Cystitis pathophysiology

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Steven C. Campbell, M.D., Ph.D. Associate Editor(s)-in-Chief: Usama Talib, BSc, MD [2], Maliha Shakil, M.D. [3]

Overview

Urine is normally sterile due to the low pH and unidirectional flow of urine that does not allow bacteria to grow and invade the urinary tract. Cystitis occurs when the normally sterile lower urinary tract (urethra and bladder) is either infected by bacteria or rarely a fungus, which leads to irritation and inflammation. Irritation followed by inflammation can also occur in response to trauma, chemicals or foreign bodies. Females are more prone to the development of cystitis because of their relatively shorter and straighter urethra. Bacteria does not have to travel as far to enter the bladder, which is in part due to the relatively short distance between the opening of the urethra and the anus. The pathogenesis of complicated cystitis include obstruction and stasis of urine flow. Normal flow of urine washes away the pathogens and clears the tract. Obstruction leads to overdistension and bacterial growth is facilitated by the residual urine. Stasis of urine flow allows entry of pathogens into the urinary tract.

Pathophysiology

Acute Uncomplicated Cystitis

  • Acute uncomplicated cystitis is an inflammation of the urinary bladder that occurs in the absence of any structural or functional pathology. In women, vaginal colonization of the uropathogens leads to the development of a urinary tract infection.
  • Cystitis occurs when the normally sterile lower urinary tract (consisting of urethra and bladder) is infected by bacteria and becomes irritated and inflamed.
  • Once bacteria enter the bladder, they are normally removed through urination. When bacteria multiply faster than they are removed by urination, it results in their accumulation leading to an infection.[1][2]

Cystitis is rare in males but when occurs, is predominantly found in homosexual or uncircumscribed individuals.

  • Females are more prone to the development of cystitis because of their relatively shorter urethra.
  • Bacteria do not have to travel as far to enter the bladder, which is in part due to the relatively short distance between the opening of the urethra and the anus.[3][4]

Complicated cystitis

The pathogenesis of complicated cystitis include obstruction and stasis of urine flow.

  • Complicated cystitis is usually a result of an abnormality in the structure or function of the urinary tract.
  • This abnormality can result from various causes like foreign bodies such as:
  • Any process leading to the obstruction leads to over distension and so bacterial growth is facilitated by the residual urine.
  • Stasis of urine flow allows entry of pathogens into the urinary tract and also hinders the natural preventive mechanism by which urine flushes away the pathogens and prevents colonisation in the urinary tract.[1][5][6][7]

Recurrent/Chronic cystitis

Recurrent inflammation of the bladder that is usually due to an infection, needs intensive investigation. Recurrent urinary infections may result from:

The most common pathogen involved in recurrent infections resulting in inflammation of the bladder is E.coli.

  • Chronic inflammation of the urinary bladder can cause alterations in the functional mechanisms and may lead to structural changes.
  • It is understood that recurrent or chronic cystitis can lead to changes in the expression of the neuropeptides like substance P and calcitonn gene-related peptide (CGRP).
  • This manifests as altered sensation of bladder filling called allodynia and hyperreflexia of the urinary bladder due to defect in the agents responsible for regular sensing ability of the bladder. [8][9][10][11][12]

Interstitial Cystitis

The pathogenesis of Interstitial cystitis also known as bladder pain syndrome, includes:[13][14][15][16]

  • Epithelial dysfunction
  • Mast cell activation
  • Bladder sensory nerve up-regulation
  • Organ cross talk

Certain foods have been associated with the interstitial cystitis, some of these include:

  • Spicy foods
  • Citrus fruit
  • Tomatoes
  • Carbonated and alcoholic drinks
  • Coffee or tea
  • Vitamin C

The urothelium acts as a barrier against damage to the bladder. The urothelium produces a mucous layer which regulates the entry of potassium in the bladder interstitium.

  • Damage to the urothelium results in the production of cytokines which activate mast cells in the interstitium.
  • Mast cell activation is further triggered by the diffusion of excess potassium into the bladder interstitium.[17]

Cystitis cystica

Chronic irritation from infection, calculi or even tumors results in metaplasia of the urothelium, which proliferates into buds, which grow down into the connective tissue beneath the epithelium in the lamina propria.

  • In the case of cystitis cystica, the buds then differentiate into cystic deposits.
  • The pathogenesis of cystitis cystica follows a positive feedback mechanism where with each infection there is a greater chance of subsequent changes in the bladder mucosa.
  • Long term chemoprophylaxis and transurethral resection of the bladder are amongst the possible treatment options for cystitis cystica.[18][19][20][21]

Eosinophilic Cystitis

Inflammation of the urinary bladder by infiltration of eosinophils is the core of the process.

