giant cells with centrally located nuclei or nuclei located along the periphery of the cytoplasm are often found. In gummas with curdled degenerations, such granulation tissue is located on the periphery; fibrous transformation is noticeable early in it with the development of scar connective tissue surrounding the gumma and cords spreading laterally into the adjacent tissue. In the arteries and veins found in the marginal parts of the gumma, and in neighboring tissues, thickening of the walls and narrowing of the lumen are observed, sometimes until it is completely closed due to the proliferation of tissues of the inner lining of the vessel. Gumma, which has undergone cheesy degeneration, under a microscope has the appearance of an amorphous, fine-grained, dead mass, but in it, unlike the tuberculous structureless cheesy mass, it is always possible to see the outlines of the structure of the tissue that was here, especially blood vessels, and elastic fibers stand out well.

In some cases, especially when typical tubercles form along the periphery of the gumma, it is extremely difficult to distinguish it from a tuberculosis focus. In these cases, one must keep in mind the predominance of lymphoid and plasma cells characteristic of gumma, the very early appearance of fibroblasts and the development of fibrous connective tissue along the periphery, the onset of cheesy degeneration during the period of cicatricial transformation of the periphery of the gumma and the preservation of the outline of the former tissue in the curdled mass of the gumma, especially its vessels. Over time, the curdled mass gradually dissolves and is replaced by scar tissue. As a result of this outcome of the gumma, rough, dense radiant scars are formed, strongly constricting the tissue, leading to deep retractions on the surface of the organ, causing a narrowing of the lumen.

When gummous ulcers become scarred, similar scars are formed with the same consequences. In addition to limited gummous nodes in the tertiary period of syphilis, nested or more diffuse gummous infiltration of round or plasma cells, sometimes with giant cells, can be observed. Subsequently, the cells of the infiltrates undergo necrobiotic changes and gradual resorption. In their place, scar tissue develops.

With syphilitic damage to blood vessels, especially arteries, limited or diffuse growths of granulation tissue or gummous infiltrates develop, involving the middle and outer membranes of the vessel and accompanied by necrosis of the wall. Such a lesion is often accompanied by thrombosis of the lumen of the vessel. In other cases, a picture of obliterating endarteritis is observed, expressed in the growth of the tissue of the inner membrane with a narrowing of the lumen, sometimes to its complete closure. With all changes in the vessel, there is a disruption in the blood supply to the tissues to which the affected artery brings blood. At the same time, its atrophic changes occur, up to necrosis.

Actinomycosis of the bladder is most often secondary and develops as a result of the transition of the process from the affected peri-vesical tissue. In these cases, in histological preparations, among the accumulation of purulent exudate and the proliferation of specific granulation and fibrous tissue, actinomycete drusen are visible. Microbes form branching threads in tissues in the form of a ball.

Along the periphery of the ball, the threads have flask-shaped thickenings at the ends, similar to the rays of a star. To the naked eye, these colonies, or drusen, appear as small whitish or yellowish translucent grains or grains of sand.

The disease is expressed in the development of dense nodes, sometimes resembling a tumor. The nodes consist of granulation tissue, built from epithelioid and round cells, among which there are often groups of xanthoma cells containing many small lipid droplets. Multinucleated giant xanthoma cells are also found. You can often find numerous fuchsinophilic Roussel's bodies. Among such granulation tissue there are small pustules. In each pustule, among the pus, you can see a druse of radiant fungus.

In the spaces between the pustules and along the periphery of the entire node, granulation tissue undergoes gradual fibrous transformation and scarring. In this regard, with actinomycosis, which has been around for some time, strong compaction occurs in the affected area due to the powerful proliferation of connective tissue. On a section of this tissue, pustules with drusen grains among the pus are visible to the naked eye. Due to the large number of pustules, which are more or less the same size, the cut surface through the actinomycotic node may resemble a honeycomb. Sometimes spontaneous death of the radiant fungus is observed. In this case, the drusen is completely surrounded by granulation tissue and giant cells appear directly near the drusen, which resolve it like a foreign body.

Trichomoniasis of the bladder is a complication of Trichomonas urethritis. It develops in an ascending urogenic way. More common in women. The resulting cystitis in most cases is caused not only by trichomoniasis, but also by the accompanying bacterial flora.

Gangrene of the bladder, or gangrenous cystitis, has a severe course and is accompanied by high mortality. This type of pathology is relatively rare and is the result of impaired blood circulation in the bladder, damage to the central nervous system due to diabetes mellitus, or the unintentional introduction of substances damaging the mucous membrane into the bladder cavity. This pathology is most fully described in the monograph by A.V. Ayvazyan and A.M. Voino-Yasenetsky (1985). The authors found that the mortality rate for gangrenous cystitis was twice as high among men as among women. Apparently, this ratio can be explained by the following anatomical features of the body: in women, in the area of ​​the bottom of the bladder, there is a weak connection between the mucous membrane and the muscle layer, while in men, the mucous membrane of the bladder is more tightly connected to the muscle layer, especially in the area of ​​the triangle Lieto. This affects the rejection of necrotic tissue. In men, small areas of dead tissue may pass through the urethra. In women, almost all of the dead mucous membrane with the submucosal layer of the bladder leaves through the short and wide urethra.

If a patient with gangrenous cystitis survives, then after the dead layers are rejected, a hypervascularized red bladder mucosa appears. The muscle membrane does not restore its elasticity. It is atrophic and sclerotic. As a result, the bladder is wrinkled and its capacity is greatly reduced. All this results in changes in the upper urinary tract.

Trigonitis is an isolated inflammation of the mucous membrane of the bladder triangle. Acute trigonitis, as a rule, is a consequence of the spread of infection during inflammation of the posterior urethra, as well as prostatitis. Chronic trigonitis is observed mainly in women and has the character of a stagnant process. It is based on a circulatory disorder in the area of ​​the bladder triangle and the neck of the bladder due to incorrect position of the uterus or prolapse of the anterior vaginal wall. In some cases, a chronic inflammatory process in the parametrium is important.

Radiation cystitis occurs as a complication of radiation therapy for diseases of the female genital organs and rectum, developing depending on the dose of radiation and the sensitivity of the irradiated tissues at different times during the course of radiation therapy: during the course, immediately after it, several weeks, months, years. In the acute period, a trophic ulcer of the bladder develops. Such an ulcer has flat or undermined edges; over time they become dense and sclerotic. The bottom of the ulcer is covered with necrotic plaque. The ulcer does not heal well and can lead to the formation of a fistula. In the later stages of radiation cystitis, cicatricial and ulcerative changes in the bladder wall are characteristic.

COURSE AND CLINICAL PICTURE OF CYSTITIS

According to the course, acute and chronic cystitis are distinguished.

Acute cystitis usually occurs suddenly, some time after hypothermia or exposure to another provoking factor. Its main symptoms are frequent painful urination, pain in the lower abdomen, and pyuria. The intensity of pain when urinating increases. The pain can be almost constant, but is more often associated with the act of urination and occurs at the beginning, at the end or throughout the entire act of urination. Due to the frequent imperative urge to urinate, patients are unable to hold urine.

The severity of clinical signs in acute cystitis varies. In some milder cases, patients feel only heaviness in the lower abdomen. Moderate pollakiuria is accompanied by slight pain at the end of urination. Sometimes these phenomena are observed within 2-3 days and disappear without special treatment. However, more often acute cystitis, even with timely treatment, lasts 6-8 days, sometimes 10-15 days. A longer course indicates the presence of a concomitant disease that supports the inflammatory process and requires additional examination.

Severe forms of acute cystitis (phlegmonous, gangrenous, hemorrhagic) are characterized by severe intoxication, high body temperature, and oliguria. The urine is cloudy with a putrid odor, contains fibrin flakes, sometimes layers of necrotic mucous membrane, and an admixture of blood. The duration of the disease in these cases increases significantly, and severe complications may develop. With total, diffuse inflammation of the mucous membrane of the bladder, the pain intensifies as urine accumulates and the inflamed mucous membrane stretches. Increased pain at the end of urination is associated with contraction of the inflamed mucous membrane of the bladder and contact of inflamed surfaces.

When inflammatory processes are localized in the area of ​​the bladder neck, pain of the most intense nature occurs at the end of the act of urination, which is associated with tenesmus and convulsive contraction of the bladder sphincter. Patients are forced to empty their bladder frequently, and then the pain is constant. In addition to pyuria (leukocyturia), macroscopic and microscopic hematuria is possible in acute cystitis. Hematuria, as a rule, is terminal, which is associated with trauma to the inflamed mucous membrane of the bladder neck and Lieto's triangle at the end of urination. Erythrocyturia is observed as often as leukocyturia.

The main symptom of acute trigonitis is pronounced dysuria, sometimes terminal hematuria. A significant number of leukocytes are detected in the urine.

The main clinical symptoms of trichomoniasis of the bladder consist of frequent and painful urination, pyuria, and hematuria. The cystoscopic picture of Trichomonas lesions of the bladder is not typical.

The clinical picture of bladder gangrene consists of patient complaints of difficult painful urination, pain in the sacrum, weakness, and high temperature. When examining patients, their extremely serious condition, pallor of the skin, and subicteric sclera of the eyes are noted. In some cases, acute gangrenous cystitis can develop suddenly and simulate an acute abdomen, especially since when the wall of the bladder is perforated, its contents can enter the abdominal cavity, causing peritonitis.

With gangrenous cystitis, the most characteristic symptom is hematuria. The passage of dead tissue is accompanied by severe pain and difficulty urinating, up to complete urinary retention, more often in men. Nitrogen is detected in the blood, and urea levels reach high levels. Due to the melting of the mucous and submucosal membranes, the urine becomes fetid with an alkaline reaction.

The process is characterized by persistent progression of purulent necrotic lesions of the bladder. It is rare to achieve a successful outcome. In some cases, gangrenous cystitis can occur without urination disorders. In this case, the main manifestations of the disease may be high body temperature, pain in the pubic and perineal area, urine has the smell of sulfur, contains an admixture of blood and small areas of mucous membrane. If the internal opening of the urethra is blocked by exfoliated necrotic tissue, then urination is difficult or completely impossible. If the etiological factor of gangrenous cystitis is gram-negative microflora, then bacterial shock may occur.

Postpartum cystitis occurs due to the peculiarities of the course of labor or the transfer of infection from the genitals to the bladder. Occurs when E. coli enters the bladder, less commonly staphylococcus and streptococcus. For the development of the disease, the presence of predisposing factors is necessary, of which the main ones are urinary retention in the bladder and changes in the mucous membrane of the bladder wall during prolonged labor and trauma. Symptoms of postpartum cystitis are urinary retention, pain at the end of urination, and cloudiness of the last portion of urine. There is a moderate number of leukocytes in the urine. Cystoscopy reveals hyperemia of the mucous membrane, extravasation, ecchymoses, edema, and vascular injections. The temperature is usually normal. The general condition of the patients changes little. Cystitis is often observed as a concomitant disease with postpartum lesions of the pelvic organs, often occurring as cystopyelitis.

