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Other pelvic pain conditions

I. Other causes of painful bladder or painful urination - infection

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  bacterial cystitis
diverticula
fistulas
fungal infection (Candida infection)
kidney infection
Mycoplasma hominis
orchitis
pelvic inflammatory disease
schistosomiasis/bilharzia
sexually transmitted infection
tuberculosis (urogenital)
urethritis
vaginitis
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Urinary Tract Infections (UTI)

A urinary tract infection (UTI) can occur anywhere in your urinary tract: in the kidneys, ureters, bladder, urethra and in men the prostate gland. The term genitourinary tract infection may also be used. This refers to an infection in the reproductive organs and urinary tract.
Infections in the kidneys are known as pyelonephritis, infections in the bladder as cystitis, infections in the prostate as prostatitis, infections in the urethra as urethritis and infections in the vagina as vaginitis.

An infection may be caused by a bacterium, virus, fungus, parasite or protozoa.

 
   

Bacterial bladder infection – cystitis

Bacterial cystitis, usually known as cystitis, is a common bladder infection. Both men and women may get cystitis but it is much more common in women and girls. This is because the urethra in females is much shorter than in males and therefore infections invading from outside only have a short distance to travel in order to attack the bladder. By far the most common cause of cystitis is infection by bacteria that normally live in the intestines (E. coli). In women, the anus - a constant source of bacteria - is situated close to the short urethra. Women and girls should therefore practice hygiene by wiping from front to back after going to the toilet, to prevent intestinal bacteria having the chance to enter the urethra.
Some women seem to be much more prone to infection than others. These women should also practice strict hygiene before and after sexual intercourse and empty the bladder after sex so as to reduce the risk of infection. Urination after intercourse will flush out most bacteria that may have entered the urethra.
In men, bacterial cystitis is usually a consequence of infection of the urethra or the prostate, the result of catheterisation, surgery, use of instruments such as a cystoscope during investigations or hospitalisation.

 
   

Symptoms may include:

  • burning, stinging pain, particularly when urinating
  • frequent, urgent need to urinate
  • passing frequent, small amounts of urine
  • cloudy urine sometimes containing blood, sometimes strong-smelling
  • pain in lower abdomen or back
  • suprapubic pain or pressure
  • feverishness or chills
  • nausea/vomiting

Unlike PBS/IC, the pain symptoms of bacterial cystitis are not related to filling of the bladder.
Unlike PBS/IC, symptoms of bacterial cystitis will be relieved by appropriate antibiotics.

A urine test will reveal the presence of bacterial infection since urine itself is normally sterile. This test may be a dipstick test or a urine culture. A dipstick may test for the presence of glucose (sugar), blood, protein, leucocytes and nitrite in the urine and the pH level (level of acidity) of the urine. The dipstick can detect microscopic amounts of blood that are not visible to the naked eye. Excess glucose is usually an indication of diabetes. Leucocytes show the presence of inflammation, while nitrite indicates that bacteria may be present in significant numbers. Dipsticks are not infallible: if an infection is suspected but the dipstick is negative, it may be advisable to carry out a urine culture.
A urine culture requires a so-called clean-catch mid-stream urine specimen to prevent external contamination of the urine specimen. Men should pull back the foreskin and wash their penis before the specimen is taken. Women should wash around the vulva and entrance to the vagina and separate the labia (vaginal lips) before urinating to prevent contamination from the skin or vaginal discharge. The culture will reveal the type of urinary tract infection and the best antibiotic to be used.
In the case of recurrent urinary tract infection, it is important to rule out the presence of stones in the urinary tract since these can cause chronic infection.

Treatment

Bladder infections should always be investigated and treated since untreated bladder infections can rise up through the ureters and cause a potentially serious kidney infection.
Treatment of cystitis consists of an appropriate antibiotic, depending on the type of infection.

