Cystitis, UB Injuries, UB Tumors PDF

Cystitis UB Injuries UB Tumors BY AYMAN RASHED, MD Asso. Prof of Urology 6th of October University General principles 📍 Incidence: females > males 📍 Aetiology and pathology 🚩 Causative organisms:  Escherichia coli (E. coli) in 80% of U...

Cystitis UB Injuries UB Tumors BY AYMAN RASHED, MD Asso. Prof of Urology 6th of October University General principles 📍 Incidence: females > males 📍 Aetiology and pathology 🚩 Causative organisms:  Escherichia coli (E. coli) in 80% of UTIs  Proteus mirabilis (urea-splitting organism, produces ammonia and alkalinizes urine)  Pseudomonas aeruginosa (with urinary stasis  Gram Positive Cocci (staphylococci and Enterococci) are rare  Chlamydia (with diabetes, prolonged antibiotic abuse and decreased immunity) 📍 Route of infection 🚩 Ascending infection is the most common route 🚩 Haematogenous spread is rare. It occurs with a perinephric abscess 🚩 Lymphatic spread, from colonic and rectal lymphatics, is also rare 📍 Predisposing factors 🚩 Bacterial virulence and strains 🚩 Females, particularly the sexually active, are more prone to infection because of short urethra 🚩 Pregnancy is associated with functional ureteric slow peristalsis, and hence a higher incidence of pyelonephritis 🚩 Defective immunity, e.g., diabetes mellitus and immunosupressive drugs 🚩 Urinary stasis 🚩 Congenital anomalies, e.g., posterior urethral valves or VUR 🚩 Urethral instrumentation 📍 Types of UTI 🚩 Uncomplicated UTI 🚩 Complicated UTI In which UTI is accompanied with obstruction; This is usually requires relief of the obstruction 📍 Complications of UTI Bacterial persistence and chronicity if not treated properly Septicaemia and septic shock Stone formation Impairment of renal function that may end in renal damage 📍 Clinical features depend on: 🚩 Whether it is UUTI or LUTI 🚩 Whether infection is acute or chronic 🚩 The affected organ Acute infections of the parynchymatous organs of the GUT (kidney, prostate and testis) are usually associated with fever and need urgent treatment 📍 Investigations 🚩 The aim of investigations is to: 1. Establish the diagnosis of infection; identify the organism and its antibiotic sensitivity. 2. Exclude structural and pathological abnormalities, e.g, stones, congenital anomalies,…etc 🚩 Investigations include: Urinalysis, C/S; and Plain X-Ray, Ultrasound, IVU and in selected cases Ascending urethrocystogram and VCUG e.g.:  Upper tract infections (e.g. pyelonephritis), specially if associated with fever  Infections in children (to look for congenital anomalies)  Persistent bacteriuria  Recurrent infection Treatment 1. High fluid intake in order to induce diuresis and dilute organisms 2. Antibiotics are mandatory for all cases Choice of antibiotics depends on C/S; the most commonly used are Trimethoprim/sulphamethoxazole (septrin), nitrofurantoin and quinolones 3. Relief of obstruction, which may be urgent 4. Drainage of an abscess, if present. 📍 Prophylaxis for recurrent cases 1. Fluid intake of at least 2 - 3 litres per day 2. Perineal hygiene especially in females 3. Regular voiding 4. Avoid constipation, which may impair bladder emptying 5. Prophylactic small doses of antibiotics may be used at bedtime for months  Cystitis Aetiology 🚩 Causative Organism: E. coli is the commonest organism and may occur in single or mixed infections 📍 Predisposing factors 1. Incomplete evacuation of the bladder that leads to accumulation of residual urine 2. Constant reinfection from the upper or lower urinary tract, or from neighbouring structures such as the prostate, colon and cervix uteri (e.g., contraceptive device). 3. Lowered general resistance, e.g., diabetes 4. Devitalization of the bladder by instrumentation, calculi, foreign bodies and growths 5. Drugs ( anticholinergic ) 📍 Routes of infection Descending from the kidney Ascending (commonest) from the urethra, prostate and vulva or during instrumentation Lymphatic from the cervix uteri, prostate, seminal vesicles or bowel Direct through a vesico-vaginal or vesico-intestinal fistula Haematogenous from distant foci, e.g. boils, carbuncles and infected tonsils 📍 Clinical features 🚩 Symptoms 1. Frequency: both diurnal and nocturnal, is the chief symptom 2. Suprapubic and perineal pain: Severe terminal pain and is referred to the glans penis or labia majora 3. Pyuria: 4. Haematuria: terminal haematuria, and in severe cases the whole specimen may be blood-stained. 