Cystitis - inflammation of the bladder caused by the reproduction of pathogenic and conditionally pathogenic flora. The disease is more common in girls and women, although it happens in men. It is also possible cystitis in children, which can occur in boys and girls of different ages.
In most cases, infection of the urinary tract in women occurs when bacteria from the anus reach the urethra and enter the bladder (due to violations of intimate hygiene). The second most common route of infection is sex. There is even a special name - honeymoon cystitis, which means a disease that began after the first sexual intercourse. Intimacy contributes to the penetration of bacteria from the outside into the urinary canal, which then leads to the disease. During menopause and menopause, the mucous membrane of the vagina can dry out, which makes the urethra more vulnerable to infections. Pregnant women are also at risk. First, an enlarged uterus can interfere with the removal of urine, which adversely affects the bladder. Secondly, against the background of hormonal changes, smooth muscles of the urethra relax, due to which the leakage of urine back into the bladder is possible.
In men, cystitis can occur against a background of sexually transmitted diseases, but more often, problems with prostate gland lead to inflammation. In addition, the disease can be the result of anatomical pathologies, urolithiasis or other diseases. In children, cystitis usually occurs after hypothermia or delayed change of diapers, or against the background of other diseases. That is, the causes of inflammation can be very different, so anti-cystitis therapy should be comprehensive, and primarily aimed at eliminating the factor that caused the disease.
Almost immediately after infection or hypothermia, cystitis manifests itself with discomfort and burning during urination, pain in the lower abdomen. Usually, after a few days, the patient's well-being improves even without taking medication. But if the attack went away by itself, it does not mean recovery. Such a scenario is fraught with complications and the transition of inflammation into a chronic disease. Therefore, as soon as the first signs of cystitis appear, it is important to begin treatment. The patient can provide first aid at home, even before the visit to the doctor. Emergency care usually comes down to pain relief.
The first thing you need to know: the beginning of an attack can sometimes be prevented and it is very easy to do. If the patient suffers from chronic cystitis and after hypothermia fears exacerbation of the disease, then emergency help for him is a warm bath or a hot foot bath. If a moment has been missed, other methods may be helpful.
Immediately after the appearance of the first signs of the disease, experts advise to drink a warm solution of baking soda (1 teaspoon to half a glass). This fast-acting medicine alkalizes urine, relieves burning, soothes the bladder. Cranberry juice, millet or barley water have a similar effect.
The second rule: drink as much liquid as possible (at least 2 liters per day). This allows you to quickly remove bacteria from the bladder, not allowing them to multiply. It is useful to use decoctions of herbs with antiseptic and anti-inflammatory properties. It can be calendula, chamomile, parsley. But categorically you should not drink coffee, alcohol, orange, pineapple and grape juices, which increase the acidity of urine.
Before visiting the doctor, it is important to keep your body warm, avoid drafts, and walk barefoot on the cold floor. You should also exclude exercise, swimming in the pool. Instead, it is better to take a warm bath with the addition of sea salt. But it is categorically impossible to apply a heating pad to the lower abdomen or to the perineum until the cause of the disease is established, especially if the urine comes out with blood. If there are no contraindications, the heat applied to the lower abdomen is an effective and quick help. The procedure causes an expansion of the ureters and urethra, which improves the flow of urine.
The described methods can alleviate the patient's condition. But do not be mistaken, then this can cure cystitis. To cope with the disease is really only under the supervision of a doctor. And the sooner you see a specialist, the easier the treatment will be. If an exacerbation of cystitis is accompanied by bloody or purulent discharge, very severe pain, you should immediately call an ambulance.
Each time, prescribing a drug treatment to a patient with cystitis, a qualified doctor applies an individual approach. The type of therapy, types of drugs and their dosage are determined based on the form and stage of the disease, the patient's age, general condition, and other diseases in history. For women in the position of the program of therapy are, given the duration of pregnancy.
Nowadays, cystitis can be treated according to several schemes:
- using tablets;
- with the use of herbal medicine;
- by alternative medicine.