 
   

Special risk categories

  • females who do not practice adequate toilet hygiene
  • pregnant women
  • women using a diaphragm (with spermicide) as contraception
  • people with urinary retention who are unable to empty the bladder fully (this is seen in patients with neurologic disorders e.g. spina bifida, multiple sclerosis, spinal cord injury)
  • people with a congenital deformity or obstruction in the urinary tract (this is more commonly the cause of UTIs in men); men with an enlarged prostate, preventing the bladder from emptying properly
  • stones in the urinary tract
  • reflux: leakage of the valve between the bladder and ureter, allowing urine (containing bacteria) to flow back up into the ureters in the direction of the kidneys.
  • underlying disease such as diabetes, any disorder that suppresses the immune system increases the risk of a urinary tract infection;
  • steroid therapy;
  • infrequent voiding, giving bacteria the chance to multiply
  • people using a catheter (intermittent or indwelling)
  • a fistula between the bowel and bladder or the vagina and the bladder
  • sexual abuse/assault
  • postmenopausal women are more susceptible to UTIs.
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Tips

  • Drink plenty of fluids to flush out the urinary tract and give bacteria no chance to take hold.
  • Make sure your bladder completely empties when urinating.
  • Urinate after sexual intercourse.
  • Urinate regularly. Avoiding urination for long periods can give bacteria a chance to take hold.
  • Women and girls should wipe from front to back after using the toilet.
  • Keep the urogenital area clean and wash genitals and hands before and after sex.
  • If you are prone to repeated infections, it may be worth drinking cranberry juice which is believed to help control bacterial levels by preventing bacteria from sticking to the wall of the urinary tract.
  • Wear cotton underwear and loose clothing to allow the urogenital area to keep ventilated and dry, thereby helping to prevent growth of bacteria.
  • If your partner has the same symptoms, consider the possibility of a sexually transmitted infection and seek immediate treatment for both of you.
 
   

Diverticula

Diverticula are small pouches that form in weak areas of the wall of organs, including the bladder. They may be congenital or acquired and may be completely harmless causing no symptoms.
However, diverticula may cause problems in the bladder due to obstruction and the urine that collects in them may stagnate and become infected, causing recurrent cystitis. A chronically infected diverticulum may be a cause of inflammation. Obstruction caused by diverticula can lead to stone formation. Surgical removal is required for diverticula that are causing infection or blockage.

Fistulas

A genito-urinary fistula is an abnormal connecting passage or “hole” between the bladder and other organs. This includes vesicovaginal fistulas (between the bladder and the vagina), uretero-vaginal (between ureters and vagina), cervico-vesical (between cervix and bladder), urethra-vaginal (between urethra and vagina) or an enterovesical fistula (between bowel and bladder).
Fistulas can cause infectious cystitis due to infectious organisms being passed from the bowel or the vagina into the bladder through leakage. This kind of infection is more common in third world countries.
Vesico-uterine fistulas (between the bladder and uterus) do not lead to urinary incontinence but to loss of menstrual blood through the urethra.

Fistulas can be caused for example by:

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  • surgery in the pelvic area,
  • bladder cancer, colon cancer,
  • radiation therapy,
  • diverticular disease,
  • inflammatory bowel disease such as Crohn’s disease
  • injury due to complications of childbirth
  • difficult labour caused by genital mutilation due to traditional practices
  • traditional (harmful) remedies inserted in the vagina
  • accidents due to penetrating injuries
  • infections
  • sexual abuse or rape.
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Vesicovaginal fistulas are commonly found in women in poor communities in developing countries where they are usually due to the consequences of injury caused by childbirth complications, days of being in labour and lack of adequate emergency obstetric care such as caesarians. Labour may be obstructed due to traditional practices of genital mutilation in girls, sometimes involving sewing up vulvar tissue to almost completely close the entrance to the vagina.

Treatment is surgical repair of the hole but this is not always possible if tissue damage is extensive. Some fistulas may be completely irreparable and urinary diversion may be the only solution. In practical terms, surgery is only available for the lucky few and urinary diversion – if available – is not automatically going to be a practical option in third world countries where long-term follow-up, stoma care and the necessary hygiene are likely to be non-existent.

