Trigonitis is an inflammatory process in the bottom of the bladder, according to other data – a benign change in urothelial cells by the type of non–corneal squamous metaplasia. It may be asymptomatic or accompanied by discomfort with frequent urination, urgent urges, hematuria. Diagnostics is based on the data of urine test, cystoscopy. Verification of foci of metaplasia occurs by means of a biopsy. With minor changes, asymptomatic course, dynamic observation is shown, the detection of inflammation involves the appointment of antimicrobial drugs, the implementation of instillations, the ineffectiveness of therapy is an indication for surgery.
ICD 10
N30.3 Trigonite
Meaning
Trigonitis is a process delimited by the Lieto triangle, the vertices of which are the openings of the ureters and the internal urethral sphincter. It is named after the French anatomist J. Lieto, who identified this zone as the most typical location of pathology. Trigonitis was first described by Heyman in 1905, and in a number of observations it was of an infectious and inflammatory nature. To date, it is unclear whether trigonitis is supported by non-keratinizing metaplasia or, conversely, inflammation initiates changes in the urothelium. The asymptomatic course of the hormone-dependent process is typical for women of fertile age and for men receiving hormone therapy for prostate cancer.
Causes
Although the exact cause of the pathology is unknown, specialists in the field of urology believe that it may be associated with an irritative (irritating) or infectious process. Limitation of lesion by the Lieto triangle is possible due to the estrogenic effect. This is due to the fact that this area is embryologically different from the histology of the rest of the bladder due to affinity with the vagina, which allows the trigonal epithelium to respond to hormonal stimulation. The following causes of trigonitis are distinguished:
- Hormonal imbalance. Increased production of estrogen and progesterone leads to changes in cells with the development of pseudomembranous trigonitis, which occurs in women of childbearing age, especially during pregnancy. In men, trigonitis is a rare condition that accompanies long–term hormone therapy for prostate cancer. Inflammation is aggravated by transurethral resection of the gland. According to studies, trigonitis is detected in 40% of women and 5% of men.
- Inflammatory processes. Recurrent diseases of the urinary tract (chronic cystitis with a tendency to frequent exacerbations), urethritis, concretions cause changes in the urothelium lining the inner layer of the bladder, ureters, urethra. Sedentary stones on ligatures, provided constant contact with the mucous membrane, provoke trigonitis. A long-functioning transurethral catheter or epicystostoma is also considered as the causes of inflammation and metaplasia.
Predisposing factors include irrational nutrition associated with a preference for spicy and salty dishes, a large amount of spices. Insufficient fluid intake leads to the formation of highly concentrated urine, contact with which contributes to the destruction of the glycosaminoglycan protective layer and the progression of pathology. Violation of blood circulation with the omission of the uterus and the anterior wall of the vagina, complete prolapse of the pelvic organs in a woman is often accompanied by changes characteristic of trigonitis.
Pathogenesis
According to one theory, it is believed that a violation of cell growth and differentiation potentiates recurrent inflammation or prolonged injury; nerve irritation causes pain, symptoms of urinary hyperactivity. Some authors believe that metaplasia precedes the infectious process. Under favorable conditions, a cascade of inflammatory reactions is triggered against the background of a decrease in immunity reactivity.
One of the functions of the urothelium is the production of a protective mucopolysaccharide substance that prevents the penetration of urine and bacteria deep into the wall of the organ. Violation of the integrity of the glycosaminoglycan layer and the penetration of chemical agents through it, even after infection suppression, is manifested by dysuria, urgency.
According to the third hypothesis, pseudomembranous trigonitis in women develops under the influence of hormones: the metaplastic urothelium undergoes changes similar to the vaginal epithelium during the menstrual cycle. Receptors for estrogen and progesterone were isolated in biopsies of the bladder wall. It is noteworthy that men receiving estrogen therapy are also diagnosed with squamous cell metaplasia of the urethra.
Symptoms
Clinical manifestations and changes in urine tests are often absent. If trigonitis is caused only by a change in the hormonal background – pronounced symptoms are not detected, many researchers consider this metaplasia as a variant of the norm. If significant histological transformations occur against the background of cystitis, dysuria is typical: frequent urge to urinate day and night, discomfort, suprapubic pain. Urgent urges, burning sensation, feeling of incomplete emptying are characteristic. Sometimes the only complaint is the periodic painless appearance of blood at the end of urination.
The pain with trigonitis occurs periodically, is dull, dragging, aching in nature. When taking antimicrobial drugs, temporary relief occurs, especially if inflammation of the mucous membrane of infectious and bacterial genesis is at the heart of it. The body temperature of patients during exacerbation increases to subfebrile figures. The degree of bacteriuria, leukocyturia correlates with the severity of symptoms.
Complications
Trigonitis of inflammatory origin can progress to total cystitis, acquire a chronic form and often recur. Due to the tendency of the glycosaminoglycan layer of this zone to form holes against the background of metaplasia, chronic pelvic pain syndrome often develops, significantly impairing the quality of life. Inflammation, edema can lead to obstruction of the neck of the organ, leading to difficulties with emptying up to acute urinary retention.
The constant excretion of urine in small portions contributes to the formation of a microcyst. It is not possible to restore the capacity of the organ, since the accompanying fibrous-sclerotic processes reduce the elasticity of the tissue. Some authors consider squamous cell metaplasia as a probable cause of interstitial cystitis leading to disability. Urinary incontinence in trigonitis often provokes dermatitis, vulvovaginitis.
