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RGU Exam 3 > Bladder Pathology > Flashcards

Bladder Pathology Flashcards

1
Q

Mneumonic to help recall which abdominal viscera are retroperitoneal

A

“SAD PUCKER”

  • S = suprarenal (adrenal) glands
  • A = aorta/IVC
  • D = duodenum (except the duodenal cap-first 2cm)
  • P = pancreas (except tail)
  • U = ureters
  • C = colon
  • K = kidneys
  • E = (o)esophagus
  • R = rectum
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2
Q

Double and Bifed Ureters

A
  • May be assoc. w/ distinct double renal pelves
  • May be assoc. w/ anomalous development of a large kidney having a partially bifed pelvis terminating in separate ureters
  • Double ureters may pursue separate courses in the bladder wall and drain thru a single ureteral orifice
  • Most double ureters are U/L and are of no clinical significance
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3
Q

Uretopelvic Junction Obstruction

A
  • A congenital disorder that is the most common cause of hydronephrosis in infants and children which is more common in boys
  • The condition has been ascribed to abnormal organization of smooth muscle bundles at the UPJ, to excess stromal deposition of collagen b/w smooth muscle bundles, or rarely to congenitally extrinsic compression of the UPJ by renal vessels
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4
Q

Ureter Diverticula

A
  • Saccular outpouchings of the ureteral wall
  • Usually asymptomatic
  • May cause stasis and secondary infections
  • Dilation, elongation and tortuosity of the ureters may occur
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5
Q

Disease states that result from obstruction of the ureter

A
  • Hydroureter
  • Hydronephrosis
  • Pyelonephritis
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6
Q

Causes of Intrinsic Obstructive Lesions of the Kidneys

A
  • Calculi
  • Strictures
  • Tumors
  • Blood clots
  • Neurogenic
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7
Q

Causes of Extrinsic Obstructive Lesions of the Kidneys

A
  • Pregnancy
  • Periureteral inflammation
  • Endometriosis
  • Tumors
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8
Q

Most common primary malignant tumor of the ureter

A
  • Urothelial carcinomas
  • Resemble those arising in the renal pelvis
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9
Q

Urothelial carcinomas

A
  • Most common malignant tumor of the ureter
  • Occur most frequently during the 6th and 7th decade of life and cause obstruction of the ureteral lumen
  • Sometimes are multifocal and commonly occur concurrently w/ similar neoplasms in the bladder or renal pelvis
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10
Q

Ureter Calculi

A
  • Rarely >5mm in diameter

*larger renal stones typically cannot enter ureters

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11
Q

3 points of ureter narrowing prone to calculi obstruction

A
  • Ureteropelvic junction

*where the renal pelvis meets the ureter

  • Ureterovesical junction

*where they enter the bladder

  • Where the ureter crosses the iliac vessels
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12
Q

Sclerosing retroperitoneal fibrosis

A
  • Uncommon cause of ureteral narrowing or obstruction
  • Characterized by a fibrotic proliferative inflammatory process encasing the retroperitoneal structures and causing hydronephrosis
  • Occurs in middle to late age and is more common in males than females
  • Most have no obvious cause and are considered primary or idiopathic

*a subset of cases are related to IgG4-related disease (elevated lvls serum IgG4, fibroinflammatory lesions rich in IgG4–secreting plasma cells)

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13
Q

Sclerosing retroperitoneal fibrosis causes

A
  • Drugs

*ergot derivatives

*beta-adrenergic blockers

  • Adjacent inflammatory conditions

*vasculitis

*diverticulitis

*crohn’s disease

  • Malignant disease

*lymphoma

*urinary tract carcinoma

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14
Q

Congenital anomalies of the bladder

A
  • Diverticula
  • Exstrophy
  • Vesicoureteral reflux
  • Urachal anomalies
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15
Q

Vesicoureteral reflux

A
  • 1-2% of otherwise normal kids
  • May lead to renal infection and scarring
  • Incompetence of vesicoureteral valves
  • Bacteria may ascend ureter to renal pelvis
  • Due to congenital absence or shortening of intravesical portion of ureter
  • Ureter is not compressed during micturition
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16
Q

Bladder Diverticula

A
  • Pouch like defect of bladder wall that may be congenital or acquired

*congenital: failure of development of normal musculature

*acquired: obstruction to urinary outflow and thickening of bladder wall (increased pressure)

  • Most asymptomatic but can predispose to calculi, infection and vesicoureteral reflux
  • Often multiple
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17
Q

Exstrophy of bladder

A
  • Also called “Exstrophy-Epispadias Complex”
  • Developmental failure during embryology of the anterior abdominal wall and bladder causing:

