You can ask a DOCTOR a question and get a FREE ANSWER by filling out a special form on OUR SITE, using this link >>>

Differential diagnosis of pyelonephritis - methods of diagnosis

Pyelonephritis is a widespread disease that is not so easy to diagnose. It is easily confused with appendicitis or acute cholecystitis, and also with some infectious diseases(flu, sepsis, etc.). Differential Diagnosis pyelonephritis allows you to identify the disease at an early stage, and, therefore, start treatment as soon as possible.

What is pyelonephritis?

Pyelonephritis is a urological disease. This inflammatory process affects the pelvicalyceal system of the kidney. There are three stages of the course of the disease: acute, chronic and chronic with exacerbation. The acute stage is of two types: acute serous pyelonephritis and purulent. Pyelonephritis is the most common kidney disease. Girls and young girls are most susceptible to it.

There are several reasons for the development of the disease and its transition to the chronic stage:

1. Advanced diseases urinary tract: nephroptosis, urolithiasis, prostate adenoma, etc.
2. Complications after acute pyelonephritis or improper treatment
3. Reproduction of bacteria that were in the kidneys for a long time in a passive state and became more active with a decrease in immunity
4. Related chronic diseases: obesity, diabetes, gastrointestinal diseases
5. State of immunodeficiency
6. Cystitis, pregnancy.

Types of disease and their qualification

Pyelonephritis is classified according to different criteria.

1. By place of education: one-sided and two-sided
2. By pathogenesis: primary and secondary
3. By the presence of complications: complicated and uncomplicated

4. Other forms: pyelonephritis of senile age, childhood pyelonephritis, calculous, generic and postpartum, pyelonephritis on the background of the lesion spinal cord and diabetes.

The complicated stage of the disease is expressed in severe kidney damage, an abscess may occur, an increase in the kidneys, or the formation of gas in the kidneys. All complications can be detected by computed tomography. The chronic course of the disease occurs after the acute stage or after repeated infection of the kidneys. The diagnosis of pyelonephritis is a very serious disease, and careful verification and extensive research are needed to confirm it.

Symptoms of the disease at different stages

The chronic course of the disease may not have clear symptoms for years. Its manifestation depends on the stage of the inflammatory process and its activity. At initial stage latent pyelonephritis, clinical symptoms may be completely absent, only a slight increase in the number of leukocytes can be detected with a blood test. Active leukocytes speak in favor of polynephritis. Children may experience pain when urinating, a slight increase in body temperature and fatigue. These symptoms are not easy to detect. Other signs of illness: weakness and malaise, headache in the morning, chills, dull pain in lumbar, skin pallor.

In the later stages of the disease, all symptoms only increase. An unpleasant taste is observed in the mouth, especially in the morning, stool disturbances begin, flatulence increases. Poor kidney function leads to dry mouth, constant thirst. The skin becomes yellowish. Anemia and arterial hypertension may appear, and shortness of breath also appears.

How to diagnose a disease?

With pyelonephritis, diagnosis often takes a long time. The main role in the correct and timely diagnosis is played by a complete anamnesis. To make a diagnosis, you need to find out if the patient suffered kidney or urinary tract diseases in childhood. For women, it is important whether cystitis or acute pyelonephritis was transferred during pregnancy. In men, spinal injuries, diseases of the genitourinary system and urethra play an important role. Also important factors that predispose to the onset of the disease: diabetes, prostate adenoma, nephroptosis and others.

When calling an ambulance medical care you need to tell the doctor about all the symptoms and complaints, even those that seem insignificant. X-ray, radioisotope methods and laboratory tests will help diagnose pyelonephritis. Ultrasound is also important.

A general urine test is not enough to establish the correct diagnosis. Leukocyturia will help according to the Kakovsky-Addis method, which determines the content of leukocytes in daily urine. If pyelonephritis is suspected, all patients are given a sick leave.

The formation of the diagnosis will be faster if an X-ray examination is performed. Here are important the following symptoms: change in the size and contours of the kidneys, Hodson's symptom, change in the shape of the pelvicalyceal system.

Also, if pyelonephritis is suspected, urography is needed. Excretory research is the main method in X-ray diagnostics of this disease. In the chronic course of the disease, asymmetry of the kidneys and a decrease in their function will be expressed. There are also various deformations of the cups. Difficult questions in the diagnosis will also help to solve radiodiagnosis acute pyelonephritis.

Features of differential diagnosis

Differential diagnosis of acute pyelonephritis is difficult because the disease must be differentiated from tuberculosis of the kidneys and many other diseases similar in symptoms. When examining urine, you need to pay attention to the following factors:

1. Changes in urine sediment may be absent during the first days of illness in hematogenous pyelonephritis.
2. In the urine, pathological elements can be determined if the patient suffers from an acute purulent disease. It can also be caused by the localization of another inflammatory process.

Acute pyelonephritis

Causes of acute pyelonephritis:

The development of pyelonephritis is always associated with infection. At present, the possibility of the occurrence of acute pyelonephritis and its purulent forms in the presence of an infectious focus of any localization in the body has been proven. The causes of acute pyelonephritis can be: influenza, scarlet fever, furunculosis, bronchitis, typhoid fever, chronic tonsillitis, septicopyemia, osteomyelitis, etc.

The most common causative agents of acute pyelonephritis are Escherichia coli and para-Escherichia coli. Among other microorganisms in the development of pyelonephritis, staphylococci, streptococci, Pseudomonas aeruginosa, enterococci, gonococci, salmonella, mycoplasmas, proteus, viruses, fungi such as Candidia, etc. are important.

The presence of a large number of anastomoses between the lymphatic tracts colon, appendix and ureters causes a lymphogenous pathway for the development of pyelonephritis in intestinal diseases. Allergy plays a well-known role as a predisposing factor in the genesis of the disease.

Pathological anatomy of the kidneys:

The kidneys are slightly enlarged, swollen, full-blooded; the capsule is easy to remove.

The mucous membrane of the renal pelvis is inflamed, edematous, ulcerated in places. The pelvis is often filled with inflammatory exudate. Multiple abscesses are sometimes found in the cortical and medulla of the kidneys. The interstitial tissue of all layers of the kidney is infiltrated with leukocytes. The tubules are in a state of dystrophy, their lumens are clogged with cylinders of mucous epithelium and leukocytes. In some cases, purulent fusion of the renal tissue predominates.

Symptoms of acute pyelonephritis:

Signs of acute pyelonephritis vary depending on the form and course of the process. Serous pyelonephritis proceeds more calmly. Rapid clinical manifestations are characteristic of patients with purulent pyelonephritis.

Pyelonephritis and cystitis

There is no woman in the world who has not experienced at least once a strong and burning pain when urinating. According to statistics, there is no person who did not complain of back pain or did not suffer from kidney disease. Diseases of the urinary system occupy the first place among the popular pathologies of our century. It is the genitourinary system that suffers primarily from a fast-paced lifestyle, from lack of sleep, malnutrition and constant stress.

Among the known pathologies are cystitis and pyelonephritis. In order not to suffer, or rather, not to get sick with these diseases and, most importantly, to prevent their transition to the chronic stage, you need to arm yourself with information and start the treatment process and preventive measures in time. So what are these pathologies?

General presentation of diseases of the urinary system

An infectious-inflammatory process of the mucous layer of the bladder with a symptomatic picture of burning in the urethra, frequent and scanty urge to urinate is called cystitis. A wide variety of endogenous and exogenous factors cause inflammation of the mucosa. The most common infectious agents are coccal flora, rarely E. coli and opportunistic fungal infection. Inflammation can provoke severe hypothermia or poisoning with poisons.

In cystitis, the lining of the bladder becomes inflamed.

Pyelonephritis is a pathology of the kidneys, namely inflammation of the renal calyces and pelvis. This disease is divided into two types: acute and chronic. And also divided into single-sided and double-sided type. Each form is characterized by a specific symptomatology. Clinical manifestation each form has its own picture. According to statistical studies, women are more likely to suffer from pyelonephritis. Their anatomical design differs from the male urinary system. Women have a short urethra, it contributes to the rapid infection of the bladder. Further, in an ascending pattern, it allows the inflammatory agent to move up the ureters to the kidneys.

Causes of diseases of the kidneys and bladder

For cystitis to occur, there must be two factors: an infectious agent and certain conditions. What exactly are agents? Infectious pathogens are of microbial, viral and toxic origin. Staphylococci, streptococci, gonococci, opportunistic fungi, Klebsiella and chemical poisons or toxins of infectious diseases such as hepatitis, salmonellosis, brucellosis, botulism and many other diseases are indirect agents that cause inflammation of the bladder mucosa.

Pathogenic microorganisms are the direct cause of pyelonephritis

Indirect causes include chronic diseases of internal organs. And the conditions for the development of the disease include a sharp hypothermia of the body, reduced immunity and an increased allergological barrier.

The list of factors predisposing to the development of pyelonephritis includes the above infectious agents that cause bladder inflammation. This explains close relationship between these pathologies of the urinary system.

5072 0

Chronic cystitis rarely occurs as an independent disease and in most cases is secondary, i.e. complicates existing diseases of the bladder, urethra, kidneys, genital organs (stone, diverticulum, bladder tumor, prostate adenoma, urethral stricture, phimosis, sclerosis of the bladder neck, neurogenic bladder dysfunction, chronic pyelonephritis). In this regard, with a protracted course of the inflammatory process in the bladder, one of the above reasons should be sought, as well as the specific nature of the inflammatory process (tuberculosis, Trichomonas invasion, schistosomiasis, etc.) should be excluded.

With chronic cystitis, all Clinical signs diseases are the same as in acute, but less pronounced.

As a result of a protracted, recurrent inflammatory process in the bladder, children often experience relapses of urethritis, fibrosis and sclerosis of tissues occurs with destruction of elastic fibers in the affected areas, which leads to a violation of the elasticity of the urethral wall. In advanced cases, stenosis of the wall of the distal urethra occurs, which aggravates the severity of the infectious and inflammatory process in the bladder.

The occurrence of a turbulent flow of urine in case of violation of its passage at the level of the distal urethra creates conditions for retrograde reflux of microorganisms from the distal urethra into bladder, which leads to frequent recurrences of the chronic inflammatory process in it. Narrowing of the distal urethra in girls may be congenital.

The presence of chronic inflammatory infiltration and edema of the own layer of the mucosa, submucosa and muscular membranes in the region of the vesical triangle and the neck of the bladder with involvement in the pathological process of the orifices of the ureters and their intramural sections, in combination with an increase in intravesical pressure, create conditions for dysfunction of the closing apparatus of the vesicoureteral fistula and as a result - for the development of vesicoureteral reflux. The latter is detected in every fourth child with cystitis.

Based on clinical and laboratory, endoscopic, radiological and radioisotope research methods, sick children can be divided into two groups:

1) with chronic cystitis without complications;

2) with chronic cystitis and complications (vesicoureteral reflux, pyelonephritis, stenosis of the distal urethra, etc.).

For children of the first group, indications in the anamnesis of a short-term occurrence of dysuria and pyuria after an illness - tonsillitis, acute respiratory disease, pneumonia, etc. urine and enuresis. Often children complain of pain in the abdomen when urinating.

Children of the second group are characterized by the sudden appearance of frequent painful urination, the presence of pain in the abdomen, lumbar region, fever. Through various periods - from 1 to 6 years - from the onset of the disease, the main symptoms in the clinical picture are often recurring pain in the abdomen and lumbar region, accompanied by fever. During the period of diseases with intercurrent diseases, pyuria intensifies.

Diagnostics acute cystitis does not present great difficulties and is based on the symptoms listed above: pain, dysuria, pyuria, terminal hematuria. On palpation of the bladder, there is tenderness in the suprapubic region. The diagnosis is confirmed by laboratory data (a large number of leukocytes in the middle portion of urine). Cystoscopy, as well as the introduction of any instrument into the bladder, is contraindicated in acute cystitis, since this procedure is extremely painful and fraught with the progression of inflammatory complications.

In recognizing chronic cystitis, cystoscopy is essential. It allows you to establish changes in the mucous membrane of the bladder, and in some cases, the causes that support the infection. In chronic cystitis, an X-ray examination of the kidneys and upper urinary tract is mandatory.

Differential Diagnosis

In children with suspected acute cystitis, differential diagnosis with acute appendicitis should be made, especially often in the pelvic location of the appendix. It should be noted that in most cases acute appendicitis accompanied by nausea or vomiting, fever, tachycardia, with rectal examination there is a sharp pain, blood tests reveal leukocytosis.

