Menopause cystitis is an inflammatory lesion of the bladder pathogenetically associated with involutive changes in female urogenital organs. It is manifested by pollakiuria, imperative urge to urinate, pain in the lower abdomen, turbidity of urine and its staining with blood. It is diagnosed with the help of a general urine analysis, echography of the bladder, cystoscopy. HRT is used for treatment in combination with antibiotics, nonsteroidal anti-inflammatory drugs, peripheral vasodilators, stimulants and detrusor receptor blockers, nootropics, antidepressants. With severe atrophy, cystoplasty is performed.
Menopausal cystitis is the most common urological pathology in patients aged over 40-45 years. During menopause, it is diagnosed in 10-15% of women, in postmenopause – in 15-20%. In postmenopausal cystitis may be a development factor or one of the manifestations of a specific urogenital disorder during menopause. Despite the common etiology with classical acute and chronic bacterial inflammation of the bladder in patients of reproductive age, the influence of hormonal changes during menopause, the clinical picture and complications justify the consideration of involutional cystitis as a separate form of the disease.
The traditional anatomical and functional prerequisites that contribute to the more frequent development of cystitis in women than in men in the menopausal period are supplemented by involutive changes in the organs of the urinary system. The leading role in the formation of atrophic processes is played by hypoestrogenism, observed during menopause. According to experts in the field of urogynecology, the main factors that increase the likelihood of developing cystitis in peri- and postmenopause are:
- Atrophy of the bladder mucosa. Against the background of progressive estrogen deficiency, the epithelial layer is thinning, the folding is smoothed out. As a result, the vulnerability of the mucosa increases, cracks form faster on it, and microorganisms adhere more easily.
- Violation of the blood supply to the genitourinary organs. Atrophic processes are aggravated by ischemia of the detrusor, the wall of the urethral canal. The resulting hypoxia reduces the protective potential of the mucous membrane, which contributes to the rapid development of the inflammatory process.
- Changes in the activity of the receptor apparatus. With menopause in the urethra, the bladder decreases the number of adrenoreceptors, the sensitivity of acetylcholine receptors decreases. The reduction of detrusor becomes less coordinated, the passage of urine is disrupted.
- Other urogenital disorders. Atrophic changes in the epithelium of the vagina, urethra lead to a decrease in the primary antibacterial potential of the mucous membranes. Colpitis and urethritis that occur during menopause are more quickly complicated by the development of cystitis.
- Weakening of the ligamentous apparatus. With estrogenic insufficiency, the muscles and ligaments that form the pelvic floor weaken, which contributes to the formation of a cystocele, ureterocele. Prolapse of the urinary organs simplifies the penetration of microorganisms into the bladder.
The causative agents of the inflammatory process are usually the same microbial agents as in the banal forms of cystitis. Escherichia coli are most often sown from urine and tissue biopsy, less often – other nonspecific conditionally pathogenic microflora: Staphylococci, Streptococci, Klebsiella, Proteus, Pseudomonas aeruginosa, Enterobacter, Enterococci, candida. In comparison with reproductive age, specific forms of cystitis caused by mycoplasmas, ureaplasmas, chlamydia, trichomonas, gonococci are less common during menopause.
The mechanism of disease development is based on a significant suppression of natural protective factors that prevent the introduction and reproduction of infectious agents. The main links in the pathogenesis of cystitis during menopause are thinning of the mucosa, impaired urine flow caused by detrusor dysfunction, rapid upward spread of infection from the vagina and urethra due to weakening of fascial-muscular structures.
Normally, the removal of microorganisms from the bladder is facilitated by the peeling of the epithelium. With atrophy of the epithelial membrane, this process slows down. Due to the presence of pathogenicity factors, bacteria that linger in the organ cavity due to functional disorders of urination are more quickly fixed to epithelial cells.
The process is aggravated by an involutive decrease in the anti-adhesive effect of the mucopolysaccharide layer of the urothelium. The active reproduction of microorganisms, their release of endo- and exotoxins provokes the occurrence of a local catarrhal reaction with intense secretion of inflammatory mediators, tissue edema, and microcirculation disorders.
Thinning of the mucous and submucosal layer contributes to a deeper spread of the inflammatory process in the interstitium of the bladder, stimulation of numerous receptors of the muscular membrane, the appearance of a pronounced pain syndrome, the development of sclerotic processes. The inflammation quickly becomes chronic.
Symptoms of cystitis during menopause
The clinical picture of the disease is largely similar to the typical manifestations of bacterial inflammation. Signs of menopausal cystitis are increased urination (up to 30 times a day), imperative urges, sharp pain at the end of the act of urination, a feeling of incomplete emptying, constant aching pains in the lower abdomen.
With the progression of pathology, the urine becomes cloudy, an admixture of blood appears in it. With menopause, the disease is characterized by a chronic recurrent course. Symptoms worsen after sexual intercourse, stress, eating spicy food and alcohol. Violations of the general condition with cystitis are expressed slightly – in the acute period, subfebrile body temperature, headaches, weakness, decreased performance are possible.
With a prolonged course of the disease, the risk of interstitial inflammation increases, in which irreversible scarring changes occur in the organ wall, a wrinkled bladder is formed. With menopause, cystitis is often complicated by pyelonephritis, the occurrence of which is facilitated by the upward spread of pathogenic microorganisms into the cup-pelvic system of the kidneys. In rare cases, there is a gangrenous form of the disease with necrotic changes in the bladder. Involutional cystitis is one of the provoking factors of the development of urogenital post-menopausal disorder with detrusor hyperfunction and urinary incontinence.