Hemorrhagic Cystitis

Hemorrhagic cystitis is associated with hematuria.

  • The hematuria results from rupture of the small mucosal blood vessels that are damaged due to:
  • Treatments targeting eradication of the causative viruses, drugs or metabolites and intravenous hydration that flushes the urinary tract are very effective in treating hemorrhagic cystitis.[23]
  • Several adenovirus serotypes have been associated with an acute, self-limited hemorrhagic cystitis, which occurs primarily in boys.
  • It is characterized by hematuria, and virus can usually be recovered from the urine.[24][25][26][27][28][29]

Traumatic Cystitis

Traumatic cystitis is caused by trauma to the bladder.

  • Damage to the bladder predisposes it to invasion by pathogens that are normally not able to infect the bladder.
  • Traumatic cystitis is a common phenomenon in females and follows invasion of a bruised bladder that follows an abnormally forceful sexual intercourse.
  • Absence of circumcision increase chances of the normal pathogen in the skin to be lodged into the urinary tract, though the evidence is not convincing.
  • Traumatic cystitis can also occur postoperatively in children.
  • Trauma can also lead to stricture formation which in turn leads to stasis of urine and growth of bacteria or viruses in the bladder. [30][31]

Foreign Body Cystitis

Foreign bodies like kidney stones, indwelling catheters, and contraceptive devices can either result in:

Removal of the foreign body and flushing the urinary tract with fluids are very effective treatment options.

  • Polypoid/Papillary cystitis is caused by obstruction of the bladder by a benign tutor that leads to stasis leading to infection and inflammation of the bladder.[32][33][34][35][36][37]

Emphysematous Cystitis

Gas production inside the bladder is the key feature to diagnose emphysematous cystitis. Diabetes has been strongly associated with this emphysematous cystitis.

  • Though the pathogenesis is not exactly understood, high tissue glucose content in a patient with diabetes mellitus and fermentation of glucose in urine are considered to be important mechanisms that facilitate invasion of gas forming bacteria.
  • E.Coli and Klebsiella are amongst the found pathogens.
  • Another important aspect in the pathogeneses of emphysematous cystitis is the imbalance between the accumulation of gas and its clearance.
  • Emphysematous cystitis can be an incidental finding on abdominal imaging done for abdominal pain or any other suspected pathology.
  • Abdominal pain and hematuria can be seen in patients with this disease due to damage caused by gas forming bacteria.
  • Since air accumulation interferes with normal oxygenation of the tissues, provision of hyperbaric oxygen has been associated with improvement of symptoms in patients with emphysematous cystitis.[38][39][40][41][42]

Cystitis Glandularis

Cystitis glandularis is considered a premalignant condition. The following are some significant aspects in the pathogenesis of cystitis glandularis:

Ketamine Cystitis

Ketamine cystitis is a complication of procedures where ketamine is used as anaesthetic agent. Ketamine cystitis differs from other drugs that cause cystitis like cyclophosphamide, ifosfamide and penicillin G, in that it does not cause haemorrhage. The pathogeneses of ketamine cystitis includes urothelial dysfunction by the following mechanisms:[47]

Genetics

Though the genetics of cystitis have not been studied extensively. It is understood that family history of urinary tract infection is a strong risk factor recurrent urinary infections in relatives. This risk is stronger in closer than distant relatives suggesting the role of a genetic component.[8][48]

Associated Conditions

The following conditions can be associated with cystitis.[1][4][49][50]

Gross Pathology

The gross pathology of cystitis does not yield any findings.

Microscopic Pathology

The microscopic pathology helps to confirm the diagnosis and to differentiate different types of cystitis.[51][52]

  • Cystitis Cystica. Source: Libre Pathology[51]

    Cystitis Cystica. Source: Libre Pathology[51]

  • Cystitis Glandularis. Source: Libre Pathology[52]

    Cystitis Glandularis. Source: Libre Pathology[52]