5. Pyrexia: rarely occurs in acute cases and it seldom reaches 38°C 🚩 Signs 1. Tenderness over the bladder on abdominal, rectal or vaginal examination. 2. Urethral discharge, tender prostate (prostatitis), chronic cervicitis or erosion may be detected 📍 Investigations 1. Urinalysis: A mid-stream specimen sent for analysis with culture and antibiotic sensitivity tests. In acute stage, Instrumentations are contraindicated 2. Cystoscopy: In chronic cases, it may reveal the precise pathological lesions, and local predisposing causes in the bladder, urethra or prostate e.g. bladder ulcer 📍 Treatment Follows the previously mentioned general principles interstitial cystitis  Specific Infections Urinary Tuberculosis 📍 Incidence 🚩 The disease affects young adults of 20-40 years of age 🚩 Males are more affected than females 🚩 The disease is unilateral in early stages, but attacks the opposite kidney in 40% of untreated cases 📍 Etiology 📍 Organism: Mycobacterium Tuberculosis. Human strain 75% & bovine strain 25% 📍 Route of infection: Renal tuberculosis is always secondary. Infection is haematogenous from a hidden focus, e.g. pulmonary, mediastinal or mesenteric tuberculous nodes. The primary site is often asymptomatic  Pathology 🚩 Tubercle bacilli settle first at the apex of a papilla. The typical tubercles develop and spread towards the cortex and ulcerate into a calyx. Then attacks the pelvis and renal substance. The kidney becomes enlarged and tubercles develop on the surface, resulting in adhesions to the peri-renal fat. Cut surface shows large caseous masses with yellowish lines radiating outwards from the initial lesion 🚩 Open tuberculosis. The kidney is transformed into cavities lined by caseous matter and granulation tissue and containing thick white pus (ulcero-cavernous tuberculosis). Secondary spread down the ureter produces tuberculous ureteritis with thickening and shortening of its walls, and results in characteristic retraction of the ureteric orifice (golf-hole meatus). Secondary cystitis may follow 🚩 Closed tuberculosis. In some cases, the progress of the disease is modified by blockage of the pelvi-ureteric junction by tuberculous debris or stricture formation. If the obstruction develops at an early stage the pelvis and calyces become dilated with turbid urine (tuberculous hydronephrosis or hydrocalycosis) 🚩 In other cases, the obstructed kidney becomes a functionless multi-locular sac filled with caseous material (tuberculous pyonephrosis). Occasionally, such sequestrated lesions undergo calcification that heals by fibrous tissue, which leads to contraction, atrophy and loss of function (auto-nephrectomy)  Clinical Features Symptoms 1. General symptoms. Loss of weight, night sweating and evening pyrexia. 2. Upper urinary (renal) symptoms. Renal pain is often absent. Occasional dull ache; Passage of tuberculous debris or blood clots may give rise to ureteric colic 3. Lower urinary Tract (vesical) symptoms (LUTS)  Symptoms are very distressing and not responding to ordinary treatment  Progressive severe frequency due to bladder contracture from fibrosis  Suprapubic and penile pain with burning during and after micturition  Urgency & Haematuria  Polyuria from inflammation of the kidney Signs 1. Physical examination is usually negative 2. The patient may be generally ill with loss of weight, cachexia and anemia 3. An enlarged tender kidney may be palpable 4. DRE may reveal a focus of infection in the prostate or seminal vesicles 5. Examination of the scrotum may show tuberculous epididymitis 📍 Complications 📍 Renal complications Perinephric abscess Calcifications and stone formations Renal atrophy and renal damage Renal failure in bilateral renal damage 📍 Ureteric complications Ureteric stricture and hydronephrosis Vesico-ureteric reflux 📍 Vesical complications Bladder ulcers Contracted bladder 📍 Genital complications Epididymal infections and abscess formation Epididymal sinus Vasal obstruction that leads to infertility  Investigations 🚩 Urine analysis  Sterile Pyuria. Urine is pale, strongly acidic, of low specific gravity, and contains pus cells but no organisms.  Tubercle bacilli may be demonstrated in the centrifuged deposit of repeated 24 hours urine collections. It is examined by ZeihI-Neelsen stain for acid-fast bacilli  Culture of tubercle bacilli or animal inoculation may be done to detect the bacilli. PCR (polymerase chain reaction) detects DNA of the organism. 