Ch 17: Lower Urinary Tract

Question 1

This congenital defect involving the LUT results from absence of an anterior abdominal wall due to incomplete resorption of the anterior cloacal membrane. What is the abnormality and what other defect is it associated with?

Answer 1

Exstrophy of the urinary bladder

• associated with epispadias (opening of urethra on superior surface of penis)
• even after surgical treatment, bladder is at increased risk for malignant transformation (bladder carcinoma)

Question 2

A 65 yo male presents complaining of difficulty starting and stopping his flow (urine, not beats). After further questioning, you suspect nodular prostatic hyperplasia (BPH). What is causing his symptoms, and what are some other changes you should look out for?

Answer 2

• urinary symptoms caused due to the tendency of hyperplasia to develop in the PERIURETHRAL region - urethra is compressed
• impaired bladder emptying causes hypertrophy of bladder wall smooth muscle and eventual diverticula or hydronephrosis
• increased risk for infections and bladder stones

Question 3

How do symptoms help differentiate between acute cystitis vs. acute pyelonephritis?

Answer 3

• Acute cystitis: lower pelvic discomfort, pain during urination, gross blood in urine, inflammatory cells in urine
• Acute pyelonephritis: flank pain without gross blood in urine
• most common causes are coliform bacteria (E. coli)
• both are more likely to occur in females, especially when pregnant

Question 4

What are the most important risk factors for bladder cancer and what is the most common presenting symptoms?

Answer 4

Risks: cigarette smoking (polycyclic hydrocarbons), azo dyes, infection with Schistosomiasis, drugs (cyclophosphamide, analgesics), radiation therapy

Symptoms: sudden hematuria (with or without pain) in older male

Question 5

A 65 yo male presents complaining of urinary frequency and pain. You think prostate until he says that he had his prostate out 6 months ago. You think acute cystitis until you culture his urine and find no growth. What is your next step and why?

Answer 5

• think of looking at that bladder a little closer, probably with a biopsy
• you will find predominance of lymphocytes and plasma cells, which leads you to –> chronic cystitis

Question 6

A 65 yo male presents complaining of blood in his urine, but has not had any associated pain. Upon cystoscopy, you find a solitary tumor that with closer inspection in lined by epithelium that is indistinguishable from normal urothelium. What is your diagnosis?

Answer 6

• urothelial papilloma, of the classical exophytic type
• inverted papillomas are the much more rare possibility, but you would see normal epithelium with cords of transitional epithelium descending into lamina propria

Question 7

What are the histological characteristics of urothelial cell carcinoma in situ?

Answer 7

• full thickness malignant changes (cellular atypia) in non papillary bladder mucosa

Question 8

What is the most common tumor in the ureter?

Answer 8

urothelial cell carcinoma

- presents with hematuria and flank pain

Question 9

A child presents with blood in their urine, and workup reveals a bladder tumor. What is it?

Answer 9

• Embryonal rhabdomyosarcoma
• manifests as sarcoma botryoides - edematous, mucosal, polypoid masses (cluster of grapes)
• sidenote: in adults, most common sarcoma is leiomyosarcoma

Question 10

A 60 yo woman presents with a history of pain and bleeding, which you discover is coming from right around the urethral meatus. What is the diagnosis?

Answer 10

Urethral caruncle:

• occurs exclusively in women as an exophytic, ulcerated, polypoid mass with inflamed granulation tissue and hyperplasia of epithelium
• does not lead to cancer! (even though it looks like it)

Question 11

Squamous cell carcinoma of the bladder is usually associated with what?

Answer 11

• schistosomiasis
• chronic cystitis
• long standing nephrolithiasis

Question 12

Soft, yellow plaques on the surface of the bladder with accumulation of large macrophages

Answer 12

• malakoplakia

- macrophages can have calcospherites (Michaelis-Gutmann bodies)

Question 13

Transmural inflammation of the bladder wall with mast cells and fibrosis.

Answer 13

• chronic interstitial cystitis
• affects middle aged women
• may be associated with a mucosal Hunner ulcer
• persistent and refractory to therapy

Question 14

Potential causes of a mucin-producing tumor in the bladder?

Answer 14

• tumor = adenocarcinoma

- arises from urachal remnant, cystitis glandularis, or exstrophy