It is advisable to differentiate acute urinary retention in boys with acute cystitis with stones of the bladder and urethra. Data of anamnesis, ultrasound and X-ray examinations in most cases allow to establish the correct diagnosis.

The rapid improvement of the patient's condition under the influence of antibacterial treatment and the typical clinical picture make it easy to establish the diagnosis of acute cystitis. In cases where the inflammatory process in the bladder is difficult to treat and the disease takes on a protracted, chronic nature, it is always necessary to find out the cause of this or differentiate chronic cystitis from other diseases: tuberculosis, simple ulcers, schistosomiasis, bladder cancer, prostate cancer. Factors predisposing to the development of chronic inflammation of the bladder can be benign prostatic hyperplasia (adenoma), bladder stones, bladder diverticulum, its neurogenic dysfunction, urethral stricture, etc.

Tuberculosis of the bladder can be recognized by a characteristic cystoscopic picture (tuberculous tubercles, ulcers, scars), the detection of Mycobacterium tuberculosis in the urine with its persistently acidic reaction, and characteristic radiographic changes in the kidneys and urinary tract. With cystoscopy, a tumor of the bladder is not always possible to differentiate from the inflammatory process. In these cases, it is necessary to carry out a course of dibunol instillations into the bladder (10 ml of a 10% emulsion per day for 10-12 days) to relieve perifocal inflammation, after which the recognition of a bladder tumor during cystoscopy is facilitated.

Endovesical biopsy plays an important role in differentiating chronic cystitis (especially granulomatous) and bladder tumors. Inflammation of the bladder, which has developed as a result of the presence of a stone in it, is accompanied by an increase in pain and dysuria during movement and a decrease in them at rest. With benign prostatic hyperplasia (adenoma), the improvement in urination is more pronounced at night. Chronic cystitis with neurogenic dysfunction of the bladder or severe infravesical obstruction is accompanied by the presence of residual urine, which is easily determined by ultrasound scanning of the bladder before and after urination.

Lopatkin N.A., Pugachev A.G., Apolikhin O.I. and etc.

• Primary diagnosis of cystitis
• Criteria for diagnosis and differential (distinctive) diagnosis of cystitis
• Laboratory diagnostics
• Bacteriological research methods
• Instrumental diagnostics

Inflammation of the mucous, submucosal or muscular layers of the bladder of infectious etiology is called cystitis. This urological disease is one of the most common and its signs are observed by specialists at least once in a lifetime in more than half of the female population. For men, the symptoms of cystitis go almost unnoticed, and the lives of women can turn into real torment, and this, unfortunately, is not uncommon.

Primary diagnosis of cystitis

At the very beginning of the disease, both women and men are concerned about such symptoms as:

• Pain in the pelvis.
• Frequent urination in small portions (up to 20 ml) with a feeling of pain.
• Rise in temperature to subfebrile norms.
• Feeling of incomplete emptying of the bladder.
• There may be bloody inclusions in the excreted urine.

When interviewing patients, an experienced specialist pays special attention to the circumstances that caused such problems:

• Has there been hypothermia?
• Are frequent changes of sexual partners possible?
• Has the patient been exposed to recent times stress.
• What illnesses he suffered shortly before the first symptoms appeared, what medications and procedures he took.

To clarify the diagnosis of acute cystitis, a laboratory analysis is immediately prescribed - microscopy of the urinary sediment. If, as a result of a urine test, an increased content of leukocytes and bacteria is detected, they speak of a disease such as acute inflammation of the bladder.

Criteria for diagnosis and differential (distinctive) diagnosis of cystitis

Features of the structure of the urinary canal in women, the closely located vagina and anus contribute to infection of the bladder. The disease can very often appear against the background of existing colpitis, vulvitis, urethritis, which are caused by:

• Coccal flora (streptococci, staphylococci, Escherichia coli).
• Candida.
• Gardenerella.
• Mycoplasmas.
• Chlamydia.
• Trichomonas.

In women, during the bearing of a baby, the disease can occur against the background of hormonal changes occurring in the body of the expectant mother and due to changes in the microflora of the urethra and genital organs. The bladder in men becomes inflamed with sexually transmitted problems, this is often associated with the presence of gonorrhea.

In girls, cystitis most often develops when:

• The appearance of menstruation.
• Avitaminosis.
• Wearing synthetic underwear and miniskirts in cold weather.
• Weakening of immunity against the background of frequent SARS.

Older people are also prone to this problem, most often the cause is:

• Foci of inflammation in nearby organs - the prostate, uterus and appendages.
• dishormonal disorders.
• Hypothermia.
• Failure to comply with the rules of hygiene of the genitals.
• Immunodeficiency and avitaminosis.
• Irregular emptying of the bladder.

Diagnosis of cystitis is a complex of studies, which consists of visits to specialists, studies of biomaterials, and instrumental examinations.

The treatment is carried out by a specialist - a urologist and family doctor, to clarify the diagnosis in women and conduct effective treatment, it is necessary to visit a gynecologist.

Laboratory diagnostics

Early diagnosis of cystitis is timely laboratory tests, they are highly accurate, their results play an indispensable role in effective treatment. An experienced specialist will immediately write out a referral to the patient for:

• Clinical analyzes of urine and blood.
• Urine analysis according to the Nechiporenko method.
• A smear on the microflora of the vagina and urethra.
• Biochemical study of venous blood for the renal complex.
• Bacteriological culture of urine.

The biomaterial for a general blood test is capillary blood (from a finger), the selection is carried out directly in the laboratory from 8 to 10 o'clock, it is advisable for the patient not to have breakfast and not to smoke. To obtain reliable results on the eve of the study, it is important to follow some simple rules:

1. The day before the analysis, cancel training in the gym.
2. It is advisable to refrain from sexual intercourse.
3. Dinner should be no later than 21 hours, do not overeat and do not take alcohol.

In acute cystitis, there will be no special changes in the general blood test, they can appear with more serious problems - cancerous tumors of the bladder and uterus, urolithiasis, venereal diseases, kidney diseases.

Urine collection for analysis is carried out in the morning, after waking up from the first urination:

1. Before delivery, carry out hygiene measures, it is advisable for women to close the entrance to the vagina with a napkin - it is necessary to avoid getting secretions and epithelium into the urine.
2. Use a clean container designed for analysis (jars from mayonnaise, sauces, baby food can store protein deposits on the walls - this will affect the result).
3. The first portion should be urinated into the toilet, the middle one should be collected in a container for urine, the last portion should be released into the toilet.
4. The biomaterial must be delivered to the laboratory no later than 2.5 hours after sampling.

Urine with acute cystitis becomes cloudy and may have a pink color (in the presence of red blood cells in it), with an admixture of pus (due to an increase in the content of leukocytes in the urine) - this is an indicator of inflammation. The Nechiporenko method will allow you to determine the exact amount of 1 cu. mm of urine of erythrocytes, cylinders and leukocytes - this affects the degree of inflammation in the disease.

Diagnosis of cystitis in men is based on a mandatory visit to a specialist - a venereologist, he will conduct additional examinations and, if a problem is identified, prescribe a comprehensive treatment.

Bacteriological research methods

Sowing urine on cultural media helps to identify the etiology of the inflammatory process, the genus of microbes - pathogens and determine the antibacterial drug that can effectively neutralize them, this is a very valuable advantage of bakposev.

When examining women, a gynecologist takes a swab from the urethra and vagina for the presence of pathogenic microorganisms, if necessary, the patient can be referred for a consultation with a dermato-venereologist.

To obtain accurate results, it is very important to properly prepare for the study:

1. The test is carried out before the appointment of all antifungal and antibacterial agents.
2. For two days it is desirable to avoid sexual contact.
3. Women are recommended to take an analysis on the 6th day of the cycle.
4. In the evening on the eve of taking a smear, you need to wash yourself only with warm water, do not use the toilet in the morning.
5. Three hours before the examination, you should try not to urinate.

If an infection is detected that is transmitted during sexual intercourse, treatment must be taken by both partners.

Instrumental diagnostics

In the diagnosis of recurrence of the disease, an important role is played by:

• Cystoscopy is a study using an endoscope, during the procedure, a morphological examination of the walls of the bladder is performed, tumors, ulcers, fistulas, foreign bodies, and urinary stones can be detected. If necessary, a biopsy is performed during the examination.
• Cystography is an x-ray examination, it is carried out in order to obtain an image of the bladder on an x-ray. The test is carried out by filling the organ with an X-ray contrast agent to evaluate its shape, size and position.
• Ultrasound is prescribed in order to exclude kidney and genital diseases in women, it also shows the presence of urinary stones, damage and changes in the size of the bladder.

These diagnostic methods help in making an accurate diagnosis and exclude other possible concomitant diseases.

Cystitis, like many other diseases, is very easy to prevent. To this end, it is recommended:

• Timely identify and eliminate factors that can cause this problem.
• Follow the basic rules of intimate hygiene.
• Don't get cold.
• Use protective equipment during sex.

It is very important to refuse self-diagnosis and self-treatment. These tips will help you deal with difficult situations.

You can learn more about the diagnosis and treatment of cystitis from the video:

See also: cystitis after sex
antibiotics for cystitis
Canephron for cystitis - read here.

Complications and treatment of hemorrhagic cystitis

What is the difference between a typical inflammation of the bladder membrane, familiar to every woman since childhood, and hemorrhagic cystitis? The main symptom of the latter is hematuria (bloody discharge in the urine with cystitis at the time of urination). This means that the mucosal surface urothelium is significantly damaged, the destructive process has spread to the endothelium of microcapillaries.

Up to 150 million people are affected by urinary tract infections each year. According to medical statistics, this disease develops more often in women, especially during menopause, when the protective barrier of the vaginal microflora is lowered due to the deterioration of the hormonal background.

Hemorrhagic cystitis also occurs in newborns. In most cases, this is due to urogenital infections that the mother did not cure in time.

Perhaps the development of cystitis with blood and after the use of medications, especially in high dosages. For example, when transplanting bone marrow such complications develop when prescribing Ifosfamide and Cyclophosphamide.

Prerequisites for the development of the disease

The infectious and non-infectious nature of the hemorrhagic form of cystitis is distinguished.

Its bacterial variety occurs after penetration into the urinary tract of Escherichia coli, staphylococci, Proteus bacillus and other pathogenic flora. Penetrating into the cells, aggressive microorganisms colonize the urinary tract. The nutrient medium for them is iron compounds, which they extract from the biomaterial. As a result of their vital activity, toxins are produced that provoke inflammatory reactions.

In women, hemorrhagic cystitis can also be caused by mycoplasma, Trichomonas, chlamydia, gonococci. The primary form of fungal cystitis is not so common: it is usually associated with the consequences of therapy for the bacterial type of cystitis. With the suppression of the vaginal microflora with antibiotics, a fungal infection such as Candida and lactobacilli feel comfortable.

Inflammation of the prostate may cause cystitis with blood in men of mature age. Infection can be provoked by illiterate catheterization of the bladder, damaging its membrane.

Cystitis with blood of a viral nature, like SARS, in children, including newborns, is due to the activation of adenovirus or polyomavirus BK. In a "sleeping" form, these infections remain in the genitourinary system and tonsils for life.

Activation of "dormant" viruses occurs due to a failure immune system with AIDS or immunodeficiency in infants, pregnant women and in adulthood. Using medicines that suppress the immune system (for example, during bone marrow transplantation), its reactivation can also occur. Especially often hemorrhagic cystitis is diagnosed in children after such operations.

According to doctors, a chronic form of pathology of non-bacterial origin occurs when there are stones in the bladder cavity. Calculi injure the shell, and acidic urine corrodes the damage even deeper. This form of cystitis our urologists gave the name "ulcerative".

Not related to infectious etiology and radiation cystitis, as well as a chemically induced form. Radiation inflammation of the mucous membrane of the urinary system occurs as a result of irradiation malignant tumors pelvic organs. Radiation therapy provokes damage to the DNA chain, followed by activation of genes for the repair of breaks. Radiation also penetrates into the deeper layers of the bladder, worsens the elasticity of blood vessels.

Cystitis with blood in women occurs after douching with the penetration of drugs for intravaginal use: vaginal candidiasis, methyl violet antiseptic, spermicidal agents.

Who is at risk

The probability of earning such a complex form of cystitis is primarily associated with the state of the immune system. Other common factors include:

In children, the risk of infection of the urinary system occurs with abnormal progression of urine (vesicoureteral reflux) and constipation.

