Preface

Bladder inflammation is described as cystitis, a pathological condition caused by microbial agents and a common urinary tract infection (UTI). Although the prevalence of infectious cystitis is increasing worldwide, often representing a therapeutic challenge due to the resistance to antibiotics expressed by the responsible pathogens, bladder inflammation also recognizes different etiopathogenetic mechanisms. In fact, several non-infectious diseases may determine bladder inflammation, which is responsible for bothersome symptoms such as increased micturition frequency, urinary urgency, urinary burning, urinary incontinence, bladder pain, and hematuria. Various studies have shown that the impact of cystitis on a patient's quality of life is strongly negative, especially when the inflammation recurs or becomes chronic, causing pain or discomfort that is difficult to eradicate. The literature provides several data on various types of cystitis, however, most of these manuscripts focus only on a specific type of bladder inflammation, providing updates or describing results of research that explain new pathogenetic mechanisms or propose new therapeutic strategies. There is a lack of publications specifically dedicated to describing all main types of cystitis. As such, this book provides a comprehensive overview of the most important categories of cystitis. Written by experts in the field, this book includes six chapters.

Chapter 1: "Introductory Chapter: Presenting an Overview on the Main Clinical, Diagnostic and Therapeutic Aspects of Human Cystitis"

Chapter 2: "Recurrent Cystitis in Women: Optimal Recommended Diagnostic Evaluation, Management and Prevention Options"

Chapter 3: "Cystitis in Children"

Chapter 4: "Interstitial Cystitis/Bladder Pain Syndrome"

Chapter 5: "Radiation Cystitis"

Chapter 6: "Drug-Related Cystitis: An Overview"

After an introductory chapter that presents a general overview of the topic, the book moves on to a discussion of bacterial cystitis in adults. Today, there are several doubts about the correct approach to treat this condition, particularly recurrent bacterial cystitis, due to the abuse of antibiotics in the last years and the consequent increase of bacterial resistance to drugs expressed by the most common etiopathogenetic agents of *Escherichia coli, Klebsiella pneumoniae, Proteus mirabilis, Enterococcus faecalis,* and *Staphylococcus saprophyticus*. Chapter 2 provides evidence of the current etiopathogenetic aspects of bacterial cystitis, reviews proper diagnostic procedures, and discusses recommended treatment to limit bacterial resistance and thus prevent the recurrence of infection. The chapter also discusses the prevention of cystitis. Chapter 3 is dedicated to pediatric patients. Inappropriate management of infectious disease in pediatric patients may lead to severe complications that can become life-threatening or chronic. In addition, therapeutic regimens in childhood are different from those in adults. Chapter 4 discusses the

diagnosis and therapeutic management of interstitial cystitis. Many patients with this condition, almost all of whom are women, receive a late diagnosis because the early clinical presentation of the disease is often misinterpreted as an infectious disease. Chapter 5 discusses radiation cystitis. Radiation therapy has become the standard treatment for many tumors, especially those involving the pelvic area. Despite the reduction of inflammatory complications by new devices, the number of patients undergoing radiation therapy is increasing and a significant number of these patients experience radiation cystitis. As the population ages, more patients are developing neoplastic conditions of the pelvic area. Elderly patients may not be eligible for surgery and thus they may need to undergo radiation therapy. Furthermore, this therapeutic option is very often used as adjuvant treatment after surgery of the prostate and bladder (and some other tumors of this anatomic area), and cystitis can be a frequent consequence. Finally, Chapter 6 examines drug-related cystitis. Some pharmacological agents used in chronic treatments can be the cause of severe bladder inflammation. Being that iatrogenic cystitis is rare, its diagnosis and treatment are not well-known by clinicians. An important aspect that must be considered is the cost of diagnosis and treatment of cystitis, as the prevalence of this condition is increasing worldwide. The expense of antibiotics constitutes a real economic emergency in healthcare systems and is partly due to inappropriate use of these drugs due to inadequate knowledge of guidelines and recommended therapeutic regimens.

This book presents diagnostic-therapeutic schemes useful in daily clinical practice for using effective therapies and preventing abuse of antibiotics and thus limiting the development of drug resistance. This aspect is particularly important because clinical research has not yet introduced new drugs onto the market that can overcome the limits caused by the resistance of microorganisms, which in some cases can cause severe clinical conditions for patients, especially those who are hospitalized or immunosuppressed. With reference to non-infectious cystitis, the therapeutic approach often takes little consideration of relevant guidelines because the treatment options are not always readily available. However, this can lead to an aggravation of the disease with a very negative impact on the patient's quality of life. Therefore, especially in non-infectious cystitis, which is discussed in this book, a medical intervention must strictly adhere to current guidelines in order to choose the appropriate therapies and limit chronicity and worsening of the disease to improve patient quality of life.

I want to thank all the contributing authors for their participation, effort, professionalism, and clinical and scientific expertise.

> **Giovanni Palleschi, MD, Urologist, Ph.D.** Hemodialysis Unit, Nefrocenter Group, Frascati, Rome, Italy

> > **Antonio Cardi** San Giovanni Addolorato Hospital, Urology Unit, Rome, Italy

Prologue

Inflammatory disorders of the urinary tract have high incidence and prevalence worldwide. These conditions affect women and men from childhood to old age and therefore have a significant negative impact on quality of life, being sometimes responsible for severe, life-threatening complications. Cystitis is the most prevalent inflammatory condition of the urinary tract. It is responsible for bothering symptoms, but very often it is clinically underestimated for several reasons. Many patients have the habit of self-managing this condition when symptoms develop, using antibiotics and anti-inflammatory drugs without consulting a doctor or undergoing laboratory examinations or other diagnostic tests. This is very common, especially among women and it is one of the most important reasons for the significant increase of bacterial resistance to drugs in the last years as well as the high incidence of recurrent or chronic cystitis. There is also the common idea that cystitis could be only the consequence of bacterial infections; however, many inflammations of the bladder have a non-infectious origin, even if the symptoms are similar. Furthermore, non-infectious cystitis is usually chronic and difficult to treat, often representing a challenge for clinicians because its pathophysiologic mechanisms are still not completely understood and therapies in some cases are still experimental. This book reviews the different types of cystitis, providing detailed information on etiopathogenesis, pathophysiology, and treatments. It is an important guide for clinical practice not only for specialists but also for general practitioners. In addition, the text can also be consulted by patients, helping them to

seek proper medical intervention instead of self-medicating.

**Valeria Rossi** Nephrologist,

Frascati, Rome, Italy

Chief of Nefrocenter Haemodialysis Centre,