The diagnosis of cystitis during menopause is not difficult in the acute form of the disease with a characteristic clinical picture. However, in menopausal women, the disease often has a chronic course with minimal symptoms, which complicates the diagnostic search. The examination plan of a patient with a suspected inflammatory process of the bladder includes the following instrumental and laboratory methods:
- Urine tests. With cystitis, leukocyturia, bacteriuria, pyuria, epithelial cells and mucus are detected in the urine, the protein concentration increases (more than 1 g / l). In advanced cases, a sharp unpleasant smell appears. The study is supplemented by a Nechiporenko analysis, in which the quantitative content of cellular elements in 1 ml of urine is evaluated. It is mandatory to perform bacteriological urine culture to identify pathogenic microorganisms and clarify their sensitivity to antibiotics.
- Ultrasound examination. Ultrasound of the bladder allows you to detect changes in the thickness of the walls (during menopause they are thinned due to a lack of sex hormones), a decrease in the volume of the organ. A characteristic feature is the presence of a fine hypoechoic suspension. Also, sonography may show signs of fibrosis and sclerosis, deformation of the contours of the bladder.
- Endoscopic examination. The introduction of a flexible endoscope through the urethra makes it possible to assess the condition of the mucous membrane, the mouths of the ureters, and the Lieto triangle. Cystoscopy is performed only in the remission phase, so as not to injure the urethra or bladder. The study helps to exclude other causes of dysuric phenomena (neoplasms, diverticula). In complex diagnostic cases, endoscopic biopsy with histological examination of the material is recommended.
- Additional research. In a clinical blood test for cystitis, signs of bacterial inflammation are determined: neutrophilic leukocytosis with an increase in the number of young cells, increased ESR. Also, with cystitis, a smear is taken from the vagina to be examined for the presence of sexually transmitted infections. To assess the urodynamics of the lower urinary tract, uroflowmetry can be performed.
Differential diagnosis of urinary inflammation in menopause is carried out with:
- paraurethral cysts;
- interstitial cystitis;
- malignant neoplasms;
- tuberculosis of the urinary system;
- gynecological diseases — cervical cancer, adnexitis, parametritis.
In addition to the examination of the urologist and gynecologist, the patient is recommended to consult a nephrologist, oncologist, phthisiologist, infectious disease specialist.
Treatment of cystitis in menopause
The main medical tasks in the case of involutional inflammation of the bladder are considered to be the correction of the hormonal background and the elimination of the causative agent of the infectious process. The treatment regimen is two-stage: at the initial stage, with the predominance of inflammatory symptoms, combination therapy is recommended to relieve the main manifestations of the disease, followed by long-term hormone replacement treatment. In the first phase of therapy of menopausal cystitis , the following groups of drugs are used:
- Female sex hormones. In the acute period, the best results are provided by a combination of intravaginal agents with systemic estrogens. This allows you to quickly restore normal vaginal flora, proliferation of the epithelium of the vagina, urethra, bladder, mucus secretion, elasticity of the tissues of the urogenital organs.
- Antibacterial drugs. When choosing an antibiotic, the sensitivity of the pathogen should be taken into account. Usually, fluoroquinolones, phosphomycins, derivatives of pipemidic acid, nalidixic acid, 14-membered macrolides, nitrofurans, cephalosporins, and other uroantiseptics are used for the treatment of involutional cystitis.
- Nonsteroidal anti-inflammatory drugs. NSAIDs in the active phase of cystitis inhibit the secretion of inflammatory mediators, reducing the infectious-inflammatory response. By increasing the threshold of receptor sensitivity and the effect of medications on the brain nociceptive centers, it is possible to reduce the pain syndrome.
- Drugs to improve microcirculation. The use of purine derivatives and other peripheral vasodilators makes it possible to improve tissue perfusion, which contributes to a faster recovery of the damaged mucous membrane. Against the background of sufficient oxygenation, the risk of fibrosclerotic processes decreases.
- Stimulants and detrusor receptor blockers. With a combination of cystitis and dysfunction of the vesical muscles, taking into account the type of disorder, M-cholinolytics, α1-adrenomimetics, M- and H-cholinomimetics are prescribed. Nootropics, selective serotonin reuptake inhibitors can be used to correct detrusor hyperactivity.
As a supportive treatment, it is recommended to carry out hormone replacement therapy for life, constantly adjusting the type of drugs, dosage and method of management. Local remedies can be applied all the time. To prevent hyperestrogenic effects after the relief of inflammation, women with a preserved uterus who plan to continue systemic therapy are shown to cancel estrogens and a continuous monophasic regimen of estrogen-progestogenic drugs.
In 5-6% of cases, the disease takes a persistent recurrent course with gradual shrinking of the organ and requires surgical intervention (augmentation cystoplasty, intestinal bladder plastic surgery).
Prognosis and prevention
With early diagnosis and the appointment of complex therapy, recovery occurs in most patients. It should be borne in mind that without the use of hormonal drugs, taking antibiotics usually has only a temporary effect. The prognosis for menopausal cystitis is favorable. An important link in the prevention of cystitis during menopause is the appointment of hormone replacement therapy to all menopausal women, which prevents atrophic changes in the urinary tract mucosa. Also, to prevent the development of the disease, it is necessary to monitor the timeliness of emptying the bladder, avoid hypothermia, observe the rules of personal hygiene, exclude excessively spicy food from the diet.