How to recognize cystitis with blood

You can think of this form of cystitis already with symptoms of pollakiuria, when going to the toilet becomes more frequent, and the volume of urine decreases. In parallel, constant false urges to defecate appear, and the night in this regard is no exception. An attempt is accompanied by burning and acute pain, most pronounced in the final stage. Later, other signs join:

Problems arise not only in the small pelvis: appetite worsens, the temperature may rise, the fever is accompanied by fever and weakness.

Complications from an untreated disease

The consequences of hemorrhagic cystitis, regardless of the reasons that provoked it, are expressed as:

Features of diagnostics

Primary diagnosis is carried out by urologists. With cystitis in women, it is necessary to visit a antenatal clinic. The study is carried out in the form of the following stages:

Instrumental examinations are also prescribed: ureteroscopy, cytoscopy, ultrasound examination of the small pelvis. In order to clarify the state of the muscular layer of the organ, in the chronic form of pathology, urodynamics is studied using uroflowmetry or electromyography.

In addition to the general examination, differential diagnosis is also carried out so as not to confuse the symptoms of cystitis with blood with hematuria, which occurs with urethritis (inflammation of the urinary tract).

Similar symptoms occur in other diseases:

1. Neoplasms in the bladder and urinary tract;
2. Prostate adenoma - for men;
3. Endometriosis - for women;
4. Glomerulonephritis;
5. Pyelonephritis;
6. Polycystic kidney disease.

How to treat cystitis with blood medication

Complex therapy is designed to eliminate the cause of the development of inflammation and alleviate the symptoms of the disease. With the bacterial nature of cystitis, antibiotics are prescribed, the most active are the class of fluoroquinols such as Norfloxacin and Ciprofloxacin. These drugs are produced under various trade names: Tsiploks, Tsiprobay, Urobacil, Tsiprolet, Tsiprinol, etc.

Norfloxacin is generally recommended for the 1st tab. (400 mg) for 7-14 days. Multiplicity of reception - 2 rubles / day. Among the undesirable consequences after taking an antibiotic are a deterioration in appetite, dyspeptic disorders, a violation of the rhythm of defecation, and weakness. The drug is contraindicated in renal dysfunction, in childhood(up to 15 years) and during pregnancy.

The bactericidal capabilities of Ciprofloxacin are more pronounced. The drug is released in the form of tablets or vials with a solution for infusion. The standard dose is 0.25-0.5 g 2 times a day. In severe cases, the drug must be administered parenterally.

Contraindications for the drug are similar to Norfloxacin, and unforeseen consequences are in the form of skin allergies, epigastric pain, dyspeptic disorders, a decrease in the level of leukocytes and platelets in the blood, photosensitivity (increased sensitivity to ultraviolet radiation).

The antibiotic Fosfomycin (trade names - Monural, Fosmycin, Ecofomural) is also used for cystitis with blood. Its effectiveness is due to the concentration in the renal tissues active substance fosfomycin trometamol.

They release the medicine in granules, which must be dissolved in half a glass of water. Take the medicine at 300 mg 1 rub. / Day. 2 hours before meals. For children, this remedy is prescribed only after 5 years. Dosage - 200 mg 1 rub / day. Adverse events, in accordance with the instructions, are heartburn, dyspepsia, urticaria, upset stool.

Additionally, with hemorrhagic cystitis, treatment with suppositories with analgesic, antibacterial, anti-inflammatory effect is prescribed.

If hematuria does not disappear even after removal of the thrombus, irrigation with silver nitrate preparations or Carboprost is continued. In severe situations, formalin (3-4% solution) is used intravesically. It is dripped after anesthesia, with cystoscopic control. After the procedure, the cavity is thoroughly irrigated.

In complex therapy, medicines with hemostatic capabilities are also used: aminocaproic and tranexamylic acids, Dicynon (inside), Etamzilat (injections). In complex therapy, it is mandatory to take vitamins C and K.

In the radiation form of the pathology, physiotherapy is prescribed: hyperbaric oxygenation, which stimulates immunity at the cellular level, restores the mucous membrane of the bladder cavity, helps to reduce the lumen of the vessel and eliminate bleeding with oxygen.

Surgical treatments

If instillation (irrigation) of the bladder with a catheter is not possible, the blood clot is removed using an endoscope. Cytoscopy is performed under anesthesia, the effect is fixed with antibiotics. In parallel, to eliminate bleeding, hemorrhagic zones are cauterized by electrocoagulation or argon coagulation.

The operation is usually prescribed for the refractory form of hemorrhagic cystitis (in cancer patients). In addition to the listed methods of surgical intervention, selective embolization of the artery (its hypogastric branch) is used.

If the bladder is severely deformed, many scars and ulcers are found on the walls, the organ is removed (cystectomy). Urine in this case is diverted through the ileum or sigmoid colon or with the help of percutaneous ureterostomy.

According to surgeons, the removal of the organ is advisable only in special cases, because the operation is prescribed for debilitated patients who have undergone chemotherapy and radiation. Mortality and serious complications, unfortunately, are practically guaranteed.

Alternative therapy

Phytotherapy is more often used in the bacterial type of the disease. Cystitis with blood does not involve treatment at home, and even quickly, so the doctor will insist on hospitalization.

For increased diuresis and relief of inflammation, infusions are used. medicinal herbs with a diuretic effect: succession, horsetail, harrow, clover, wheatgrass, nettle, corn stigmas. To prepare the medicine, it is necessary to prepare raw materials (1.5 tablespoons) and water (0.5 liters). Keep on low heat after boiling for 10 minutes. Drink a decoction after cooling, 100 ml. Multiplicity of reception - 3-4 rubles / day.

From medicinal plants, which are used for inflammation, recommend lingonberries, bearberry, juniper, yasnotka. For a decoction, you need to take one part of each type of raw material and mix. For one dose, a tablespoon of the collection and 3 cups of boiling water are enough. After insisting, you can drink a glass of healing tea 3 rubles / day. The course of treatment is 8-10 days.

Prevention of cystitis and prognosis

Prevention of infection of the genitourinary system and timely diagnosis of urogenital infections with subsequent treatment will be a good prevention of hemorrhagic cystitis, but such measures will not be able to protect 100% from non-infectious cystitis.

They try to prevent complications in cancer patients during chemotherapy with the help of the parallel use of Mesna. But if hemorrhagic cystitis has already been identified, the remedy is powerless. The toxicity of oncological drugs reduces the drug Amifostine.

In any case, for the prevention of all types of cystitis, it is necessary to strengthen the immune system, fight bad habits, and follow a diet. Its main principles:

Heat treatment should exclude frying, smoking, salting, canning.

The prognosis for the treatment of inflammation of the bladder, accompanied by hematuria, is associated with the causes of the development of the disease, competent and timely diagnosis, adequate therapy and the general condition of the patient's body at the time of treatment.

Should I go to the doctor for cystitis? Professor E. Malysheva advises on video.

The bladder is a hollow organ, it has several parts: the bottom, body and neck. The neck of the bladder passes into the urethra. At the bottom, the ureters open into the bladder. The bladder is located on the urogenital diaphragm. In women, the uterus and the upper part of the vagina are adjacent to it behind. In men, behind the bladder are the seminal vesicles, the ampulla of the vas deferens, and the rectum. The prostate gland is adjacent to 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 with a mucous membrane lying on a submucosal base, followed by the muscular and outer adventitial membrane. The serous membrane covers only the bottom of the bladder. The empty bladder has a thick wall, the mucous membrane is collected in numerous folds. In the stretched state, the mucous membrane becomes thinner, has no folds. The structure of the mucous membrane ensures its ability to remain intact in the presence of a rather fluid - urine - in the cavity of the bladder.

The transitional epithelium lining the inside of the bladder cavity in an extended state resembles a stratified squamous non-keratinized epithelium. In this case, the cells do not move apart, as they are connected by tight contacts and desmosomes, which prevent the penetration of urine 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 bladder mucosa, fused with the submucosa, is richly supplied with blood and lymphatic vessels, and the small vessels are so close to the epithelium that it seems they penetrate into 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 the Lieto triangle. The top of Lieto's triangle is directed to the internal opening of the urethra, and at the corners of its base there are 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 membrane, consisting of smooth muscle tissue. In the muscular membrane, three unsharply limited layers are distinguished, intertwined with each other. The inner and outer layers have longitudinally arranged muscle fibers. In the middle, most developed layer of the muscular membrane, the muscle fibers go circularly and form the sphincter of the bladder neck in the region of the internal opening of the urethra. Layers of loose fibrous connective tissue that separate individual muscle bundles and layers of the muscular membrane pass into the outer adventitia of the bladder.

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

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 amount of fluid drunk, the filtration function of the kidneys, and on various mental phenomena. The bladder is able to retain 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 receipt. Slowly flowing urine can be retained by the bladder for a longer period of time than fast flowing urine. This feature is due to the muscular membrane 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 is able to hold 200 to 400 ml of urine. The volume of urine retained depends on the sex and age of the individual. Women have less bladder capacity than men. In old age, the ability of the muscles of the bladder to contract decreases. As a result, the capacity of the organ increases.

A healthy person urinates about five times a day. Frequent urination (polyuria) may be due to either increased daily amount urine due to increased drinking or cold weather, or from some metabolic disease (diabetes mellitus or diabetes insipidus), or from diseases of the kidneys, renal pelvis, 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 thus depriving him of sleep.

The normal daily amount of urine in men is approximately 1.5 liters, in 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 be 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.

At normal condition 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 retention of urine in the bladder may depend on the muscles of the urogenital diaphragm, the state of the anterior abdominal wall, muscles of the urethra. So, in older women with flabby muscles, slight straining when coughing, sneezing, 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 which enters it, that is, it does not absorb water, mineral and organic substances.

The development of the bladder comes from blind outgrowths that are laid at the confluence of both wolf ducts into the cloaca. Bookmark to the seventh week lined with multilayer 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 fusiform shape. In the second year of life, this shape is smoothed out and it becomes round, taking the form of an adult by the age of 15-17.

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

Several tubular unbranched glands are found in the region of the bubble triangle. 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 as dense epithelial bands in the mucosa or secretion-filled small cavities in the epithelium. There are also transitional forms between these formations. In adults, glands are not always found.

The musculature of the bladder is actively growing from the age of 6. The sphincter reaches its development by the age of 12.

CYSTITIS

Cystitis is called acute or chronically current 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, due to which patients turn to emergency and emergency medical doctors, general practitioners, urologists, gynecologists, and sometimes surgeons. Women get sick more often, which is associated with the anatomical, morphological and hormonal characteristics of their body.

Cystitis can be primary, i.e., occur initially in a healthy organism, and secondary, i.e., 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 is more common in young women. Secondary cystitis mainly affects older men, who tend to develop prostate adenoma. As a consequence of this, urinary retention occurs, and then instrumental studies, catheterization, and cystoscopy are carried out. 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 neck of the bladder is involved in the inflammatory process, cervical cystitis develops, and the bladder triangle develops trigonitis. 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.

Distinguish between infectious and non-infectious cystitis. Cystitis of non-infectious origin occurs when the mucous membrane of the bladder is irritated by chemicals excreted in the urine, including drugs with their long-term use in high doses, with burns of the mucous membrane, for example, if a concentrated solution of a chemical is injected into the bladder, as a result of washing bladder with a solution whose temperature exceeds 45 ° C (burn cystitis), if the mucous membrane is damaged foreign body, urinary stone, as well as in the process of endoscopic examination, with 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. With cystitis of an infectious nature, which are much more common than cystitis of non-infectious genesis, pathogens are more often Escherichia coli, staphylococcus aureus, streptococcus, enterococcus and Proteus vulgaris, sometimes gas-producing microorganisms.

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

The causative agents of cystitis can be tuberculosis mycobacteria and rarely - pale treponema - the etiological factor of syphilis.

PATHOGENESIS AND PATHOLOGICAL ANATOMY OF CYSTITIS

Infectious cystitis can occur in ascending, descending, hematogenous, lymphogenous and contact ways.

The causative agents of infections can penetrate into the bladder ascending in inflammatory diseases of the urethra, prostate, seminal vesicles, testis and its appendages. The descending route of infection most often occurs with tuberculous lesions of the kidney. The hematogenous path of damage to the mucous membrane of the bladder occurs with 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 its catheterization or during cystoscopy. Direct infection of the bladder can occur when there are fistulas connecting the vagina to bladder or vagina with rectum.

The mucous membrane of the bladder has a 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 due to hypothermia, overwork, beriberi, exhaustion, previous diseases, secondary immunodeficiency, hormonal disorders, and surgical interventions.

