Diseases of the Bladder

Question 1

Bladder anatomy

Answer 1

Layers
Innermost = MUCOSA
Submucosa
Muscular
Peritoneum = outermost

In females, bladder is IMMEDIATELY ANTERIOR TO THE UTERUS/CERVIX

In males, the bladder is ANTERIOR TO THE SIGMOID COLON and IMMEDIATELY SUPERIOR TO THE PROSTATE

Cancers in adjacent organs can increase overall incidence of bladder cancer

Question 2

Congenital Bladder Diseases

Answer 2

BLADDER DIVERTICULUM –> pouch-like structure outside of the bladder (evagination of bladder wall) – Predisposes to INFECTIONS, STONES and can potentially INCREASE cancer incidence BPH especially

PERSISTANT URACHUS –> urachus is the fetal outflow tract for urine that runs in the umbilical cord –> persistent means it didn’t close at birth; presents as cysts, diverticula or fistulae; can become INFECTED; significantly INCIDENCE incidence of ADENOCARCINOMA

Exstrophy –> FAILURE OF CLOSURE OF ABDOMINAL WALL OR BLADDER

Question 3

Inflammation of the bladder

Answer 3

CYSTITIS

Bacterial - most common; E. coli, Klebsiella

Granulomatous inflammation – BCG TB vaccine, TB/Fungal infections in the immunocompromised – Shistosoma Hemtobium - Northern African patients

Hemorrhagic - results from viral, autoimmune and/or chemotherapy

Interstitial (Hunner’s) Cystitis – associated with TRANSMURAL FIBROSIS (F >M); potentially autoimmune

Radiation

Malakoplakia –> macrophages do not completely digest invading bacteria, leading to collections of FOAMY HISTIOCYTES and Michaelis-Gutman bodies –> gives the characteristic RINGED NUCLEI look

Question 4

METAPLASTIC Bladder Diseases

Answer 4

Cystitis Cystic et Glandularis –> chronic irritation and inflammation in the TRIGONE area induces invaginations, glandular epithelial transformation and cyst formation

Common microscopic incidental findings in relatively normal bladders

Lesions showing extensive metaplasia like this ARE NOT ASSOCIATED WITH INCREASED CANCER RISK!

Squamous metaplasia –> M > F, linked to SQUAMOUS CELL CARCINOMA, results from chronic irritation

Mesonephroid (Nephrogenic) metaplasia –> results from chronic irritation/inflammation; occurs often with cystitis cystica et glandularis

Question 5

BENIGN Bladder Neoplasms

Answer 5

Typical and Inverted Papillomas
Typical –> young patients with few risk factors; solitary masses < 2 cm, finger-like projections histologically, fibrovascular core; some MAY progress to carcinomas

Inverted –> RARE, 100% benign, grow in on themselves histologically

VILLOUS ademonas –> look very similar to COLORECTAL CANCERS a lot of goblet cells –> highly associated with CYSTITIS CYSTICA et GLANDULARIS

Paragangliomas –> Benign neural cell tumors that appear BROWN and DISCOLORED; stain with neural S100 marker

Question 6

Bladder Carcinomas Overview

Answer 6

Come in several varieties, based on the type of cell proliferating

Classifications

Transitional Cell Carcinomas: either can be PAPILLARY (TCC) or FLAT (TCC in situ, CIS), or MIXED
Associated with CIGARETTES; dyes; chemo, NSAID abuse

Squamous Cell Carcinoma –> associated with irritation on the URETHRAL side (chronic UTIs, recurrent stones, schistosoma hematobium infection (TB in african americans!)

Adenocarcinoma –> Associated with URACHAL remnants (persistent urachus!), CHRONIC UTI, GLANDULAR METAPLASIA

Question 7

TRANSITION CELL CARCINOMA, PAPILLARY TYPE

Answer 7

MOST COMMON type of epithelial malignancy of the bladder (90%); M > F

Majority btw 50-80

3% of all cancer related deaths

Can arise from ANY WALL OF THE BLADDER (multiple common)

Deeper penetration (muscle or peritoneal layer = worse

GRADES –> I and II similar (increased cell layers, dark chromatin), III very different (highly undifferentiated giant cells!)

Question 8

TRANSITION CELL CARCINOMA IN SITU

Answer 8

Uncommon as a primary carcinoma (< 10%)

M > 50 y.o. ALMOST EXCLUSIVELY

Presents as INTERSTITIAL CYSTITIS, or is ASYMPTOMATIC (25%)

Associated with a PREVIOUS or CURRENT TCC!!!!!!

Histology –> transitional epithelial cells lose polarity and adhesion; HUMUNGOCYTES; CIS progresses invasively into the lamina propria, muscular layer and adventitia

Question 9

SQUAMOUS CELL CARCINOMA

Answer 9

Occurs mostly in OLDER MEN; Northern Africans have a younger age of onset (due to endemic Schistosoma hematobium); Prevalence of SCC in Africa is much greater (73% in Egypt!!!)

RISK FACTORS –> Keratinizing squamous metaplasia secondary to recurrent infections, stones, or indwelling catheters

See KERATIN on histology

Question 10

ADENOCARCINOMA

Answer 10

Accounts for LESS THAN 1% of all bladder cancers, again M > F

Can occur PRIMARILY FROM RECURRENT UTI and glandular metaplasia

OR secondarily from direct extension from the prostate/colon; or metastatic from stomach, breast, lung

PRIMARY looks GLANDULAR on histology

If from METS, it may contain markers specific to that cell type (i.e. estrogen from breast)

• Associated with urachal remnants, chronic UTI, glandular metaplasia

Question 11

SMALL CELL (Neuroendocrine) CARCINOMA

Answer 11

May METASTASIZE to the bladder

Middle aged men

Much like lung neoplasms, it is USUALLY DETECTED LATE and at ADVANCED STAGE!

Could present with paraneoplastic syndromes

Stains with SYNAPTOPHYSIN or CHROMOGRANIN

Question 12

Bladder Cancer STAGING

Answer 12

Based on DEGREE OF INVASION

T1 = Penetrates lamina propria
T2 = muscle (a superficial, b deep)
T3 = peritoneum (a microscopically, b grossly)
T4 = SURROUNDING ORGANS (a = prostate, uterus, vagina; b = pevic or further

Question 13

What is the classic presentation of bladder cancer?

Answer 13

PAINLESS HEMATURIA