References

  1. ↑ 1.0 1.1 1.2 Hooton TM (2000). "Pathogenesis of urinary tract infections: an update". J Antimicrob Chemother. 46 Suppl A: 1–7. PMID 10969044.
  2. ↑ Nicolle LE (2008). "Uncomplicated urinary tract infection in adults including uncomplicated pyelonephritis". Urol Clin North Am. 35 (1): 1–12, v. doi:10.1016/j.ucl.2007.09.004. PMID 18061019.
  3. ↑ Russell DB, Roth NJ (2001). "Urinary tract infections in men in a primary care population". Aust Fam Physician. 30 (2): 177–9. PMID 11280121.
  4. ↑ 4.0 4.1 Platt R, Polk BF, Murdock B, Rosner B (1986). "Risk factors for nosocomial urinary tract infection". Am J Epidemiol. 124 (6): 977–85. PMID 3776980.
  5. ↑ Pallett A, Hand K (2010). "Complicated urinary tract infections: practical solutions for the treatment of multiresistant Gram-negative bacteria". J Antimicrob Chemother. 65 Suppl 3: iii25–33. doi:10.1093/jac/dkq298. PMID 20876625.
  6. ↑ Nicolle LE (2001). "A practical guide to antimicrobial management of complicated urinary tract infection". Drugs Aging. 18 (4): 243–54. PMID 11341472.
  7. ↑ Lichtenberger P, Hooton TM (2008). "Complicated urinary tract infections". Curr Infect Dis Rep. 10 (6): 499–504. PMID 18945392.
  8. ↑ 8.0 8.1 Franco AV (2005). "Recurrent urinary tract infections". Best Pract Res Clin Obstet Gynaecol. 19 (6): 861–73. doi:10.1016/j.bpobgyn.2005.08.003. PMID 16298166.
  9. ↑ Wada K, Uehara S, Ishii A, Sadahira T, Yamamoto M, Mitsuhata R; et al. (2016). "A Phase II Clinical Trial Evaluating the Preventive Effectiveness of Lactobacillus Vaginal Suppositories in Patients with Recurrent Cystitis". Acta Med Okayama. 70 (4): 299–302. PMID 27549677.
  10. ↑ Holland SM, Gallin JI (1998). "Evaluation of the patient with recurrent bacterial infections". Annu Rev Med. 49: 185–99. doi:10.1146/annurev.med.49.1.185. PMID 9509258.
  11. ↑ Arbiser JL (1995). "Genetic immunodeficiencies: cutaneous manifestations and recent progress". J Am Acad Dermatol. 33 (1): 82–9. PMID 7601952.
  12. ↑ Vizzard MA (2001). "Alterations in neuropeptide expression in lumbosacral bladder pathways following chronic cystitis". J Chem Neuroanat. 21 (2): 125–38. PMID 11312054.
  13. ↑ Sant GR (2002). "Etiology, pathogenesis, and diagnosis of interstitial cystitis". Rev Urol. 4 Suppl 1: S9–S15. PMC 1476007. PMID 16986036.
  14. ↑ Kind T, Cho E, Park TD, Deng N, Liu Z, Lee T; et al. (2016). "Interstitial Cystitis-Associated Urinary Metabolites Identified by Mass-Spectrometry Based Metabolomics Analysis". Sci Rep. 6: 39227. doi:10.1038/srep39227. PMC 5156939. PMID 27976711.
  15. ↑ Friedlander JI, Shorter B, Moldwin RM (2012). "Diet and its role in interstitial cystitis/bladder pain syndrome (IC/BPS) and comorbid conditions". BJU Int. 109 (11): 1584–91. doi:10.1111/j.1464-410X.2011.10860.x. PMID 22233286.
  16. ↑ Winnard KP, Dmitrieva N, Berkley KJ (2006). "Cross-organ interactions between reproductive, gastrointestinal, and urinary tracts: modulation by estrous stage and involvement of the hypogastric nerve". Am J Physiol Regul Integr Comp Physiol. 291 (6): R1592–601. doi:10.1152/ajpregu.00455.2006. PMID 16946082.
  17. ↑ French LM, Bhambore N (2011). "Interstitial cystitis/painful bladder syndrome". Am Fam Physician. 83 (10): 1175–81. PMID 21568251.
  18. ↑ Cystitis Cystica. Radiopaedia 2016. http://radiopaedia.org/articles/cystitis-cystica. Accessed on February 9, 2016
  19. ↑ Halder P, Mandal KC, Mukherjee S (2016). "Prolapsing cystitis cystica causing bladder outlet obstruction: An unusual complication". Indian J Urol. 32 (4): 329–330. doi:10.4103/0970-1591.189718. PMC 5054670. PMID 27843222.