Of importance are the violation of the outflow and stagnation of urine in patients with prostate adenoma, urethral stricture, with a bladder stone, neurogenic dysfunction of the bladder. The predisposing moment is a violation of blood circulation in the wall of the bladder or pelvis. Changes in the mucous membrane of the bladder with cystitis are recorded during cystoscopy, 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 quite fully describes the cystoscopic picture that develops with cystitis of various etiologies. With cystitis, where coccal flora, E. coli, chlamydia, Trichomonas, mucosal changes will be quite similar, devoid of any specificity. Another thing is with a specific lesion of the bladder with tuberculous mycobacteria, pale treponema and actinomycetes. In these cases, cystoscopic and morphological studies will reveal typical changes.

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

Pathological anatomical 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 one or another amount. 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 form of serous catarrh, mucous catarrh, 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 catarrh. With mucous catarrh, mucus is mixed with the exudate, because of which it takes the form of a thick, viscous mass. In addition, more significant desquamation of epithelial cells is characteristic. With a pronounced desquamation, inflammation is called desquamative.

Purulent catarrh is based on the release of purulent exudate with an admixture of mucus. Such exudate has the appearance of a viscous, cloudy mass of yellowish-gray or greenish-gray color. The mucous membrane of the bladder with purulent catarrh is often subjected to a limited extent of superficial destruction, which leads to the formation of small ulcers, called erosions. The course of catarrhal inflammations is often acute.

With recovery, exudation and mucus secretion gradually stop. 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 passes to the surrounding tissue, purulent pericystitis develops (inflammation of the serous membrane of the bladder) or purulent paracystitis (inflammation of all tissues surrounding the bladder).

In essence, paracystitis can be considered as one of the forms of peritonitis. Acute purulent paracystitis may occur as a consequence of pericystitis. At the same time, one or more abscesses appear in the edematous tissues around the bladder, causing acute diffuse inflammation of the entire fiber. 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. Mucosal ulceration is usually linear. As a result of interstitial cystitis, the bladder shrinks, its capacity decreases. Sometimes catarrh takes a long chronic course. In chronic cystitis, the entire mucous membrane of the bladder is usually involved in the pathological process. It is infiltrated, edematous, thickened, its elasticity is reduced. To a greater extent, especially in women, the region of the vesical triangle suffers. The mucous membrane in the affected areas is moderately hyperemic, loosened with areas of easily bleeding granulation tissue.

In some cases, microabscesses appear in the wall of the bladder, after their opening, ulcers appear. Ulcers of the mucous membrane in chronic cystitis have different sizes, depths and configurations, can be single and multiple. Long-existing ulcers are encrusted with uric acid salts with the occurrence of 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 catarrhs ​​is the weakening of hyperemia, a change in the cellular composition of the exudate with an admixture of lymphocytes, sometimes plasma cells. Tissues are infiltrated by small lymphocytes, pigmentation of the tissue in brown color can be observed. It is the result of the deposition of hemosiderin in the tissue from destroyed erythrocytes, which are released by diapedesis from dilated full-blooded vessels.

Along with pigmentation, atrophy of the mucous membrane is often noted, 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 submucosa 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 moments matters only as a predisposing factor that weakens the resistance of the mucous membrane, but microorganisms are the main cause of inflammation.

Hemorrhagic inflammation in the mucous membrane of the bladder develops in cases where there is an abundant release of red blood cells from 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 than with conventional inflammation, permeability vascular walls. The latter may be due either to the previous state 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 beriberi, especially with a lack of ascorbic acid and rutin, with congenital hemophilia.

In our opinion, the description of the picture of a specific tuberculous lesion of the bladder deserves special attention, since tuberculosis has now become a very common disease. Moreover, the strains of microbes encountered are very resistant to traditional therapeutic methods, and this explains the alertness of doctors to tuberculosis, which has now gone out of the category of social diseases.

Tuberculosis of the bladder is always a secondary process arising from tuberculosis of the kidney. Less often, the infection spreads from the primary foci of tuberculosis of the genital organs. With tuberculosis of the kidney, the process in the bladder begins with focal hyperemia in the region of the mouth of the ureter, a rash of tuberculous tubercles, followed by their ulceration and the formation of deep ulcers and scars. In 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, the multiplication of cells of local origin begins, resulting in focal growth of granulation tissue.

With the naked eye, such growth is perceived as a gray nodule ranging in size from a barely noticeable point to a millet seed. Such nodules are called tubercles, or tubercles. Microscopic examination of the tubercles shows the presence of alteration, exudation, and proliferation, depending on the reactive state of the organism. 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-staining vesicular nucleus. Among the epithelioid cells, delicate argyrophilic fibers or a granular mass of clotted protein exudate are usually visible. In addition, cells of the lymphoid series, macrophages and polymorphonuclear leukocytes are found in the tubercle.

A characteristic feature of the tuberculous tubercle is the presence among the cellular elements of giant cells with numerous nuclei. The nuclei are usually arranged 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, the granulation tissue that makes up them 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, which differ from those described above in that they do not contain epithelioid cells, 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 referred to as the exudative form of tuberculosis.

The third type of tubercles can be represented by focal necrosis of the organ tissue. These are necrotic tubercles, which are the result 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 is relatively short-lived. Soon the central part of the tubercle loses its translucency, becomes opaque, dry and yellowish. It looks like boiled cottage cheese. This process is called cheesy, or caseous, rebirth. The cells of such a tubercle undergo karyopyknosis, karyorrhexis, and then fine-grained, dusty detritus containing the remains of decayed nuclei remains in the area of ​​decayed cells. 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 is preserved for a long time in the presence of a caseously altered center. In lymphoid tubercles, necrosis develops very quickly and in a short time captures 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, gradually replacing cellular elements.

Fibrous connective tissue develops at the site of the tubercle or along its periphery. If fibrous transformations take place in the 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, salts of uric acid may be deposited in the curd mass.

With special staining for tuberculous 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, sometimes they are difficult to detect. In the lymphoid tubercles, they are found in much greater quantities, especially with curdled degeneration of the tubercles. A lot of microorganisms are present in necrotic tubercles. With the spread of the tuberculous process, 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 way from the banal granulation tissue, especially at the beginning of the process. Only by the presence of tubercle bacilli in it can its nature be determined.

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

In some cases, there is swelling of the mucous membrane, the formation of papillomatous outgrowths of the epithelium and the deposition of uric acid salts in the ulcerated areas. In the outcome of the disease, sclerosis of the bladder wall and perivesical tissue may develop. Adhesions are formed with nearby organs, fistulas and cold abscesses appear. The walls of the bladder thicken, are replaced by scar tissue, wrinkling of the bladder occurs, the closing mechanism of the mouth of the ureters is disturbed with the onset of vesicoureteral reflux.

With syphilitic damage to the bladder, which is rare, changes in it are not recorded in the primary period. In the secondary period of syphilis, the lesion of 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 and appear to the naked eye as gray dots or nodules, similar to gray malignant tubercles.

In the case of solitary gumma, the nodes range in size from a pea to a chicken egg. When fresh, solitary gum is a soft gray-pink knot. Milliary gumma has the appearance of a gray dot or it is so small that it can only be detected under a microscope. Later, necrobiotic changes begin in the gumma, leading its tissue to necrosis. At the same time, in some cases, the necrotic tissue undergoes decomposition, turning into a gelatinous, translucent, glue-like mass. More often, the necrosis of gumma 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 the necrosis of the gumma tissue along its periphery, the development of scar-connective tissue occurs. In this period, gumma is one or more nearby foci of dry yellowish curdled mass, surrounded by a thin translucent grayish layer, passing along the periphery into a powerful development of scar connective tissue. Curdled degeneration and necrotic liquefaction of the gum located on the surface of the mucous membrane are accompanied by the separation of the dead mass and the formation of a gum ulcer.

On microscopic examination, the gummas turn out to be composed of granulation tissue containing vessels and built from epithelioid, lymphoid and plasma cells. Often there are giant cells with centrally located nuclei or nuclei located along the periphery of the cytoplasm. In gummas with cheesy 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 strands extending to the sides into the adjacent tissue. In the arteries and veins that occur in the marginal parts of the gumma, and in neighboring tissues, there is a thickening of the walls and a narrowing of the lumen, sometimes until it is completely closed due to the growth of the tissues of the inner shell of the vessel. Gumma, which has undergone a curdled transformation, under a microscope looks like an amorphous, fine-grained, dead mass, but in it, unlike a tuberculous structureless curdled mass, it is always possible to see the outlines of the structure of the tissue that was here, especially the vessels, elastic fibers protrude well.

In some cases, especially with the formation of typical tubercles along the periphery of the gumma, it is extremely difficult to distinguish it from a tuberculous focus. In these cases, it is necessary to 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 already cicatricial transformation of the gumma periphery and the preservation of the outline of the former tissue in the curdled mass of gumma, especially its vessels. Over time, the curd mass gradually resolves and is replaced by scar tissue. As a result of this outcome of 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 scarring gummy ulcers, 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 from round or plasma cells, sometimes with giant cells, can be observed. In the future, 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, capturing the middle and outer shells of the vessel and accompanied by necrosis of the wall. Thrombosis of the lumen of the vessel often joins such a lesion. In other cases, there is a picture of obliterating endarteritis, which is expressed in the growth of the tissue of the inner shell with a narrowing of the lumen, sometimes until it is completely closed. With all changes in the vessel, there is a violation of 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 paravesical tissue. In these cases, in histological preparations among the accumulation of purulent exudate, the growth 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 cone-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. There are also multinucleated giant xanthoma cells. It is not uncommon to find numerous fuchsinophilic Roussel bodies. Among such granulation tissue are small pustules. In each abscess, among the pus, one can see a druse of a radiant fungus.

In the intervals between the pustules and along the periphery of the entire node, the granulation tissue undergoes a gradual fibrous transformation, scarring. In this regard, with actinomycosis, which has some prescription, a strong seal occurs in the affected area from a powerful proliferation of connective tissue. On a section of this tissue, pustules with grains of drusen among 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 there is a spontaneous death of the radiant fungus. In this case, the drusen is surrounded entirely by granulation tissue and giant cells appear directly next to the drusen, which dissolve 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 due not only to trichomoniasis, but also to the accompanying bacterial flora.

Gangrene of the bladder, or gangrenous cystitis, has a severe course, accompanied by high mortality. This type of pathology occurs relatively rarely and is the result of a violation of the blood circulation of the bladder, damage to the central nervous system in diabetes mellitus, or inadvertent 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. Voyno-Yasenetsky (1985). The authors found that mortality from gangrenous cystitis among men is twice as high 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 has an effect on the rejection of necrotic tissues. 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 departs through the short and wide urethra.

If a patient with gangrenous cystitis survives, then after the rejection of dead layers, a hypervascularized red bladder mucosa appears. The muscular layer does not restore its elasticity. She is atrophic, sclerotic. As a result, the bladder is wrinkled, its capacity is greatly reduced. All this is a consequence of 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 occurs mainly in women and is in the nature of a stagnant process. It is based on a circulatory disorder in the region of the vesical triangle and the neck of the bladder with an incorrect position of the uterus or with the prolapse of the anterior wall of the vagina. In some cases, a chronic inflammatory process in the parametrium matters.

Radiation cystitis occurs as a complication of radiation therapy for diseases of the female genital organs, rectum, which develops 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, after several weeks, months, years. In the acute period develops trophic ulcer Bladder. 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 late stages of radiation cystitis, cicatricial and ulcerative changes in the bladder wall are characteristic.

COURSE AND CLINICAL PICTURE OF CYSTITIS

Along 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, pyuria. The intensity of pain during urination increases. 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 act of urination. Due to the frequent imperative urge to urinate, patients are not able to hold urine.

The severity of clinical signs in acute cystitis is different. In some milder cases, patients feel only heaviness in the lower abdomen. Moderately pronounced pollakiuria is accompanied by slight pain at the end of the act 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. At the same time, 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, pain intensifies as urine accumulates, stretching the inflamed mucous membrane. Increased pain at the end of the act of urination is associated with a reduction in the inflamed mucous membrane of the bladder and with the contact of the inflamed surfaces.