*open bladder

*exposure of bladder and urethral on surface of lower abdomen and dorsal penis

*low set umbilicus

*diastasis of symphysis pubis

*anteriorly displaced anus

*genital defects

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18
Q

Exstrophy of bladder diagnosis

A
  • US before birth
  • At birth thru physical exam
  • Treatment = surgery
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19
Q

Urachal anomalies

A
  • Urachus is a fibrous remnant of the allantois, a canal that drains the urinary bladder of the fetus that joins and runs within the umbilical cord, normally obliterated after birth
  • May remain patent in part or in whole

*totally patent = fistulous urinary tract connecting bladder w/ umbilicus

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20
Q

Urachal anomaly symptoms

A
  • Infant has persistent wet belly button
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21
Q

Bladder obstruction causes

A
  • Neoplastic

*prostatic hyperplasia or carcinoma

*invasion by perivesicular lesions

*bladder tumors

  • Inflammation

*cystitis

  • Foreign body and calculi
  • Injury to bladder innervation leading to a neurogenic bladder
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22
Q

Cystitis

A
  • Inflammation of bladder
  • Pyruia (WBC’s in urine) is present in almost all pts w/ acute cystitis or pyelonephritis
  • More likely to develop in women due to shorter urethras
  • Frequently precedes pyelonephritis (infection of the kidneys) w/ retrograde spread of microorganisms into the kidneys and their collecting systems
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23
Q

Cystitis causes

A
  • Inflammation of the bladder
  • Most commonly due to bacterial infection

*E. Coli

*S. Saprophyticus

*P. Mirabilis

*K. Pneumoniae

  • Fungal infection

*candida

  • Parasitic

*S. Haematobium

  • Iatrogenic

*radiation

*hemorrhagic

*polypoid

  • Idiopathic

*interstitial cystitis

  • Sometimes a secondary complication of an underlying disorder assoc. w/ urinary stasis

*prostatic enlargement

*cystocele of the bladder

*calculi

*tumors

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24
Q

Bacterial causes of cystitis

A
  • E. Coli (most common cause)
  • S. Saprophyticus
  • P. mirabilis
  • K. Pneumoniae

All gram (-) rods except staph saprophyticus (gram (+))

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25
Q

Fungal causes of cystitis

A
  • Candida
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26
Q

Parasitic causes of cystitis

A
  • S. Haematobium
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27
Q

Iatrogenic causes of cystitis

A
  • Radiation
  • Hemorrhagic
  • Polypoid
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28
Q

Cystitis Symptoms

A
  • Inflammation of the bladder is characterized by a triad of symptoms
    1. Frequency- acute cases may necessitate urination every 15-20min.
    2. Lower abdominal/suprapubic pain
    3. Dysuria- pain or burning on urination
  • Can be caused by a number of inflammatory lesions, many of which manifest w/ frequency and dysuria
  • Acute or chronic bacterial cystitis is extremely common, particularly in women, and results from retrograde spread of colonic bacteria in most cases
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29
Q

Secondary complications that can causes cystitis

A
  • Prostatic enlargement
  • Cystocele of the bladder
  • Calculi
  • Tumors
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30
Q

Acute and chronic cystitis predisposing factors

A
  • Bladder calculi
  • Urinary obstruction
  • Diabetes mellitus
  • Instrumentation
  • Immune deficiency
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31
Q

Acute and chronic cystitis diagnosis

A
  • Tissue biopsy plays little role in diagnosis
  • Diagnosis by urine culture, urinalysis and clinical symptoms
  • Urinalysis for eval of pyuria is the most valuable lab diagnostic test for UTI
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32
Q

Most common cause of cystitis

A
  • E. Coli

*gram (-) rod (appear pink on histo slide w/ purple being gram (+))

*facultatively anaerobic

33
Q

E. Coli

A
  • Gram (-) rod
  • Facultatively anaerobic
  • Most common cause of UTIs
34
Q

Staphylococcus saprophyticus

A
  • Gram (+) coccus
  • Coagulase-neg.
  • Commonly seen in sexually active females 17-27, it is the 2nd most common cause of community-acquired UTIs, after E.coli
35
Q

Klebsiella pneumoniae

A
  • Gram (-) rod
  • Non-motile
  • Facultatively anaerobic
  • Encapsulated
  • Appears as a mucoid lactose fermenter on MacConkey agar
36
Q

Proteus mirabilis

A
  • Gram (-) rod-shaped
  • Facultatively anaerobic
  • Urease activity
  • Swarming motility (almost resembles tree rings on agar)
37
Q

Malakoplakia

A
  • Chronic cystitis assoc. w/ E. Coli and proteus
  • Etiology is defects in phagocytic function
  • Increased incidence in immunosuppressed and transplant pts
38
Q

