Chronic Cystitis Treatment
What is Chronic Cystitis?
Chronic cystitis is the long-term inflammation of the bladder. It usually occurs as a result of recurrent urinary tract infections (UTIs), but chemicals that come into contact with the bladder (such as soap, deodorants, or certain antiseptics), radiation therapy, injuries to the bladder, or complications following surgical intervention can also lead to chronic cystitis. In addition, bladder stones, certain kidney disorders, and some chronic diseases such as diabetes can increase the risk of inflammation by affecting the immune system.
What Are the Recent Developments in Chronic Cystitis Treatment and the Differences We Apply in Our Clinical Practice?
Symptoms may include frequent urination, painful urination, and discomfort in the lower abdomen. Patients often prefer to manage the process themselves during stages when infection attacks are infrequent and can be treated with antibiotics. Treatment generally involves identifying the underlying cause and a step-by-step approach to address it.
Medications used to treat chronic cystitis may vary depending on the severity of symptoms and underlying causes. Here are some commonly used medications:
- Antibiotics: If a bacterial infection is present, appropriate antibiotic treatment may be administered.
- Pain relievers: Nonsteroidal anti-inflammatory drugs (NSAIDs) or medications such as acetaminophen can be used to relieve pain caused by bladder inflammation.
- Antispasmodics: They may help reduce discomfort experienced during urine storage and urination by relaxing the bladder muscles.
- Bladder protectors: Drugs such as heparin and sodium pentosan polysulfate can be used to protect the bladder wall.
- Canephron: Canephron is a herbal product used to support kidney and urinary tract health. It contains plants such as licorice root, thyme, and lovage, and is generally thought to be helpful in treating or preventing urinary tract infections.
- Cimetidine: Cimetidine is an H2 antihistamine medication commonly used to reduce stomach acid. It may be recommended for the treatment of chronic cystitis due to its protective effects on the bladder wall and anti-inflammatory properties.
Some herbal remedies and natural treatments can be used in the treatment of chronic cystitis. However, the effectiveness of these methods may vary from person to person, and it is important that they are used under a doctor’s supervision:
- Cranberry: Cranberry juice contains proanthocyanidins, which are thought to help prevent urinary tract infections.
- D-Mannose: D-mannose is a type of sugar that may help prevent certain urinary tract infections. It is suggested that it may reduce the risk of infection by preventing E. coli bacteria from adhering to the bladder.
- Herbal mixtures for kidney stones: Certain plants (such as dandelion) can be used, particularly to aid in their expulsion.
- Nettle: Known for its diuretic properties, it may support bladder health.
- Valerian: Due to its relaxing effect, it may alleviate symptoms related to stress and anxiety.
The treatments listed so far are first-line treatments for chronic cystitis. In cases that become resistant to these treatments, second-line treatment is initiated. Before starting second-line treatment, cystoscopy, which involves looking inside the bladder, is recommended. Cystoscopy is a minimally invasive procedure performed to examine the bladder and urinary tract. It is usually performed under local anesthesia using a thin tube called a cystoscope. The tip of the cystoscope is equipped with a camera and light source, allowing the doctor to see directly inside the bladder.
The main purposes of cystoscopy are as follows:
- Assessment of symptoms: Determining the cause of symptoms such as frequent urination, bleeding, or painful urination.
- Diagnosis: Detection of bladder inflammation, stones, tumors, or other abnormalities.
- Treatment objectives: Removal of stones or performance of certain procedures (e.g., biopsy).
This procedure is usually performed in an outpatient setting without requiring hospitalization and is considered safe for most patients. However, as with any procedure, there are potential risks and complications, so it is important to discuss the process in detail with your doctor.
The typical finding we encounter in most patients with chronic cystitis during cystoscopy is changes occurring in the areas of the bladder neck and trigone, which are the inlet and outlet regions of the bladder. In fact, this area is the meeting point of the internal and external urinary tracts during embryonic development and, at the cellular level, contains different characteristics from all other bladder walls. It is precisely these different characteristics and its proximity to external factors that cause infections from outside to frequently create permanent tissue changes and irritation on the bladder neck and trigone. The transformation of the bladder neck and trigone tissues into a different epithelium presents as tissue differentiation, which we call squamous metaplasia, leukoplakia, or trigonitis. The transitional epithelial cells, which are the main cell type of the bladder tissue, have now undergone a change and become squamous cells with the characteristics of vaginal tissues. While normal bladder tissues consist of smooth transitional epithelial cells that bacteria cannot adhere to, the cells of the bladder neck and trigone where the change is seen have become cells with an uneven surface where bacteria can easily settle.
