Cystitis 1

Cystitis describes a clinical syndrome of dysuria, frequency, urgency, and occasionally suprapubic pain 2

3 Reduced Urine Flow Outflow obstruction, prostatic hyperplasia, prostatic carcinoma, urethral stricture, foreign body (calculus) Neurogenic bladder Inadequate fluid uptake (dehydration) Promote Colonization Sexual activity—increased inoculation Antimicrobial agents—decreased indigenous flora Facilitate Ascent Catheterization Urinary incontinence Fecal incontinence Residual urine with ischemia of bladder wall Risk Factors for UTIs

Laboratory Diagnosis The presumptive laboratory diagnosis of acute cystitis is based on microscopic urinalysis, which indicates microscopic pyuria, bacteriuria, and hematuria presence of 10 2 cfu/mL or more of urine usually indicates infection 4

Tubercular cystitis Never primary Treatment – Medical: ATT – Surgical: failure of medical treatment Nephroureterectomy to remove the source of infection 5

Abacterial cystitis Presence of pus in urine but without any accompanying bacteria Aetiology Mycoplasma Chlamydia Adenovirus 6

Pathology Inflammation of the bladder 7

Clinical features Urethral discharge Abrupt onset features of cystitis 8

Investigations All investigations should be done to exclude tuberculous cystitis 9

Treatment Spontaneous resolution Analgesics, antispasmodic & bladder sedatives Antibiotics: tetracycline, chloramphenicol 10

Interstitial cystitis 11

Interstitial cystitis Painful bladder syndrome Epidemiology prevalence: ~20/100,000 90% of cases are in females mean age at onset is 40 years higher prevalence in Jews 12

Etiology: unknown theories: increased epithelial permeability; autoimmune; neurogenic associations: severe allergies; IBS, fibromyalgia 13

14 Hypothesis for etiologic cascade of painful bladder syndrome/interstitial cystitis

❏ Classification non-ulcerative (more common) - younger to middle-aged ulcerative – middle-aged to older 15

16 Hunner's ulcer in interstitial cystitis nonulcerative interstitial cystitis

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❏ diagnosis (not usually adhered to) NIDDK required criteria 1) glomerulations (submucosal petechiae) or Hunner’s ulcers on cystoscopic examination, AND 2) pain associated with the bladder or urinary urgency 18

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❏ differential diagnoses UTI vaginitis bladder tumour radiation/ chemical cystitis eosinophilic/TB cystitis 20

❏ treatment symptomatic only (no cure) bladder hydrodistension (also diagnostic) intravesical dimethylsulfoxide (DMSO) intravesical hyaluronic acid or heparin amitriptyline pentosan polysulfate (Elmiron) surgery is last resort 21

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Complicated Cystitis Complicated UTIs are those that occur in a patient with a compromised urinary tract or that are caused by a very resistant pathogen 25

26 Functional/structural abnormalities of urinary tract Recent urinary tract instrumentation Recent antimicrobial agent use Diabetes mellitus Immunosuppression Pregnancy Hospital-acquired infection Complicating Host Factors

27 Common Pathogens Mitigating Circumstances Recommended Empirical Treatment E. coli, Proteus species, Klebsiella species, Pseudomonas species, Mild-to- moderate illness, no nausea or vomiting— outpatient therapy Oral norfloxacin, ciprofloxacin, or ofloxacin for days Serratia species, enterococci, staphylococci Severe illness or possible urosepsis— hospitalization required Parenteral ampicillin and gentamicin, ciprofloxacin, levofloxacin, ceftriaxone, aztreonam, ticarcillin- clavulanate or imipenem- cilastin until fever gone; then oral trimethoprim- sulfamethoxazole, norfloxacin, ciprofloxacin, or levofloxacin for days Treatment of Complicated UTIs trimethoprim- sulfamethoxazole, 160 to 800 mg 12h; norfloxacin, 400 mg 12h; ciprofloxacin, 500 mg 12h; levofloxacin, 500 mg/day. ciprofloxacin, 400 mg 12h; levofloxacin, 500 mg/day; gentamicin, 1 mg/kg 8h; ceftriaxone, 1 to 2 g/day; ampicillin, 1 g 6h; imipenem- cilastin, 250 to 500 mg 6-8h; ticarcillin- clavulanate, 3.1 g 6h; and aztreonam, 1 g 8-12h

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