Cystitis is a bacterial infection of the bladder that is more common in women due to their shorter urethra. Common causes include bacterial ascension from the urethra or spread from other infected sites. Symptoms include increased urinary frequency, urgency and pain. Examination may reveal abdominal or suprapubic tenderness. Urine analysis shows white blood cells and bacteria. Treatment involves antibiotics based on culture and sensitivity, along with pain relief, hydration and urinary alkalization.

1. CYSTITIS
DR POTNURU SRINIVASA SUDHAKAR

2. AETIOLOGY
• Cystitis is much more common in women than in
men probably due to short urelhra through
which the bacteria ascend.
• Cystitis also accompanies haematogenous renal
infection in rare cases.
• Lymphatic spread from infected cervix is also a
probable cause of cystitis though rare.
• Bowel infections e.g. appendicular abscess,
diverticulitis etc. may cause cystitis by involving
bladder by contiguity.

3. • In men, cystitis is almost always secondary to
some other causes e.g. infection of the
prostate, enlarged prostate associated with
residual urine, presence of vesical calculus or
an ulcerated vesical neoplasm.

4. PREDISPOSING CAUSES
• The various predisposing causes which may
indulge to cause cystitis are being mentioned
here —
• 1. Presence of a calculus, foreign body or
neoplasm in the bladder
• 2. Obstruction in the urethra due to urethral
stricture or enlargement of prostate or prostatic
carcinoma or stenosis of the external urinary
meatus may lead to stasis and formation of
residual urine in the urinary bladder which
initiate cystitis.

5. PREDISPOSING CAUSES
• 3. Presence of diverticulum in the bladder may
cause cystitis due to residual urine inside the
diverticulum.
• 4. Injuries or diseases of the spinal cord which
hinders proper evacuation of the bladder may
lead to cystitis.
• 5. Presence of vesicoureteral reflux may incite
cystitis.
• 6. Malnutrition with lowered general resistance
and particularly avitaminosis may lead to cystitis.

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

7. CAUSATIVE ORGANISMS
• The most common infecting agent is E. coli. This
is followed by Proteus mirabilis, particularly in
young women, Staphylococcus aureus.
• Staphylococcus albus. Various Streptococci,
Pseudomonas and Klebsiella.
• Schistosoma haematobium produces cystitis
which may be complicated by stone formation
and high incidence of cancer.
• Mycotic infection ofthe bladder is rare.
• Monilial vaginitis may secondarily infect bladder.

8. CAUSATIVE ORGANISMS
• Very rarely actino-mycosis may involve the
bladder by direct extension from lesions in the
bowel.
• Tuberculous cystitis is a specific form of cystitis.
• The students must remember that in this
condition there will be plenty of pus cells without
any organisms found with ordinary staining
(abacterial pyuria).
• But besides tuberculous cystitis, abacterial pyuria
is also seen in abacterial cystitis or in an
ulcerative bladder carcinoma.

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

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

11. PATHOLOGY
• MICROSCOPIC FEATURES
• In acute cystitis:
• it is the submucous coat which shows major changes.
• There is much congestion and dilatation of capillaries.
There is infiltration with the cells of acute
inflammation.
• The superficial layers of the epithelium may be
desquamated, but the deeper layer remains intact.
• Leucocytic infiltration may extend into the muscle, but
otherwise the muscle layer remains unaltered.

12. PATHOLOGY
• MICROSCOPIC FEATURES
• In chronic cystitis:
• all coats are involved.
• There is diffuse fibrosis which is most evident in
the submucosa.
• The mucosa is ulcerated in places.
• There may be abundant formation of granulation
tissue covered by epithelium giving rise to
polypoid excrescences.

13. CLINICAL FEATURES
• SYMPTOMS
• Severity of the symptoms depends on severity of
the disease.
• (i) Increased frequency of urine both in day and at
night is the most important symptom.
• This may disturb sleep of the patient at night
which may make the patient drawn and tired.
• (ii) Urgency is also a very characteristic symptom
of this condition.
• At times the desire to micturate becomes so
urgent that incontinence may result.

14. CLINICAL FEATURES
• (iii) Pain, though often associated with, is not
a major symptom.
• Pain varies from mild to agonising in severe
cystitis.
• When the superior surface of the bladder is
involved pain is referred to the suprapubic
region.
• When the trigone is involved pain is referred
to the tip of the penis or the labia majora.

15. CLINICAL FEATURES
• (iv) Haematuria.— It should be remembered that
cystitis is the commonest cause of haematuria.
• Such haematuria is usually terminal that means
at the end of micturition
• Later on as severity increases, the whole urine
may be blood stained, but it will be more so at
the end of micturition.
• (v) Pyuria.— This is often seen in cases of cystitis.

16. PHYSICAL SIGNS
• Examination of the abdomen is usually normal.
• Tenderness may be elicited at the suprapubic
region.
• Rectal examination should always be performed
It may reveal an enlarged prostate (benign
enlargement of prostate) which is the cause of
cystitis.
• It may reveal an enlarged firm and tender
prostate (acute prostatitis as the cause of
cystitis).
• It may reveal presence of residual urine.

17. PHYSICAL SIGNS
• In female, pelvic examination is highly
important to exclude any pathology in the
genital system as the cause of cystitis.

18. SPECIAL INVESTIGATIONS
• 1. Blood examination.— White blood count is
usually elevated. E.S.R. is also increased.
• 2. Urine examination usually shows pus cells,
bacteria and red blood cells. In case of
presence of associated prostatitis threads may
be seen in the initial specimen, so midstream
urine specimen should be taken for culture
and sensitivity test.

19. SPECIAL INVESTIGATIONS
• 3. X-rays are not indicated unless stasis or
renal infection is suspected.
• X-ray is also required if the patient fails to
respond to adequate antibiotic treatment for
cystitis or the infection is recurrent and there
is presence of obstruction, vesicoureteral
reflux, tuberculosis or calculus.

20. SPECIAL INVESTIGATIONS
• 4. Cystoscopy is contraindicated in acute
phase.
• But it should be done 10 days later
whenhaematuria is continuing to exclude
presence of vesical neoplasm or stone or
foreign body.

21. TREATMENT
• A. GENERAL MEASURES
• B. SPECIFIC TREATMENT

22. GENERAL MEASURES
• 1. The patient is urged to drink plenty.
• 2. Alkalinisation of the urine should be achieved. This
provides symptomatic relief.
• By raising the pH of the urine, it counteracts the
burning sensation of acidic urine which normally
accompanies infection.
• 60 to 20 g of sodium bicarbonate may be given for this.
• 3. Antispasmodics.— Various antispasmodics e.g.
baralgan, buscopan, atropine with phenobarbital or
tincture of belladonna may be used.
• This relieves muscular spasm and provides
considerablerelief to the patient.

23. GENERAL MEASURES
• 4. Urinary tract analgesic.— Phenazopyridine
is an urinary tract analgesic. 100 mg tablets of
phcnazopyridine (pyridium) may be used in
the dosage of 2 tablets thrice daily after meals
provides considerable relief.
• 5. Local heat.— Hot sitz baths may ease
severe pain and spasm.

24. SPECIFIC TREATMENT
• Antibiotics are prescribed according to the
sensitivity test report.
• A few antibiotics are particularly effective in
cystitis.
• These are nalidixic acid 500 mg, nitrofurantoin
100 mg tablets, amoxycillin, trimethoprin and
sulphamethoxazole, chloramphenicol,
ampicillin etc.