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

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

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

The clinical picture of gangrene of the bladder consists of complaints of patients on difficult painful urination, pain in the sacrum, weakness, high temperature. When examining patients, their extremely serious condition is noted, pallor of the skin, subicteric sclera of the eyes. In some cases, acute gangrenous cystitis can develop suddenly and simulate 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 discharge of dead tissue is accompanied by severe pain and difficulty urinating, up to complete urinary retention, more often in men. Nitrogen is determined in the blood, the level of urea reaches high numbers. 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. Successful outcomes are rarely achieved. In some cases, gangrenous cystitis can occur without urination disorders. In this case, the main manifestations of the disease can be high body temperature, pain in the pubic area and perineum, urine smells of sulfur, contains an admixture of blood and small areas of the mucous membrane. If there is a blockage of the internal opening of the urethra with exfoliated necrotic tissues, then urination is difficult or completely impossible. If the etiological factor of gangrenous cystitis is a gram-negative microflora, then a bacterial shock may occur.

Postpartum cystitis occurs due to the peculiarities of the course of childbirth or the transition of infection from the genitals to the bladder. Occurs when E. coli enters the bladder, less often 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 the act of urination, turbidity of the last portion of urine. There is a moderate amount of leukocytes in the urine. Cystoscopy reveals mucosal hyperemia, extravasation, ecchymosis, edema, and vascular injections. The temperature is usually normal. The general condition of patients changes a little. Cystitis is often observed as a concomitant disease in postpartum lesions of the pelvic organs, often occurs 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 in acute cystitis, but less pronounced. Chronic cystitis proceeds 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 proceed 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 a different content of mucus in it. An acid reaction of urine is observed in cystitis caused by Escherichia and tubercle bacillus. 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 not very pronounced. Usually, urination is somewhat frequent, discomfort is noted during the act of urination. There are no changes in the urine. During cystoscopy, the mucous membrane of the bladder triangle is loosened, edematous, slightly hyperemic.

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

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

Bladder syphilis is rare. The clinical picture does not have any clearly expressed specific features. The disease proceeds 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.

The complications of cystitis include the transition of the inflammatory process from the wall of the bladder to the surrounding tissue of the bladder, with the occurrence of paracystitis. In chronic cystitis, microorganisms can penetrate the ascending lymphatic vessels 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 decreases sharply, and dysuric disorders become extremely severe.

DIAGNOSIS

In most cases, the 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 rapid increase in symptoms with their maximum severity in the first days (with acute cystitis) or pre-existing cystitis are important ( with chronic cystitis). Urinalysis reveals objective signs of cystitis 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 side of the rectum and from the side of 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 in the mucous membrane and muscle layers of the bladder and paravesical tissue occur. A pronounced lesion of the bladder wall in gangrenous cystitis occurs with symptoms of shock. Operations to divert urine and remove necrotic tissues, early detection of microbial flora, determination of sensitivity to antibiotics and, accordingly, antibacterial treatment can lead to a decrease in mortality in gangrenous cystitis.

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

With urinogenic downward spread of the process, cystoscopy reveals hyperemia and swelling of the mucous membrane in the region of the mouths of the ureter of the affected kidney, typical small tuberculous tubercles of yellowish color with a corolla 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, simulating a tumor of the bladder. On cystograms in tuberculosis, deformation of the contours of the bladder, bevelling 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 on the basis of the detection of Trichomonas in the second portion of urine. In their absence, the 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 a pale spirochete in the urine. With cystoscopy in the primary period, there are practically no changes in the bladder. In the secondary period of syphilis, there is a picture of ulcerative cystitis, which almost does not differ from other forms of similar lesions, in particular tuberculous ulcers, but in the absence of tubercles characteristic of tuberculosis. In the gummy period with cystoscopy of the bladder, the picture resembles a tumor. In favor of the diagnosis of syphilis of the bladder, a long and persistent course of the disease that is not amenable to conventional methods of treatment, anamnestic data or the presence of syphilitic lesions of other organs and systems speak. A positive Wasserman reaction is decisive, as well as a quick and almost always positive effect of a specific treatment.

In the diagnosis of chronic cystitis and the identification of the causes that support inflammation, cystoscopy and cystography are of paramount 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, ulcers are determined. In some cases, during cystoscopy, signs of kidney and ureter disease accompanying cystitis are found, for example, the 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 under the condition of 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 in it pathological processes apply contrast cystography by introducing iodine-containing drugs into it, a suspension of barium sulfate, oxygen or carbon dioxide. The most physiological is descending cystography, which is obtained 20-30 minutes after intravenous administration of a radiopaque preparation. Ascending (retrograde) cystography is performed by introducing a radiopaque fluid into the bladder through the urethra or urethral catheter, or suprapubic drainage.

A biopsy of the mucous membrane of the bladder, as a rule, is performed in patients with chronic cystitis, as well as for the purpose of differential diagnosis. At the same time, the results of the biopsy cannot reflect the state of the entire bladder wall, since in this case we have only the tissue of the mucous membrane, without deep submucosal and muscular layers.

Laboratory studies of urine continue to occupy an important place in modern clinical practice. Graduated glass cylinders are used to determine the daily amount of urine. To correctly account for the amount of urine per day, it is necessary 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 act of defecation. It is important, along with the change 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 usually 100 to 400 ml of urine is sent, taken from the total amount collected per day. Daily urine must be shaken beforehand so that the sediment gets into it. If the urine collected during the day decomposes rapidly, 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 stopper. The transparency of the urine disappears after a long standing due to the precipitation of urinary salts from its solution. Urates are brick red, phosphates are white. As a result, transparency can be judged by fresh urine. If it is cloudy, then perhaps it contains pathological, unusual impurities. Turbidity of urine is given by protein, pus, blood, salts of uric acid.

The smell of urine should also not escape the attention of medical personnel. The fetid odor of freshly expelled urine speaks of its advanced decomposition, caused by a disease of the bladder. The reaction of normal urine is acidic. When standing for a long time in a warm place, the reaction may become alkaline due to the fermentation process that occurs. The alkaline reaction of freshly released urine indicates the process of fermentation in the bladder itself. In the absence of a specialized laboratory, the reaction of urine, its pH is simply determined using red and blue litmus paper used simultaneously. In the case of an acid reaction of urine, blue litmus paper turns red, and red does not change its color. With an alkaline reaction of urine, red litmus paper turns blue, and blue 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 bromthymol blue indicator, the presence of protein is judged by a unified sample with sulfosalicylic acid, using the Brandberg-Roberts-Stolnikov method.

Quantitative methods for determining protein in urine include a test with sulfosalicylic acid, a biuret method. The appearance of blood in the urine, visible to the naked eye, always indicates a severe lesion of the urinary tract: hemorrhagic inflammation of the kidneys, stone, tuberculosis, cancer. In this case, urine can look like real blood. Formed elements are determined by microscopy of the urinary sediment, which will be discussed later. Now we should dwell on the causes of hematuria and pyuria in cystitis and on the methods of correct interpretation of macroscopic data. When examining urine obtained from a patient with cystitis, hematuria and pyuria are detected, as mentioned earlier. Hematuria - excretion of blood, erythrocytes 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.

According to the patient's story about the portion of urine with which blood is excreted, it is already possible to get an idea of ​​the place of its source. If drops of bloody exudate are released from the urethra in addition to urination or washed off with the first portions of urine, then this indicates the appearance of blood in the urethra. Blood from the bladder usually settles to the bottom and is excreted with the last portion of urine. Blood from the kidneys evenly stains all portions of urine. This can be seen especially clearly when conducting a test with three glasses. The patient is offered to collect the first, middle and last portions of urine separately in one urination into three separate vessels 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 cylinders, albuminuria, sand confirm the renal origin of hematuria. Urine with renal nephritic hematuria has the color of meat slops. It is more brown than bright red. Already an admixture of one cubic centimeter of blood per 1 liter gives the urine a look suspicious of 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 a small leukocytosis in female urine is rather the rule and depends on contamination from the genitals. Therefore, to avoid an erroneous diagnosis, it is recommended that only urine obtained by a catheter be examined for leukocytes in women. Cystic or renal origin of pyuria is easily solved with the help of a cystoscope and ureteral catheterization. In order to correctly prescribe treatment for a patient with cystitis, it is necessary to conduct microscopy of the urine sediment and its microbiological examination in the clinic. Microscopic examination of native preparations of urinary sediment is carried out after centrifugation of 10 ml from the morning portion of urine, after thoroughly mixing it. Sediment is divided into organized and unorganized parts. In an organized sediment, uniform elements and the epithelium of the bladder can be found. Erythrocytes are disc-shaped and yellow-green in color. In the acidic reaction of urine, red blood cells shrivel and acquire a stellate shape. Yeast fungi are very similar to erythrocytes, but unlike the former, fungi often have an oval shape, a bluish tint and bud. The addition of a 5% solution of acetic acid to the sediment helps the diagnosis, under the influence of which the erythrocytes are hemolyzed, and the yeast remains. Leukocytes in the urine sediment have a rounded shape and granular cytoplasm. With bacteriuria in alkaline urine, leukocytes are rapidly destroyed. Normal in urinary sediment urine 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 a different shape and size, 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 in the cytoplasm of cells of the transitional epithelium, degenerative changes, which look like coarse granulation and vacuolization of the cytoplasm. There are many of these cells in cystitis. The nature of the unorganized sediment in the urine with cystitis is not critical. 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 for microbiological examination is carried out before the start of antibiotic therapy. First, a thorough toilet of the external genital organs is carried out. Then, 3-5 ml of an average portion of freely released urine is collected in a sterile container. If possible, bladder catheterization should be avoided. It is carried out only when the patient is unable to urinate on his own or to determine the localization of the inflammatory process. In the case of catheterization, the bladder is first emptied, then 50 ml of neomycin solution mixed with polymyxin is injected through the catheter. If cystitis occurs, then the urine will be sterile when cultured (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 the amount of 105 CFU / ml of urine. The association of microorganisms is more common in chronic processes.

Streptococci isolated from urine are spherical or oval in shape and are arranged 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 slightly alkaline medium pH - 7.6 - 7.8. When growing on blood agar, microbes form small grayish or colorless colonies. Hemolytic streptococci on blood agar form around the colonies a transparent zone of hemolysis (b-hemolytic streptococcus) or a greenish zone (a-hemolytic streptococcus). Around non-hemolytic streptococci, the environment does not change. On liquid nutrient media, hemolytic streptococci form a precipitate that can rise to the top, while the medium remains colorless. Streptococcus is a facultative anaerobe, immobile. The reaction to enzymes: catalase and oxidase is negative. Gram-stained stains Gram-positive. Strep. agalacticae (group B) usually inhabits 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, may be the cause of the development of colpitis. Hemolytic streptococci die when heated to 56°C after 30 minutes. Group B streptococci are more resistant: they can withstand temperatures up to 60°C for 30 minutes.

The staphylococci found in cystitis are gram-positive cocci that have the shape of regular balls. In the preparation, microbial cells are arranged singly, in pairs, or, more often, in the form of bunches of grapes. Staphylococci are non-motile, do not form spores or capsules, 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 elective medium is a medium with the addition of bile acids with a high content of sodium chloride. Diagnostic value is the ability to ferment glucose and mannitol under anaerobic conditions. 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 form a variety of extracellular enzymes: plasmacoagulase, hyaluronidase, protease, esterase, lysozyme, phosphatase, and others. They liquefy gelatin, hydrolyze proteins, fats, restore nitrates. When growing on liquid nutrient media, staphylococci form diffuse turbidity, followed by precipitation. Staphylococci are quite resistant to factors environment, tolerate drying well, remain viable in dust for a long time. Direct sunlight kills them after 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. In smears, they are arranged in pairs, Gram-stained negatively, immobile, do not form spores, demanding on cultivation conditions. For their isolation, nutrient agar (pH - 7.2-7.4) containing amine nitrogen, blood or inactivated horse serum is used. Grow in an atmosphere with a high content of carbon dioxide. On nutrient agar with the addition of ascitic fluid, gonococci grow in 24-48 hours in the form of transparent colonies with smooth edges and a smooth shiny surface. Gonococci are unstable outside the human body, quickly die when dried. At temperatures above 56 ° C, they die after 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 into the cylindrical epithelium and do not penetrate into the flat, covering the bladder.

