What is the treatment for trigonitis?

Treatment for Trigonitis

The most effective treatment for trigonitis includes antibiotics for active infection, with nitrofurantoin 100mg twice daily for 5 days as first-line therapy, followed by preventive measures including increased fluid intake and potential intravesical therapies for recurrent cases. While there are no specific guidelines dedicated solely to trigonitis treatment, management follows principles for recurrent urinary tract infections (UTIs) with consideration of the trigone's involvement.

Diagnostic Considerations

• Trigonitis is characterized by inflammation of the bladder trigone, often diagnosed through:
  • Cystoscopy (gold standard) showing inflammatory lesions, cystitis cystica, or squamous metaplasia 1
  • Transvaginal bladder ultrasound (non-invasive alternative) showing trigone mucosa thickening >3mm, irregular mucosa lining, and free debris in urine 2

Treatment Algorithm

1. Acute Treatment of Active Infection

For active infection with trigonitis, antibiotic selection should follow UTI guidelines:

• First-line options:

  • Nitrofurantoin 100mg twice daily for 5 days 3
  • Trimethoprim-sulfamethoxazole (one double-strength tablet every 12 hours for 3 days) if local resistance is <20% 3
  • Fosfomycin 3g single dose 3

• Second-line options (when first-line cannot be used):

  • Fluoroquinolones (e.g., levofloxacin 500mg daily for 7 days) 4
  • Consider local resistance patterns and patient allergies when selecting antibiotics 5

2. Management of Recurrent Trigonitis

For patients with recurrent episodes (≥3 UTIs/year) and confirmed trigonitis:

• Oral therapy options:

  • Phytotherapeutic products (e.g., Cistiquer) have shown efficacy comparable to intravesical treatments with better adherence and fewer adverse events 6

• Intravesical therapy options:

  • Gentamicin plus betamethasone intravesical instillations (though higher dropout rates and infection risk compared to oral therapy) 6
  • Electrofulguration or laser coagulation of trigone lesions in selected cases 1

3. Preventive Measures

• Non-antibiotic approaches:

  • Increased fluid intake (additional 1.5L daily) 3
  • Urination after sexual activity if infections are related to sexual activity 3
  • Avoiding spermicides 3
  • For postmenopausal women: vaginal estrogen therapy to address hormonal influences on trigone 3, 1

• Antibiotic prophylaxis for frequent recurrences:

  • Nitrofurantoin 50-100mg daily 3
  • Trimethoprim 100mg daily 3
  • Post-coital single dose when UTIs are related to sexual activity 3

Special Considerations

• Older women often have higher rates of antibiotic allergies and resistance:

  • Nearly 20% may be allergic or resistant to all three first-line antibiotics (TMP-SMX, fluoroquinolones, and nitrofurantoin) 5
  • Nitrofurantoin may be the only viable alternative in approximately 28% of older women with recurrent UTIs and trigonitis 5

• Renal function assessment is crucial:

  • Avoid nitrofurantoin in patients with GFR <30 ml/min 3
  • Adjust fluoroquinolone dosing in older patients with impaired renal function 3

• Upper tract imaging is generally not indicated:

  • Studies show no significant upper tract abnormalities in women with recurrent UTIs and trigonitis, regardless of whether caused by bacterial persistence or reinfection 7

Treatment Monitoring

• Evaluate clinical response within 48-72 hours of initiating therapy
• No routine follow-up urine culture needed in patients who respond to therapy 3
• For persistent symptoms despite appropriate therapy, consider repeat cystoscopy to evaluate treatment response

Trigonitis treatment requires addressing both the acute infection and implementing strategies to prevent recurrences, with antibiotic selection guided by patient factors, local resistance patterns, and renal function.