The clinical picture of chronic cystitis is varied and depends on the etiological factor, the general condition of the patient and the effectiveness of the treatment. The main clinical symptoms are the same as for acute cystitis, but less pronounced. Chronic cystitis occurs either as a continuous process with constant, more or less pronounced complaints and changes in the urine (leukocyturia, bacteriuria), or there is a recurrent course with exacerbations that occur similarly to acute cystitis, and remissions, during which all signs of cystitis are absent.

Chronic cystitis is accompanied by an alkaline reaction of urine with varying mucus content. An acidic urine reaction is observed in cystitis caused by Escherichia coli and tuberculosis. Proteinuria in patients with cystitis is associated with the content of formed elements (leukocytes and erythrocytes) in the urine. The more pronounced leukocyturia and erythrocyturia, the more pronounced proteinuria.

In chronic trigonitis, clinical signs are mild. Usually, urination is somewhat frequent, and discomfort is noted during the act of urination. There are no changes in urine. During cystoscopy, the mucous membrane of the bladder triangle is loosened, swollen, and slightly hyperemic.

Clinical manifestations and changes in urine with radiation cystitis are the same as with banal chronic cystitis.

With tuberculosis and Proteus infections, the course of cystitis is always chronic. With tuberculous cystitis, dysuria usually increases gradually. Initially, there is moderately frequent urination (pollakiuria) without pain, and sometimes there is an urge to urinate at night. As the disease progresses, urination becomes significantly more frequent, becomes sharply painful, urine is released in small portions, and blood is often visible in the last drops.

Bladder syphilis is rare. The clinical picture does not have any clearly defined specific features. The disease occurs as a banal chronic cystitis, with frequent and painful urge to urinate with varying degrees of pyuria. More often than with other forms of cystitis, hematuria appears.

Complications of cystitis include the transition of the inflammatory process from the wall of the bladder to the tissue surrounding the bladder, with the occurrence of paracystitis. In chronic cystitis, microorganisms can penetrate upward through the lymphatic vessels of the ureter into the pelvis and kidney tissue, causing an inflammatory process in them. Chronic cystitis, most often of tuberculous origin, leads to sclerosis of the bladder wall, as a result of which its capacity sharply decreases, and dysuric disorders become extremely severe.

DIAGNOSIS

In most cases, making a diagnosis of cystitis is not difficult. Since acute cystitis and chronic cystitis in the acute stage are accompanied by characteristic complaints of frequent painful urination with pain, anamnestic data on a sudden acute onset and a rapid increase in symptoms with their maximum severity in the first days (with acute cystitis) or on pre-existing cystitis are important ( with chronic cystitis). When examining urine, objective signs of cystitis are revealed in the form of leukocyturia and hematuria. Deep palpation of the suprapubic region is painful. With inflammation of the lower wall of the bladder and with severe local inflammation of its neck, palpation from the rectum and from the vagina is also sharply painful.

Gangrenous cystitis is sometimes difficult to diagnose early. This is sometimes associated with an atypical manifestation of the disease. If early diagnosis of gangrenous cystitis was not carried out and, accordingly, treatment was started late, then irreversible morphological changes occur in the mucous membrane and muscle layers of the bladder and paravesical tissue. Severe damage to the bladder wall with gangrenous cystitis occurs with symptoms of shock. Operations to divert urine and remove necrotic tissue, early detection of microbial flora, determination of sensitivity to antibiotics and, accordingly, antibacterial treatment can lead to a reduction in mortality in gangrenous cystitis.

The main symptoms of bladder tuberculosis are dysuria. Anamnestic data with complaints of a gradual increase in the frequency of urination, which becomes painful over time, help in making a diagnosis. It is accompanied by pyuria and terminal hematuria. The detection of tuberculous mycobacteria in the urine, specific changes during cystoscopy and radiography of the urinary tract and kidneys are of decisive importance for the diagnosis of bladder tuberculosis.

With urinogenic descending spread of the process, cystoscopy reveals hyperemia and swelling of the mucous membrane in the area of ​​the ureteral orifices of the affected kidney, typical small tuberculous tubercles of a yellowish color with a rim of hyperemia, ulcers with uneven, undermined edges, the bottom of which is covered with a grayish-yellow purulent-fibrinous coating. Sometimes tuberculous granulomas are found that simulate a bladder tumor. On cystograms for tuberculosis, deformation of the contours of the bladder, bevel of one of its walls, a decrease in the volume of the organ, and vesicoureteral reflux are observed.

The diagnosis of Trichomonas cystitis is established based on the detection of Trichomonas in the second portion of urine. In their absence, discharge from the urethra and vagina is examined.

The diagnosis of syphilitic lesions of the bladder is quite complicated. It is not always possible to detect the pale spirochete in urine. With cystoscopy in the primary period, there are practically no changes in the bladder. During the secondary period of syphilis, there is a picture of ulcerative cystitis, almost no different from other forms of similar lesions, in particular tuberculous ulcers, but in the absence of tubercles characteristic of tuberculosis. During the gummous period, cystoscopy of the bladder resembles a tumor. The diagnosis of syphilis of the bladder is supported by the long and persistent course of the disease, which is not amenable to conventional methods of treatment, anamnestic data, or the presence of syphilitic lesions of other organs and systems. The positive Wasserman reaction is of decisive importance, as is the rapid and almost always positive effect of specific treatment.

In the diagnosis of chronic cystitis and identifying the causes that support inflammation, cystoscopy and cystography are of utmost importance. At the same time, the degree of damage to the bladder, the form of cystitis, the presence of a tumor, urinary stone, foreign body, diverticulum, fistula, and ulcers are determined. In some cases, during cystoscopy, signs of kidney and ureter disease accompanying cystitis are detected, for example, discharge of blood or pus from the mouth of the ureters. If necessary, other methods of general or urological examination are also used.

Cystoscopy can be performed provided there is satisfactory patency of the urethra, sufficient capacity of the bladder - at least 50 ml and transparency of the medium in it. To study the configuration of the bladder and identify pathological processes in it, contrast cystography is used by introducing iodine-containing drugs, a suspension of barium sulfate, oxygen or carbon dioxide into it. The most physiological is descending cystography, which is obtained 20-30 minutes after intravenous administration of a radiocontrast agent. Ascending (retrograde) cystography is carried out by injecting a radiopaque liquid into the bladder through the urethra or urethral catheter, or suprapubic drainage.

A biopsy of the bladder mucosa is usually performed in patients with chronic cystitis, as well as for the purpose of differential diagnosis. At the same time, the results of a biopsy cannot reflect the condition of the entire wall of the bladder, since in this case we have only mucosal tissue, without deep-lying submucosal and muscle layers.

Laboratory testing of urine continues to occupy an important place in modern clinical practice. To determine the daily amount of urine, graduated glass cylinders are used. To correctly record the amount of urine per day, you need to collect it from a certain hour of one day to a certain hour of another. It is better to collect urine separately during the day and at night. In addition, it is necessary to urinate before each bowel movement. It is important, simultaneously with changes in the daily amount of urine, to also note the amount of fluid you drink per day.

A detailed description of the properties of urine is obtained from the laboratory, where 100 to 400 ml of urine taken from the total amount collected per day is usually sent. Daily urine must first be shaken so that sediment gets into it. If the urine collected during the day quickly decomposes, it is recommended to send a portion of fresh urine at the same time. In some cases, two portions of urine are sent for analysis - morning and evening, since the quality of urine changes at night. Urine for analysis is collected in a spotlessly clean glass vessel, if possible, with a ground-in stopper. The transparency of urine disappears after standing for a long time due to the loss of uric salts from its solution. Urates are brick-red in color, phosphates are white. As a result, transparency can be judged by fresh urine. If it is cloudy, then perhaps it contains pathological impurities that are unusual for it. Turbidity is caused by protein, pus, blood, and uric acid salts.

The smell of urine should also not escape the attention of medical personnel. The fetid smell of freshly released urine indicates advanced decomposition caused by bladder disease. The reaction of normal urine is acidic. If left in a warm place for a long time, the reaction may become alkaline due to the fermentation process that occurs. The alkaline reaction of freshly released urine indicates a fermentation process in the bladder itself. In the absence of a specialized laboratory, the urine reaction and its pH can be easily determined using red and blue litmus paper used simultaneously. If urine is acidic, blue litmus paper turns red, but red litmus paper does not change color. With an alkaline reaction of urine, red litmus paper turns blue, but blue litmus paper does not change its color. If both blue and red litmus papers do not change their color, then the urine reaction is neutral. In clinical laboratory conditions, urine pH is determined using the bromothymol blue indicator; the presence of protein is determined by a standardized test with sulfosalicylic acid, using the Brandberg-Roberts-Stolnikov method.

Quantitative methods for determining protein in urine include a test with sulfosalicylic acid and the biuret method. The appearance of blood in the urine, visible to the naked eye, always indicates severe damage to the urinary tract: hemorrhagic inflammation of the kidneys, stones, tuberculosis, cancer. In this case, the urine may look like real blood. Formed elements are determined by microscopy of urinary sediment, which will be discussed a little later. Now we should dwell on the causes of hematuria and pyuria in cystitis and on ways to correctly interpret macroscopic data. When examining urine obtained from a patient with cystitis, hematuria and pyuria are found, as mentioned earlier. Hematuria - excretion of blood and red blood cells in the urine. Hematuria should not be called the release of hemoglobin in the absence of blood cells during intravascular hemolysis. False hematuria occurs when urine is contaminated with menstrual blood, with metrorrhagia.

Based on the patient's story about the portion of urine that produces blood, one can already get an idea of ​​the location of its source. If drops of bloody exudate are released from the urethra in addition to urination or are washed away with the first portions of urine, this indicates the appearance of blood in the urethra. Blood from the bladder usually settles to the bottom and is released with the last portion of urine. Blood from the kidneys colors all portions of urine evenly. This can be seen especially clearly when conducting a test with three glasses. The patient is asked to collect the first, middle and last portions of urine separately into three separate vessels during one urination and compare their color. Hematuria of renal origin is likely when, in the absence of symptoms of damage to the bladder, prostate or urethra, the blood is thoroughly mixed with urine and the contents of all three glasses are evenly colored. The presence in the urine of thin and long worm-like clots, erythrocyte casts, albuminuria, and sand confirm the renal origin of hematuria. Urine with renal nephritic hematuria has the color of meat slop. It is more brown than bright red. Already the admixture of one cubic centimeter of blood per 1 liter gives the urine an appearance suspicious for hematuria.