Malakoplakia appearance

A
  • On cystocopy appear as soft yellow raised mucosal plaques which may resemble carcinoma on cystoscopy
  • On microscopy appear with foamy macrophages, multinucleated giant cells and lymphocytes
  • Michaelis-Gutmann bodies: laminated mineralized concretions of calcium deposition in lysosomes within macrophages
39
Q

Michaelis-Gutmann bodies

A
  • Present in malakoplakia
  • Laminated mineralized concretions of calcium deposition in lysosomes within macrophages
40
Q

Candiduria Risks

A
  • Candida caused cystitis
  • ICU pts
  • Older age
  • Diabetes mellitus
  • Antimicrobial use
  • Indwelling bladder catheters
41
Q

Candiduria treatment

A
  • Fluconazole

*excreted into the urine in its active form (allowing for effects within the bladder)

42
Q

Schistosoma

A
  • Parasitic worm infection
  • 3 major species causing human infections:

*schistosoma mansoni (intestines and liver)

*schistosoma haematobium (GU tract)

*schistosoma japonicum (intestines and liver)

  • Schistosoma eggs, which induce predominantly Th-2 immune responses
43
Q

Schistosoma haematobium infection

A
  • Early infection

*inflammatory granulomatous reaction

*eosinophilic infiltration

*local tissue destruction and fibrosis

  • Chronic infection

*fibrosis and calcifications of bladder wall

*bladder neck obstruction

*hematuria

*pyuria

  • Assoc. w/ bacterial superinfection, acute renal failure, and development of bladder cancer (squamous cell carcinoma)
44
Q

Schistosoma haematobium chronic infection major risk

A
  • Squamous cell carcinoma
45
Q

Schistosoma mansoni appearance on histology slide

A
46
Q

Schistosoma japonicum appearance on histology slide

A
47
Q

Schistosoma haematobium microscopic appearance

A
48
Q

Schistosoma haematobium appearance on histology slide

A
49
Q

Radiation cystitis

A
  • Radiation cystitis may be acute or chronic and can occur any time the bladder is included in the treatment field
  • Clinically, the acute symptoms of radiation cystitis may appear as early as 4-6wks after initiation of therapy
  • Chronic symptoms appear as much as 10yrs later
  • Can present w/ hematuria, suprapubic pain
50
Q

Schistosoma mansoni microscopic appearance

A
  • Elongated/oval egg w/ a lateral spine (protrusion of the lateral side)
51
Q

Polypoid cystitis

A
  • Inflammatory lesion resulting from irritation of the bladder mucosa
  • Indwelling catheters are the most commonly cited culprits
  • Urothelium shows broad bulbous polypoid projections as a result of marked submucosal edema
52
Q

Hemorrhagic cystitis

A
  • Surface urothelium is ulcerated or thinned
  • Extensive hemorrhage in the bladder wall
  • Can cause massive hematuria
  • Caused by cyclophosphamide in 1950’s

*unrelated to dose

*metabolic byproducts get excreted thru kidney

*pts given lots of fluid to counteract nowadays when on this drug

53
Q

Interstitial cystitis

A
  • “Chronic pelvic pain syndrome”
  • Chronic form of cystitis that occurs most frequently in women
  • Etiology of this troubling condition is unknown, its evaluation and diagnosis remain controversial, and its treatment is largely empiric
54
Q

Interstitial cystitis clincal findings

A
  • Suprapubic pain

*intermittent

*sever

  • Urinary frequency
  • Urgency
  • Hematuria
  • Dysuria
55
Q

Interstitial cystitis cytoscopic findings

A
  • Hunner ulcer

*reddened lesions on the bladder mucosa

  • Glomerulations

*petechial red areas

  • Fissures
  • Later in the course, transmural fibrosis may appear, leading to a contracted bladder
56
Q

Urothelial neoplasia epidemiology

A
  • Carcinoma of the bladder affects men more than women at a ratio of 3 to 4:1
  • ~80% of pts are b/w 50 and 80
  • Cigarette smokers have an increased relative risk of developing bladder cancer up to 4x
  • Developing cancer increases w/ cigarette smoking but not w/ cigar or pipe smoking; suggesting inhalation is an important factor
57
Q

Human bladder carcinogens

A
  • Aromatic amines

*napthylamines

*benzidine

*biphenyls

  • Phenacetin-containing analgesics
  • Alkylating drug cyclophosphamide
58
Q

Urothelial neoplasia (bladder cancer) presentation

A
  • Painless hematuria; dominant and sometimes only clinical manifestation
  • Frequency, urgency and dysuria occasionally accompany the hematuria
  • When the ureteral orifice is involved, pyelonephritis or hydronephrosis may follow
59
Q

Most common bladder cancer?