Cystitis is an inflammation caused by microbes that has occurred against the background of a weakened immunity. The essence of proper anti-cyst therapy is to eliminate these causes. Therefore, the classic treatment program usually consists of:
- antibacterial drugs;
Depending on the form and type of disease, the treatment regimen may differ slightly. For example, mild primary cystitis is sometimes treated even without the use of antibacterial agents, and a new generation of strong antibiotic is usually needed for the treatment of chronic disease. In addition, the treatment of recurrent cystitis requires serious attention to immunity. Therefore, such patients are prescribed a multivitamin, nutrient-rich diet, immunomodulators (for example, Genferon), uroseptics, agents that promote the regeneration of damaged tissues (methyluracil and its analogues).
Medicines against cystitis come in different forms: tablets, capsules, drops, suppositories, ointments, for injections, for drip, solutions, powder, paste. For example, anti-inflammatory drugs, many manufacturers produce in the form of tablets or rectal suppositories. Candles are usually prescribed to people with diseases of the gastrointestinal tract, children. For the treatment of cystitis in women used vaginal suppositories with antimicrobial, antifungal, anti-inflammatory or bactericidal effect (for example, polygynax). For a similar purpose, you can use a paste, ointment or gel intended for insertion into the vagina, as well as antiseptic solutions (chlorhexidine, miramistin, betadine), which make syringing. Drops and capsules in anti-cystic therapy are most often herbal preparations, and solutions for parenteral administration are mostly fast-acting antispasmodics to relieve severe pain in the acute period, as well as antibiotics. Sometimes in chronic cystitis, traditional antibacterial therapy is replaced by another type of treatment. The patient is prescribed a bacteriophage - a substance that dissolves and kills bacteria. More precisely, bacteriophages are viruses that, when they enter the body, selectively infect bacteria.
Phytodrugs are usually prescribed as an aid. This group of drugs enhances the action of antibiotics, has antimicrobial, anti-inflammatory, diuretic and antispasmodic activity, reduces swelling and improves microcirculation, some prevent recurrences and dissolve stones. In addition, patients with cystitis are often advised to take probiotics (they restore healthy microflora, are especially useful against the background of antibiotics), and for women who have cystitis caused by hormonal changes - estrogen preparations.
The treatment program and the duration of medication should be determined by the doctor, having familiarized with the results of the urine, blood, ultrasound of the patient. Below we will deduce possible schemes of anti-cystitis therapy as a trial material. But it should be understood that anti-cystitis drugs are produced by many pharmaceutical companies, and sometimes drugs based on the same substance are called differently by different manufacturers.
Hypothermia is not the main cause of cystitis. It only creates in the body favorable conditions for the development of infection. In this case, the doctor may advise the patient drugs to strengthen the immune system, for example, from traditional medicine, as well as a drug course. It can be antimicrobial Furagin (2 tablets 3 times a day), at night - indomethacin suppositories, and as an ambulance for pain - 2 tablets of shpy.
Viral cystitis is always treated with antiviral drugs. The type of medication depends on the virus that caused the inflammation. If the cystitis in an adult patient was provoked by the herpes simplex virus, the doctor may prescribe a weekly course of the antiviral drug acyclovir 500 mg 5 times a day. Alternatively, valacyclovir, 500 mg twice a day for 5-10 days. For individuals with reduced glomerular filtration rate, the dosage may be revised.
Sometimes for the treatment of hemorrhagic cystitis caused by cytomegalovirus or adenovirus, Ganciclovir or Vidarabin is prescribed. An alternative to Ganciclovir is a drug for oral use - Valganciclovir. In other cases, the doctor may prescribe Viferon (gel, ointment, or suppositories).
The treatment regimen for cystitis caused by chlamydia includes the following drugs:
- Doxycycline (100 mg twice a day for a week);
- Erythromycin (0.5 g 4 times a day, 7 days);
- Azithromycin (once 1 g);
- Fluoroquinolones (for example, ofloxacin, 300 mg twice a day, 7 days).
For the treatment of cystitis of chlamydial etiology in pregnant women, as a rule, use Erythromycin, Azithromycin, Amoxicillin, which are included in the list of so-called safe antibiotics for women in the situation.
Cystitis caused by mycobacterium is treated based on the state of the patient’s immune system. Standard drug therapy may look like this:
- Isoniazid (300 mg per day);
- Rifampicin (600 mg per day);
- Pyrazinamide (2 g per day);
- Ethambutol (daily dose: 15 mg per 1 kg of body weight).
The doctor may also prescribe Streptomycin (0.75-1 g), Ethionamide (1 g) or a drug from the group of fluoroquinolones. The treatment regimen is adjusted depending on the body's sensitivity to drugs.