E. coli is a common etiological factor in banal cystitis. It is a rod-shaped microbe, gram-negative. On nutrient agar, the S-form forms hazy, 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 jagged edges. E. coli causes a uniform turbidity of the liquid nutrient medium with the formation of a small sediment. This microbe is a facultative anaerobe; it grows well on ordinary nutrient media with a slightly alkaline reaction of the medium and an optimum temperature of 37°C. Growth and reproduction of bacteria are possible with significant fluctuations in the pH of the environment and temperature. E. coli has a high enzymatic activity. Ferments glucose, often lactose. Fairly stable in the environment: can be stored 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 peritrichous flagella, 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 range of growth - from 20 to 37°C. Ferments many carbohydrates to form acidic products. Glucose breaks down with the formation of acids and a small amount of gas. Proteus vulgaris is an inhabitant of the intestines of many animals, found in sewage and soil. Proteus is quite resistant to environmental factors, tolerates 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 normal media at 20-37°C, producing 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. They are single-celled microscopic animals. They, unlike bacteria, have nuclei and organelles inherent in eukaryotes. The body of Trichomonas pear-shaped. At the anterior end there are four flagella extending from the basal grains. 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 in front of the cell. Trichomonas are mobile, move quickly with the help of flagella and an undulating membrane. Trichomonas quickly die in the external environment, are not resistant to heat, and easily die under the influence of disinfectants. In the urine of the patient are stored up to 24 hours. Trichomonas grow well on nutrient media in the presence of the bacteria they feed on.

Mycoplasmas, unlike other prokaryotes, do not contain a cell wall. Morphologically, they are pleomorphic, consisting of different sizes of spherical and filamentous cells. Most mycoplasmas are facultative anaerobes. They grow on artificial nutrient media, but need the addition of cholesterol, fatty acids, which they receive when mammalian serum is added to the nutrient medium. Mycoplasmas on media with agar form colonies, the center of which grows into the nutrient medium. For uroplasma, the pH of the nutrient medium is 6.5. Mycoplasmas are not resistant to high temperature. Due to the absence of a cell wall, penicillin and other antibiotics of 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 the laboratory test does not differ in cystitis and colpitis, and the presentation of these methods is more appropriate when covering issues of sexually transmitted diseases.

Tuberculosis is caused by mycobacteria. In shape, these are straight or slightly curved sticks. In cultures, granular forms or branching, resembling the letter V are found. Gram-staining is positive. Acid and alkali resistant. Selective staining of mycobacteria according to Ziehl-Nelsen in red. The dispute does not form, motionless. The acid resistance of Mycobacterium tuberculosis is due to the content of a large amount of lipids. For the cultivation of mycobacteria, special media are used. They grow especially well on media with glycerin. On dense nutrient media, Mycobacterium tuberculosis forms wrinkled, dryish colonies with an uneven edge. On liquid nutrient media, the causative agent of tuberculosis 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 visible on microscopy. The main method for determining mycobacteria is bacteriological, since it allows you to obtain a pure culture with its subsequent identification. The material is pre-treated with acid or alkali, then mycobacteria are removed by centrifugation and the sediment is inoculated onto a nutrient medium. Due to the slow growth on a nutrient medium, it is advisable to grow Mycobacterium tuberculosis in microcultures on glasses. 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 bundles. In grown cultures, sensitivity to antibiotics is determined. 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 (adenoma), urethra (stricture), bladder stones, cystalgia, diseases of the female genital area, since dysuric disorders, expressed by increased urination, its pain, difficulty, occur in the diseases listed above. The pathogenetic mechanisms of dysuria are based on general and local factors. Common factors include various negative emotions, psychogenic reactions. Such dysuria, as a rule, is reversible after the elimination of 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. You can think of acute cystitis with acute painful urination, equally frequent at different times of the day. At the same time, the patient experiences an imperative urge to urinate, in which he is not able to keep urine in the inflamed bladder.

With cystitis, fever is usually not observed, since the bladder is often emptied and absorption from it is negligible. The exception is necrotic-gangrenous forms of the disease. Suspicion of a tumor of the bladder may occur when persistent dysuria is combined with hematuria. For acute prostatitis, the sharpest dysuria with an imperative urge to urinate is typical. It is usually accompanied by general phenomena in the form of fever, chills, sweating, tachycardia, which increase with the development of the inflammatory process.

Dysuria in an elderly man raises the suspicion of prostate adenoma or bladder stone. Dysuria due to 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 occurs when walking or shaking driving. It has a characteristic irradiation - to the perineum, testicles or glans penis. The pain is exacerbated by the presence of thorn-like stones - oxalates or with frequent concomitant cystitis. The pain is due to the movement of the stone and irritation of the mucous membrane, especially the neck of the bladder as the richest receptor zone. Urination disorder is manifested by an increase in urges, their intensification when moving the body. During sleep, the pain stops.

Typical for bladder stones is the sudden cessation of the stream of urine during urination - a symptom and the resumption of urination when the patient's body position changes. Small stones can become lodged in the posterior urethra and cause acute urinary retention. Often, patients experience urinary incontinence when a stone is placed in the bladder with one part, and the other is in the posterior urethra. In these cases, complete closure of the sphincter of the bladder is impossible. Long-term presence of a stone in the bladder neck and posterior urethra leads to sclerosis. As a result, urinary incontinence may persist after stone removal. The change in the nature of urine with bladder stones is characterized by macro- and microhematuria, which is explained by trauma to the bladder mucosa. 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 when a metal catheter is inserted into the bladder. A more accurate diagnostic method is a survey 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 cistrography with a solution of a contrast agent. In these cases, filling defects indicate the presence of a stone. Final Diagnosis established on the basis of cystoscopy. However, a stone located in the diverticulum of the bladder is not always possible to detect.

Often, pain in the bladder area can be reflected in nature and be associated with diseases of the kidneys, prostate and urethra. Therefore, if the cause of the pain cannot be explained by a direct lesion of the bladder, it should be sought in a possible disease of the listed organs. With 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 makes the patient toss and turn in bed. Above the bosom, a distended bladder is determined.

Constant pain in the bladder area can be caused by infiltrating growth of a malignant tumor. These pains can be aggravated by the phenomena of tumor disintegration with the occurrence of secondary cystitis. The first manifestation of prostate cancer is also characterized by increased urge to urinate, especially at night. Many patients have difficulty urinating with straining or a sluggish thin stream of urine intermittently, sometimes urine is excreted in drops, this is accompanied by a feeling of incomplete emptying of the bladder. Often the patient complains of pain during urination 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, the occurrence of pain during urination, as well as pain in the perineum, sacrum, and lower abdomen. Sometimes the pain is insignificant. The severity of painful symptoms can be different. With long-term processes, neurotization of the personality develops.

Along with complaints, a clinical study of a patient with cystalgia did not reveal organic changes in the bladder. There is also no pyuria. However, pain in 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 bladder mucosa characteristic of cystitis, detected during cystoscopy. With cystalgia, morphological signs of chronic urethritis are very often found.

Pain in cervical cancer can be misinterpreted by the germination of the tumor in the bladder. The correct diagnosis can only be made by cystoscopy.

Often sharp pains in the area of ​​the bladder, accompanied by a violation of urination, occur during pathological processes of the female genital organs. This occurs with adnexitis, para- and perimetritis. Moreover, inflammatory changes in the mucous membrane of the bladder are often found, caused by the spread of infection from the female genital area.

With gangrenous cystitis, before conducting instrumental research methods, there may be suspicions about the presence of a stone in the bladder, a tumor of the bladder. Urosepsis, chronic cystitis should be excluded.

Outwardly, 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 characteristic of cystitis if 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, the pus usually quickly settles to the bottom, and the layer of urine above the sediment becomes much clearer and sometimes becomes transparent. With pyelonephritis, urine is diffusely turbid, grayish, when standing in a vessel at the bottom, a sediment of various thicknesses 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 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, sharp pain during its filling. In addition, during this period of the disease, cystoscopy can cause complications. If there is a need for cystoscopy, then it is carried out under anesthesia. At the same time, cystoscopy in 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-cup test indicates urethritis. In the differential diagnosis of chronic cystitis that occurs with the formation of ulcers, a tumor of the bladder should be excluded. Crucial in this case belongs to endovesical biopsy.

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

Treatment of gangrenous cystitis is extremely difficult. In men, surgical treatment is indicated, aimed at diverting urine and revision of the bladder. In women, conservative measures can be taken. However, if women fail to extract necrotic tissue through the dilated urethra, then urgent surgery is indicated. According to vital indications, cystostomy and the release of the bladder from necrotic tissues should be carried out, urine diversion, which limits the depth of the destructive process, saves the patient from fatal complications.

In acute cystitis, patients need bed rest. Assign plentiful drink, a diet with the exception of spicy dishes, pickles, sauces, seasonings, canned food, the use of alcoholic beverages is prohibited. Vegetables, fruits, dairy products are recommended. Thermal procedures are prescribed only when the cause of dysuria is established. They should be avoided if the diagnosis is not established, especially with gross hematuria, since heat increases bleeding.

Heat is contraindicated in tuberculosis of the bladder. In order to reduce pain, warm baths are prescribed. With pronounced dysuria, in addition to antispasmodics, microclysters are prescribed with a 2% warm solution of novocaine. In severe cases, presacral novocaine blockades are performed. With 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, blacks - 0.5 g 4 times a day, 5-NOC - 0.1 g 4 times a day and broad-spectrum antibiotics actions (oletethrin, oxacillin, tetracycline, erythromycin, etc.) orally or intramuscularly. Usually one of the listed drugs is used for 8-10 days, which leads to a rapid decrease in dysuria and normalization of the urine composition.

Treatment for postpartum cystitis includes plenty of fluids and a non-irritating diet. With severe pain and tenesmus - candles with belladonna, warm enemas from chamomile. Active treatment of the underlying disease should be carried out. The appointment of antiseptic and analgesic drugs in the first days of the disease allows further pathogenetic therapy when examining urine, identifying flora, and determining sensitivity to antibacterial drugs. Perhaps the appointment of antihistamines. Assign a plentiful drink - up to 2-3 liters per day to reduce the concentration of urine and more leaching of bacteria, pus and other pathological impurities.

Treatment of chronic cystitis is to eliminate the causes that caused chronic inflammation. Treatment of chronic cystitis is aimed at restoring disturbed 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 the microflora to antibacterial drugs. Adults and older children are washed with a solution of furacilin 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 impaired bladder emptying. Also used are instillations into the bladder of rosehip seed oil, sea buckthorn, and antibiotic emulsions. To improve the blood supply to the bladder wall, UHF, inductothermy, and mud applications are used. The local effect of drugs is achieved using iontophoresis with nitrofurans, antiseptics. In chronic cystitis, accompanied by a persistent alkaline reaction of urine, sanatorium treatment is indicated in Truskavets, Zheleznovodsk, Essentuki, Borjomi.

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

Treatment of tuberculosis consists in the use of anti-tuberculosis drugs, vitamin therapy, restorative and spa treatment. With pronounced dysuria, local treatment is additionally used: instillation of sterile fish oil into the bladder, 20-30 ml of a 5% solution of saluzide, 50 ml of a 5% solution of PAS, dicain electrophoresis on the bladder area. With cicatricial wrinkling of the bladder, they resort to its plastic surgery.

In radiation cystitis, in addition to symptomatic and antibacterial treatment, instillations of fish oil, methyluracin, and intravesical injections of corticosteroids are used. With extensive lesions of the bladder and the absence of the effect of conservative treatment, resection of the affected area or its intestinal plastic is performed. The prognosis is relatively favorable only with early treatment.

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

Comprehensive treatment of trichomonas cystitis includes the use of broad-spectrum antibiotics, trichopolum, flagyl, washing the bladder with solutions of oxycyanic mercury, furacilin, silver nitrate. Treatment is successful only when carrying out the prevention of reinfection by sanitation of foci in the genital organs and simultaneous treatment of the sexual partner.

Treatment of interstitial cystitis is conservative, complex. Sedative, hyposensitizing, antispasmodic and anti-inflammatory drugs are prescribed, hydrocortisone instillations in the bladder in combination with antibiotics and anesthetics are prescribed, presacral novocaine blockades, and physiotherapy are performed. Improvement can occur only 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 a violation of its function, as a result of which there is a need for intestinal plastics.

Antibacterial treatment cystitis will be effective only after the establishment of the etiological factor and its sensitivity of the flora to antibiotics. Of the penicillin preparations for urinary tract infections caused by Escherichia coli, Proteus, enterococci, ampicillin trihydrate and ampicillin sodium salt are especially effective. The kidneys excrete cephalosporin (a group of cephalosporins), which is effective in 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 antibiotics of the macrolide group for urinary tract infections, oleandomycin, which is effective in staphylococcal, streptococcal, chlamydial inflammation, and oletethrin, which has a noticeable effect on gonococci and Escherichia coli, should be especially noted. If a syphilitic or chlamydial lesion is detected, it is possible to administer erythromycin, which is effective against staphylococci, streptococci and gonococci.