Pyuria, or the discharge of purulent, cloudy urine, can be a symptom of many diseases, since leukocytes, pus, like blood, can be mixed with urine in various parts of the urinary tract. The presence of slight leukocytosis in female urine is rather the rule and depends on contamination from the genital organs. Therefore, to avoid misdiagnosis, it is recommended to test only urine obtained by catheter for leukocytes in women. The cystic or renal origin of pyuria can be easily resolved with the help of a cystoscope and catheterization of the ureters. In order to correctly prescribe treatment for a patient with cystitis, the clinic must conduct microscopy of urine sediment and its microbiological examination. Microscopic examination of native preparations of urinary sediment is carried out after centrifugation of 10 ml from the morning portion of urine, having first mixed it thoroughly. The sediment is divided into organized and unorganized parts. Formed elements and epithelium of the bladder can be found in the organized sediment. Red blood cells are disc-shaped and yellow-green in color. In the acidic reaction of urine, red blood cells shrink and take on a star-shaped shape. Yeast fungi are very similar to erythrocytes, but unlike the former, fungi are more often oval in shape, bluish in color, and bud. Diagnosis is aided by adding a 5% solution of acetic acid to the sediment, under the influence of which the red blood cells are hemolyzed, but the yeast remains. Leukocytes in urine sediment have a round shape and granular cytoplasm. With bacteriuria in alkaline urine, leukocytes are quickly destroyed. Normally, in urinary sediment obtained from a man, there are up to 3 leukocytes, from a woman - up to 5 in the field of view. With cystitis, leukocyturia can reach 45% or more.

The cells of the transitional epithelium of the bladder have different shapes and sizes, they are usually yellowish in color and contain a fairly large nucleus. There may be cells with two nuclei. With inflammation of the mucous membrane of the bladder, degenerative changes are observed in the cytoplasm of transitional epithelial cells, which look like coarse granularity and vacuolization of the cytoplasm. In cystitis there are many of these cells. The nature of the unorganized sediment in the urine during cystitis is not decisive. To study the protein composition of urine in more equipped laboratory conditions, informative methods are used: analytical ultracentrifugation, laser nephelometry, gel chromatography, as well as numerous electrophoretic, immunochemical and radioimmune methods.

Urine collection for microbiological examination is carried out before the start of antibacterial therapy. First, a thorough toilet of the external genitalia is performed. Then 3-5 ml of an average portion of freely released urine is collected in a sterile container. Bladder catheterization should be avoided whenever possible. It is carried out only if the patient is unable to urinate independently or to determine the localization of the inflammatory process. In the case of catheterization, the bladder is first emptied, then 50 ml of a solution of neomycin mixed with polymyxin is injected through the catheter. If cystitis occurs, then the urine when cultured will be sterile (if the microflora is sensitive to these antibiotics). If there is an increase in microflora, then one should think about the presence of microbial damage to the kidneys. In the case of acute cystitis, a monoculture of Escherichia coli, Proteus, staphylococci and streptococci is more often isolated in an amount of 105 CFU/ml of urine. Association of microorganisms is more common in chronic processes.

Streptococci isolated from urine have a spherical or oval shape and are located in smears in the form of chains of different lengths or in groups, possibly in pairs. Streptococci are cultivated on nutrient media with the addition of glucose, serum or blood at 37°C and a slightly alkaline pH of 7.6 - 7.8. When microbes grow on blood agar, they form small, grayish or colorless colonies. Hemolytic streptococci on blood agar form a transparent zone of hemolysis (b-hemolytic streptococcus) or a greenish zone (a-hemolytic streptococcus) around the colonies. The environment around non-hemolytic streptococci does not change. On liquid nutrient media, hemolytic streptococci form a sediment that can rise to the top, while the medium remains colorless. Streptococcus is a facultative anaerobe, nonmotile. The reaction to enzymes: catalase and oxidase is negative. When stained with Gram, they stain Gram-positive. Strep. agalakticae (group B) usually lives on the vaginal mucosa. On blood agar it forms a narrow zone of b-hemolysis. Strep. faecalis (group D), being a normal inhabitant of the intestinal tract, can cause the development of colpitis. Hemolytic streptococci are killed when heated to 56°C after 30 minutes. Group B streptococci are more resistant: they can withstand heating up to 60°C for 30 minutes.

Staphylococci found in cystitis are gram-positive cocci that have the shape of regular balls. In the preparation, microbial cells are located singly, in pairs, or, more often, in the form of bunches of grapes. Staphylococci are nonmotile, do not form spores or capsules, and are aerobes or facultative anaerobes. They grow well on simple nutrient media at large temperature ranges - from 6.5 to 46°C, preferably at 37°C. The election medium is a medium with the addition of bile acids with a high content of sodium chloride. The ability to ferment glucose and mannitol under anaerobic conditions is of diagnostic importance. Colonies of staphylococci on a dense nutrient medium are round, smooth, shiny or matte, pigmented. The pigment is white or golden, clearly visible after 24-36 hours of growth. Staphylococci produce a variety of extracellular enzymes: plasmacoagulase, hyaluronidase, protease, esterase, lysozyme, phosphatase and others. They liquefy gelatin, hydrolyze proteins and fats, and restore nitrates. When growing on liquid nutrient media, staphylococci form diffuse turbidity followed by precipitation. Staphylococci are quite resistant to environmental factors, tolerate drying well, and remain viable in dust for a long time. Direct sunlight kills them within a few hours. When heated to 70-80°C, they die after 20-30 minutes, in a 1% solution of chloramine - after 2-5 minutes.

Gonococci, which are quite rare in cystitis, have an irregular spherical or bean-shaped shape. They are located in pairs in smears, stain negatively for Gram, are immobile, do not form spores, and are demanding regarding cultivation conditions. To isolate them, use nutrient agar (pH - 7.2-7.4) containing amine nitrogen, blood or inactivated horse serum. They grow in an atmosphere with a high carbon dioxide content. On nutrient agar with the addition of ascitic fluid, gonococci grow within 24-48 hours in the form of transparent colonies with smooth edges and a smooth shiny surface. Gonococci are not very stable outside the human body and die quickly when they dry out. At temperatures above 56°C they die within 5 minutes. Solutions of silver nitrate and potassium permanganate have a detrimental effect on gonococci. One of the pathogenicity factors of gonococci is the presence of fimbriae, with which they attach to the epithelial cells of the genitourinary tract. The rarity of their detection in cystitis is explained by the fact that they penetrate only the columnar epithelium and do not penetrate the flat epithelium covering the bladder.

Escherichia coli is a common etiological factor of banal cystitis. It is a rod-shaped microbe, gram-negative. On nutrient agar, the S-form forms cloudy, slightly convex, moist colonies with a smooth edge and a shiny surface. The R-form and transitional forms form flat colonies with a rough surface and uneven edges. E. coli causes uniform turbidity of the liquid nutrient medium with the formation of a small sediment. This microbe is a facultative anaerobe and grows well on ordinary nutrient media with a slightly alkaline reaction and an optimal temperature of 37°C. The growth and reproduction of bacteria is possible with significant fluctuations in pH and temperature. Escherichia coli has high enzymatic activity. Ferments glucose, often lactose. Quite stable in the external environment: it can persist in water and soil for several months. Heating to 55°C for an hour kills E. coli.

Proteus is a gram-negative straight rod, although coccoid and filamentous forms can occur; it does not form spores or capsules. It has peritrichially located flagella and is not picky about the nutrient medium. On a dense nutrient medium it forms a creeping growth or can form large colonies with a smooth edge. Proteus is a facultative anaerobe. It has a fairly wide growth range - from 20 to 37°C. Ferments many carbohydrates to form acidic products. Glucose breaks down to form acids and a small amount of gas. Proteus vulgaris is an inhabitant of the intestines of many animals and is found in wastewater and soil. Proteus is quite resistant to environmental factors and can withstand heating up to 76°C for an hour.

Bladder candidiasis is most often caused by C. albicans. In pathological material and cultures it forms oval, budding yeast cells and pseudomycelium. C. albicans grows well on ordinary nutrient media at 20-37°C with the formation of smooth, creamy colonies resembling bacterial colonies. With age they become wrinkled and rough. Mushrooms are quite resistant to environmental factors. Yeast-like fungi are common representatives of the normal human microflora, but become pathogenic when the body's resistance decreases.

Trichomonas are pathogenic protozoa. These are single-celled microscopic animals. They, unlike bacteria, have nuclei and organelles inherent in eukaryotes. The body of Trichomonas is pear-shaped. At the anterior end there are four flagella extending from the basal granules. One of the flagella runs along the edge of the body towards its posterior end. The remaining flagella are directed forward. The round nucleus is located at the front of the cell. Trichomonas are mobile, moving quickly with the help of flagella and an undulating membrane. Trichomonas quickly die in the external environment, are not resistant to heat, and are easily killed by disinfectants. They remain in the patient’s urine for up to 24 hours. Trichomonas grow well on nutrient media in the presence of bacteria on which they feed.

Mycoplasmas, unlike other prokaryotes, do not contain a cell wall. Morphologically, they are pleomorphic, consisting of spherical and filamentous cells of varying sizes. Most mycoplasmas are facultative anaerobes. They grow on artificial nutrient media, but need the addition of cholesterol and fatty acids, which they receive by adding mammalian serum to the nutrient medium. Mycoplasmas form colonies on agar media, the center of which grows into the nutrient medium. For uroplasmas, the pH of the nutrient medium is 6.5. Mycoplasmas are not resistant to high temperatures. Due to the absence of a cell wall, penicillin and other antibiotics with a similar mechanism of action do not act on mycoplasmas.

Features of laboratory diagnosis of chlamydia and mycoplasma infections of the urogenital tract will be described in the diagnosis of colpitis, since the nature of laboratory research does not differ in cystitis and colpitis, and the presentation of these methods is more appropriate when covering issues of sexually transmitted diseases.

The causative agent of tuberculosis is mycobacteria. The shape is straight or slightly curved sticks. In crops, they are found to be granular or branching, resembling the letter V. Gram staining is positive. Acid and alkali resistant. Selective Ziehl-Neelsen staining of mycobacteria in red. They do not form spores, they are immobile. The acid resistance of Mycobacterium tuberculosis is due to the content of a large amount of lipids. Special media are used for cultivating mycobacteria. They grow especially well on media containing glycerol. On solid nutrient media, Mycobacterium tuberculosis forms wrinkled, dryish colonies with an uneven edge. On liquid nutrient media, the tuberculosis pathogen grows with the formation of a film. On nutrient media, mycobacteria grow slowly (within 12-25 days). These microorganisms are characterized by significant resistance to various factors, including drying and the action of disinfectants. The luminescent method is also used to detect mycobacteria. Bacteria may not be detected by microscopy. The main method for determining mycobacteria is bacteriological, since it allows one to obtain a pure culture with its subsequent identification. The material is pre-treated with acid or alkali, then the mycobacteria are removed by centrifugation and the sediment is inoculated onto a nutrient medium. Due to the slow growth of Mycobacterium tuberculosis on a nutrient medium, it is advisable to grow it in microcultures on glass. Slides with the test material are placed in a liquid nutrient medium. After a few days, microcolonies grow, which can be seen under a microscope in the form of strands. The sensitivity to antibiotics is determined in grown cultures. For laboratory diagnosis of tuberculosis of the genitourinary system, bioassay animals can be used.