This form of the disease is most often cystitis and thrush "two in one", so it is often called candidal cystitis. The disease is treated with antifungal drugs intended for oral use, vaginal suppositories and ointments. The classic scheme: take four tablets of Nystatin four times a day every day. Alternatively, Miconorm: take 1 tablet on the third day of therapy and one day after the end of the course of antibiotics.
If Fluconazole or another antifungal agent does not work, use irrigation (bladder washing) using Amphotericin B (50 µg / ml for 5 days). This drug can be administered intravenously.
By the way, candidal cystitis often does not respond to drugs from the azole group, especially if the patient has previously undergone antifungal therapy. In this case, the alternative may be echinocandins (Micafungin, Caspofungin), which represent a newer class of drugs against fungi.
This form of cystitis in our latitudes is a rare phenomenon. The cause of the disease is usually the schistosome, a parasite that is widespread in the waters of Africa and Central Asia. Parasitic cystitis is treated with the use of the drug Praziquantel. A single dose of 40 mg per kilogram of patient weight. For one day you need to take two doses. This treatment regimen gives a positive result in 8 cases out of 10.
Running form of cystitis
If therapy was not started at the first symptoms of the disease, the patient is prescribed a new generation of antibiotics with a wide spectrum of action. This may be doxycycline, cephalexin, norfloxacin or newer drugs. But the appointment is possible only after laboratory determination of the type of pathogen.
If at the time of going to the doctor the infection in the body has acquired a progressive nature, urinary incontinence or other complications have appeared, complex therapy is prescribed. Sample treatment program:
- Furamag (50 mg twice a day, 7 days);
- Zyromin (500 mg, 1 tablet at lunch, 3 days);
- Secnidox (2 tablets simultaneously on the 8th day of treatment);
- Diclofenac (rectal suppositories, 10 days).
Comprehensive treatment can be supplemented with anti-inflammatory herbal teas (chamomile, calendula, St. John's wort, and others). In addition, diuretics and excessive drinking are prescribed for any form of the disease in order to accelerate the excretion of infection with urine.
|Tradename||Active substance||Pharmaceutical Group|
|5-NOK, nitroxoline||Nitroxoline||Antiseptics, antimicrobial|
|Biseptol||Sulfamethoxazole + Trimethoprim|
|Nolitsin, norbaktin, normaks||Norfloxacin|
|Amoxiclav, augmentin, flamoklav, panklav, ecoclav||Amoxicillin + clavulanic acid||Antibacterial agents|
|Amoxicillin, Flemoxin, Amosin, Flemoxin, Hiconcil||Amoxicillin|
|Doxycycline, Unidox Solutab||Doxycycline|
|Ofloxacin, zanocin, zofloks, ofloksin, tarvid||Ofloxacin|
|Suprax, Pancef, Ceforal||Cefixime|
|Ciprolet, ciprofloxacin, cyfran, ciprinol, cyprobay, ecocifol||Ciprofloxacin|
|Diclofenac||Phenylacetic acid||Nonsteroidal anti-inflammatory|
|Cyston||Dvoroplodnik, stone, madder, fed, strawflower, onosma, vernon||Vegetable|
|Urolesan||Fir, mint, wild carrot, hop cones, oregano|
|Fitolizin, uronefron||Pyreus, onion peel, birch leaves, fenugreek seeds, parsley root, goldenrod, horsetail, lovage, bird of the hills|
|Canephron||Centaury, lovage, rosemary|
|Flavia||Mint, fir, motherwort, Ammi tooth, chamomile, pine|
|Urokholum, urohol||Wild carrot, ortosiphon, corn silk, black elderberry, hop cones, birch buds, St. John's wort, mint|
Even knowing the type of medications and an exemplary treatment program for some form of cystitis, it is strictly forbidden to engage in self-treatment. First, the most suitable drug from the group is determined based on the results of laboratory tests. Secondly, most drugs have contraindications, side effects and incompatibility with some other medicines. Wrong choice can lead to complications in the form of allergies, poisoning, bleeding, disruption of the liver, kidneys or stomach. For pregnant women, an improperly chosen drug serves as a threat to the baby or causes premature birth. The use of many drugs is strictly prohibited in early pregnancy (in the first trimester). With extreme caution choose the least "harmless" drugs for children, the elderly, people with chronic kidney disease or liver, with lactation ("chemistry" enters breast milk).
