Paracystitis is an acute or chronic inflammation of the fatty tissue surrounding the bladder. It is manifested by dysuria, pain over the pubis, hyperthermia. With a chronic course, pain and dysuric symptoms are less pronounced, subfebrility is noted. Paracystitis is diagnosed by cystoscopy, cystography, echography of the bladder. In the course of treatment, broad-spectrum antibiotics are used in combination with sulfonamides, nitrofurans and nalidixic acid derivatives, absorbants, physiotherapy, autopsy and drainage of the abscess, bladder plastic surgery.
ICD 10
N30.8 Other cystitis
Meaning
According to research in the field of modern urology, paracystitis is a relatively rare disease, which is associated with the high effectiveness of antibacterial therapy of cystitis and the improvement of the technique of invasive interventions. The disease is more susceptible to women whose inflammation of the paravesical fiber usually develops against the background of previous urogynecological pathology or after operations on the internal genitalia. In men, paracystitis is more often provoked by transurethral endoscopic procedures. The relevance of timely diagnosis of the disease is due to the possibility of its chronization with the development of fibrotic-sclerotic processes.
Causes
The inflammatory lesion of the amniotic membrane is preceded by the ingestion of pathogenic, conditionally pathogenic microorganisms from surrounding organs or distant foci of infection. The most common causative agent of paracystitis is E. coli, less often the disease is caused by staphylococci, proteus, Pseudomonas aeruginosa, candida. When Mycobacterium tuberculosis, gonococci, mycoplasmas, chlamydia, trichomonas enter the paravesical fiber, specific inflammation develops. Infection of the amniotic fatty tissue is promoted by:
- Injuries during instrumental manipulations. The most common cause of paracystitis is considered to be damage to the urethral or vesical wall during endoscopic examination or treatment, puncture of the bladder, its catheterization with a metal or semi-rigid catheter. The role of traumatism is constantly increasing due to the increase in the number and expansion of the volume of transurethral surgical interventions.
- Diseases of the pelvic organs. The second most common cause of paracystitis is necrotic and gangrenous cystitis, tuberculosis of the bladder with gross destruction of the organ wall. Less often, paravesical inflammation is complicated by diseases of neighboring anatomical structures: osteomyelitis of the pelvic bones, salpingitis, adnexitis, prostatitis, vesiculitis, appendicitis, etc. Contact infection is possible with parametritis, paraproctitis, peritonitis.
- Operations on pelvic organs. Paracystitis can develop with intraoperative damage to the urogenital wall during herniation, prostatectomy, suturing of soft tissue ruptures after childbirth, cesarean section, extirpation of the uterus, other interventions on the bladder, prostate, seminal vesicles, rectum, uterus, its neck and appendages. In postoperative paracystitis, inflammation is often preceded by urinary congestion.
- Hematogenic and lymphogenic infection. Extremely rarely, paracystitis develops primarily without the contact spread of the pathogen from the surrounding tissues. Infectious agents can contaminate the amniotic fluid hematogenically in sepsis, which complicated the course of purulent inflammation of other organs. Paracystitis may occur with the lymphogenic spread of infection from the intestine or bladder.
Pathogenesis
The initial stages of the development of paracystitis depend on the method of infection of the amniotic fluid. With the contact spread of the pathogen, the primary inflammatory alteration occurs in areas of adipose tissue seeded with a microbial agent. In response to the action of endo- and exotoxins of the pathogen, inflammatory mediators begin to be actively released in the affected area, which leads to local microcirculation disorders, exudative impregnation of fiber with fluid coming out of cells and vessels, infiltration by leukocytes and macrophages.
Due to the loose structure of adipose tissue, inflammation quickly spreads to other areas and can take on a diffuse (phlegmonous) character. With lymphogenic and hematogenic infection, several inflammatory foci are usually formed at once, which soon merge with each other. The insufficiency of antibacterial therapy contributes to the chronization of the process with the formation of calcified ulcers or fibrous-lipomatous compaction of adipose tissue.
Classification
The systematization of clinical forms of paracystitis takes into account the etiological factor, the localization of the inflammatory process, and the features of the course. There is a rare primary inflammation without previous pathological processes in the pelvis and peritoneum, as well as a secondary inflammatory process that complicated the course of diseases of the bladder and adjacent organs. Depending on the localization, paracystitis can be anterior, posterior, total. The most significant for the choice of therapeutic tactics is the classification by type of course:
- Acute paracystitis. The most common variant of the disease, taking into account the stage of the inflammatory process, can be infiltrative and purulent. It is characterized by violent clinical symptoms with a high risk of complications. Requires immediate intensive antibacterial therapy.
- Chronic paracystitis. It is usually the outcome of acute untreated inflammation. Taking into account morphological changes, purulent and fibrotic-lipomatous forms of pathology are distinguished. Clinical symptoms are often smoothed and nonspecific. Due to therapeutic resistance, long-term combined treatment is required.
Symptoms
Clinical manifestations of the acute form of the disease are sharp unbearable pain in the supraplonic region, frequent painful urination with the release of small portions of urine. In acute paracystitis, symptoms of intoxication are expressed: an increase in body temperature to 39-40 ° C, chills, headaches, myalgia, weakness. In patients with asthenic physique, painful swelling above the pubis is determined.