DIFFERENTIAL DIAGNOSIS OF CYSTITIS

Acute cystitis should be differentiated from a number of diseases of other organs: kidneys, prostate gland (adenoma), urethra (stricture), bladder stones, cystalgia, diseases of the female genital area, since dysuric disorders, expressed by increased frequency of urination, its pain, difficulty, also occur in the diseases listed above. The pathogenetic mechanisms of dysuria are based on general and local factors. Common factors include various negative emotions and psychogenic reactions. Such dysuria is usually reversible after eliminating the causes that caused it. Local factors include a tumor, the presence of urethral stricture, urinary stones that impede the passage of urine, as well as dynamic disorders of the neuromuscular apparatus of the bladder. One can think of acute cystitis when there is acute painful urination, equally frequent at different times of the day. The patient experiences an imperative urge to urinate, during which he is unable to hold urine in the inflamed bladder.

With cystitis, there is usually no increase in temperature, since the bladder is often emptied and absorption from it is negligible. The exception is necrotic-gangrenous forms of the disease. Suspicion of a bladder tumor may arise when persistent dysuria is combined with hematuria. For acute prostatitis, severe dysuria with an imperative urge to urinate is typical. It is usually accompanied by general symptoms in the form of fever, chills, sweating, tachycardia, which increase with the development of the inflammatory process.

Dysuria in an elderly man makes one suspect most likely a prostate adenoma or a bladder stone. Dysuria caused by adenoma is most pronounced at night and at rest. During the day, with an active lifestyle, it decreases. In the presence of stones in the bladder, the symptoms are very similar to the complaints of patients with cystitis. However, with bladder stones, pain often appears when walking or shaking. It has a characteristic irradiation - to the perineum, testicle or glans penis. The pain intensifies in the presence of thorn-shaped stones - oxalates or in the frequently occurring concomitant cystitis. The pain is caused by the movement of the stone and irritation of the mucous membrane, especially the bladder neck as the richest receptor zone. Urination disorder is manifested by an increased frequency of urges, which intensify when the body moves. During sleep, the pain stops.

Typical for bladder stones is the sudden cessation of the urine stream during urination - a symptom and the resumption of urination when the patient's body position changes. Small stones can become trapped in the posterior urethra and cause acute urinary retention. Often, patients experience urinary incontinence when one part of the stone is placed in the bladder, and the other is in the posterior urethra. In these cases, complete closure of the bladder sphincter is impossible. Prolonged presence of a stone in the neck of the bladder and posterior urethra leads to sclerosis. As a result, urinary incontinence may persist after the stone is removed. Changes in the nature of urine due to bladder stones are characterized by macro- and microhematuria, which is explained by injury to the mucous membrane of the bladder. The appearance of leukocytes and microflora in the urine indicates inflammation of the bladder. Depending on the composition of the stone, the corresponding salts are found in the urine.

Bladder stones can be detected by inserting a metal catheter into the bladder. A more accurate diagnostic method is plain radiography, on the basis of which one can judge the number and size of stones. In the case of X-ray negative stones (cystine, protein, urate), they can be detected by pneumocystography, or cystrography with a contrast agent solution. In these cases, filling defects indicate the presence of stone. The final diagnosis is made based on cystoscopy. However, a stone located in a bladder diverticulum cannot always be detected.

Often, pain in the bladder area can be referred and be associated with diseases of the kidneys, prostate gland and urethra. Therefore, if the cause of pain cannot be explained by direct damage to the bladder, it should be sought in a possible disease of the listed organs. In acute urinary retention, which occurs with prostate adenoma, urethral stricture, due to a stone getting stuck in the lumen of the urethra, pain in the bladder area is unbearable and causes the patient to rush about in bed. A distended bladder is detected above the pubis.

Constant pain in the bladder area can be caused by the infiltrating growth of a malignant tumor. These pains can intensify when the tumor disintegrates with the occurrence of secondary cystitis. The first manifestation of prostate cancer is also characterized by an increased urge to urinate, especially at night. Many patients experience difficulty urinating with straining or a sluggish thin stream of urine intermittently, sometimes urine is released in drops, and this is accompanied by a feeling of incomplete emptying of the bladder. Often the patient complains of pain when urinating at the beginning or throughout the act of urination.

Quite often, a symptom of prostate cancer is dissatisfaction with the act of urination. Pain associated with the act of urination also occurs with cystalgia. Cystalgia can develop in women during puberty and menopause. In this case, the patient complains of frequent urination, pain during urination, as well as pain in the perineum, sacrum, and lower abdomen. Sometimes the pain is insignificant. The severity of painful symptoms may vary. With long-term processes, neuroticization of the personality develops.

Along with complaints, a clinical examination of a patient with cystalgia does not reveal organic changes in the bladder. Pyuria is also absent. However, pain with cystalgia can be very pronounced. The diagnosis is made on the basis of complaints typical of cystitis, in the absence of pyuria and microflora in the urine, as well as changes in the mucous membrane of the bladder characteristic of cystitis, detected by cystoscopy. With cystalgia, morphological signs of chronic urethritis are often found.

Pain from cervical cancer may be misinterpreted as tumor growth into the bladder. The correct diagnosis can only be made by cystoscopic examination.

Often acute pain in the bladder area, accompanied by impaired urination, occurs as a result of pathological processes in the female genital organs. This occurs with adnexitis, para- and perimetritis. Moreover, inflammatory changes in the mucous membrane of the bladder are often detected, caused by the spread of infection from the female genital area.

In case of gangrenous cystitis, before carrying out instrumental research methods, there may be suspicions of the presence of a stone in the bladder or a tumor of the bladder. Urosepsis and chronic cystitis should be excluded.

Externally, cystitis, depending on the pathogen, its virulence, and complications, may manifest itself atypically. To identify the source of leukocyturia, it is necessary to conduct a two- or three-glass test. It is typical for cystitis if the urine contains leukocytes in both or all three glasses, especially if the sediment in the second portion contains more leukocytes than in the first.

With cystitis, pus usually quickly settles to the bottom, and the layer of urine above the sediment becomes significantly clearer and sometimes becomes transparent. With pyelonephritis, the urine is diffusely cloudy, grayish; when standing in the vessel at the bottom, a sediment of varying thickness is formed, consisting of pus and mucus. The layer of urine above the sediment does not clear at all and remains cloudy. With cystitis, the amount of protein corresponds to the pus in the urine. With pyelonephritis, proteinuria is more pronounced. If the amount of protein in purulent urine exceeds 1% or the number of leukocytes, while the protein content is less than 50,000, then kidney damage can be assumed.

A.V. Ayvazyan proposed a method for studying daily diuresis, in which the absolute number of leukocytes, protein, relative density of urine and transparency are examined in four portions of urine. This allows for a more reliable differential diagnosis of cystitis and pyelonephritis.

In acute cystitis, cystoscopy, as a rule, cannot be performed due to the small capacity of the bladder and severe pain when it is filled. In addition, during this period of illness, cystoscopy can cause complications. If there is a need for cystoscopy, it is performed under anesthesia. At the same time, cystoscopy for chronic cystitis is absolutely indicated; it is given great, decisive importance, since it allows not only to identify the form of cystitis, but also to carry out differential diagnosis. The differential diagnosis of chronic cystitis is carried out mainly with urethritis. The presence of pathological changes only in the first portion of urine during a two-glass test indicates urethritis. In the differential diagnosis of chronic cystitis that occurs with the formation of ulcers, a bladder tumor should be excluded. Endovesical biopsy is of decisive importance.

TREATMENT OF CYSTITIS

Cystitis is not a cause of death, with the exception of gangrene of the bladder. Due to the high ability to regenerate the mucous membrane of the bladder, most inflammatory processes pass without any consequences. As a result, the prognosis for acute primary cystitis is favorable. However, with untimely and irrational treatment, cystitis can become chronic.

Emergency care for acute cystitis consists of prescribing antispasmodics: 2 ml of 2% papaverine solution, 1 ml of 0.1% atropine solution subcutaneously, heat on the lower abdomen. Antibacterial therapy is also carried out. Patients with intractable pain, acute urinary retention, and hemorrhagic cystitis are subject to hospitalization.

Treatment of gangrenous cystitis is extremely difficult. In men, surgical treatment aimed at urinary diversion and bladder revision is indicated. In women, conservative measures can be taken. However, if in women it is not possible to remove necrotic tissue through the dilated urethra, then urgent surgery is indicated. According to vital indications, cystostomy should be performed and the bladder should be freed from necrotic tissues and urine should be diverted, which limits the depth of the destructive process and saves the patient from fatal complications.

In acute cystitis, patients need bed rest. Prescribe plenty of fluids, a diet excluding spicy foods, pickles, sauces, seasonings, canned food, and the consumption of alcoholic beverages is prohibited. Vegetables, fruits, and dairy products are recommended. Thermal procedures are prescribed only if the cause of dysuria is established. They should be avoided if the diagnosis is unknown, especially with gross hematuria, since heat increases bleeding.

Heat is contraindicated in case of tuberculosis of the bladder. To reduce pain, warm baths are prescribed. For severe dysuria, in addition to antispasmodics, microenemas with a 2% warm solution of novocaine are prescribed. In severe cases, presacral novocaine blockades are performed. For intractable severe pain, the use of narcotic drugs is permissible. As an antibacterial treatment for acute cystitis, furagin is used 0.1 g 2-3 times a day, for blacks - 0.5 g 4 times a day, 5-NOK - 0.1 g 4 times a day and broad-spectrum antibiotics actions (oletethrin, oxacillin, tetracycline, erythromycin, etc.) orally or intramuscularly. Typically, one of the listed drugs is used for 8-10 days, which leads to a rapid decrease in dysuria and normalization of urine composition.

Treatment for postpartum cystitis includes drinking plenty of fluids and a non-irritating diet. For severe pain and tenesmus - belladonna suppositories, warm chamomile enemas. The underlying disease should be actively treated. The prescription of antiseptic and painkillers in the first days of the disease allows further pathogenetic therapy to be carried out when examining urine, identifying flora, and determining sensitivity to antibacterial drugs. It is possible to prescribe antihistamines. Drinking plenty of fluids is prescribed - up to 2-3 liters per day to reduce the concentration of urine and better wash out bacteria, pus and other pathological impurities.

Treatment of chronic cystitis consists of eliminating the causes that caused chronic inflammation. Treatment of chronic cystitis is aimed at restoring impaired urodynamics, eliminating foci of reinfection, removing urinary stones, etc. Antibacterial treatment for chronic cystitis is carried out only after bacteriological examination and determination of the sensitivity of microflora to antibacterial drugs. For adults and older children, the bladder is washed with a solution of furatsilin 1:5000, solutions of silver nitrate in increasing concentrations (1:20,000; 1:10,000; 1:1000) for 10-15 days.