Diagnostics
Physical external examination is uninformative, the diagnosis is made using urethrocystoscopy. Ultrasound scanning of the bladder locates a thickening of the mucous membrane around its neck. The visible suspension in the lumen and swelling of the walls are non-pathognomonic for trigonitis, may indicate cystitis. A gynecologist’s consultation is justified for women, since the tissues of the vagina and cervix can also undergo metaplastic processes. The examination algorithm for trigonitis includes:
- Laboratory diagnostics. Bacteriuria is often present in the results of urine analysis, leukocyturia is detected in 20% of cases. In some patients, erythrocytes are detected, when conducting a 3-glass sample, their number is higher in the last portion. With severe inflammation, piuria is diagnosed. A urine culture study is prescribed to determine the pathogens and their sensitivity to drugs. To determine the cause of recurrence of urinary tract infection, STI tests are carried out, which are more informative in the exacerbation phase.
- Cystoscopy with biopsy. The lesion looks like a clearly delimited whitish zone towering over the trigone, there is a trabecularity of the detrusor, hyperemia. Some authors compare the defect with a fluffy snow coating. If there is no doubt about the diagnosis (there are no suspicions of keratinization, localization is limited to the Lieto triangle), a biopsy is not performed, since trauma during tissue sampling can increase inflammation. Cystobiopsia is justified in patients with hematuria or with the spread of inflammation beyond the bottom of the bladder.
Differential diagnosis is carried out with bladder cancer, total cystitis (including interstitial), cystolytiasis. With foci of metaplasia, the presence or absence of keratinization is determined. Similar manifestations are observed in pelvic pain syndrome, which accompanies a number of urological and gynecological pathologies. The standard of diagnosis remains cystoscopy, CT and MRI can be prescribed to exclude tumor processes.
Treatment
The therapy plan is determined individually, an adequate choice of drugs allows you to control relapses. Asymptomatic trigonitis does not involve the appointment of treatment or repeated cystoscopic examinations. The acute process reacts well to antimicrobial agents. Long-term antibacterial therapy, previously used for preventive purposes, has not confirmed its effectiveness due to the development of microbial resistance, aggravation of the state of immunosuppression, intestinal dysbiosis.
It has been proven that the exclusion of certain foods from the diet contributes to a decrease in the frequency and severity of exacerbations. Trigger substances are different for each patient, most often citrus fruits, chocolate, coffee, carbonated drinks provoke dysuria with trigonitis. It is also recommended to abandon spices, smoked meats, marinades, red fruits and vegetables. An adequate drinking regime is important, it is necessary to ensure that the daily amount of liquid is at least 1.8-2.0 liters.
Medication therapy
With confirmed chronic infection, antibacterial drugs are prescribed taking into account sensitivity, the duration of the course can reach 4 weeks, complete recovery (normalization of the cystoscopic picture, absence of complaints) was registered in 30%, improvement (including a decrease in the degree of squamous metaplasia) – in 40% of patients. In STIs, etiotropic treatment is received by both partners, and it is recommended to use condoms before control tests. Muscle relaxants, NSAIDs, analgesics are used to eliminate pain. Urgent urges are stopped by solifenacin and analogues.
The appointment of antidepressants in low doses helps to reduce pain. Positive dynamics is noted after transurethral injections into the urinary reservoir of medicinal solutions, which include vitamins, antiseptic components, oils, painkillers, heparin. Relatively recently, sodium hyaluronate began to be used, replenishing the deficiency of glycosaminoglycans of the bladder wall layer. The drug has confirmed its effectiveness in the treatment of radiation and interstitial cystitis, studies in metaplasia have not yet been completed.
Surgical treatment
If conservative therapy with antibiotics and instillations is ineffective, the question of surgical intervention is considered. Ablation of modified foci using a holmium laser is considered a minimally invasive method that carefully preserves unused tissues and leaves the possibility of restoring normal mucosa. The beam penetrates to a depth of 0.4 mm (when using diode lasers – by 6-8 mm). The operation is performed under general anesthesia, the rehabilitation period is short. Relapses occur in 4% of cases, may require repeated intervention.
The percentage of complications (hematuria, acute inflammation) with holmium ablation is minimal. A week after the procedure, well-being improves significantly: dysuric disorders are stopped, urgency disappears. Then prescribe instillations that promote the regeneration of the mucosa, antimicrobial drugs. TUR (transurethral resection) and electrocoagulation are more invasive interventions accompanied by the formation of a necrosis focus. Healing is slower, and symptoms may worsen immediately after surgery. Scarring disrupts the elasticity of the organ wall.
Physical therapy
Physiotherapy promotes the resorption of scarring, relieving spasms, reducing pain manifestations; it can be used as one of the links of conservative therapy or after surgical treatment. Electrophoresis, microwave exposure, and magnetotherapy are usually used. Physiotherapy improves blood microcirculation, thereby increasing the concentration of drugs in the area of the pathological process, reducing the likelihood of relapses.
Prognosis and prevention
The prognosis for hormone-dependent trigonitis is favorable, with the development of interstitial cystitis, the quality of life depends on the timeliness and completeness of treatment. Trigonitis is accompanied by constant symptoms in women with pelvic organ prolapse, recovery is possible after performing reconstructive operations aimed at restoring normal anatomy, eliminating chronic ischemia.
Prevention implies early detection and treatment of urinary tract infections, commitment to monogamous relationships. When performing HRT with estrogens, it is necessary to monitor their level in the blood. The rejection of certain trigger products and substances (nicotine, ethyl alcohol) that enhance the irritating properties of urine, adequate hygiene contribute to the preservation of the health of the genitourinary organs. Metaplasia without keratinization has no malignant potential, observation is carried out in order not to miss leukoplakia, which in 20% progresses to squamous cell carcinoma.