Fistulas cause suffering, illness and often premature death. The social consequences of fistulas are often life-shattering. The accompanying continuous incontinence (faecal or urinary) leads to the women being considered unclean and consequently religious and social outcasts. The patient is caused great distress, possible divorce, stigmatisation, isolation and financial destitution, causing them even greater poverty than they already had.

Fistulas resulting from childbirth in third world countries are a grossly neglected area of medicine and could be prevented by adequate, supervised maternal healthcare, better education and eradication of illiteracy especially among women, elimination of the custom of child brides and consequent childbirth before the girl has become reached the age where her pelvis is fully developed, improvement of the lowly position of women in many societies and creation of fistula centres in developing countries to treat these women.

 
   

Fungal infection

Fungal infections of the body overwhelmingly concern the Candida species of fungus. These infections can be acute or chronic, localised or systemic. Candida species are normal colonizers of the oral cavity, gastrointestinal tract and vagina and usually cause no harm in healthy people. Infection with Candida occurs when the normal population of Candida organisms present in almost everyone’s body is no longer kept under control, when a change takes place or imbalance occurs in the normal flora and overgrowth occurs for some reason, giving rise to symptoms. Most of the fungal infections in the urinary tract involve Candida albicans, with Candida glabrata becoming increasingly common.

Candida is a monocellular fungus (yeast) that can cause disease (candidiasis) in organs with mucous membranes such as the vagina, penis and mouth (also known as thrush). Candida infections can be acute or chronic, localised or systemic. A serious systemic form of Candida is known as deep candidiasis which can lead to multi-system organ failure.

Cutaneous candidiasis can cause skin infections and rash in parts of the body that receive little ventilation and remain moist.

Oral candidiasis or thrush is an infection of the mouth, tongue and gums caused by overgrowth of Candida species. It forms white plaques, under which the tissue is red and sore; it causes a burning sensation in the mouth or on the tongue, a bright red tongue and cracks in the corners of the mouth. It may lead to loss of taste and pain on eating and swallowing.

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Candida esophagitis in the esophagus can make swallowing difficult and cause pain behind the breastbone. Can be a complication of HIV/AIDS.

Vulvovaginal candidiasis, a form of vulvovaginitis, commonly occurs in women and may cause burning pain and irritation in the vagina, bladder, urethra, vulva and labia. Urine passing over this inflamed tissue may cause considerable burning or stinging. Typical of vaginal candidiasis is a thick white vaginal discharge with a cheese-like texture, pain during sex, pain passing urine, severe itching and burning red tissue at the entrance to the vagina, labia and vulva. Risk factors include: use of antibiotics, increased estrogen levels (such as use of oral contraceptives, pregnancy and estrogen therapy), corticosteroids, diabetes mellitus, HIV, diaphragm and intrauterine device use.

In men, Candida infection can cause burning, itching, redness and red patches under the foreskin or tip of the penis and pain on urination.

Candida in the urinary tract may co-exist with or follow bacterial infection. Candida is the most common type of fungal infection in the urinary tract, occurring in both men and women. Candida in the lower urinary tract can sometimes be mistaken for bacterial cystitis.

 
   

Symptoms include:

  • Irritation of bladder and urethra
  • Suprapubic tenderness
  • Painful urination
  • Blood in urine
  • Frequency/urgency
  • Fungus ball formation
 
   

While Candida in the urinary tract usually affects the bladder, through entry via the urethra, it may rise up via the ureters to the kidneys. Candida in the upper urinary tract may cause fever and pain in the back. It may be indistinguishable from bacterial pyelonephritis.

In some patients, however, there may be no symptoms at all.

Candida disease can occur for no apparent reason at all, but is common following use of antibiotics which may lead to overgrowth of the fungus. It is also commonly found in people with low resistance, such as patients with diabetes mellitus, SLE, Sjögren's syndrome and in immunocompromised patients such as HIV/AIDS. Catheterisation can also be a cause of Candida overgrowth in the urinary tract. Other risk factors include genitourinary tuberculosis, chemotherapy, radiation therapy, antibiotic use for bacterial cystitis, hospitalisation.

