What is the treatment for trigonitis or ureteral obstruction in the urinary bladder trigonal region?

Treatment of Trigonitis and Ureteral Obstruction in the Urinary Bladder Trigonal Region

For trigonitis, first-line treatment includes antibiotics for infection-related cases, while ureteral obstruction in the trigonal region requires urgent decompression via retrograde ureteral stenting or percutaneous nephrostomy, followed by definitive surgical management based on the underlying cause.

Trigonitis Treatment

Diagnosis and Evaluation

• Trigonitis is an inflammatory condition of the bladder trigone that is often underdiagnosed and misunderstood 1
• Diagnosis typically requires cystoscopy showing inflammatory lesions, cystitis cystica, or white patches of squamous metaplasia in the trigonal region 1
• Transvaginal bladder ultrasound can serve as a non-invasive diagnostic alternative, with trigonal mucosal thickening >3mm being the most relevant diagnostic criterion 2

Medical Management

• For acute trigonitis with infectious etiology:
  • First-line treatment includes appropriate antibiotic therapy based on urine culture 3
  • Non-steroidal anti-inflammatory drugs and anticholinergic agents such as oxybutynin can help manage associated symptoms 3
  • Phenazopyridine may be used for symptomatic relief of pain and discomfort 3

Advanced Treatment Options

• For refractory cases:
  • Intravesical instillation of various agents has been reported 1
  • Botulinum toxin A injection into the detrusor muscle may be considered when drug therapy is ineffective 3
  • Electrofulguration or laser coagulation of the affected trigonal area can be performed in persistent cases 1

Follow-up

• Regular follow-up with urinalysis and urine culture is recommended 3
• Symptoms are generally self-limited, and medications can be discontinued as symptoms improve 3

Ureteral Obstruction in the Trigonal Region

Acute Management

• Urgent decompression is required, especially in cases with infection (pyonephrosis) or renal dysfunction 3
• Options for decompression include:
  • Retrograde ureteral stenting - first-line approach for most cases 3
  • Percutaneous nephrostomy (PCN) - preferred when retrograde stenting fails or is contraindicated 3

Considerations for Decompression Method

• PCN may have higher technical success rates compared to retrograde stenting in cases of extrinsic compression or obstruction involving the ureterovesical junction 3
• In cases of infection with obstruction, urinary tract decompression can be lifesaving with patient survival rates of 92% with PCN compared to 60% for medical therapy without decompression 3

Definitive Management Based on Etiology

For Malignant Obstruction

• For bladder cancer involving the trigone:
  • Radical cystectomy is the standard treatment for muscle-invasive disease 3
  • Partial cystectomy is generally contraindicated for lesions in the trigone or bladder neck area 3
  • Neoadjuvant chemotherapy should be considered before radical cystectomy for T2-T4a lesions 3

For Ureteral Tumors at the Trigonal Region

• Distal ureteral tumors may be managed with 3:
  • Distal ureterectomy with reimplantation of the ureter (preferred if clinically feasible)
  • Endoscopic resection for small, low-grade tumors
  • Nephroureterectomy with a cuff of bladder for higher-grade tumors

For Benign Strictures/Obstruction

• Endoscopic management including balloon dilation or endoureterotomy 3
• Ureteral reimplantation for persistent strictures 3
• For bullous cystitis affecting the trigone causing ureteral obstruction, treatment of the underlying inflammation is required 4

Special Considerations

• Dose to the bladder trigone should be limited during radiation therapy to reduce the risk of severe late urinary toxicity; D2cm³ ≤80 Gy EQD2 is recommended 3
• The trigone is anatomically important for the anti-reflux mechanism, and surgical interventions should aim to preserve this function 5, 6

Pitfalls and Caveats

• Failure to distinguish between trigonitis and bladder cancer can lead to inappropriate treatment; biopsy is essential in uncertain cases 1
• Delaying the clearance of ureteral blockage increases the risk of serious long-term morbidity, including infections, kidney damage, and arterial hypertension 3
• When managing ureteral obstruction, careful attention to patient selection is critical, particularly in cases of advanced malignancy where intervention may offer little benefit 3