This procedure is especially indicated for patients with bladder emptying problems. Instillations of rosehip seed oil, sea buckthorn, and antibiotic emulsions into the bladder are also used. To improve blood supply to the bladder wall, UHF, inductothermy, and mud applications are used. The local effect of drugs is achieved using iontophoresis with nitrofurans and antiseptics. For chronic cystitis, accompanied by a persistent alkaline reaction of urine, sanatorium-resort treatment in Truskavets, Zheleznovodsk, Essentuki, Borjomi is indicated.

The prognosis for chronic cystitis is less favorable than for acute cystitis. Satisfactory results can be obtained only with persistent complex treatment and elimination of predisposing factors. If acute cystitis is complicated by vesicoureteral reflux, the infection may spread upward with the development of cystopyelonephritis. With secondary cystitis, the prognosis is determined by the course and outcome of the underlying disease.

Treatment of tuberculosis consists of the use of anti-tuberculosis drugs, vitamin therapy, restorative and sanatorium treatment. For severe dysuria, local treatment is additionally used: instillation of sterile fish oil into the bladder, 20-30 ml of a 5% saluzide solution, 50 ml of a 5% PAS solution, electrophoresis of dicaine on the bladder area. When cicatricial wrinkling of the bladder occurs, plastic surgery is used.

For radiation cystitis, in addition to symptomatic and antibacterial treatment, instillations of fish oil, methyluracin, and intravesical injections of corticosteroids are used. If there are extensive lesions of the bladder and there is no effect from conservative treatment, resection of the affected area or intestinal plastic surgery is performed. The prognosis is relatively favorable only with treatment in the early stages.

Treatment of chronic trigonitis is symptomatic, the prognosis is favorable.

Complex treatment of Trichomonas cystitis includes the use of broad-spectrum antibiotics, Trichopolum, Flagyl, rinsing the bladder with solutions of mercuric oxycyanide, furatsilin, and silver nitrate. Treatment is successful only when preventing reinfection by sanitizing lesions in the genitals and simultaneously treating the sexual partner.

Treatment of interstitial cystitis is conservative and comprehensive. Prescribe sedatives, hyposensitizing, antispasmodic and anti-inflammatory drugs, instillation of hydrocortisone into the bladder in combination with antibiotics and anesthetics, presacral novocaine blockades, and physiotherapy. Improvement can only occur in cases of intensive treatment started in the early stages of the lesion. The progression of the disease leads to irreversible changes in the bladder with disruption of its function, resulting in the need for intestinal plastic surgery.

Antibacterial treatment of cystitis will be effective only after establishing the etiological factor and its sensitivity of the flora to antibiotics. Of the penicillin drugs for urinary tract infections caused by Escherichia coli, Proteus, and enterococci, ampicillin trihydrate and ampicillin sodium salt are especially effective. The kidneys excrete cephalosporin (a group of cephalosporins), which is effective against staphylococcal, streptococcal microflora and gonorrhea. Levomycetin (streptomycin group) should be used for infections caused by both gram-positive and gram-negative microorganisms, as well as chlamydia. Of the macrolide antibiotics for urinary tract infections, especially noteworthy are oleandomycin, which is effective against staphylococcal, streptococcal, chlamydial inflammation, and oletethrin, which has a noticeable effect on gonococci and E. coli. If a syphilitic or chlamydial lesion is detected, it is possible to administer erythromycin, which is effective against staphylococci, streptococci and gonococci.

For inflammatory lesions of the bladder and urethra, aminoglycoside antibiotics may be administered. Gentamicin has a particularly wide spectrum of action, which does not have the nephrotoxic effect established for neomycin and monomycin. For tuberculous and gonorrheal cystitis, administration of rifampicin is indicated. Along with antibiotics, sulfonamide drugs have proven themselves well for cystitis. Urosulfan is effective against staphylococcal infections and infections caused by E. coli. Sulfapyridazine and sulfadimethoxine are especially indicated for purulent infections, in which the etiological factors are staphylococci, streptococci, E. coli, Proteus, gonococci, and chlamydia. Of the naphthyridine derivatives, nevigramon can be prescribed, which is effective in diseases caused by Escherichia coli and Proteus. Drugs of the nitrafuran series (furadonin, furagin) have proven themselves to be effective against inflammation of the bladder and infections of other urinary tracts, which are caused by many gram-negative microorganisms and trichomonas.

Recently, lomefloxacin hydrochloride has been recognized as one of the most effective synthetic broad-spectrum chemotherapeutic drugs. It is a long-acting fluoroquinolone. It is especially effective in purulent-inflammatory processes caused by gram-negative microflora - Escherichia coli, Proteus vulgaris, and gonococci. It is successfully used to treat urinary tract infections, also caused by mycoplasmas, chlamydia, including mixed chlamydial-bacterial nature.

Lomefloxacin is indicated for tuberculosis. It is equally effective in both acute and chronic processes. If renal function is not impaired, it is administered once a day in the amount of 400 mg orally, fractional administration of 200 mg 2-3 times a day, or 300 mg 2 times a day is possible. In especially severe cases, it is possible to use up to 800 mg per day. The course of treatment takes 3-5 days for uncomplicated cases or 7-14 days, sometimes longer for chronic processes. Thus, the duration of treatment with lomefloxacin depends on the severity and severity of the disease. Relief of symptoms occurs within two days from the moment of administration, the urine becomes sterile. Lomefloxacin can be combined with streptomycin and isoniazid. The drug is contraindicated during pregnancy, lactation, and children under 15 years of age.

When treating chronic cystitis, the recommendations of herbalists should not be neglected. It is recommended to brew the following herbs.

Collection No. 1

• Calamus root - 2 parts,
• black elderberry flowers - 4 parts,
• lemon balm herb - 2 parts,
• kidney tea leaf - 3 parts,
• knotweed grass - 5 parts,
• bearberry leaf - 5 parts,
• fennel fruits - 2 parts.

Collection No. 2

• Calamus root - 3 parts,
• blue cornflower flowers - 4 parts,
• stinging nettle leaf - 5 parts,
• common juniper fruits - 3 parts,
• peppermint leaf - 1 part,
• chamomile flowers - 4 parts,
• prickly tartar grass - 4 parts,
• tricolor violet herb - 5 parts.

Collection No. 3

• Marsh wild rosemary shoots - 5 parts,
• Veronica officinalis herb - 5 parts,
• St. John's wort herb - 5 parts,
• corn silk - 3 parts,
• flax seed - 2 parts,
• peppermint leaf - 3 parts,
• Scots pine buds - 3 parts,
• horsetail grass - 4 parts.

Collection No. 4

• White birch buds - 2 parts,
• Oregano herb - 7 parts,
• St. John's wort herb - 3 parts,
• flax seed - 3 parts,
• peppermint leaf - 2 parts,
• garden parsley herb - 5 parts,
• rhizomes of asparagus officinalis - 2 parts,
• knotweed grass - 5 parts,
• Western thuja shoots - 4 parts,
• eucalyptus leaf - 1 part.

The mixture is brewed in the evening and left for at least 6 hours. For half a liter of boiling water take 2-3 tbsp. l. collection, take warm 30 minutes before meals 3 times a day. In case of exacerbation of chronic cystitis, these preparations are taken in loading doses - 5-6 tbsp. l. the collection is brewed in a thermos in 1 liter of boiling water. This is the daily dose of infusion. After 2-3 weeks of use, proceed to the usual dose. It is advisable to add 1 tbsp to the thermos each time. l. rosehip. The course of treatment usually lasts from 1 to 1.5 years, until the manifestations of the disease completely disappear. For prevention, it is useful to take the collection for 2 months in the future in spring and autumn, as well as for any acute respiratory diseases that can provoke an exacerbation of cystitis. During exacerbations, you can brew a three-component mixture:

• 5 parts bearberry leaf,
• 3 parts birch buds,
• 5 parts horsetail herb.

The infusion is prepared as usual and taken for 2-3 weeks.

In case of alkaline urine reaction, bearberry infusion is taken for 7-10 days: daily dose - 2 tbsp. l. for a half-liter thermos.

It is recommended to continue herbal treatment for several years. The training sessions should be alternated and a short break should be taken every two months. Usually herbs do not have any side effects, however, it is necessary to do a urine test from time to time. The following herbal infusions are recommended for sitz baths:

Collection No. 1

• White birch leaf - 5 parts,
• oregano herb - 3 parts,
• black currant leaf - 5 parts,
• tricolor violet herb - 2 parts,
• thyme herb - 4 parts,
• eucalyptus leaf - 1 part.

Collection No. 2

• Bedra ivy grass - 5 parts,
• Calendula officinalis flowers - 3 parts,
• knotweed grass - 5 parts,
• horsetail grass - 5 parts,
• celandine grass - 2 parts.

Collection No. 3

• Sweet clover herb - 2 parts,
• chamomile flowers - 5 parts,
• marshweed grass - 5 parts,
• hop fruit - 3 parts,
• Salvia officinalis herb - 5 parts.

To prepare a decoction for baths, take 3 tbsp per 1 liter of water. l. collection, bring to a boil, filter and cool. The duration of the sitz bath is 10-15 minutes. It is taken 1-2 times a day for 8-12 days.

For cystitis, you can place linen pads filled with hot steamed herbs on the bladder area: chamomile, sage, cucumber, horsetail.

PREVENTION OF CYSTITIS

In the prevention of cystitis, an important role is played by compliance with the rules of personal hygiene, timely treatment of inflammatory diseases, urodynamic disorders, prevention of hypothermia, observance of asepsis during endovesical examinations and bladder catheterization. Prevention of postpartum cystitis consists of rational assistance during childbirth, combating urinary retention, and careful adherence to asepsis when collecting urine with a catheter. Prevention of chronic cystitis consists of rational treatment of acute cystitis, as well as timely detection and treatment of diseases of the genitourinary system. Prevention of radiation cystitis consists of rational planning of radiation therapy, taking into account the radiation sensitivity of tissues and organs, as well as the use of protective devices.

Inflammation of the bladder, or cystitis, occurs for many different reasons and has characteristic symptoms, so diagnosing cystitis usually does not cause problems. However, having identified the disease, it is necessary to thoroughly determine its causes, provoking factors, and possible complications - otherwise treatment may be ineffective. Diagnosis of cystitis in men and women will be slightly different, and diagnosis of cystitis in children requires much more time, since other diseases may have similar symptoms in childhood.