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Treatment is important because genitourinary Candida can be transferred between sexual partners. Candida albicans does not usually cause any serious long-term health problems and can be easily treated using fungicidal pessaries, a special cream or tablets e.g. fluconazole and itraconazole. Candida glabrata is more resistant to treatment and consequently more troublesome.

Deep candidiasis is when Candida infection spreads to the bloodstream. This is a serious systemic condition since it can cause a range of severe symptoms varying from fever to shock and multiple organ failure. It is particularly found in newborn babies with very low birth weights and in people with severely weakened immune systems (e.g. HIV/AIDS) or those with serious medical problems (cancer, diabetes). The kidney is the most common organ involved in systemic Candida. This severe form of Candida infection is usually treated intravenously.

 
   
Other fungal infections

Although much rarer, other fungi can infect the urinary tract, for example: fungi causing the inflammatory condition coccidiomycosis and blastomycosis, a rare infection caused by inhaling a fungus which may affect bladder, kidneys, prostate and testes.
 
   

Kidney infection (pyelonephritis)

Pyelonephritis (acute or chronic) is a bacterial infection of one or both kidneys. It generally concerns Escherichia coli, a type of bacteria usually found in the bowel which is a common cause of bacterial cystitis. The infection usually travels up to the kidneys via the ureters from the bladder and urethra.
Possible causes include: bladder infections, catheterisation, use of instruments (e.g. cystoscope) to examine the bladder and urethra, urinary tract surgery, obstruction caused by stones or an enlarged prostate gland, or reflux (backflow) of urine from the bladder into the ureters.

Infection can also occur through organisms being carried to the kidneys from other parts of the body or the skin via the bloodstream, for example a staphylococcal skin infection.

Symptoms may begin suddenly and include:

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  • chills and fever
  • pain on either side of the lower back
  • pain in the pubic area and groin
  • frequent need to urinate
  • burning pain when urinating
  • nausea and vomiting
  • fever and chills
  • symptoms of cystitis
  • blood and pus in the urine
 
Kidney infections should always be treated since untreated infections can lead to scarring of the kidneys and permanent kidney damage. A kidney infection can enter the bloodstream and cause a life-threatening condition.
Treatment usually consists of an appropriate antibiotic. Surgery may be needed if there is an obstruction or stone.
 
   

Mycoplasma hominis

Mycoplasma hominis is a bacterium, commonly present in the genital flora of sexually active males and females, which can cause infection in the genitourinary tract. It is associated with pelvic inflammatory disease (PID), vulvo-vaginitis, urethritis, postpartum and postabortal fever, pyelinephritis and chorioamnionitis. M.hominis has also been linked with non-genitourinary infections such as: septicaemia, wound infections, central nervous infections, joint infections, lower respiratory tract infections and endocarditis. Treatment of choice for M. hominis infections is tetracycline, doxycycline.

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Orchitis

Orchitis or inflammation of one or both testicles may be caused by many different bacterial or viral organisms and is often a complication of other urinary tract infections in men. Mumps is a well-known cause of viral orchitis. Other risk factors include indwelling catheters (Foley), genitourinary instrumentation or surgery, recurrent UTIs and congenital abnormalities of the urinary tract. Other causes of orchitis include sexually transmitted infections and allergic reactions.
Symptoms may include:

  • swelling of the testicle and scrotum
  • pain in the scrotum
  • fever  
  • pain on urination
 
   

Pelvic inflammatory disease (PID)

Pelvic inflammatory disease is an umbrella term for inflammation of the female reproductive organs (vagina, cervix, uterus, ovary, Fallopian tubes), usually caused by bacteria entering the body through sexual intercourse (sexually transmitted infection). If untreated, it can lead to infertility. However, in some cases no bacterial cause can be found.
Symptoms may include:

  • Abdominal/pelvic pain
  • Abnormal vaginal discharge
  • Fever
  • Nausea or vomiting
  • Irregular menstrual bleeding
  • Pain on urination
  • Pain during sexual intercourse
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Schistosomiasis / Bilharzia

Schistosomiasis, also known as Bilharzia, is an infestation caused by parasitic trematode flatworms also called flukes or schistosomes. There are five major species and it is Schistosomiasis haematobium which affects the urinary tract (kidneys, ureters and bladder) and is mainly transmitted by Bulinus snails.