A
  • Urothelial cell carcinoma
60
Q

Urothelial cell carcinoma

A
  • Approx. 90% of malignant bladder tumors are urothelial/transitional cell carcinomas
61
Q

Grading of bladder cancer

A
  • CIS = carcinoma in situ; cancer is not invading the basement membrane
  • Ta = noninvasive papillary
  • T1 = invasion past the basement membrane w/ projections into the lamina propria
  • T2 = invasions of the detrussor muscles (muscularis propria); treated by cystectomy
  • T3 = invasion of adipose tissue
  • T4 = invasion into the organs (prostate, seminal vesicles,…)
62
Q

Papilloma

A
  • Individual finger-like papillae have a central core of loose fibrovascular tissue covered by epithelium that is histologically identical to normal urothelium
63
Q

Low-grade non-invasive papillary UCC

A
  • Mild degree of nuclear atypia consisting of scattered hyperchromatic nuclei, infrequent mitotic figures predominantly toward the base, and slight variation in nuclear size and shape
  • These low-grade cancers may recur and, although infrequent, may also invade. Only rarely do these tumors pose a threat to the pts. life
  • Particularly common (occurring in 30-60% of tumors) are losses of genetic material on chromosome 9 (including monosomy or deletions of 9p and 9q). These abnormalities are often the only chromosomal changes present in superficial noninvasive papillary tumors
64
Q

High-grade non-invasive papillary UCC

A
  • Dyscohesive cells w/ large hyperchromatic nuclei
  • Mitotic figures, including atypical ones, are frequent
  • Compared to low-grade lesions, these tumors have a much higher incidence of invasion into the muscular layer, a higher risk of progression, and, when assoc. w/ invasion, a significant metastatic potential
65
Q

Non-invasive papillary UCC treatment

A
  • Transurethral resection of bladder tumor

*TURBT

66
Q

High-grade non-invasive papillary UCC

A
  • Transurethral resection of bladder tumor

*TURBT

  • Intravesicular bacillus calmette-guerin (BCG)
  • OR-
  • Intravesicular chemotherapy
67
Q

Carcinoma in situe of the bladder

A
  • Defined by the presence of cytologically malignant cells within a flat urothelium
  • Cystoscopy: usually appears as an area of mucosal reddening, granularity, or thickening w/o an evident intraluminal mass
  • Is commonly multifocal and may involve most of the bladder surface and extend into the ureters and urethra
  • If untreated, 50-75% of CIS cases progress to invasive cancer
68
Q

Carcinoma in situ of the bladder treatment

A
  • Intravesical therapy

*BCG is standard treatment

  • Cystecomy is common treatment for pts refractory to intravesical therapy
69
Q

Invasive UCC

A
  • Urothelial carcinoma that invades beyond basement membrane
  • Loss-of-function mutatiosn in the TP53 and RB tumor suppressor genes are almost always seen in high-grade and, frequently, muscle invasive tumors
  • May be papillary, polypoid, nodular, solid or ulcerate
  • Background urothelium may be normal or erythematous
  • Solitary or multifocal
70
Q

Detrussor muslce histology

A
71
Q

Invasive UCC treatment

A
  • Invasion into lamina propria (T1) usually managed w/ intravesical therapy
  • Invasion into muscularis propria (T2) usually managed by radical cystectomy; radiation therapy in some centers

*neoadjuvant or adjuvant chemotherapy may be offered

72
Q

Bladder squamous cell carcinoma etiology

A
  • Developmental

*bladder exstrophy

  • Environmental exposure

*tobacco smoking

*bladder stones

*chronic indwelling catheters

*neurogenic bladder

  • Infectious agents

*s. haematobium

*HPV assoc. is very rare

73
Q

Bladder squamous cell carcinoma epidemiology

A
  • Incidence varies by geographic region

*5% of bladder tumors in USA

*75% in Egypt/Sudan (endemic schistosomiasis)

74
Q

Bladder squamous cell carcinoma prognosis

A
  • Poor prognosis

*high-stage disease at presentation is common

  • Reported 5yr survival = 7-50%

*in pT3 disease = 13%

75
Q

Bladder squamous cell carcinoma treatment

A
  • Surgical

*radical cystecomy is standard therapy

  • Adjuvant therapy

*often have neoadjuvant or adjuvant radiation

*adjuvant chemotherapy is less standardized

76
Q

Bladder squamous cell carcinoma macroscopic appearanc

A
  • Fungating, tan-white mass
  • Typically large and deeply invasive, often ulcerated
77
Q

Bladder squamous cell carcinoma microscopic appearance

A
  • Diagnosis of squamous cell carcinoma should be reserved for those tumors that are purely or almost entirely keratin forming and exhibiting intercellualr bridges
  • 2 major histologic features: keratin pearls and intercellular bridges
78
Q

Metastatic tumors to the bladder

A
  • Prostate
  • Breast
  • Melanoma
  • Lung
  • Kidney
  • Stomach
  • Pancreas
  • Ovary

RGU Exam 3 (19 decks)

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