Symptoms of cystitis

There are a number of specific symptoms that suggest cystitis. Diagnosis and treatment usually meet the standards, and the list of signs by which a preliminary diagnosis is made is quite large:

1. The patient complains about

• painful urination
• frequent urge to toilet
• pain in the lower abdomen and lower back
• burning in the urethra
• temperature increase
• symptoms of intoxication

1. According to the analysis results

• urine is cloudy, dark
• with a pungent odor
• with whitish or bloody inclusions

Additionally, there may be complaints of decreased libido, increased unpleasant symptoms after sexual intercourse or before the onset of menstruation. In such situations, the problem may not only be cystitis - differential diagnosis can reveal disturbances in the functioning of the kidneys, inflammation and neoplasms in the pelvic organs, enlarged prostate and bending of the uterus.

Unusual cystitis

It happens that most of the symptoms are absent, and only blood in the urine or rare cases of discomfort appear. This is often what interstitial cystitis looks like at the initial stage. Its causes lie not in a bacterial infection, nor in fungi, but in damage to the mucous membrane of the bladder itself, which loses its elasticity and bursts when stretched, forming ulcers. If a problem with urination occurs only in cases where you had to “be patient,” it is most likely interstitial cystitis. Diagnostics, 3 important criteria of which require mandatory cystoscopy - insertion of a cystoscope tube into the bladder with a camera that allows assessing damage to the mucosa. You can also take tissue samples for analysis using a cystoscope.

Checking bladder compliance is another important diagnostic method, as is a potassium test. Having found out how severe the damage is and how quickly it appears, the doctor can immediately begin treatment by introducing anti-inflammatory and healing agents into the bladder cavity.

Typical cases of cystitis

It is impossible to miss acute cystitis - the diagnosis here is minimal, it is much more important to quickly determine the cause of the disease and begin therapy as early as possible. Diagnosis of cystitis in children also requires drastic measures; urine collection for analysis is often done at the very beginning of treatment in order to prevent the transition of the acute phase to chronic cystitis. Tests, diagnostics using equipment, and hospitalization if there are signs of intoxication are mandatory for children.

Diagnosis of cystitis in women includes, first of all, clarification of all the circumstances, since measures against postcoital cystitis will differ from the treatment of a non-infectious form of the disease. Also, a woman will be required to undergo an examination by a gynecologist and an ultrasound of the pelvic organs to rule out inflammation outside the bladder.

Acute cystitis, including interstitial cystitis, which is diagnosed and treated in a timely manner, may never recur. However, if you ignore the symptoms and engage in self-diagnosis, you can develop the condition into chronic cystitis. Here the diagnosis will be carried out differently: it is necessary to establish what causes the exacerbation of the disease and develop measures to eliminate provoking factors.

As a rule, provoking factors include:

• poor personal hygiene
• unprotected sexual intercourse
• decreased immunity
• presence of inflammation in the body
• physiological characteristics
• unstable weather, off-season
• inability to empty the bladder in a timely manner

Some factors cannot be excluded, but the use of drugs to prevent cystitis can reduce the risk of the disease several times.

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Practical help from doctors and experts in the fight against cystitis.

Cystitis

Clinical picture Different forms of acute cystitis are expressed by a triad of symptoms: pain, pollakiuria and pyuria. In the hemorrhagic form, macrohematuria comes first. Pain in the lower abdomen appears either when the bladder is filling, or during urination, especially at the end of it. Little boys complain of pain in the head of the penis. Pain at the end of urination is characteristic of the predominant localization of cystitis in the area of ​​\u200b\u200bthe exit from the bladder (cervical cystitis, trigonitis).

Pollakiuria occurs around the clock. Its degree depends on the form of cystitis: relatively moderate in catarrhal forms, it becomes unbearable in the ulcerative process, when an imperative urge to urinate appears, reaching the point of incontinence. These disorders reach their culminating point in patients with a wrinkled bladder. In young boys, a paradoxical phenomenon can be observed - acute cystitis is manifested not by pollakiuria, but by acute urinary retention. The child begins to strain, a few drops of urine appear, the child screams, and urination stops. This situation is explained by sphincter spasm, which occurs as a result of severe pain caused by the passage of urine through the neck of the bladder and the urethra.

With severe pyuria, cloudy urine is macroscopically determined. Less severe pyuria can only be determined microscopically.

The temperature in patients with various forms of cystitis (with the exception of gangrenous) remains normal. An increase in temperature, if there is no other infectious focus located outside the urinary apparatus, indicates an ascending infection of the kidney, the addition of pyelonephritis. In rare cases, an increase in temperature depends on the spread of infection to the peri-vesical tissue (paracystitis).

Diagnostics Acute cystitis is based on the triad of the listed symptoms, as well as on data from physical, laboratory, and, where indicated, endoscopic and x-ray studies.

In patients with acute cystitis, there is pain when palpating the bladder area above the pubis or during vaginal examination in women. In addition to leukocyturia and bacteriuria, a laboratory test of urine can detect a small amount of protein (albuminuria is false in these cases) and a larger or smaller number of red blood cells. Total macrohematuria is characteristic of the hemorrhagic form of cystitis, terminal hematuria is characteristic of cervical cystitis.

Endoscopic examination is contraindicated in acute cystitis, as it causes severe pain and can lead to an exacerbation of the process; it should be performed only in cases of prolonged cystitis. The exception is the hemorrhagic form of cystitis with severe total hematuria, when it is necessary to establish the cause of the latter. Cystoscopy in patients with acute protracted uncomplicated cystitis reveals changes in the mucous membrane of varying intensity and extent: hyperemia, edema, fibrinous deposits, ulcerations. In case of complicated and secondary cystitis, the primary disease of the bladder is determined; violation of the release of indigo carmine from the mouths of the ureters makes it possible to determine the spread of infection towards the kidney. X-ray examination makes it possible to diagnose a calculus, bladder diverticulum, and vesicoureteral reflux. Acute cystitis causes relapses in 12-17% of cases.

Chronic cystitis is mainly a secondary disease. Some authors deny the possibility of primary chronic cystitis. An exception is the so-called cystic cystitis, which occurs without other damage to the bladder. The appearance of small cysts is not always accompanied by signs of cystitis. In some patients, these cysts are discovered accidentally during an examination undertaken for another disease. The symptoms of chronic cystitis are the same as acute ones, but the duration of the disease is longer.

Cystoscopy and x-ray examination are mandatory components of diagnosis. In most cases, they allow us to find out the secondary nature of the disease. It is clear that at the same time a general examination of the patient should be carried out, the condition of the kidneys, ureters, urethra, and reproductive organs should be determined. Trigonitis is characterized by severe dysuria, chronic course and mild pyuria.

During cystoscopy, loosening and hyperemia of the mucous membrane is limited to the area of ​​Lieto's triangle. Cystoscopy image of various forms of cystitis - see color. table, fig. 1-12.

Rice. 1. Acute cystitis, vascular injection. Rice. 2 and 3. Hemorrhagic cystitis. Rice. 4 and 5. Chronic cystitis. Rice. 6. Follicular cystitis. Rice. 7. Fibrinous cystitis. Rice. 8. Cystic cystitis. Rice. 9. Encrusting cystitis. Rice. 10. Bullous cystitis. Rice. 11. Interstitial cystitis. Rice. 12. Polypous cystitis.

Differential diagnosis of cystitis in most cases is not difficult. To avoid diagnostic errors, it is necessary to keep in mind the following rules: without pyuria there is no cystitis; pollakiuria and pyuria may be manifestations of pyelonephritis with secondary changes in the bladder. Primary chronic cystitis is rare. Therefore, if cystitis persists, it is necessary to exclude the possibility of secondary cystitis, find out the root cause, and also make sure that there is no tuberculosis of the urinary apparatus. In each case of persistent cystitis, a thorough examination of the pelvic organs is indicated.

With bladder neurosis, isolated pollakiuria is noted. Vola and pollakiuria without pyuria are characteristic of a polyetiological disease, with a pathogenesis that has not yet been clarified - the so-called cystalgia. Cystalgia is observed only in women; with it, pain and pollakiuria occur mainly during the day and disappear during sleep; there are no pathological elements in the urine. During cystoscopic examination, the mucous membrane in the vast majority of cases appears unchanged. In a number of patients, in the area of ​​Lieto's triangle, lighter islands of epithelium are detected, histologically similar to the vaginal epithelium. The occurrence of cystalgia is associated with endocrine disorders, uric acid diathesis, congestion in the pelvis, and a trace reaction after previous cystitis. Abroad, persistent forms of cystalgia are sometimes classified as psychosomatics. Treatment should be aimed at eliminating the suspected causes and normalizing the neuromuscular tone of the bladder (various types of novocaine blockade, physiotherapeutic procedures). Endovesical manipulation should be avoided.

A detailed laboratory, endoscopic and x-ray examination of the condition of the urinary apparatus as a whole makes it possible to make a differential diagnosis between cystitis and tuberculosis, between cystitis and pyelonephritis complicated by cystitis, as well as to establish the cause of secondary cystitis. A gynecological examination allows us to exclude damage to the female genital organs as a cause of secondary cystitis. In men, digital rectal examination can identify the primary source of infection in the prostate gland.

With polypous forms of cystitis, there is a need for a differential diagnosis with a tumor. Often it is not possible to make a correct diagnosis based solely on the cystoscopic picture. Cytological examination of urine sediment and biopsy are helpful. There are certain difficulties in the differential diagnosis between limited encrusting cystitis and encrusting surface of a small neoplasm. The issue is resolved by surgical intervention.

Complications of cystitis are associated with the spread of infection to the upper urinary tract and surrounding tissues. Ascending pyelonephritis can complicate the course of both acute and chronic cystitis. The infection can spread directly through the lumen of the ureter with vesicoureteral reflux or hematogenously. This is favored by impaired patency of the lower urinary tract (for example, in patients with prostate adenoma), exacerbation of chronic cystitis. The occurrence of pyelonephritis is accompanied by a deterioration in general condition, chills, and fever. It is extremely rare that ulcerative and necrotizing cystitis are complicated by purulent peritonitis. More often, these forms of cystitis lead to paracystitis.

Paracystitis - inflammation of the peri-vesical tissue - occurs most often, especially in the conditions of modern antibacterial treatment, in the form of an inflammatory infiltrate with subsequent sclerotic changes in the tissue. A number of patients develop either limited purulent cavities or widespread purulent melting. In cases where the abscess is limited to the reticular space, a protrusion is detected above the pubis in non-obese individuals, which can be mistaken for a full bladder.

Diffuse ulcerative chronic cystitis in rare cases results in the formation of a small, wrinkled bladder. In practice, the detrusor as a whole is replaced by scar connective tissue, the epithelium is preserved only in the area of ​​Lieto's triangle.

Complications of chronic cystitis include leukoplakia of the bladder and malakoplakia. However, in a number of patients with leukoplakia, during cystoscopy the mucous membrane around the circumference of the leukoplakia plaque is not changed.