Fluke larvae are released into water by freshwater snails. These larvae burrow into human skin where they mature into adults. Female flukes lay eggs which cause infestation.

It is a disease of the tropics and can cause serious long-term illness. Schistosomiasis is endemic in 74 developing countries and is the second most prevalent tropical disease in Africa after malaria. It can affect people who bathe in rivers, lakes, canals or freshwater pools that have not been chlorinated in the tropics. Children are at greatest risk of becoming infected through playing or swimming in water and because they lack the partial immunity gradually developed by adults. However, this disease can be contracted through any contact with contaminated water while performing daily domestic tasks such as washing clothes and fetching water. Fishermen and irrigation workers are also vulnerable through being constantly in contact with infected water.
When infected people, often children, urinate or defecate in the water, the eggs are released into the water source. The eggs then infect freshwater snails which serve as the intermediate host. The parasites develop and multiply inside the snails and are then able to enter the skin of new victims and continue the cycle.

Symptoms depend on the type of fluke causing the infestation. Within a few weeks, worms grow inside the blood vessels and produce eggs. Some of these eggs travel to the bladder or intestines and are then passed in the stools or urine. The rest of the eggs stay in the body where they can cause vital damage.

Schistosomiasis haematobium infection, also called bilharzial bladder disease,specifically affects the urinary tract. Damage to the urinary tract may be revealed by blood in the urine. Urination becomes painful and is accompanied by progressive damage to the bladder (fibrosis, contracted bladder with diminished capacity), ureters and then the kidneys. In advanced cases, cancer of the bladder is common.

Sometimes the only symptom is so-called “swimmer’s itch” which develops where the parasite entered the skin.
However, other symptoms may include:

  • fever
  • flu-like symptoms
  • fatigue
  • muscle aches
  • burning pain when urinating
  • urinary frequency and urgency
  • blood in the urine

Eggs may be found in the urine, but their absence does not automatically exclude infestation.

Schistosomiasis infestations are treated with medication to kill the parasite. If untreated, the eggs can cause life-threatening damage to the urinary tract and liver, bladder tumours and bowel cancer. Severe infections can produce serious urinary tract lesions. In rare cases, eggs may travel to the brain or spinal cord causing lesions and neurologic complications.

A standard treatment is praziquantel in a single dose and is effective in all species of schistosomiasis.

See also further reading and references below.

 
   

Sexually transmitted infection (venereal disease)

Sexually transmitted infections are an important cause of pain, urgency and frequency in the bladder, urethral pain and burning, inflammation of the pelvic floor and chronic pelvic pain in both men and women.

Symptoms include:

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  • pelvic pain/inflammation
  • pain with sexual intercourse
  • epididymitis
  • genital warts
  • genital ulcers
  • genital rash
  • urethral discharge
  • urethritis
  • unusual vaginal discharge
  • painful bladder
  • painful, burning urination
 
Infections may be caused by viruses, bacteria, protozoa and fungi. Examples are: chlamydia, gonorrhoea, syphilis, herpes, ureaplasma urealyticum, human papilloma virus, trichomoniasis, HIV/AIDS. Risk factors are unprotected sexual activity, sexual assault.  
   