  20. ↑ Vrljicak K, Turudić D, Bambir I, Gradiski IP, Spajić B, Batinić D; et al. (2013). "Positive feedback loop for cystitis cystica: the effect of recurrent urinary tract infection on the number of bladder wall mucosa nodules". Acta Clin Croat. 52 (4): 444–7. PMID 24696993.
  21. ↑ Varo Solís C, Bachiller Burgos J, Báez JM, Estudillo F, González Moreno D, Alvarez-Ossorio Fernández JL; et al. (2000). "[Glandular cystic cystitis]". Actas Urol Esp. 24 (7): 594–8. PMID 11011454.
  22. ↑ Leutscher PD, Pedersen M, Raharisolo C, Jensen JS, Hoffmann S, Lisse I; et al. (2005). "Increased prevalence of leukocytes and elevated cytokine levels in semen from Schistosoma haematobium-infected individuals". J Infect Dis. 191 (10): 1639–47. doi:10.1086/429334. PMID 15838790.
  23. ↑ Wakamiya T, Kuramoto T, Inagaki T (2016). "[Two Cases of Spontaneous Rupture of the Urinary Bladder Associated with Radiation Cystitis, Repaired with Omentum Covering]". Hinyokika Kiyo. 62 (10): 545–548. doi:10.14989/ActaUrolJap_62_10_545. PMID 27919130.
  24. ↑ Russo P (2000). "Urologic emergencies in the cancer patient". Semin Oncol. 27 (3): 284–98. PMID 10864217.
  25. ↑ PHILIPS FS, STERNBERG SS, CRONIN AP, VIDAL PM (1961). "Cyclophosphamide and urinary bladder toxicity". Cancer Res. 21: 1577–89. PMID 14486208.
  26. ↑ Watson NA, Notley RG (1973). "Urological complications of cyclophosphamide". Br J Urol. 45 (6): 606–9. PMID 4775738.
  27. ↑ Cox PJ (1979). "Cyclophosphamide cystitis and bladder cancer. A hypothesis". Eur J Cancer. 15 (8): 1071–2. PMID 510344.
  28. ↑ Klastersky J (2003). "Side effects of ifosfamide". Oncology. 65 Suppl 2: 7–10. doi:73351 Check |doi= value (help). PMID 14586140.
  29. ↑ Toma Y, Ishiki T, Nagahama K, Okumura K, Kamiyama T, Kohagura K; et al. (2009). "Penicillin G-induced hemorrhagic cystitis with hydronephrosis". Intern Med. 48 (18): 1667–9. PMID 19755771.
  30. ↑ Pugachev AG, Kniaz'kina OM (2001). "[Traumatic postoperative cystitis in children]". Urologiia (5): 41–5. PMID 11641980.
  31. ↑ Aydos MM, Memis A, Yakupoglu YK, Ozdal OL, Oztekin V (2001). "The use and efficacy of the American Urological Association Symptom Index in assessing the outcome of urethroplasty for post-traumatic complete posterior urethral strictures". BJU Int. 88 (4): 382–4. PMID 11564026.
  32. ↑ Cunha BA, Lee P, Kaouris N, Raza M (2015). "The safety of nitrofurantoin for the treatment of nosocomial catheter-associated bacteriuria (CAB) and cystitis". J Chemother. 27 (2): 122–3. doi:10.1179/1973947814Y.0000000202. PMID 25004793.
  33. ↑ Teal SB, Craven WM (2006). "Inadvertent vesicular placement of a vaginal contraceptive ring presenting as persistent cystitis". Obstet Gynecol. 107 (2 Pt 2): 470–2. doi:10.1097/01.AOG.0000164072.91339.9e. PMID 16449153.
  34. ↑ Bilichenko SV, Maĭzel's IG, Golovina EI, Arkhipov VV (2001). "[Bladder foreign body in a 4-year-old girl]". Urologiia (3): 42–3. PMID 11505545.
  35. ↑ Worthington T, White J, Lambert P, Adlakha S, Elliott T (1999). "Beta-lactam-dependent coagulase-negative staphylococcus associated with urinary-tract infection". Lancet. 354 (9184): 1097. doi:10.1016/S0140-6736(99)02474-5. PMID 10509508.
  36. ↑ Sievert DM, Ricks P, Edwards JR, Schneider A, Patel J, Srinivasan A; et al. (2013). "Antimicrobial-resistant pathogens associated with healthcare-associated infections: summary of data reported to the National Healthcare Safety Network at the Centers for Disease Control and Prevention, 2009-2010". Infect Control Hosp Epidemiol. 34 (1): 1–14. doi:10.1086/668770. PMID 23221186.