🚩 Tuberculin test. Positive test is insignificant. Negative test excludes tuberculosis 🚩 Plain chest X-ray. May show pulmonary lesions 🚩 Radiography  Plain x-ray may show calcification in the kidney.  IVU shows irregular dilatation of a calyx with indistinct and uneven borders (moth-eaten appearance) due to erosion of the apex of a calyx. Later, cavitations and eventually hydrocalycosis  The Ureter shows irregular areas of dilatation and constriction throughout its course, due to ulceration and stricture formation  The Bladder shows small capacity and irregular from secondary cystitis and contraction Cystoscopy may be normal 📍 Hyperemia extending from the ureteric orifice over the trigone Tubercles appear on and around the ureteric orifice 📍 Small ulcers with irregular undermined edges 📍 Contraction of the ureter causes characteristic gaping and retraction of the ureteric orifice (golf-hole ureteric meatus) 📍 Bladder capacity is diminished 📍 Ureteric catheterization. ureters may be catheterized to collect separate urine samples for examination and to do ascending pyelography that may show multiple ureteric strictures Tuberculous Ureteric Orifice (Golf-hole)  Treatment 📍 Essentially Medical 🚩 Medical treatment  At least two antituberculous drugs as isoniazide and rifampicin are given for at least 9-12 months, provided urine cultures are negative for tubercle bacilli. Treatment should also be started before any surgical interventions 🚩 Surgical treatment  Surgery is indicated mainly to treat complications of the disease  A stricture at the ureterovesical junction is treated by excision and reimplantation of the ureter to the bladder. Stricture of upper ureter may need excision with end- to-end anastomosis  Augmentation cystoplasty for Contracted bladder  Nephroureterectomy. If one kidney is grossly damaged with total function loss, provided the other kidney is normal  Urinary Bilharziasis 📍 Incidence 🚩 The disease affects adolescents and adults between the ages of 10 and 30. Males suffer more than females (4:1). The majority are those whose occupations entail exposure to water canals especially of small streams, such as farmers and fishermen 📍 Aetiology 🚩 The parasite Schistosoma haematobium is the usual cause (96%) but rarely Schistosoma mansoni (4%) is implicated. The worms migrate from the liver to the mesenteric veins, and reach the urinary bladder through the anastomotic channels between the haemorrhoidal and vesico-prostatic plexuses  Pathology The Urinary Bladder is the commonest site of Bilharzial infection 1. Patchy hyperaemia over the trigone 2. B. Sandy Patches. Aggregations of calcified dead ova in the submucosa 3. B. Tubercles. consist of small bilharziomata, which may undergo resolution, calcification or ulceration 4. B. Nodules. are spheroidal bodies, larger and more prominent than the tubercles. They are greyish in colour and may be discrete or aggregated and of cystic appearance (cystitis glandularis and cystitis cystica) 5. B. Papillomata. are polypoid projections of the mucous membrane. They vary in size, number and distribution, may undergo necrosis, ulceration and encrustation with phosphates crystals. They may obstruct the flow of urine from the ureter or bladder 6. B. Granulomata. are submucous masses of bilharzial granulation tissue, which form smooth tumour-like swellings projecting into the bladder 7. B. Ulcers. are usually single and small with clean-cut edges and superficial pale yellowish floors covered with scanty granulation tissue. They occur most frequently on the posterior wall of the bladder and are often surrounded by congestion and sandy patches.  Complications 1. Secondary infection is very common 2. Stone formation from stasis, changing pH and deposition of debris 3. Ureteric obstruction from infiltration and fibrosis of the ureter. It usually affects the intramural portion 4. Bladder-neck obstruction due to fibrosis. Obstruction leads to hypertrophy and trabeculation of the bladder and later on to dilatation and incomplete evacuation 5. Peri-cystitis from extension of the disease from the bladder, ureters, prostate and seminal vesicles 6. Associated Lesions Spreads to seminal vesicles, prostate, urethra and scrotum with consequent urethral strictures and fistulae 7. Malignancy Bilharzial cancer of the bladder is a common malignant tumor in Egypt. The malignancy commences most often in patches of leukoplakia or alkaline encrusting cystitis leading to Squamous Cell Carcinoma A, Plain x-ray film of the abdomen shows a rim of calcification