Treatment Primary acute cystitis consists of a certain regimen, creating “rest” for the bladder, using antibacterial agents, and thermal procedures. For severe forms, bed rest is indicated. In all cases, exclude spicy seasonings from food and alcoholic beverages. A good effect is achieved by presacral novocaine blockade (100 ml of 0.25% novocaine solution) applied on the first day, which significantly relieves spastic contractions of the detrusor. For the same purpose, various antispastic drugs are prescribed: belladonna preparations, papaverine, platifillin, kellin, etc. Antibacterial treatment usually comes down to the use of sulfonamides (etazol, urosulfan) and nitrofuran drugs (furadonin, furazolidone) in normal dosages. If the course is persistent, antibiotics are also indicated, the choice of which should be based on urine culture and antibiogram data. In more than 50% of cases, cystitis can be relieved on the first or second day. If the course is prolonged, a full examination is indicated to determine the cause of such a course. When cystitis lasts more than 5-6 days, you can resort to installing antibiotics, 3% collargol in an oil solution, into the cavity of the bladder.

Treatment of primary chronic cystitis presents significant difficulties due to the persistent course of the disease. Measures are taken to generally strengthen the body, eliminate various possible purulent foci (in the mouth, throat, etc.), and constipation. Antibacterial treatment should be carried out systematically over a period of months with a change of antibiotics every 5-7 days in accordance with the results of repeated antibiograms (during the treatment the type of flora and its sensitivity to antibiotics changes), combining them with sulfonamide and nitrofuran drugs. Local treatment is also indicated in the form of rinsing the bladder with weak solutions of ethacridine, furatsilin, boric acid, followed by the installation of 3% collargol in oil.

For any form of secondary cystitis, the basis of treatment is the elimination of the primary disease: calculus, neoplasm, bladder diverticulum, urethral stricture, prostate adenoma, inflammatory focus in the female genital organs, in the prostate gland.

After eliminating the cause, it is possible to eliminate cystitis using the measures listed above.

Prevention cystitis is based on the prevention and timely elimination of the causes contributing to its occurrence.

Refusal from various endovesical examinations, as well as from catheterization of the bladder, when there are no absolute indications for this, is justified, since in this case the danger of infection of the urinary tract, despite taking the necessary aseptic measures, is very significant.

Differential diagnosis of cystitis

On April 7, 2016, a regional scientific and practical conference “Differential diagnosis of cystitis” was held in Novosibirsk, bringing together more than 170 participants from Novosibirsk, Omsk, Tomsk, Novokuznetsk, Barnaul. The guest of honor at the conference was a recognized authority on the problem of painful bladder both in Russia and abroad - Professor Andrey Vladimirovich Zaitsev (Moscow). As always, his presentation aroused great interest and lively discussion in the hall.

In speeches at the conference, a lot of new data on this problem was presented. Thus, Professor A.V. Gudkov (Tomsk) spoke about the possible causes of chronic cystitis and ways to overcome them. Alexander Vladimirovich emphasized that in some cases, due to the special virulence of the Escherichia coli strain or the characteristics of the human body, and in particular the wall of the bladder, this pathogen can penetrate into its deep layers, thereby causing inflammation not only of the mucous membrane, but also of the deeper layers, up to adventitia. A short course of monotherapy with an antibacterial drug in such cases does not guarantee a cure and may cause a relapse of the disease or the development of a chronic process and complications, and the additional use of a complex of anti-inflammatory measures will help increase the effectiveness of treatment of patients with acute uncomplicated cystitis.

Professor E.V. Kulchavenya’s report with the intriguing title “Is there an alternative to bacterial treatment of cystitis?” ended with an optimistic statement: “Yes!” According to the results of a study conducted under her leadership, it was found that in 82.4% of young non-pregnant women with acute uncomplicated cystitis, the disease was cured without the use of antibiotics, and only 17.6% of patients required additional prescription of antibacterial drugs. In all patients who showed a decrease in the severity of symptoms after 48 hours of combined therapy with a non-steroidal anti-inflammatory drug and the combined herbal drug Canephron N, a cure was achieved; none of them developed a relapse of the disease over the next 6 months. Thus, the researchers came to the conclusion that with early (up to 12 hours from the moment of illness) treatment and monitoring the effectiveness of therapy over the next 48 hours, it is possible to limit oneself to the prescription of non-steroidal anti-inflammatory drugs and a combined herbal preparation.

The report of the epidemiologist of the Novosibirsk Research Institute of Tuberculosis, Ph.D., aroused great interest. MM. Zorina “Legal basis for BCG therapy in a municipal clinic - the view of an epidemiologist.” The BCG method of therapy for superficial bladder cancer has long and firmly gained a leading position in European oncourology, but in Russia doctors often encounter difficulties in organizing this type of treatment. Marina Mikhailovna explained that BCG therapy can be performed in any clinic and gave a step-by-step algorithm for the actions of the doctor and the patient when carrying out this treatment method.

With a report by M.M. Zorina echoed an interesting message from Ph.D. D.P. Kholtobin “Possible complications of BCG therapy for bladder tumors: how to prevent and how to correct.” Denis Petrovich, who has extensive experience in the surgical treatment of patients with cancer of the genitourinary organs, shared with the audience a sore point, so his report was received by the audience with great interest. Denis Petrovich convincingly showed that BCG therapy is an obligatory component of the treatment of patients with superficial bladder cancer, and all adverse reactions should resolve spontaneously within 48 hours. However, in case of prolonged deviation from the usual course of the treatment process, interaction with phthisiatricians is necessary.

Doctor of Medical Sciences, Associate Professor A.V. Mordyk spoke about the peculiarities of organizing the diagnosis and differential diagnosis of urogenital tuberculosis in Omsk, which is one of the three leaders in the Siberian and Far Eastern Federal Districts in terms of detection of urogenital tuberculosis. This is the considerable merit of Anna Vladimirovna as the head of the department of phthisiology and phthisiosurgery of the Omsk Medical Academy.

Chief urologist of the Siberian Federal District, Professor A.I. Neimark reported on modern approaches to the treatment of chronic infectious inflammatory diseases of the urinary tract. Thus, Alexander Izrailevich noted that when studying the immune status of patients with chronic recurrent cystitis associated with urogenital infection, changes in the subpopulation of lymphocytes, an imbalance of immunoglobulins, a decrease in phagocytic activity with inhibition of the cellular component of immunity were diagnosed. The inclusion of azoximer bromide in the treatment complex led to a pronounced positive trend in the main clinical symptoms of the disease, the elimination of laboratory signs of inflammation, a significant increase in the frequency of elimination of pathogens, and normalization of immune status indicators.

Two reports were from the Innovative Medical and Technological Center of the Federal State Budgetary Institution NNIITO named after. Ya.L. Tsivyan Ministry of Health of the Russian Federation. Head of the Center for Urology and Gynecology, Ph.D. G.Yu. Yarin spoke about urinary dysfunction as a mask and the cause of chronic cystitis, and gave recommendations for the early diagnosis of complications in a neurogenic bladder. V.N. spoke about the features of treatment of urinary infection in patients with neurogenic urination disorders. Fedorenko. At this conference, Vitaly Nikitovich was awarded the title “Best Diagnostician” and received a letter of gratitude from the Novosibirsk Research Institute of Tuberculosis. He drew the attention of listeners to the fact that in spinal patients, in order to prevent infectious and inflammatory diseases of the lower urinary tract, it is necessary to maintain low pressure during the phase of urine accumulation in the bladder, ensure its complete emptying, reduce the duration of drainage in the urinary tract, replace them in a timely manner, keep the drainage system closed. Antibacterial therapy in some cases can be successfully replaced by the use of bacteriophages.

And again, there were no indifferent people in the room, since every outpatient urologist sooner or later encounters similar problems.

The clinical observation given by Ph.D. was very revealing. E.V. Brizhatyuk. The 67-year-old patient worked in a catering establishment and regularly underwent medical examinations. However, during the last 5 years, due to retirement, she was not examined.

Medical history: rare episodes of acute cystitis in the past. Habitual one or two urinations every night for many years. At the age of 33, two ectopic pregnancies; therefore, tubectomies were performed successively on both sides. Since then, a nagging pain appeared above the womb, which was associated with previous operations and the adhesive process. During the examination, against the background of an acute respiratory viral infection, pyuria, erythrocyturia, and kidney cysts were detected (according to ultrasound examination), and therefore the patient was referred to a urologist.

The results of the initial examination by a urologist at the clinic showed the following data. General urine test: leukocyturia 25–30 per field of view, erythrocytes 5–8 per field of view, bacteria. Bacteriological analysis of urine revealed Staphylococcus spp. 103 CFU/ml, Corynebacterium spp. 103 CFU/ml. Uroflowmetry: bladder volume 385 ml, Qmax – 34 ml/sec., Qave – 14 ml/sec. The urologist at the clinic prescribed standard therapy for acute uncomplicated cystitis: fosfomycin 3 g once and furazidine 100 mg three times a day for 7 days, accompanied by herbal medicine (Canephron N). The result was not obtained, so cefixime 400 mg was prescribed once a day for 10 days, which also did not lead to a significant reduction in subjective and laboratory symptoms. We would like to emphasize the correctness of the chosen tactics: the prescribed drugs are optimal for the treatment of patients with cystitis, but do not mask tuberculosis, because do not inhibit the growth of Mycobacterium tuberculosis. And then the doctor did absolutely the right thing: she referred the patient to a phthisiourologist.

At the Novosibirsk Research Institute of Tuberculosis, multislice computed tomography (MSCT) showed on the right the tuberous contours of the kidney at the level of the upper third due to multiple hypodense round formations, the size of which reached 16 mm, the contrast in them was revealed in the form of levels. Some of these lesions did not accumulate contrast agent. There was an expansion of the pelvis to 23×22×38 mm, the contrast agent in it was detected as a level. There was an uneven persistent narrowing of the ureter at the level of the pyeloureteral segment and the upper third. The contours of the ureter are uneven, its walls are thickened throughout. On the left, the contours of the kidney are uneven due to bulging formations. The structure of the formation in the upper segment is heterogeneous with areas of liquid density that do not contrast during the excretory phase; denser areas intensively accumulated the contrast agent. The connection between this formation and the pyelocaliceal system has not been established. In the left kidney, two large cysts (Bosniak I) were also identified, located at the level of the middle and lower segments. The pyelocaliceal system on the left was well differentiated and not dilated. The ureter is not dilated, its walls are not thickened (Fig. 1). Cystoscopically revealed a picture of follicular cystitis (Fig. 2). A forceps biopsy was performed; Pathomorphologically tuberculosis was detected.

Based on the totality of clinical, laboratory and anamnestic data, a diagnosis was made: polycavernous tuberculosis of the right kidney, tuberculosis of the right ureter, tuberculosis of the bladder. MBT (mycobacterium tuberculosis) “-”; Comprehensive anti-tuberculosis chemotherapy was started. Regarding the concomitant disease (hypernephroid cancer of the left kidney T1N0M0, simple cysts of the left kidney), Denis Petrovich Kholtobin performed laparoscopic resection of the upper segment of the left kidney and excision of the cysts.