The choice of antibiotics should always be considered carefully, since they suppress not only the pathogenic but also the healthy microflora of the body, weaken the immune system. But it is necessary to realize that phytopreparations, although called safe, but in fact they are not as harmless as some patients think: if they do not follow the rules of administration, they can cause allergies and other serious side effects. For example, if the same monural has almost no contraindications, and it is prescribed even for pregnant women and breastfeeding, then the popular ciproflaksatsin and nitrofuradin are strictly forbidden to "vulnerable" patients.
No matter how effective may be modern drugs against different types of cystitis, but there are clinical cases where you can not get rid of the disease with pills alone. And then surgeons come to the rescue. Sometimes the operative method is the only way to cure infectious or non-infectious cystitis.
Surgical treatment of female cystitis is most often resorted to if the disease has a post-coital nature (exacerbated after sexual intercourse) or when the external opening of the urethra is too low and E. coli easily falls into the urinary tract. In such situations, reconstructive plastic surgery (transposition of the external opening of the urinary canal) helps, during which the urethra is moved a little higher from the vaginal entrance. This prevents the penetration of bacteria during sexual intercourse or hygiene procedures.
Male cystitis is surgically treated in several cases. If sclerosis of cicatricial nature occurs, bladder neck deformity or a patient has been diagnosed with persistent narrowing of the urethra. Most often, this method is used in the presence of prostate adenoma.
Cervical cystitis requires more complex surgery, which is done directly on the bladder. The task of the procedure is to remove the damaged mucous membrane of the organ. The operation is performed in the area of the bladder neck using laser ablation, electrocoagulation or transurethral resection. This method of treatment is resorted to in case of tuberculous cystitis, as well as for the treatment of a disease of parasitic etiology (if the tablets did not give the desired result). In cases of gangrenous cystitis, the affected parts of the organ are removed during the operation, and in the case of total gangrene, the entire bladder is removed.
Physiotherapy methods are generally used to treat chronic cystitis. In many cases, the procedure is carried out on the background of drug therapy with the use of antibiotics, uroseptics, hormonal, anti-inflammatory, nonsteroid, enzyme preparations and vitamins. There is a wide range of physiotherapeutic procedures for the treatment of inflammation of the bladder. Which method is suitable for the patient can only be determined by the attending physician, and then give the patient a referral to a sanatorium or physiotherapy in the clinic.
The following procedures may be offered to patients with cystitis in hospitals, specialized clinics and sanatoriums:
- magnetic therapy;
- laser therapy;
- induction therapy;
Electrophoresis is an electrical shock with the use of drugs. The procedure helps to speed up the "delivery" of the active substance to the diseased organ. Assign, when it is necessary to reduce inflammation, calm the bladder, relieve swelling, destroy pathogens.
The essence of magnetic therapy is the effect of a magnetic field on the inflamed organ. It is successfully used to treat cystitis in men and women. During the procedure, bacteria and viruses are destroyed.
Induction therapy involves heating the bladder with electrical impulses. The procedure helps to expand the blood vessels, speed up blood flow and restore the urinary system.
Magnetophoresis is done only by prescription. The procedure resembles electrophoresis, but the magnetic field acts directly on the damaged areas of the bladder mucous layer.
EHF stands for extremely high frequency therapy. During this procedure, the bladder feels the influence of an electromagnetic field, as a result of which pain and inflammation are reduced, viruses and bacteria die.
Ultrasound with the use of high frequencies in anti-cystitis therapy is useful in helping to destroy pathogens, cures inflammation, improves blood flow. By the way, UHF is a universal procedure for various types of inflammations.
Hyperthermia is the effect on the inflamed bladder using chemotherapy and radiation devices. Like most other physiotherapy, it leads to the destruction of bacteria, improves blood circulation, treats inflammation.
Physical therapy with a laser restores the structure of damaged tissues, relieves pain and swelling, accelerates the recovery process.
Hirudotherapy is treatment with leeches. This procedure can be prescribed to the patient as an adjunct to medication and other physiotherapeutic methods of treatment. It is believed that leeches secrete into the patient's bloodstream a substance that stops inflammation and destroys the infection in the body.