Tuberculosis

The urogenital tract is the second most common site for tuberculosis after the lungs. Primary infection may have occurred many years earlier. Once a person has become infected, the tuberculosis organisms may be harboured anywhere in the body and reactivated under suitable conditions.
Infection of the kidneys may be passed from the lungs via the blood. Once tuberculosis has affected the kidneys, infected urine may then infect the ureters, bladder, epididymis, penis (very rare), urethra(very rare) and prostate (rare). Bladder tuberculosis is almost always secondary to tuberculosis in the kidneys. Tuberculosis inflames the mucosa of the bladder, forming tubercles which may ulcerate, especially around the trigone and ureters. Thickening and scarring of the bladder wall also occurs, resulting in diminished capacity. Symptoms of urogenital tuberculosis are similar to those of PBS/IC.  The shrunken “thimble” bladder causes frequency/urgency and there is sometimes also pain. The patient may also have low grade evening fever, weight loss and night sweats.

While it is very rare for genital TB to be passed from male to female through sexual relations, the possibility may exist of sexual transmission from female to male in the case of females with pelvic tuberculosis.

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In the regions of the world where tuberculosis is very common, it is important to exclude tuberculosis in a patient with painful bladder syndrome since tuberculosis is a curable condition. The World Health Organization estimates that almost one third of the world’s population is infected with Mycobacterium tuberculosis. Furthermore, the HIV/AIDS epidemic is causing an increase in tuberculosis.

EAU Guidelines for the Management of Genitourinary Tuberculosis were published in European Urology volume 48, issue 3 September 2005, pages 353-362. Detailed information on the diagnosis and treatment of this condition can be found in these guidelines.

Further information from the World Health Organization:

http://www.who.int/topics/tuberculosis/en/

http://www.who.int/docstore/gtb/publications/ttgnp/pdf/2003.313.pdf

 
   

Urethritis

Acute or chronic urethritis (inflammation of the urethra) can occur when infectious organisms (bacterial or viral) invade the male or female urethra. The symptoms may be difficult to distinguish from cystitis. See also sexually transmitted infection. It can also be caused by chemical irritants.
Symptoms may include:

  • frequent need to urinate
  • pain when urinating
  • discharge of pus from the urethra
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Vaginitis

Vaginitis is the term used to describe any inflammation or infection of the vagina. Sometimes also referred to as vulvovaginitis (inflammation of the vagina and the vulva or external genital area). The common symptoms are itching, burning and a discharge which looks different to your normal vaginal discharge and may have an odour. Burning in the vagina can also cause irritation in the bladder wall.
Some of the most common causes of vaginitis are:

 
   
  • Candida “overgrowth” infections
  • Bacterial vaginosis: a common bacterial vaginal infection caused by “overgrowth” as in Candida
  • Trichomoniasis vaginitis: caused by an organism known as a protozoa, can be sexually transmitted
  • Chlamydia vaginitis: a sexually transmitted infection and may cause no symptoms in women, making diagnosis difficult
  • Viral vaginitis, including the Herpes simplex virus and human papillomavirus (HPV). These are sexually transmitted infections
  • Non-infectious vaginitis: allergic reactions or irritation from vaginal deodorants, feminine hygiene sprays, perfumed soap or bubblebath, douches or spermicidal products, laundry detergents, hormonal changes, latex, semen.
 
NB Forgotten tampons left in the vagina can be a common cause of vaginitis!  
   
Further reading and references

Incontinence, volumes 1 & 2, Editors: P Abrams, L Cardozo, S Khoury, A Wein, 3rd International Consultation on Incontinence, 2004

Urinary tract infections:
http://kidney.niddk.nih.gov/kudiseases/pubs/uti_ez/index.htm

Urinary tract infections in children:
http://kidney.niddk.nih.gov/kudiseases/pubs/utichildren/

Urinary Tract Infection in the Female.
Edited by Stuart L Stanton, Peter L Dwyer
Published by Martin Dunitz
ISBN 1 85317 689 3

Urogenital schistosomiasis:
EAU Guidelines for the Management of Urogenital Schistosomiasis
Karl-Horst Bichler et al, European Urology 49 (2006) 998-1003

 
   
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