Inflammation of the Bladder (Cystitis): Causes

Pathogenesis (development of disease)

Cystitis (bladder inflammation) is usually caused by an ascending (ascending) infection from the urethra.For this purpose, pathogenic (disease-causing) pathogens accumulate on the urothelial cells (transitional epithelium lining the renal calices, renal pelvis, urinary bladder and, in men, the upper urethra) with the help of so-called adhesins. After this colonization, inflammatory processes occur with damage to the epithelial cells and the underlying cell assemblies. Toxins (poisons) produced by the bacteria play a role in this process, such as alpha-hemolysin and CNF1 (cytotoxic necrotizing factor) in the bacterium E. coli. Other toxins include endotoxin A, proteases, or ureases. Many pathogens can defend themselves against an immune response from the body, for example by capsule formation.The most common pathogen is the gram-negative bacterium E. coli (Escherichia coli), which is an intestinal bacterium and causes approximately 75-80% of all acute urinary tract infections (UTIs). Other possible pathogens include:

• Chlamydia – Chlamydia trachomatis
• Enterococci (most common in mixed infection) – uropathogenic Escherichia coli (UPEC) (community-acquired UTI).
• Enterobacter
• Gardnerella vaginalis – indirect trigger for recurrent urinary tract infections with Escherichia coli bacteria resting retracted in the urinary bladder wall and reactivated (mouse model).
• Klebsiella (Klebsiella pneumoniae).
• Mycoplasma
• Neisseria
  • Neisseria gonorrhoeae (gonococci)
  • N. meningitidis (“US Nm urethritis clade”, US_NmUC for short).
• Proteus mirabilis
• Pseudomonas
• Salmonella (0.5% of all UTIs) – patient usually has had a previous intestinal infection in such cases
• Staphylococcus (Staphylococcus saprophyticus).
• Ureaplasma
• Mycoses (fungi) – Candida and other fungal species.
• Viruses – e.g. herpes simplex, adenoviruses.

Similarly, it is possible that an infection of the kidneys spreads to the urinary bladder, which is called descending (descending) infection. This may be the case, for example, with pyelonephritis (inflammation of the renal pelvis).

Etiology (causes)

Biographic causes

• Genetic predisposition – Mothers of patients who have frequent urinary tract infections also have a higher than average incidence of infection. Apparently, the number and type of receptors to which bacteria can attach plays a special role
• Congenital anatomical changes in the urinary tract or functional limitations (e.g., due to vesicoureteral reflux, neuropathic bladder, mechanical or functional obstruction) can lead to stasis, that is, retention of urine or residual urine in the urinary bladder, which promotes inflammation.
• Age
  • Juvenile age at first urinary tract infection.
  • Menopause/postmenopause/menopause in women (because of change in pH and decreased colonization by lactobacilli; this leads to increased vaginal colonization by Enterobacteriaceae and anaerobes; urogenital atrophy because of estrogen deficiency)
• Hormonal factors
  • Pregnancy – the risk is increased, about 2 to 8 percent of pregnant women are found to have cystitis (urinary tract infection)
  • Menopause/postmenopause/menopause in women (see age below).

Behavioral causes

• Nutrition
  • Inadequate fluid intake – the better the urinary bladder is “flushed”, the less likely it is to be inflamed
  • Micronutrient deficiency (vital substances) – see Prevention with micronutrients.
• Psychosocial conflict situations (stress and constant tension – tense bladder walls increase the risk due to decreased mucus production):
  • Bullying
  • Mental conflicts
  • Social isolation
  • Stress
• Use of vaginal diaphragms and spermicides – this alters the normal bacterial vaginal flora (microbiota), so there may be an increase in E. coli (Escherichia coli) bacteria in the vagina, which is associated with an increased risk of cystitis
• Sexual activity:
  • Through coitus (sexual intercourse) bacteria can enter the bladder and cause cystitis (= timely sexual intercourse).Postcoital micturition (urination) (after intercourse) can reduce the risk, as this flushes out any bacteria that may be present. Furthermore, the male partner should ensure adequate hygiene
  • After the honeymoon due to frequent sexual intercourse (“honeymoon cystitis“); common symptoms here are alguria (pain when urinating), dysuria (difficult (painful) urination) and pollakisuria (urge to urinate frequently without increased urination).
• Anal intercourse / anal sex in men who have sex with men (MSM) is associated with increased risk
• Lack of hygiene – but also exaggerated hygiene.
• Wearing damp swimwear for a long time, cold drafts.

Causes related to disease

• Ascending (descending) infections from the kidneys and upper urinary tract – for example, in pyelonephritis (inflammation of the renal pelvis).
• Diabetes mellitus
• Urinary flow disorders* , e.g.:
  • Obstruction (obstruction) or anatomical abnormality of the urinary tract.
  • Benign prostatic hyperplasia (BPH) – benign enlargement of the prostate gland.
  • Urethral stricture (narrowing of the urethra) – for example, due to venereal diseases (sexually transmitted diseases) such as syphilis (lues) or gonorrhea (gonorrhea) or congenital (congenital).
  • Nephrolithiasis (kidney stones), urolithiasis (urinary stones).
  • Neurogenic bladder emptying disorders – e.g. in diabetes mellitus, multiple sclerosis (MS), tabes dorsalis.
  • Vesicoureteral reflux (VUR; unphysiologic reflux of urine from the bladder via the ureters (ureters) into the renal pelvis) (urinary tract infections (UTIs) in childhood).
  • Pregnancy
• HIV infection
• Immunodeficiency with accompanying immune deficiency
• Immunodeficiency/immune deficiency*
• Renal insufficiency* (kidney weakness)
• Residual urine (> 180 ml)
• Tumors of the kidneys, for example renal cell carcinoma.
• Urolithiasis* (urinary stones)
• Previous urinary tract infections
• Cystic kidneys

Medication

• Analgesic abuse (misuse of painkillers).
• Immunosuppressed patient(s)* .
• Contraception (birth control) with DMPA (depot medroxyprogesterone acetate).
• Antibiotic therapy 2 to 4 weeks ago.
• Cytostatic drugs (e.g. methotrexate)

Operations

• Surgery in the urinary tract (especially after transurethral resection of the prostate/urological surgical technique in which pathologically altered prostate tissue can be removed without an external incision through the urethra (urethra)).
• Instrumental urological procedures (e.g. cystoscopy / cystoscopy), which may be associated with germ transmission.
• Kidney transplantation* (NTx, NTPL).

X-rays

• Radiatio (radiation therapy) for tumors in the urinary tract or pelvis* – so-called “radiation cystitis”.

Other causes

• Use of diaphragm and spermicides.
• Mechanical stimuli – foreign body in the urinary tract* (indwelling bladder catheter, suprapubic catheter/bladder catheter inserted above the pubic bone through the abdominal wall into the urinary bladder, ureteral stent, nephrostomy/application of a renal fistula to drain urine to the outside)
• Stress and constant tension – tense bladder walls increase risk due to decreased mucus production
• Condition after discharge from an inpatient facility within the last two weeks.

* Risk factors for the development of complicated urinary tract infection.