In addition, for the treatment of cystitis, physiotherapists use:
- heat therapy (thermal applications of ozokerite and melted paraffin, relaxes the muscles);
- infrared irradiation (relieves spasm);
- vibrotherapy (low-frequency current; has anesthetic effect);
- pelotherapy (treatment with mud; improves the condition of the bladder);
- diademotherapy (diadem overlaps the lumbar area; relieves pain);
- Suf-irradiation (pain blockade);
- amplipulse therapy (restores bladder tone);
- sessile mineral baths (iodine-bromine, sodium chloride, rhodon).
Phytotherapy. It is the most popular alternative to drug treatment. When it comes to cystitis, doctors themselves often recommend that patients take herbal medicines. In folk medicine, medicinal plants, some cereals and berries since ancient times were used to eliminate the symptoms of an inflamed bladder. But a little remark should be made here. Researchers say that several centuries ago, human organisms responded better to natural medicines. Modern man, accustomed to the pharmacy "chemistry", on the phytomedicals "responds" worse. Meanwhile, for the treatment of cystitis, herbalists today offer infusions, decoctions, tinctures and teas from bearberry, birch leaves, horsetail, plantain, flax and dill seeds, licorice root, parsley greens, black currant leaves, sage, succession, celandine, Althea, calamus swamp, lingonberry, black elderberry, St. John's wort, calendula, linden, cloudberry. But it is considered that the best natural remedy is cranberry juice. The researchers proved that the berries contain substances with a bactericidal and anti-inflammatory effect. People who drink cranberry drinks get faster cystitis.
Aromatherapy. Proponents of treatment with essential oils are advised at the first signs of cystitis to resort to the help of aromas of anise, bergamot, oregano, spruce, cedar, cypress, pine, lavender, incense, lime, juniper, myrtle, sandalwood, thyme, fennel, eucalyptus, tea tree, sage . The best helpers for painful attacks are bergamot, lavender, eucalyptus and tea tree.
The recipe for a therapeutic mixture: 10 drops of lavender, 8 drops of bergamot, 5 drops of eucalyptus, 3 drops of tea tree. The mixture can be added to baths, compresses, mixed with the base oil and lightly applied to the lower abdomen.
Apitherapy. This is a beekeeping treatment. One of the most popular medicines for painful urination and pain in the lower abdomen is an infusion of herbs and propolis. Apitherapists are advised to prepare a mixture of 40 g of plantain, 30 g of Potentilla roots and the same amount of horsetail. 2 tablespoons of the mixture pour 500 ml of boiling water, and after 3 hours, strain. In half a glass of broth add 20-30 drops of alcohol tincture of propolis (20%). Take half an hour before meals. Also useful in cystitis is considered to be birch, nettle and chamomile honey. This sweet medicine is advised to take a teaspoon three times a day. Some recommend before drinking honey to drink 1 teaspoon of aloe juice.
Hydrotherapy is based on treatment with the help of water. With cystitis, the essence of hydrotherapy lies in therapeutic baths. You can make them from oat straw. To do this, a 10-liter vessel is filled with straw by a third, filled to the top with water, roasted on low heat for 30 minutes, filtered through an bath in an hour. In addition to oats, for broth, you can take pine branches, fir cones, field horsetail, oregano, black currant leaves, tricolor violet, thyme, eucalyptus, calendula, knotweed, celandine. Broths can be used for seating and foot baths. This type of therapy is prohibited in the acute period of the disease, during pregnancy or the presence of blood in the urine.
Homeopathy. Homeopathic remedies for the treatment of cystitis have both their pros and cons. The indisputable advantage of therapy is safety. Such drugs are suitable even for nursing mothers, pregnant women, children. But from this method of treatment should not be expected quick action. Minus homeopathic medicines - slow effect. They begin to act only after the substance has accumulated in the body in the required amount. Therefore, the funds of this group is not an emergency aid for cystitis. They are used to avoid recurrence of chronic cystitis. For such purposes are best suited:
- Acid nitricum;
- Argentum nitricum;
- Mercurius corrosivus;
- Thuja and others.
Fungotherapy. This is one of the oldest types of alternative medicine, based on the treatment of mushrooms. If you have tortured bacterial cystitis or other diseases of the urinary system, prostatitis or ovarian diseases, supporters of fungotherapy recommend drinking natural medicine from the fungus fungus. A medicinal alcohol tincture is prepared from it (5 g of dried mushrooms per 200 ml of vodka) or an aqueous infusion (1 tsp. Of crushed raw materials per 1 cup of boiling water). Alcohol tincture take 1 teaspoon every morning for 2 weeks, water infusion - a third cup three times a day.