surrounding the urinary bladder B, Abdominal ultrasound study shows a bright line surrounding the bladder with a definite dark rim behind it  Clinical Features 🚩 Swimmer's or bather's itch due to penetration of cercaria through the skin may be followed 4-12 weeks later by fever, urticaria and asthma 📍 Symptoms 1. Hematuria: is the cardinal symptom. It is usually slight (few drops), Painful and Terminal 2. Pain: Some urethral burning may be felt 3. Frequency 4. Difficulty in micturition: 📍 Signs No signs are elicited until complications appear 📍 Investigations 🚩 Urinalysis: In the acute congestive stage, urine looks smoky and contains living bilharzia ova and red cells. When secondary infection occurs, it becomes alkaline and turbid with blood, pus, phosphates, epithelial debris and dead ova 🚩 Plain radiography: shows Bilharzial calcification of bladder, terminal ureters, seminal vesicles (honeycomb pattern), calcified papilloma or calculi 🚩 IVU: may show strictures of the ureters, hydronephrosis or bladder neck obstruction 🚩 Cystoscopy: Cystitis, ulcers or tumor Treatment 1. Anti- Bilharzial drugs 2. Urinary antiseptics should be given if secondary cystitis is present 3. Surgical treatment depends on the individual lesion:  Cystitis cystica, Cystitis Glandularis and Bilharzial papillomata require no special treatment unless they are bulky and causing obstruction. Cystoscopic fulguration or excision biopsy if they are small  Partial cystectomy if bulky  Superficial bladder ulcers need cystoscopic excision. Partial cystectomy is necessary for deep ulcers  Bladder neck obstruction may need cystoscopic incision or resection  Lower ureteric stricture may require uretroscopic balloon dilatation, or ureterovesical implantation Sandy Patches Urinary Bladder Injury Urinary Bladder Injuries Most often due to accident, frequently associated with pelvic fractures Either extraperitoneal (80%) or intraperitoneal (20%), or mixed Aetiology 🚩 Pelvicfractured bone spikes is the commonest cause of extraperitoneal bladder rupture 🚩 Blow or Kick to full bladder is the commonest cause of intraperitoneal bladder rupture 🚩 Stabs or bullets cause open injuries 🚩 Iatrogenicduring e.g. cystoscopic procedures, sliding hernia repair, gynecological operations  Urinary Bladder Injuries 📍 Clinical Features 🚩 Extraperitoneal Rupture  Pelvic fracture  Hypovolaemic shock  Urinary collection in retropubic space ---urgency with few blood staining urinary drops  Boggy suprapubic swelling due to extravasated urine between peritoneum and fascia transversalis  DRE reveals that the prostate in normal position  Urinary chemical irritation of anterior abdominal wall  Urinary Bladder Injuries 📍 Clinical Features 🚩 Intraperitoneal Rupture  Pelvic fracture  Hypovolaemic shock  Sudden agonizing suprapubic pain and shock then dull aching pain  Severe oliguria or anuria  Peritonism then peritonitis --- tenderness, guarding, shifting dullness with large urine volume  DRE may reveals fullness in the rectovesical pouch  Urinary catheter will drain no urine 📍 Investigations Urinary Bladder Injuries PUT --- pelvic fracture and haziness over lower abdomen IVU --- lack of bladder filling and assess the rest of the urinary tract Ascending Cystogram --- leakage of contrast outside the bladder (extra- or intra- peritoneal) 📍 Deferential Diagnosis 🚩 Intrapelvic complete rupture of the Urethra --- the prostate felt higher than normal in DRE 📍 Complications Pelvic Abscess Delayed peritonitis Partial incontinence if bladder neck injury 📍 Treatment Exploration and repair of bladder wall tear, suprapubic catheter is left in the bladder. With intraperitoneal rupture; the peritoneum should be opened and the urinary collection drained and exclusion of intraperitoneal injury In minor bladder tears, fixation of urethral catheter for few days is usually enough Prophylactic antibiotic is mandatory Cystogram: Cystogram: Intraperitoneal Bladder Rupture Extraperitoneal Bladder Rupture  Urinary Bladder Injuries 📍 Ascending Escaping cystography contrast 📍 Free escape of contrast upwards 📍 Intra-peritoneal bladder rupture of the bladder Bladder Tumors  Bladder Cancer Types of bladder cancers are subdivided according to the pathology of the tumor Two types of patologies: 1. Squamous Cell Carcinoma 2. Transitional Cell Carcinoma (Urothelial)  Squamous Cell Carcinoma Incedence Sex: M : F (5:1) Age: 30s to 40s Predesposing Factors: Bilharzial cystitis Mechincal irritation by bilharzial ova