In inflammatory lesions of the bladder and urethra, aminoglycoside antibiotics may be administered. Especially a wide range action has gentamicin, which is not inherent in the nephrotoxic effect established for neomycin and monomycin. With the tuberculous and gonorrheal nature of cystitis, the introduction of rifampicin is indicated. Along with antibiotics for cystitis, sulfa drugs have proven themselves well. Urosulfan is effective in staphylococcal infections and infections caused by Escherichia coli. Sulfapyridazine and sulfadimethoxine are especially indicated for purulent infections, in which staphylococci, streptococci, Escherichia coli, Proteus, gonococci, chlamydia act as etiological moments. Of the derivatives of naphthyridine, nevigramone can be prescribed, which is effective in diseases caused by Escherichia coli and Proteus. Preparations of the nitrafuran series (furadonin, furagin) have proven themselves in 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, gonococci. They successfully 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. With intact kidney function, it is administered once a day in an amount of 400 mg through the mouth, a 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 after 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, as well as children under 15 years of age.

In the treatment of chronic cystitis, the recommendations of phytotherapists should not be neglected. It is recommended to brew the following herbs.

Collection number 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 number 2

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

Collection number 3

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

Collection number 4

• White birch buds - 2 parts,
• herb oregano ordinary - 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,
• shoots of thuja western - 4 parts,
• eucalyptus leaf - 1 part.

Fees are brewed in the evening and insisted for at least 6 hours. For half a liter of boiling water take 2-3 tbsp. l. collection, take in a warm form 30 minutes before meals 3 times a day. With exacerbation of chronic cystitis, these fees are taken in shock doses - 5-6 tbsp. l. collection is brewed in a thermos in 1 liter of boiling water. This is the daily dose of the infusion. After 2-3 weeks of admission, they switch to the usual dose. In a thermos each time it is desirable to add 1 tbsp. l. wild rose. The course of treatment usually lasts from 1 to 1.5 years, until the symptoms of the disease disappear completely. 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, which can provoke an exacerbation of cystitis. With exacerbations, you can brew a three-component collection:

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

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

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

Herbal treatment is recommended to continue for several years. Fees should be alternated and a short break should be taken every two months. Usually herbs do not have side effect, nevertheless it is necessary to do or make the control analysis of urine from time to time. For sitz baths, the following herbs are recommended:

Collection number 1

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

Collection number 2

• Ivy-shaped budra grass - 5 parts,
• flowers of calendula officinalis - 3 parts,
• knotweed grass - 5 parts,
• horsetail herb - 5 parts,
• celandine grass - 2 parts.

Collection number 3

• Medicinal sweet clover herb - 2 parts,
• chamomile flowers - 5 parts,
• marsh cudweed herb - 5 parts,
• hop fruit - 3 parts,
• medicinal sage herb - 5 parts.

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

With cystitis, you can put linen pads filled with hot steamed grass on the bladder area: chamomile, sage, cudweed, horsetail.

PREVENTION OF CYSTITIS

In the prevention of cystitis, an important role is played by the observance of the rules of personal hygiene, the timely treatment of inflammatory diseases, urodynamic disorders, the prevention of hypothermia, the observance of asepsis during endovesical studies and catheterization of the bladder. Prevention of postpartum cystitis consists in the rational provision of assistance during childbirth, the fight against urinary retention, careful observance of asepsis when taking urine with a catheter. Prevention of chronic cystitis consists in the rational treatment of acute cystitis, as well as in the timely detection and treatment of diseases of the genitourinary system. Prevention of radiation cystitis consists in the 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, appears for many different reasons and has characteristic symptoms, so the diagnosis of cystitis usually does not cause problems. However, having determined the disease, it is necessary to thoroughly find out its causes, provoking factors, possible complications - otherwise the treatment may be ineffective. The diagnosis of cystitis in men and women will be slightly different, and the diagnosis of cystitis in children requires much more time, since other diseases can have similar symptoms in childhood.

Symptoms of cystitis

There are a number of specific symptoms that make it possible to suspect cystitis. Diagnosis and treatment usually meet the standards, and the list of signs for which a preliminary diagnosis is made is quite large:

1. The patient complains about

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

1. According to the results of the analyzes

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

Additionally, there may be complaints about a decrease in libido, an increase in unpleasant symptoms after intercourse or before the onset of menstruation. In such situations, not only cystitis can be a problem - differential diagnosis can reveal abnormalities in the functioning of the kidneys, inflammation and neoplasms in the pelvic organs, prostate enlargement, and bending of the uterus.

Unusual cystitis

It happens that most of the symptoms are absent, and there is only blood in the urine or rare cases of discomfort. Often this is what interstitial cystitis looks like at an early stage. Its reasons lie not in bacterial infection, and not in fungi, but in the lesion of the mucous membrane of the bladder itself, which loses its elasticity and bursts under tension, forming ulcers. If the problem with urination occurs only in cases where you had to "be patient", with a high probability this is interstitial cystitis. Diagnosis, 3 important criteria of which require mandatory cystoscopy - the introduction of a cystoscope tube with a camera into the bladder, which allows assessing damage to the mucosa. You can also take tissue samples for analysis with a cystoscope.

Checking bladder compliance is another important diagnostic method, as well as a potassium test. Having found out how severe the damage is and how quickly they appear, 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 start therapy as early as possible. Diagnosis of cystitis in children also requires drastic measures, often urine sampling for analysis is done at the very beginning of the intake in order to prevent the transition of the acute phase into chronic cystitis. Analyzes, diagnostics with the help of equipment and hospitalization in the presence of signs of intoxication for children are mandatory.

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

Acute, including interstitial cystitis, the diagnosis and treatment of which are carried out in a timely manner, may never recur. However, if you ignore the symptoms and engage in self-diagnosis, you can reach the state of 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:

• non-compliance with personal hygiene
• unprotected intercourse
• decreased immunity
• inflammation in the body
• physiological features
• unsettled weather, off-season
• inability to empty the bladder in a timely manner

Some factors cannot be excluded, however, the use of drugs for the prevention of cystitis can reduce the risk of the disease several times.

© 2018 All rights reserved.
Practical help of doctors and experts in the fight against cystitis.

Cystitis

Clinical picture different forms of acute cystitis is expressed by a triad of symptoms: pain, pollakiuria and pyuria. In the hemorrhagic form, macrohematuria comes first. Pain in the lower abdomen appear either when the bladder is full, 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 for the predominant localization of cystitis in the area of ​​​​the exit from the bladder (cervical cystitis, trigonitis).

Pollakiuria is around the clock. Its degree depends on the form of cystitis: relatively moderate in catarrhal forms, it becomes unbearable in the ulcerative process, when there are imperative urges to urinate, reaching its incontinence. These disorders reach their climax 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 push, a few drops of urine appear, the child cries, and urination stops. This situation finds its explanation in the spasm of the sphincter resulting from severe pain caused by the passage of urine through the bladder neck and urethra.

With severe pyuria, cloudy urine is macroscopically determined. Less pronounced 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 perivesical tissue (paracystitis).

Diagnostics acute cystitis is based on the triad of these symptoms, as well as on data from physical, laboratory, and, where indicated, endoscopic and radiographic studies.

In patients with acute cystitis, pain is noted on palpation of the bladder area above the pubis or during vaginal examination in women. In addition to leukocyturia and bacteriuria, laboratory research urine can be determined by a small amount of protein (albuminuria is false in these cases) and more or less red blood cells. Total gross hematuria is characteristic of the hemorrhagic form of cystitis, terminal - for 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 made only with a protracted course of cystitis. The exception is hemorrhagic form cystitis with severe total hematuria, when it is necessary to establish the cause of the latter. When cystoscopy in patients with acute protracted uncomplicated cystitis, various intensity and prevalence of changes in the mucous membrane are determined: hyperemia, edema, fibrinous overlays, ulcerations. With complicated and secondary cystitis, the primary disease of the bladder is revealed; violation of the release of indigo carmine from the mouths of the ureters allows you to determine the spread of infection towards the kidney. X-ray examination makes it possible to diagnose calculus, bladder diverticulum, vesicoureteral reflux. Acute cystitis recurs in 12-17% of cases.

Chronic cystitis is mostly a secondary disease. Some authors deny the possibility of primary chronic cystitis. The exception is the so-called cystic cystitis, which occurs without another lesion of the bladder. The appearance of small cysts is not always accompanied by signs of cystitis. In some patients, these cysts are discovered by chance during a study undertaken for another disease. 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 the diagnosis. They allow in most cases to find out the secondary nature of the disease. It is clear that at the same time it is necessary to conduct a general examination of the patient, to determine the condition of the kidneys, ureters, urethra, organs of the reproductive apparatus. Trigonitis is characterized by severe dysuria, chronic course and mild pyuria.

With cystoscopy, loosening and hyperemia of the mucous membrane are limited to the region of Lieto's triangle. Cystoscopic 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.

The differential diagnosis of cystitis in most cases is not difficult. To avoid diagnostic errors, you must 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, with a persistent course of cystitis, 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. Volition and pollakiuria without pyuria are characteristic of a polyetiological disease, with an as yet unexplained pathogenesis - the so-called cystalgia. Cystalgia is observed only in women; with her pain and pollakiuria occur mainly during the day, disappear during sleep; there are no pathological elements in the urine. In cystoscopy, the mucosa in the vast majority of cases is unchanged. In a number of patients, lighter islets of the epithelium, histologically similar to the epithelium of the vagina, are determined in the region of Lieto's triangle. The occurrence of cystalgia is associated with endocrine disorders, uric acid diathesis, congestion in the pelvis, and a trace reaction after a previous cystitis. Abroad, persistent forms of cystalgia are sometimes referred to as psychosomatics. Treatment should be aimed at eliminating the alleged causes, at normalizing the neuromuscular tone of the bladder (various types of novocaine blockade, physiotherapeutic procedures). Endovesical manipulations should be avoided.

A detailed laboratory, endoscopic and X-ray examination of the state of the organs 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, and also to establish the cause of secondary cystitis. Gynecological examination allows to exclude the defeat of the female genital organs as the cause of secondary cystitis. In men, rectal digital examination reveals the primary focus of infection in the prostate gland.

With polyposis forms of cystitis, there is a need for a differential diagnosis with a tumor. Often it is not possible to make a correct diagnosis only on the basis of a cystoscopic picture. A cytological examination of the urine sediment and a biopsy are helpful. Certain difficulties exist in the differential diagnosis between localized encrusting cystitis and incrustation of the surface of a small neoplasm. The problem is solved by surgery.

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. Infection can spread directly through the lumen of the ureter with vesicoureteral reflux or by the hematogenous route. This is favored by impaired patency of the lower urinary tract (for example, in patients with prostate adenoma), exacerbations of chronic cystitis. The occurrence of pyelonephritis is accompanied by a deterioration in the general condition, chills, fever. Extremely rarely, ulcerative and necrotic cystitis is complicated by purulent peritonitis. More often these forms of cystitis lead to the occurrence of paracystitis.

Paracystitis - inflammation of the perivesical tissue - occurs most often, especially under modern antibacterial treatment, in the form of an inflammatory infiltrate with subsequent sclerotic changes in the tissue. A number of patients have either limited purulent cavities or widespread purulent fusion. In cases where the abscess is limited to the Retzian space, a protrusion is determined above the pubis in non-obese individuals, which can be mistaken for an overflowing bladder.

Diffuse ulcerative chronic cystitis in rare cases ends with 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 region of Lieto's triangle.

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

Treatment primary acute cystitis is in a certain mode, creating "rest" for the bladder, the use of antibacterial agents, thermal procedures. In severe cases, bed rest is indicated. In all cases - the exclusion of hot spices from food, alcoholic beverages. A good effect is given by the presacral novocaine blockade applied on the first day (100 ml of a 0.25% solution of novocaine), which largely removes the 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 preparations (furadonin, furazolidone) in normal dosages. In case of persistent course, antibiotics are also indicated, the choice of which should be based on urine culture and antibiogram data. In more than 50% of cases, it is possible to stop cystitis on the first or second day. With a protracted course, a complete examination is shown to determine the cause of such a course. When cystitis lasts more than 5-6 days, you can resort to installations in the bladder cavity of antibiotics, 3% collargol in oil solution.