Acupuncture. In Eastern culture, acupressure and acupuncture is a common treatment for cystitis, in particular chronic and interstitial. Therapy is aimed at normalizing the nervous and endocrine systems, strengthening the immune system. Impact on certain nerve endings helps to normalize urination, eliminate pain. Acupuncture regulates the adrenal glands: stimulates the release of hormones that have anti-inflammatory effects.
Other treatments. Many women leave flattering reviews about turpentine baths that helped them get rid of cystitis. As an alternative treatment of inflammation in the urinary system, some suggest thalassotherapy - treatment by the sea and the sea climate. But it is important to know that this method is contraindicated in allergy to iodine, in the acute phase of the disease, in the presence of malignant tumors, in the presence of fever. Some resort to lithotherapy or stone therapy (stone treatment). And supporters of Ayurveda tend to psychosomatic causes of cystitis, therefore, it is advised to start treatment from restoring the emotional state. They claim that bladder inflammation usually affects people who feel humiliated or disappointed.
How to relieve pain
Symptomatic therapy for cystitis is primarily aimed at relieving pain. But anesthesia is only part of the complex therapy. A painful sensation in cystitis is not the disease itself, but only a signal that something is wrong with the bladder. Meanwhile, nonsteroidal anti-inflammatory drugs prescribed for cystitis, have a wider spectrum of action than just removing the spasm. Drugs in this group stop the inflammatory process in the body. A scientific study proved the effectiveness of ibuprofen treatment in 6 out of 10 patients with uncomplicated cystitis. Therefore, many doctors in the first days of the disease (uncomplicated or the first attack in life) are advised to take NSAIDs, and only then think about treatment with broad-spectrum antibiotics. Nonsteroidal anti-inflammatory drugs block prostaglandins in the body - substances that activate inflammation, that is, stop the inflammatory process. The same drugs relieve spasm, edema and blood microcirculation disorders. But it is not recommended to take drugs for a long time, as they have side effects.
It is useful to know that not all anti-inflammatory drugs have the same power of action. Depending on the chemical composition of their activity may vary. For example, the maximum anti-inflammatory effect is Indomethacin, the minimum - Aspirin and Ibuprofen. If we talk about the ability to eliminate pain, then the leaders in this group of drugs are Ketorolac and Ketoprofen, the pain is the worst - Ibuprofen and Naproxen. From the PVNS list, Indomethacin and Ketoprofen are the most dangerous for the digestive system, with Diclofenac, Ibuprofen, Meloxicam, Nimesulide, and Celecoxib taking the lowest risk.
To relieve an attack at home, you can take tablets antispasmodics. If the pain is severe and must be removed quickly, resort to injections containing drotaverine, papaverine, benciclan, bendazole.
What doctor treats
When symptoms of inflammation of the bladder appear, many patients have questions: “Who should I contact?”, “Which doctor treats cystitis?”. The answer is unequivocal: a urologist, since it is urology that deals with the etiology, pathogenesis, diagnosis and treatment of diseases of the urinary organs. The erroneous opinion is widespread that the urologist is a male doctor, so with their illness many girls and women are used to going to the gynecologist, especially if a yellow discharge appeared on the background of the illness. If poor health is caused by non-gynecological reasons, the gynecologist should refer the patient to a specialist urologist, who is more aware of how to deal with an infection in the urinary system. And the best thing to remember is that in the field of health care there are certain standards: with any health problems, the patient must first turn to a local therapist, and he will give a referral to a specialized specialist.
Do not delay with a visit to the doctor. Cystitis is a disease that can be treated.The sooner the patient turns for help, the higher the chances of quickly recovering health. Early treatment can help prevent chronic cystitis and possible complications. But only a specialist can correctly select the means that effectively treat the disease.
Specialty: infectious diseases specialist, gastroenterologist, pulmonologist.
Total experience: 35 years.
Education: 1975-1982, 1MMI, San gig, high qualification, infectious diseases doctor.
Science degree: doctor of the highest category, PhD.
- Infectious diseases.
- Parasitic diseases.
- Emergency conditions.