In the case of a breakthrough of the abscess into the bladder cavity during urination, there is a release of a significant amount of pus with an admixture of blood, after which the general condition of the patient is often normalized. Characteristic symptoms of post-bubble paracystitis are pulling pains in the lower abdomen, subfebrile body temperature, minor dysuric phenomena. In the presence of sclerotic processes, there is an increase in urination with the discharge of small portions of urine.
Complications
Long-term paracystitis can turn into a chronic sclerotic-fibromatous form, in which the amniotic fluid is replaced by connective tissue. This leads to compression and deformation of the walls of the organ, the formation of a wrinkled bladder. Against the background of reduced reactivity of the body, the inflammatory process progresses with the development of paravesical phlegmon, which is accompanied by a change in the localization of pain, an increase in signs of intoxication, the spread of inflammation to the retroperitoneal tissue with the development of paranephritis, into the perinatal space in women and into the prostatic space in men.
The most dangerous complication of paracystitis is the penetration of pus into the abdominal cavity, as a result of which pelvic or diffuse peritonitis, an inter–loop abscess can form. With retrovesical localization, there is a risk of an abscess breakthrough into the rectum, vagina, followed by the formation of a fistula.
Diagnostics
Diagnosis is not difficult in the presence of a typical clinical picture and information about inflammatory diseases of the urinary tract in the anamnesis. Difficulties arise in the case of a chronic course with minor symptoms. An inflammatory process in the amniotic fluid should be suspected when a swelling or local soreness in the suprapubic region is detected. The patient’s examination plan includes such methods as:
- Cystoscopy. With transurethral injection of a flexible endoscope, it is possible to visualize the bladder cavity. Paracystitis is characterized by depression into the lumen of one of the walls, bullous edema and hyperemia of the mucous membrane in the area of the abscess. Sometimes, during cystoscopy, a fistulous passage is determined, through which the contents of the abscess are released.
- X-ray. Cystography allows you to detect deformation and compression of the bladder, a decrease in its volume. There is a pronounced restriction of the mobility of the vesical wall involved in the inflammatory process. Sometimes, during the formation of fistulas, a leakage of the contrast agent into the paravesical fatty tissue is detected.
- Echography. With purulent paracystitis, during ultrasound of the bladder, the abscess is viewed as a zone of reduced echogenicity with separate hyperechogenic inclusions. In the chronic process, signs of sclerosis and fibrosis are determined. Transvaginal sonography is recommended for women to improve the accuracy of the method.
In the clinical analysis of blood with paracystitis, nonspecific changes characteristic of the inflammatory process are revealed — leukocytosis with an increase in the number of rod-shaped neutrophils, an increase in ESR. In the general analysis of urine, pyuria or microhematuria may appear after opening an abscess in the bladder. The patient is prescribed a vaginal or rectal examination, during which an infiltration or fluctuation in the retrovesical tissue is detected. In addition to the observation of a urologist, consultations of a gynecologist, proctologist, oncologist, surgeon are recommended.
Differential diagnosis of paracystitis is carried out with acute and chronic cystitis, interstitial cystitis, bladder tumors, pelvioperitonitis, in women – with parametritis, subserous myoma and other uterine tumors, adnexitis, Douglas space abscess. With a phlegmonous course, it is necessary to exclude acute appendicitis, intestinal obstruction, acute prostatitis, purulent adnexitis. Anteropubular paracystitis is sometimes differentiated with symphysitis, osteomyelitis and periostitis of the pubic bones.
Treatment
The choice of therapeutic tactics is determined by the clinical form and etiology of the inflammatory process. In the acute period, the patient is shown bed rest, copious drinking, cold on the lower abdomen. The basis of the treatment of paracystitis is intensive antibacterial therapy in combination with absorbable drugs, physiotherapy techniques (laser therapy, inductotherapy, microwave and UHF sessions), surgical rehabilitation of existing ulcers. Taking into account the variant of inflammation , it is recommended:
- In acute infiltrative paracystitis. Active treatment with semi-synthetic penicillins, aminoglycosides, cephalosporins, combined drugs, which include tetracyclines and macrolides, is required. Antibiotics are supplemented with the appointment of sulfonamides, nalidixic acid derivatives, nitrofurans. Timely antibacterial therapy often ensures the resorption of the infiltrate.
- In acute purulent paracystitis. Treatment begins with the opening and drainage of the abscess or phlegmon of the amniotic fluid. Access with retrovesical location of the abscess is carried out through the perineum, with antevesical — through the suprapubic region. After the rehabilitation of the focus and determination of the sensitivity of the pathogen, appropriate antibacterial therapy, resorbing drugs and physiotherapy are prescribed.
- With chronic paracystitis. A purulent form of inflammation with closed ulcers serves as an indication for their opening, drainage and a course of antibiotic therapy. The leading method of treatment of fibrotic-lipomatous paracystitis is the use of absorbants (enzyme preparations, aloe extract, glucocorticoids). With shrinking of the organ, it is possible to perform augmentation cystoplasty and intestinal plasty of the bladder.
Prognosis and prevention
With timely diagnosis and complex treatment, recovery is observed in 100% of patients. The prognosis for paracystitis is considered favorable. Chronization of the disease is observed in the case of late access to a doctor, inadequate antibiotic therapy, with severe intercurrent pathologies. Chronic forms of inflammation are prone to recurrence.
Prevention of paracystitis consists in early detection and treatment of inflammatory processes in the organs of the urinary system, rehabilitation of chronic foci of infection (carious teeth, tonsillitis), compliance with the technique of diagnostic and therapeutic invasive interventions, rules of asepsis during catheterization of the bladder.