During a control examination at the end of the course of anti-tuberculosis therapy, MSCT showed a decrease in the largest size of the right kidney to 7.5 cm, and thinning of the parenchyma. Round hypodense formations were detected in the parenchyma. No kidney enhancement was observed throughout the study. The ureter was not contrasted. On the left, the condition after kidney resection corresponded to the volume of intervention performed. Kidney function was preserved, the kidney's excretory system had no signs of retention, the perinephric tissue was compacted, and fibrous cords were visible (Fig. 3).

Given the persistent leukocyturia and lack of right kidney function, a right nephrectomy was performed. A pathomorphological study showed continued activity of tuberculous inflammation in the kidney parenchyma, multiple tuberculous foci such as tuberculomas with loose caseous masses, cavities with a three-layer wall, an unevenly loosened layer of specific granulation tissue (Fig. 4).

Prescribing optimal empirical antibacterial therapy for patients with acute cystitis (at least in conditions of a tuberculosis epidemic - fosfomycin, furazidine; in complicated cases - 3rd generation cephalosporins and gentamicin) will contribute to the timely identification of patients with tuberculosis, since the lack of response to such therapy - direct indication for excluding tuberculosis. Will we help a patient with acute cystitis by prescribing levofloxacin at the first visit? Undoubtedly! An even better result will be obtained with the use of imipenem. But will such an approach be optimal or at least rational? Also, definitely not. There is no need for a patient with acute cystitis to be prescribed a systemic antibiotic with antituberculosis activity when we have at our disposal fosfomycin and nitrofurans, which cover, especially when used together, the main spectrum of nonspecific uropathogens. In other words, there is no need to use “carpet bombing”, i.e. use systemic antibiotics with antituberculosis activity when there is a local problem (acute uncomplicated cystitis) and a “sharp sniper” in the form of fosfomycin and nitrofurans. And prescribing herbal medicine from the first day will prevent the formation of biofilm and chronicity of the process.

Urologists who showed vigilance regarding tuberculosis and promptly referred patients to the anti-tuberculosis dispensary and tuberculosis research institute were awarded letters of gratitude, and in their honor a special cake was baked for the “Best Diagnostician”, which all conference participants were able to enjoy during the break.

Signs of cystitis in women, diagnosis and treatment regimens

• 1 Reasons

• 1.1 Predisposing factors
• 1.2 What else needs to be considered

• 4.1 History and examination of the patient
• 4.2 What the laboratory will show

• 5.1 Endoscopy

• 7.1 What medications should you take?
• 7.2 How to eliminate chronic inflammation

The development of cystitis is facilitated by the anatomical features of the structure of the urinary system in women. In the female body, the urethral canal is shorter than in the male. In addition, their urethral opening is closer to the anus, which facilitates the entry of microorganisms into the urinary system.

Causes

In most cases, this pathology is caused by the growth and reproduction of pathogenic microflora on the wall of the bladder. The most common pathogens that cause cystitis in women are:

• gram-negative enterobacteriaceae;
• viruses;
• yeast-like fungi, in particular of the genus Candida;
• protozoa;
• sexually transmitted infections.

Despite the variety of microorganisms that can cause cystitis, in most women the disease is provoked by bacteria living in the intestines:

• Escherichia coli;
• Enterococci.

Predisposing factors

For the development of cystitis, the presence of an infectious pathogen alone is not enough. Normally, immune protection of the bladder mucosa is provided by a number of antibacterial mechanisms. The most important of these is regular urination and ensuring normal flow of urine, which prevents stagnation.

Even in the presence of infection, this mechanism prevents the adhesion (attachment) of bacteria to the mucous membrane of the bladder. In addition, local immune protection of the urinary tract mucosa is due to the presence on their wall of a number of immunoglobulins, in particular Ig A, as well as nonspecific and specific blockers of bacterial growth.

That is why any conditions that lead to a weakening of general or local immunity can provoke the appearance of cystitis. Provoking factors for cystitis can be:

• foci of chronic infection in the body (tonsillitis, caries);
• previous acute respiratory infections, influenza;
• prolonged hypothermia;
• poor nutrition, hypovitaminosis;
• gastrointestinal diseases accompanied by intestinal dysbiosis;
• metabolic diseases (diabetes mellitus, thyroid dysfunction);
• chronic stress;
• physical overload.

What else needs to be considered

In some women, conditions predisposing to the occurrence of cystitis may be congenital anatomical features of the structure of the urinary system. These include:

• urethra too short;
• narrowing of its lumen;
• bladder abnormalities.

In addition, there are additional causes of cystitis in women:

• use of aggressive hygiene products;
• using a lot of soap;
• frequent sexual intercourse;
• wearing tight underwear;
• use of spermicides.

How it manifests itself

The main signs of cystitis in women are as follows:

• burning or itching after urination;
• pain above the pubis, most often after visiting the toilet;
• frequent urge to urinate;
• discharge from the urethra during cystitis in a woman, especially purulent or bloody;
• slight increase in body temperature (up to 37.5 °C).

What types of cystitis do women have?

Depending on the nature of the course, cystitis can be:

• sharp;
• chronic.

In the latter case, pathological changes extend much deeper than the mucous layer of the bladder.

In acute cystitis, the symptoms are more pronounced, and in some cases they can interfere with the patient’s ability to work. Chronic forms of the disease often have a blurred clinical picture; unpleasant symptoms can bother a woman only at the stage of exacerbation of the disease.

According to the nature of the course, chronic cystitis can be:

• latent, with rare exacerbations- when inflammatory changes are detected only during endoscopic examination;
• latent with frequent exacerbations- more than twice a year;
• persistent- with constantly present changes in urine tests;
• interstitial- with impregnation of the submucosal layer with leukocytes and dysfunction of the bladder.

Depending on the prevalence and localization of the inflammatory process on the walls of the bladder, cystitis can be cervical, local or diffuse.

How is pathology diagnosed?

Diagnostic search for cystitis includes the following steps:

• taking anamnesis and examining the patient;
• laboratory tests;
• instrumental techniques;
• endoscopic examination;
• differential diagnosis.

History and examination of the patient

During the consultation, the urologist or therapist will ask in detail about the duration and nature of the symptoms and try to find out the causes of the disease. Objectively, one can detect hyperemia and swelling in the area of ​​the urethral opening, pain on palpation of the abdomen in the suprapubic region.

What the laboratory will show

Laboratory diagnostics include, first of all, urine tests. The following studies are usually prescribed:

• general urine analysis;
• bacteriological examination;
• determination of bacterial sensitivity to antibiotics.

With cystitis, a urine test reveals bacteria (or yeast-like fungi), an increase in the number of white blood cells (leukocyturia), and sometimes red blood cells are also detected. Special test strips can be used to quickly diagnose urinary tract infections. They allow you to detect an increased number of leukocytes and nitrites. However, this method has low sensitivity and does not replace laboratory tests.

Microbiological examination of urine involves inoculating urine sediment on a special nutrient medium. After the bacteria grow, they are identified and their sensitivity to certain antibiotics is determined.

Instrumental methods for clarifying the diagnosis

To clarify the nature of cystitis, the following methods are used:

• ultrasound scanning;
• radiography using contrast agents;
• according to CT or MRI indications.

Most often, ultrasound examination is performed for cystitis. It allows you to identify signs of an inflammatory process in the wall of the bladder, foreign inclusions (stones, sand), cystic or tumor changes.

Endoscopy

Endoscopic examination of the bladder (cystoscopy) is used mainly in chronic forms of the disease. Using this method, signs of inflammation of the bladder walls (redness, swelling) are detected. Cystoscopy also helps to identify tumors and areas of abnormal development of the mucosa. If necessary, the doctor can obtain a piece of tissue for histological examination (biopsy).

Differential diagnosis

Cystitis in women should be differentiated from other diseases of the urinary system:

• neoplasms of the bladder;
• neurogenic urination disorders;
• urolithiasis;
• developmental anomalies.

What helps

Treatment of cystitis in women includes sufficient fluid intake; it is recommended to drink at least two liters of drinks per day. At home, it is best to use herbal tea (St. John's wort, lingonberry leaves, chamomile), lingonberry or cranberry juice. For acute cystitis, applying a warm heating pad to the lower abdomen helps. This reduces pain and frequency of urination and improves the patient's condition. A bath or sauna can be used as a thermal procedure.

A sitz bath with chamomile is also recommended as a folk remedy. To prepare it, you need to prepare a chamomile decoction: boil a liter of water and add three to four tablespoons of dry herbs, leave for two hours. To prepare the bath, the decoction is diluted with warm water. The duration of the procedure is about 20 minutes.

What medications should you take?

The treatment regimen for cystitis in women consists of several main points:

• prescribing antibacterial agents;
• pathogenetic therapy;
• preventive measures.

In most cases, the presence of cystitis requires the prescription of antibacterial agents. The most effective in this case are antibiotics from the fluoroquinolone group:

• "Ciprofloxacin";
• "Levofloxacin";
• "Pefloxacin";
• "Lomefloxacin".

For acute cystitis, antibiotics are taken for three to five days. There are also single-dose tablets (Monural). If cystitis has complications in the form of an ascending infection involving the renal collecting system, then treatment with antibiotics can last up to ten days.

How to eliminate chronic inflammation

In chronic forms of the disease, the use of immunomodulators is indicated. In particular, the drug Uro-Vaxom, which contains protein components of Escherichia coli, is recommended. There are clinical recommendations for the use of Lavomax (Tilorone).

Treatment of chronic cystitis in women, which occurs with frequent relapses, sometimes requires fairly long-term use of uroseptics. In some cases, they are taken in small dosages in the evening for three to six months. Also used in the treatment of chronic forms of the disease:

• drugs that improve reparative processes (“Solcoseryl”);
• stimulating venous outflow (“Eskuzan”);
• antiplatelet agents (“Trental”);
• painkillers (“Nimesil”, “Diclofenac”, “No-shpa”);
• antihistamines.

Physiotherapeutic procedures and direct injection of antibacterial agents into the bladder (Dioxidin, Silver Nitrate) are used as local treatment.

Preventive measures

Treatment for a urinary tract infection requires modification of certain habits and diet. Prevention of cystitis includes the following measures:

• a diet with limited irritating foods (spicy foods, spices);
• regular visits to the toilet;
• compliance with personal hygiene rules;
• hypothermia should be avoided;
• always change a wet swimsuit to a dry one in the pool and on the beach;
• promptly treat foci of chronic infection.

Cystitis in women is not a dangerous condition and in most cases responds well to drug therapy. However, it can become chronic, which is often observed against the background of weakened immunity or somatic pathologies. Simple prevention of cystitis in women, as well as high-quality treatment of acute forms of the disease, will help to avoid relapses.

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