Chronic Infection causing squamous metaplasia Carcinogenic effect of abnormal tryptophan metabolism Precancerous Lsions: Cystitis cystica & Cystitis glandularis Leukoplakia Brunn‘s nest  Squamous Cell Carcinoma Pathology Gross Picture Site: common on posterior and lateral wall Most commonly appears as nodular fungating mass. Also can be ulcer and rarely papillary Microscopic Picture Squamous carcinoma with cell nests of keratinized squamous epithelial pearls  Squamous Cell Carcinoma Bladder Tumors (Endoscopic) Trans-urethral resection of Bladder Tumor Bladder Tumor (TURBT) A B Bladder Wall Bladder Mucosa Bladder Tumor C  Transitional Cell Carcinoma Incidence Sex: Male:Female 3:1 Age: ≥ 60s Predisposing Factors: Smoking Industrial Carcinogenics Cyclophosphamides (Chemotherapuetic drug) Radiotherapy to the pelvis Phenacetine (large prolonged treatment course) Artificial sweetners  Transitional Cell Carcinoma Precancerous Lesions Villous Papilloma Urachal diverticulum Ectopia Vesica Site: Trigone in 40% of cases Lateral & posterior walls  Transitional Cell Carcinoma Bladder Cancer Transitional Cell Carcinoma Pathology Gross Picture 📍 Papillary tumor in 90% 📍 Nodular tumor in 6% 📍 Malignant Ulcer in 4% 📍 CIS (Erythematous) Microscopic Picture 📍 Transitional carcinoma 95% 📍 Adenocarcinoma 5%  Transitional Cell Carcinoma Microscopic Picture TCC of the urinary bladder may be subdivided into: 📍 Papillary (papillomas, low malignant potential and papillary carcinoma). Papillary tumors are predominantly exophytic, with papillae containing well-defined fibrovascular cores. The lining urothelium may vary from papilloma- like appearance to markedly anaplastic (high-grade urothelial carcinoma). Non-papillary (carcinoma in situ and invasive) 📍 The flat lesion of urothelial carcinoma in situ is characterized by extensive (often full thickness) replacement of the urothelium by cells showing severe cytologic atypia. 📍 in invasive type neoplastic cells invade the bladder wall as nests, cords, trabeculae, small clusters or single cells that are usually separated by a desmoplastic stroma.  Bladder Cancer Symptoms 📍 Chronic Cystitis (Irritation) 📍 Recent progression of cystitis symptoms (Irritative Symptoms) 📍 Recurrent attacks of hematuria (?!painful) 📍 Necroturia Signs 📍 Suprapubic Mass may be palpable 📍 Hydronephrosis 📍 DRE + Bimanual Palpation (Anaesthesia) 📍 General: of Metastasis & Uremia, if any  Bladder Cancer Spread 📍 Direct: prostate, SVs, rectum, cervix, pelvic bones 📍 Lymphatic: peri-vesicle LNs to internal iliac LNs to para-aortic LNs to thoracic duct 📍 Hematogenous: Liver, Lung, Bone Complications 📍 Renal Failure 📍 Pyelonephritis 📍 Obstructive uropathy 📍 Urinary retention 📍 Distant metastasis 📍 Malignant fistula  Bladder Cancer Staging: TNM Classification Ta Non-inasive papillary carcinoma Tis Carcinoma in-situ T1 Tumor invades Lamina Propia (subepithelial) T2a Tumor invades superficial muscle layer T2b Tumor invades deep muscle layer T3 Tumor invades peri-vesical fat T4a Adjacent organ involvement T4b Adjacent organ involvement & pelvic &/or abd. Wall N0 No LNs N1 Regional LNs M0 No Distant Mets M1 Distant Mets Bladder Cancer  Bladder Cancer Investigations Laboratory Urinanalysis RFTs Imaging KUB: soft tissue shadow ± Bl. Calcification in SqCC IVU: Bl. Filling defect ± Hydronephrosis U/S & CT: Instrumental Cystoscopy either to resect the whole tumor if applicable as a treatment or to take a biopsy for histopathologic diagnosis and grading Metastatic workup Chest x-ray, bone scan,...etc.  Bladder Cancer IVU shows irregular filling defect of the urinary bladder Radiographic diagnosis is Urinary Bladder Tumor The next step is cystoscopy and biopsy Tumor  Bladder Cancer IVU showing an irregular filling defect of the urinary bladder Bilateral hydroureter and hydronephrosis Radiographic diagnosis is Carcinoma of Urinary Bladder The next step is cystoscopy and biopsy Tumor  Bladder Cancer Tumor Tumor  Bladder Cancer Treatment Squamous Cell Carcinoma: 📍 Radical Cystectomy 📍 Bil. LNs dissection Transtional Cell Carcioma 📍 Superficial: TURBT, Laser + intravesical chemo/ immuno-therapy 📍 Muscle Invasive: Radical cystectomy + urinary diversion Chemotherapy Radiotherapy  Bladder Cancer Treatment Urinary Diversion: 📍 This is to divert the urine to another route after radical cystectomy 📍 Types of diversions: 🚩 Neo-bladder (Bladder substitute) reconstructed from small intestine 🚩 Ileal conduit 🚩 Uretero-colic 🚩 Uretro-cutaneous