There are generally two types of tissue changes. The first is raised, white, cotton-like plaque formations on the bladder surface visible during cystoscopic imaging. These are called leukoplakia, which means white plaque in Latin. When pathological samples are taken from these plaques, squamous metaplasia is observed in the tissues. The second type of change is called trigonitis. Its cystoscopic appearance is distinctly more reddened and edematous than other bladder tissues, containing cells with increased vascularization. Pathological examinations report chronic inflammatory bladder cells. While this tissue change initially leaves the patient vulnerable to bacterial infection, in the advanced stages of the disease, even contact of urine with the altered tissues causes pain and discomfort that the patient finds difficult to tolerate. At this stage, patients experience constant pain and discomfort, but all tests come back clean. This is because the antibiotics used kill the bacteria in the leukoplakia and trigonitis areas but cannot prevent the irritation caused when urine comes into contact with these different tissues.
For patients who have reached this stage in cystoscopy, treatment becomes more invasive. The first option is intravesical drug administration. In the treatment of chronic cystitis, intravesical drug administration is generally used to reduce inflammation of the bladder and alleviate symptoms. These applications are performed by injecting the drug directly into the bladder.
Here are some common intravesical drug applications:
- Hyaluronic Acid: May support the protective surface of the bladder and reduce inflammation.
- Sodium Heparin: Helps protect the bladder lining and may relieve pain.
- Antibiotics (Gentamicin): Intravesical antibiotic administration ensures that antibiotics come into direct contact with the inflamed area in the bladder. This protects against the systemic side effects of antibiotics.
- Cortisol: Cortisol is a steroid hormone secreted by the adrenal glands that plays an important role in many physiological processes. It helps cells heal themselves by reducing inflammation within the bladder.
When intravesical treatments are ineffective, the next step is the surgical removal of the altered tissues within the bladder. This procedure is called bladder fulguration.
Bladder fulguration is a procedure performed to destroy abnormal tissues or lesions within the bladder. It is usually performed using electrical or plasma kinetic energy. This method is particularly effective in treating benign (non-cancerous) tumors, polyps, or other abnormal tissues found in the bladder. This method is also used in the treatment of leukoplakia and trigonitis tissues in the bladder.
Characteristics of Bladder Fulguration:
- Procedure: Access is gained to the bladder through a cystoscope, and energy is applied to the abnormal tissue using a special device, causing tissue destruction at high temperatures.
- Objective: To eliminate abnormal tissue, reduce the risk of bleeding, and improve bladder health.
- Areas of Application: It can be used in cases of bladder cancer, interstitial cystitis, chronic cystitis, or other bladder diseases.
- Advantages: It is a minimally invasive procedure that can usually be performed in an outpatient setting without requiring hospitalization. However, when performed for chronic cystitis, an overnight hospital stay is required.
- Side Effects: Some side effects such as discomfort, bleeding, or infection may occur after the procedure, but these are usually mild and temporary.
You will stay in the hospital overnight after the procedure. Since the area where the procedure is performed completely covers the bladder outlet, the catheter may need to be left in place for more than a day. During the recovery period, cystitis-like symptoms experienced previously will continue until the tissue heals. This process usually lasts 2-3 weeks. In some patients, it can last up to 3 months.
Eighty percent of patients who undergo bladder fulguration are completely or largely cured of their disease. Their quality of life improves and they return to normal life. There is no need for permanent medication. In the remaining 20% of patients, improvements are not considered satisfactory by the patients, or improvements occur only in the very long term, or there is no benefit at all.
Studies show that patients who undergo this treatment experience significant improvements in their sexual lives.
In conclusion, recurrent bladder infection or chronic cystitis is a treatable disease that significantly affects the quality of life in some patients. Conventional drug treatments should be used as a first-line approach, and intravesical drug applications should be tried in selected patients. However, for patients who do not benefit from these treatments, the minimally invasive but effective treatment alternative of bladder fulguration may be beneficial.