Treatment of primary chronic cystitis presents significant difficulties due to the persistent course of the disease. Apply measures for the general strengthening of the body, the elimination of various possible purulent foci (in oral cavity, throat, etc.), constipation. Antibacterial treatment should be carried out systematically for months with a change of antibiotics every 5-7 days in accordance with the results of repeated antibiograms (the type of flora and its sensitivity to antibiotics change during treatment), their combination with sulfanilamide and nitrofuran preparations. Local treatment is also indicated in the form of bladder lavages with weak solutions of ethacridine, furacilin, boric acid followed by installation of 3% collargol in oil.

With any form of secondary cystitis, the basis of treatment is the elimination of the primary disease: calculus, neoplasms, 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 with the help of the above measures.

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

The refusal of various endovesical studies, as well as bladder catheterizations, when there are no absolute indications for this, is justified, since the risk of urinary tract infection, despite the adoption of the necessary asepsis measures, is very significant.

Differential diagnosis of cystitis

On April 7, 2016, the regional scientific and practical conference "Differential Diagnosis of Cystitis" was held in Novosibirsk, which brought together more than 170 participants from Novosibirsk, Omsk, Tomsk, Novokuznetsk, Barnaul. The guest of honor of 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 a lively discussion in the hall.

In the speeches at the conference, a lot of new data on this problem was reported. So, Professor A.V. Gudkov (Tomsk) spoke about possible reasons chronicity of 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 bladder wall, this pathogen can penetrate into its deep layers, thereby causing inflammation not only of the mucous membrane, but also of deeper ones. layers up to adventitia. A short-term course of monotherapy with an antibacterial drug in such cases does not guarantee a cure and may be the cause of 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 the 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?" concluded with an optimistic statement: “Yes!”. According to the results of a study conducted under her supervision, it was found that in 82.4% of young non-pregnant women with acute uncomplicated cystitis, the disease is cured without the use of antibiotics, and only 17.6% of patients required additional prescription of antibacterial drugs. In all patients who noted a decrease in the severity of symptoms after 48 hours of combined therapy with a non-steroidal anti-inflammatory drug and the combined herbal preparation Canephron N, a cure was achieved; none of them developed a relapse of the disease within the next 6 months. Thus, the researchers came to the conclusion that in case of early (up to 12 hours from the moment of illness) terms of treatment and control of the effectiveness of therapy within the next 48 hours, it is possible to limit the appointment of non-steroidal anti-inflammatory drugs and a combined herbal preparation.

Of great interest was the report of the epidemiologist of the Novosibirsk Research Institute of Tuberculosis, Ph.D. MM. Zorina "Legal basis for conducting BCG therapy in a municipal polyclinic - the view of an epidemiologist." The method of BCG therapy for superficial bladder cancer has long and firmly won 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 during this treatment method.

With a report by M.M. Zorina echoed an interesting message from Ph.D. D.P. Holtobin " Possible Complications BCG therapy for bladder tumors: how to prevent and how to fix. Denis Petrovich, who has rich experience surgical treatment patients with cancer of the genitourinary organs, shared his pain with the audience, so his report was accepted by the audience with great interest. Denis Petrovich convincingly showed that BCG therapy is an indispensable component of the treatment of patients with superficial bladder cancer, and all adverse reactions should resolve spontaneously within 48 hours. Nevertheless, with a long 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 the organization of 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 a considerable merit of Anna Vladimirovna as the head of the Department of Phthisiology and Phthisiology Surgery 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 and inflammatory diseases of the urinary tract. So, Alexander Izrailevich noted that in the study of the immune status in 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 link of immunity were diagnosed. The inclusion of azoximer bromide in the treatment complex led to a pronounced positive dynamics of 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 the normalization of immune status.

Two reports were from the Innovative Medical Technology Center of the Federal State Budgetary Institution NNIITO named after. Ya.L. Tsivyan of the Ministry of Health of the Russian Federation. Head of the Center for Urology and Gynecology, Ph.D. G.Yu. Yarin spoke about urination dysfunction as a mask and the cause of chronic cystitis, gave recommendations on early diagnosis complications in neurogenic bladder. V.N. Fedorenko. Vitaly Nikitovich at this conference was awarded the title of "Best Diagnostician" and received a letter of thanks from the Novosibirsk Research Institute of Tuberculosis. He drew the audience's attention 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 in the phase of accumulation of urine in the bladder, to ensure its complete emptying, to reduce the duration of the drainage in the urinary tract, to 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 hall, since sooner or later every polyclinic urologist encounters such problems.

Very revealing was the clinical observation given by Ph.D. E.V. Brizhatyuk. A 67-year-old patient worked in a public catering establishment and regularly underwent dispensary examinations. However, over the past 5 years, due to retirement, she has not been examined.

Medical history: rare episodes of acute cystitis in the past. Habitual one or two urination every night for many years. At the age of 33, two ectopic pregnancies, in connection with which consecutive tubectomy was performed on both sides. Since then, there has been a pulling pain over the bosom, which she associated with the surgeries and the adhesive process. When examining against the background of acute respiratory viral infection pyuria, erythrocyturia, kidney cysts were detected (according to ultrasound), in connection with which the patient was referred to a urologist.

The results of the primary examination by the urologist of the polyclinic showed the following data. Urinalysis: leukocyturia 25–30 in the field of view, erythrocytes 5–8 in the 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/s, Qave - 14 ml/s. The polyclinic urologist prescribed the standard therapy for acute uncomplicated cystitis: fosfomycin 3 g once and furazidin 100 mg three times a day for 7 days, accompanied by herbal medicine (Canephron N). The result was not obtained, therefore, cefixime 400 mg was prescribed once a day for 10 days, which also did not lead to a significant decrease in subjective and laboratory symptoms. We want 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 sent the patient to a phthisiourologist.

At the Novosibirsk Research Institute of Tuberculosis, multispiral computed tomography (MSCT) showed on the right side bumpy contours of the kidney at the level of the upper third due to multiple hypodense rounded formations, the size of which reached 16 mm, the contrast in them was detected in the form of levels. Some of these formations did not accumulate a contrast agent. There was an expansion of the pelvis up 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 protruding formations. The structure of the formation in the upper segment is heterogeneous with areas of liquid density that are not contrasted into the excretory phase, denser areas intensively accumulated a contrast agent. The connection of the specified education with the pelvicalyceal system has not been established. The left kidney also had two large cysts (Bosniak I) located at the level of the middle and lower segments. The pyelocaliceal system on the left was well differentiated, not expanded. The ureter is not dilated, its walls are not thickened (Fig. 1). Cystoscopy revealed a picture of follicular cystitis (Fig. 2). A forceps biopsy was performed; tuberculosis was pathologically detected.

According to the totality of clinical, laboratory and anamnestic data, the diagnosis was made: polycavernous tuberculosis of the right kidney, tuberculosis of the right ureter, tuberculosis of the bladder. MBT (mycobacterium tuberculosis) "-"; complex anti-tuberculosis polychemotherapy was started. Denis Petrovich Kholtobin performed a laparoscopic resection of the upper segment of the left kidney, excision of the cysts due to a concomitant disease (hypernephroid cancer of the left kidney T1N0M0, simple cysts of the left kidney).

At the control examination after completion of the course of anti-tuberculosis therapy, MSCT showed a decrease in the largest size of the right kidney to 7.5 cm, thinning of the parenchyma. In the parenchyma, rounded hypodense formations were detected. No renal enhancement was observed throughout the study. The ureter was not contrasted. On the left, the condition after kidney resection corresponded to the volume of the performed intervention. The function of the kidney was preserved, the excretory system of the kidney was without signs of retention, the perirenal tissue was thickened, and fibrous bands were detected (Fig. 3).

Given the persistent leukocyturia and the lack of function of the right kidney, a right nephrectomy was performed. A pathomorphological study showed the preservation of the 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).

The appointment of optimal empirical antibiotic therapy for patients with acute cystitis (this, at least in the conditions of an epidemic of tuberculosis - fosfomycin, furazidin; in complicated cases - 3rd generation cephalosporins and gentamicin) will contribute to the timely detection of patients with tuberculosis, since the lack of response to such therapy - a direct indication for the exclusion of tuberculosis. Can 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 would such an approach be optimal, or at least rational? Also, definitely not. There is no need for a patient with acute cystitis to prescribe a systemic antibiotic with anti-tuberculosis activity, when we have fosfomycin and nitrofurans at our disposal, blocking, especially when used together, the main spectrum of non-specific uropathogens. In other words, there is no need to use "carpet bombing", i.e. use systemic antibiotics with anti-tuberculosis activity when there is a local problem (acute uncomplicated cystitis) and a “marked sniper” in the form of fosfomycin and nitrofurans. And the appointment from the first day of phytotherapy will prevent the formation of a biofilm and the chronization of the process.

Urologists who showed vigilance against tuberculosis and sent patients to the anti-tuberculosis dispensary and the tuberculosis research institute in a timely manner were awarded letters of thanks, a special cake was baked in their honor for the “Best Diagnostician”, which all participants of the conference could enjoy during the break.

Signs of cystitis in women, diagnosis and treatment regimens

• 1 Reasons

• 1.1 Predisposing factors
• 1.2 Other things to consider

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

• 5.1 Endoscopy

• 7.1 What medications should be taken
• 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 favors the entry of microorganisms into the urinary system.

The reasons

In most cases, this pathology is caused by the growth and reproduction of pathogenic microflora on the wall of the bladder. Most often, cystitis in women is caused by the following pathogens:

• gram-negative enterobacteria;
• 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 the bacteria that live in the intestines:

• Escherichia coli;
• Enterococci.

Predisposing factors

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

Even in the presence of infection, this mechanism prevents bacteria from adhering to the bladder mucosa. 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 bacterial growth blockers.

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

• foci of chronic infection in the body (tonsillitis, caries);
• transferred acute respiratory infections, flu;
• prolonged hypothermia;
• malnutrition, hypovitaminosis;
• diseases of the gastrointestinal tract, accompanied by intestinal dysbacteriosis;
• metabolic diseases (diabetes mellitus, thyroid dysfunction);
• chronic stress;
• physical overload.

What else needs to be considered

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

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

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

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

How does it manifest

The main signs of cystitis in women are as follows:

• burning or itching after urination;
• pain above the pubis, most often after going to the toilet;
• frequent urge to urinate;
• discharge from the urethra with cystitis in a woman, especially purulent or with blood;
• 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, in some cases it can disrupt the patient's ability to work. Chronic forms of the disease often have an erased clinical picture, unpleasant symptoms can disturb 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 an 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 will 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 will the lab show?

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

• general urine analysis;
• bacteriological research;
• determination of bacterial susceptibility to antibiotics.

With cystitis, urine tests reveal bacteria (or yeast-like fungi), an increase in the number of leukocytes (leukocyturia), and red blood cells are also sometimes detected. 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 consists in sowing the urine sediment on a special nutrient medium. After the growth of bacteria, their identification is carried out, and sensitivity to certain antibiotics is also 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.

Most often with cystitis, it is ultrasound that is performed. 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 for chronic forms ah disease. Using this method, signs of inflammation of the walls of the bladder (redness, swelling) are revealed. Cystoscopy also helps to identify tumors, areas of abnormal development of the mucosa. If necessary, the doctor may 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 disorders of urination;
• 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. In acute cystitis, the use of a warm heating pad on the lower abdomen helps. This reduces pain and frequency of urination and improves the patient's condition. As a thermal procedure, a bath or sauna can be used.

From folk remedies a sitz bath with chamomile is also recommended. To prepare it, you need to prepare a decoction of chamomile: boil a liter of water and add three to four tablespoons of dry grass there, 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 be taken

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

• prescription of antibacterial agents;
• pathogenetic therapy;
• preventive measures.

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

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

In acute cystitis, antibiotics are taken for three to five days. There are also single-dose tablets ("Monural"). If the cystitis has complications in the form of an ascending infection involving the pyelocaliceal system of the kidneys, then antibiotic treatment 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" is recommended, which contains the protein components of Escherichia coli. There is clinical guidelines on the use of "Lavomax" (tiloron).

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

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

As a local treatment, physiotherapeutic procedures are used, direct injection of antibacterial agents into the bladder ("Dioxidin", "Silver Nitrate").

Preventive measures

Therapy for urinary tract infection requires the correction of some habits and diet. Prevention of cystitis includes the following activities:

• a diet with restriction of irritating foods (spicy foods, spices);
• regular visits to the toilet;
• compliance with the rules of personal hygiene;
• hypothermia should be avoided;
• in the pool and on the beach, always change a wet swimsuit for a dry one;
• timely 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 acquire a chronic course, 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, will help to avoid relapses. acute forms diseases.

Signs of cystitis in women, diagnosis and treatment regimens - all about and for health on KrasotaDiet.ru