  37. ↑ Stamatiou K (2013). "Urinary retention due to benign tumor of the bladder neck in a woman; a rare case of papillary cystitis". Urologia. 80 (1): 83–5. doi:10.5301/RU.2013.10716. PMID 23423685.
  38. ↑ Tzou KY, Chiang YT (2016). "Emphysematous Cystitis". N Engl J Med. 375 (18): 1779. doi:10.1056/NEJMicm1509543. PMID 27806219.
  39. ↑ Hu SY, Lee BJ, Tsai CA, Hsieh MS (2016). "Concurrent emphysematous pyelonephritis, cystitis, and iliopsoas abscess from discitis in a diabetic woman". Int J Infect Dis. 51: 105–106. doi:10.1016/j.ijid.2016.09.012. PMID 27637417.
  40. ↑ May T, Stein A, Molnar R, Dekel Y (2016). "Demonstrative Imaging of Emphysematous Cystitis". Urol Case Rep. 6: 56–7. doi:10.1016/j.eucr.2016.03.001. PMC 4855983. PMID 27175347.
  41. ↑ Garde H, Useros E, Hernando A, Chávez C, Paños E, Quijano P; et al. (2015). "[Emphysematous cystitis: Report of 2 cases with different outcomes]". Arch Esp Urol. 68 (7): 627–32. PMID 26331400.
  42. ↑ Grupper M, Kravtsov A, Potasman I (2007). "Emphysematous cystitis: illustrative case report and review of the literature". Medicine (Baltimore). 86 (1): 47–53. doi:10.1097/MD.0b013e3180307c3a. PMID 17220755.
  43. ↑ Yi X, Lu H, Wu Y, Shen Y, Meng Q, Cheng J; et al. (2014). "Cystitis glandularis: A controversial premalignant lesion". Oncol Lett. 8 (4): 1662–1664. doi:10.3892/ol.2014.2360. PMC 4156188. PMID 25202387.
  44. ↑ Semins MJ, Schoenberg MP (2007). "A case of florid cystitis glandularis". Nat Clin Pract Urol. 4 (6): 341–5. doi:10.1038/ncpuro0814. PMID 17551538.
  45. ↑ IMMERGUT S, COTTLER ZR (1950). "Mucin producing adenocarcinoma of the bladder associated with cystitis follicularis and glandularis". Urol Cutaneous Rev. 54 (9): 531–4. PMID 15443228.
  46. ↑ Bryan RT, Nicholls JH, Harrison RF, Jankowski JA, Wallace DM (2003). "The role of beta-catenin signaling in the malignant potential of cystitis glandularis". J Urol. 170 (5): 1892–6. doi:10.1097/01.ju.0000092740.51330.39. PMID 14532801.
  47. ↑ Tsai YC, Birder L, Kuo HC (2016). "Abnormal Sensory Protein Expression and Urothelial Dysfunction in Ketamine-Related Cystitis in Humans". Int Neurourol J. 20 (3): 197–202. doi:10.5213/inj.1632634.317. PMC 5083834. PMID 27706016.
  48. ↑ Scholes D, Hawn TR, Roberts PL, Li SS, Stapleton AE, Zhao LP; et al. (2010). "Family history and risk of recurrent cystitis and pyelonephritis in women". J Urol. 184 (2): 564–9. doi:10.1016/j.juro.2010.03.139. PMC 3665335. PMID 20639019.
  49. ↑ Zhong YH, Fang Y, Zhou JZ, Tang Y, Gong SM, Ding XQ (2011). "Effectiveness and safety of patient initiated single-dose versus continuous low-dose antibiotic prophylaxis for recurrent urinary tract infections in postmenopausal women: a randomized controlled study". J Int Med Res. 39 (6): 2335–43. PMID 22289552.
  50. ↑ Ples R, Méchaï F, Champiat B, Droupy S, Huerre M, Guettier C; et al. (2011). "[Pseudotumoral toxoplasmic cystitis revealing acquired immunodeficiency syndrome]". Ann Pathol. 31 (1): 46–9. doi:10.1016/j.annpat.2010.11.001. PMID 21349389.
  51. ↑ 51.0 51.1 Libre Pathology https://librepathology.org/wiki/File:Cystitis_cystica_-_alt_--_intermed_mag.jpg Accessed on Jan 13, 2017
  52. ↑ 52.0 52.1 Libre Pathology https://librepathology.org/wiki/File:Cystitis_cystica_et_glandularis_-_alt_--_intermed_mag.jpg Accessed on Jan 13, 2017

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