Cistite: Sintomi-terapia-prevenzione
Definizione
La cistite è un’infezione della parete della vescica e rappresenta circa l’80% delle IVU. Si possono distinguere cistiti acute e cistiti ricorrenti.
Manifestazioni cliniche
La cistite acuta è caratterizzata da esordio brusco con pollachiuria, disuria e stranguria; comune anche la nicturia con un dolore in regione ipogastrica o lombare, mentre la febbre è per lo più assente. L’urina è spesso torbida e in circa il 30% dei pazienti è presente macroematuria. Negli anziani e nei diabetici i sintomi locali possono essere assenti. Negli uomini l’infezione batterica della vescica è di solito complicata ed è generalmente dovuta a un infezione ascendente dell’uretra o della prostata o si verifica secondariamente a una manovra strumentale uretrale. Nelle donne, invece, spesso un rapporto sessuale precede la cistite non complicata. Le complicanze della cistite, frequenti in epoca pre- antibiotica, sono la sepsi urinaria e la prostatite batterica acuta e cronica.
Cistite ricorrente
Si parla di cistite ricorrente quando si verificano più di 3 episodi in un anno. È frequente nelle donne sessualmente attive, nei diabetici e negli uomini con ipertrofia prostatica. La causa va ricercata nel serbatoio batterico costituito dalla flora fecale (microrganismi aerobi gram-negativi, soprattutto Escherichia coli), che in particolari circostanze possono infettare le basse vie urinarie.
Il meccanismo di infezione più frequente nella cistite recidivante della donna è quello ascendente, rappresentato dal passaggio di batteri patogeni dalla zona periuretrale all’uretra e quindi alla vescica. Si tratta di un processo a tappe in cui i germi provenienti dall’intestino colonizzano la vagina e la mucosa uretrale per poi risalire in vescica. Pertanto la causa principale delle infezioni urinarie ricorrenti nelle donne è rappresentata dalla alterazione della normale flora batterica vaginale.
Terapia
La terapia della cistite acuta si avvale di antibiotici con un’elevata escrezione urinaria, come il cotrimossazolo, i fluorochinoloni e la nitrofurantoina che tuttavia vanno utilizzati in prima linea solo se l’incidenza della resistenza è inferiore al 10%. In caso contrario il trattamento va selezionato sulla base dell’ antibiogramma. La fosfomicina in dose singola sembra efficace, secondo alcuni autori, soprattutto nelle infezioni da Proteus e nei pazienti con allergia al cotrimossazolo. Per quanto riguarda la durata del trattamento antibiotico, nelle donne può essere sufficiente una cosiddetta
short course therapy (3 giorni) mentre negli uomini è opportuno prolungare la somministrazione per 10 -14 giorni. È importante controllare l’efficacia della terapia ripetendo l’ urinocultura due settimane dopo il termine del trattamento. Nelle forme di cistite acuta acquisite in ambito ospedaliero è sempre opportuno eseguire l’ urinocoltura con antibiogramma; in attesa del risultato si può intraprendere una terapia empirica con cefalosporine. Una situazione particolare è rappresentata dalla cistite acuta in gravidanza durante la quale è raccomandato il trattamento anche delle forme di batteriuria asintomatica, con nitrofurantoina e amoxillicina per 7 giorni. La terapia delle cistiti ricorrenti mira all’ eradicazione dell’infezione, obiettivo difficilmente raggiungibile con un trattamento di breve durata.
Sono previsti i seguenti schemi terapeutici:
*terapia continuativa dopo la fase acuta: utilizzo di farmaci (cotrimossazolo o chinoloni) a basso dosaggio in maniera prolungata (3-6-12-mesi)per via orale, da assumere la sera prima di andare a letto, dopo lo svuotamento della vescica per aumentare l’accumulo del farmaco nell’urina.
*terapia post-coitale: viene effettuata con chinoloni o cotrimossazolo in dose singola dopo il rapporto sessuale.
E’ consigliato nei casi in cui esista un rapporto temporale tra rapporto sessuale e insorgenza della cistite.
Prevenzione
La prevenzione della cistite si basa fondamentalmente sulla terapia continuativa o post-coitale nei casi di infezioni recidivanti. Sono attualmente in corso alcuni trial vaccinali contro ceppi microbiotici uropatogeni che, inducendo la produzione di anticorpi mucosali, ridurrebbero la frequenza di IVU ricorrenti. Per quanto riguarda invece le IVU nosocomiali la prevenzione si basa sull’ osservanza di alcune procedure:
*Il posizionamento del catetere vescicale solo se strettamente necessario (ritenzione urinaria, interventi sulla pelvi e sul tratto genito-urinario, interventi chirurgici di lunga durata, ematuria massiva, condizioni emodinamiche critiche);
*l’applicazione del catetere secondo le norme di asepsi (guanti sterili, lavaggio e disinfezione della zona genitale , inserimento
del catetere già collegato al sistema chiuso);
*la rimozione del catetere non appena possibile;
*l’impiego di un sistema di drenaggio chiuso.
Dolore intimo e radiofrequenza quadripolare
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