When It's Not a UTI: Understanding Trigonitis in Women

Have you been constantly feeling the frequent urge to urinate, with persistent pain similar to when you're having a urinary tract infection (UTI)? Or have you taken a urine test which came back negative for bacteria, but you feel like you have a UTI and ended up taking painkillers? For many women, this is the case when they have a condition known as trigonitis.

Trigonitis is the inflammation and tissue change in the trigone area of the bladder. Trigone, as the name indicates, is the triangular region of your bladder at the neck or base of the bladder. It is positioned between where the two ureters enter and where the urethra exits.

Even though you may not have heard the term 'trigonitis' very often, you may be familiar with the term 'interstitial cystitis' or 'painful bladder syndrome'. How does trigonitis differ from IC? Unlike interstitial cystitis, where your entire bladder is inflamed, in trigonitis only the inflammation or irritation is confined to the trigone area.

Unfortunately, despite so many women suffering this condition without even properly understanding what they have been going through, there's very little research on the condition, and no official guidelines exist for its diagnosis or treatment.

Accurate diagnosis of trigonitis

This is a rather difficult condition to diagnose, which still remains poorly understood and is often diagnosed after so many visits to the GP and several tests. So why is this condition so difficult to diagnose? It's mostly because it shares similar symptoms with a UTI, like the symptoms of frequent urination, urgency, pain during urination and suprapubic pain.

Women, when they feel like they have symptoms mimicking those of a UTI and have urine cultures with no bacteria, are often referred for further imaging tests like an ultrasound, pelvic MRI, or CT scan. While these tests can help rule out other bladder conditions like tumours, stones, or structural abnormalities, they don't give sufficient details to identify the minute tissue changes that trigonitis causes.

However, trigonitis can be accurately diagnosed with the help of a procedure known as cystoscopy. In this procedure, doctors insert a thin, flexible tube with a camera called a cystoscope through the urethra to have a look inside your bladder.

To confirm it's trigonitis, during cystoscopy, they look for specific signs such as patches of inflammation or irritation in the trigone region, maybe along with pus pockets.

How does trigonitis occur

While the exact reason why this condition affects the trigone region of the bladder is not yet completely understood by researchers, there are a few possible reasons why.

Developmental origin of the trigone during embryonic growth

One reason lies in the way in which various organs develop before birth. While your bladder develops from a single tissue type known as endoderm, the trigone is formed from a different kind of tissue known as mesoderm. This is considered a likely reason for the inflammation.

Expression levels of oestrogen receptors in the trigone area

Not only that, for this very reason that the trigone develops differently from the rest of the bladder, it may respond more strongly to oestrogen. Studies have revealed that since oestrogen receptors are more commonly found in the trigone’s surface layer, this hormonal fluctuation can influence trigonitis. However, whether this condition is caused by oestrogen or if chronic irritation of the trigone causes the development of oestrogen hormone receptors is not yet clear.

Recurrent urinary tract infections

Several other studies have associated the occurrence of trigonitis with recurrent UTIs. Trigonitis and other inflammatory changes were commonly observed during cystoscopy in women with rUTIs. A study conducted in mice revealed that Escherichia coli bacteria, which are the most common cause of UTIs, can hide themselves inside bladder cells to form intracellular bacterial communities, which can lead to repeated infections. This may potentially occur in people, as similar bacterial forms have also been discovered in the urine of women who suffer UTIs, which cause infections to come back even after taking antibiotics.

Irritation

Apart from these factors, people with long-term bladder irritation, for example, those who have to use a catheter, can also develop trigonitis. Moreover, infections like vaginitis or sexually transmitted infections (e.g., Trichomonas vaginalis) can also irritate the trigone. Especially, women between the ages of 30 and 50 are more likely to be diagnosed with it, particularly those who have given birth to several children. According to experts, these bladder abnormalities might be caused by recurrent discomfort from intercourse, childbirth, surgery, or even specific chemicals (such as douches or contraceptive medications).

Treatment Options for Trigonitis

Once you are confirmed, at the same time, relieved that you have obtained the accurate diagnosis of the condition, then the next question is, 'What are the treatment options available?' Although there are a number of common treatment approaches for trigonitis, many of which are comparable to those for recurrent bladder infections, there is still a lack of long-term evidence regarding their effectiveness.

Antibiotics

Antibiotics such as ciprofloxacin, nitrofurantoin, and trimethoprim-sulfamethoxazole are frequently prescribed by doctors. In a study prescribing the antibiotic doxycycline along with vaginal creams for infection or fungus showed symptom relief in about 71% of 103 patients, with some showing improvement in bladder tissue changes.

Vaginal estrogen

As the production of oestrogen drops after menopause, in postmenopausal women, use of vaginal oestrogen has been shown to reduce UTIs. Nonetheless, its effect on trigonitis specifically is still unclear.

Thermal treatments

If antibiotics don't provide any improvement in symptoms, sometimes heat-based treatments like laser therapy or electrofulguration (a method that uses electric current to destroy inflamed areas) are suggested.

These procedures aim to remove inflamed tissue or disrupt nerve signals in the area, though the exact way they help isn’t fully understood.

For example, a study using a side-firing laser showed that 78% of women experienced major symptom relief, and in those who improved, the abnormal bladder tissue had healed. In women with recurrent UTIs, electrofulguration was reported to help lower infections. Many reported fewer symptoms and a decreased need for antibiotics following this therapy.

Intravesical therapy

Even though rinsing of the bladder using medications like heparin or dimethyl sulfoxide has been commonly used for other bladder conditions, their effect on trigonitis hasn’t been clearly studied. According to one small trial, women with trigonitis saw a reduction in symptoms when they used a bladder treatment that included the antibiotic gentamicin and the steroid betamethasone. However, because the bladder instillation produced greater adverse effects and was more difficult to follow, more patients chose oral therapy.

While the above-discussed approaches have shown benefits, there is still a lack of long-term data or standardised guidelines for managing it. Therefore, more research is needed to understand the development of this condition and define appropriate treatment strategies.

Sources

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