Lower Urinary Tract Flashcards
how many layers of cells are in contract and dilated states of urinary bladder?
Contacted = 5-7 layers
Dilated = 2-4 layers
What are the 7 types of diseases of lower urinary tract?
Congenital and acquired anomalies, Inflammation, Metaplastic lesions, Urethral obstructive lesions, urethral caruncle, fibroepithelial polyp, & neoplasms
What are the 8 congenital and acquired lower urinary tract diseases?
Ureteropelvic junction obstruction
Ureteral diverticulum
Congenital bladder diverticulum
Acquired bladder diverticulum
Acquired urethral diverticulum
Bladder exstrophy
Vesico-ureteral junction reflex
Urachal anomalies
what is the most common cause of hydronephrosis in children & infants?
ureteropelvic junction obstruction
What is the cause of Ureteropelvic Junction Obstruction?
abnormal organization of smooth muscle bundles or excess stromal deposition of collagen at the UPJ
In congenital and adult cases, what is the usual presentation of UPJ?
congenital = bilateral; common in males
Adults = unilateral; common in females
What congenital disease of the lower urinary tract has a saccular outpouchings along the ureter wall where it gives rise to recurrent infections?
Ureteral diverticulum
What congenital disease of the LUT has saccular outpouchings due to focal weakness in the wall?
Congenital bladder diverticulum
failure in devt of bladder wall during fetal devt
What congenital disease of the LUT has saccular outpuching of the bladder wall due to INC intravesicular pressure 2ndary to obstruction of urine outflow?
Acquired bladder diverticulum
What is the gross finding in acquired bladder diverticulum?
thickening or hypertrophy of bladder wall
What are the clinical significance of seeing acquired bladder diverticulum?
could indicate:
Urine stasis, Infection, Stone formation, & Increased risk of developing carcinoma
What kind of congenital LUT disease has a pouch that forms along the urethra where it can be filled with urine & lead to infections?
Acquired urethral diverticulum
What are the clinical manifestations of acquired urethral diverticulum? Possible cause of this disease?
painful vaginal mass
cause –> repeated infections in a periurethral gland that results in blockage –> blocked gland bursts into the urethra
What kind of congenital LUT disease has failure of both abdominal wall and bladder wall to CLOSE during fetal devt?
Bladder exstrophy
How does Bladder Exstrophy present?
Protrusion of the bladder wall through the lower abdominal wall
Direct communication betw bladder & abdominal surface (exposed bladder)
What could Extrosphy indicate?
Adenocarcinoma in the bladder remnant
What kind of lower UT is the most common and serious congenital anomaly and is caused by a congenital abnormality at the UTEROVESCIAL JUNCTION
Vesico-Ureteral Junction Reflux
What happens to the bladder during Vesico-Ureteral Junction reflux?
Urine flows back to the kidneys (Faulty malfuncitoning valve)
causes UTI, ascending pyelonephritis, & Hydronephrosis
What structure connects the fetal bladder with the allantois?
Urachal canal
What congenital LUT disease has incomplete obliteration of the urachus?
Urachal anomalies
What are the 4 types of congenital anomalies?
Patent urachus
Umbilical-urachal sinus
Vesicourachal diverticulum
Urachal cyst
What is the most common urachal abnormality where there is a communication formed betw THE BLADDER & UMBILICUS as a fistulous urinary tract? What happens bcos of this?
Patent urachus
-> Total failure to involute
What kind of urachal abnormality has urachus open into the umbilicus and drainage from the umbilicus causing partial involution?
Umbilicus-urachal sinus
What kind of urachal abnormality has wide patent opening into the bladder partial involution?
Vesicoureachal diverticulum
What kind of urachal abnormality has urachal cyst formed with urothelial/metaplastic glandular epithelium formed?
Urachal cyst –> can become adenocarcinoma
What are the diff inflammatory conditions of LUT?
Acute & Chronic Cystitis
Other forms of Cystitis: Polypoid cystitis, hemorrhagic cystitis
Special types of cystitis: Malakoplakia of the urinary bladder, Interstitial cystitis
Urethritis
What is the route of infection in acute & chronic cystitis?
Ascending route
What are the predisposing factors for cystitis?
Bladder calculi
Urinary obstruction
DM
Instrumentation
Immune deficiency
What are the triad of symptoms of cystitis?
Urinary frequency (INC)
Lower abdominal pain
Dysuria
What are the 2 special forms of cystitis?
Eosinophilic cystitis
Follicular cystitis
What condition is follicular cystitis associated with?
long-standing infection
lymhoid follicles in lamina propria are affected
what are other forms of cystitis? what makes them be categorized as ‘other’?
these are from Iatrogenic causes (radiation cystitis, hemorrhagic cystitis from chemo, & polypoid cystitis)
Polypoid cystitis
Hemorrhagic cystitis
What is the cause of Polypoid cystitis?
irritation of bladder mucosa reulting to instrumentation including indwelling catheters
What is the histological feature of Polypoid cysittis?
Urothelium = broad bulbous polypoid projections as a result of marked submucosal edema
MAY BE MISTAKEN FOR PAPILLARY UROTHELIAL CARICNOMA
What other types of cystitis is associated with the cytotoxic SE of antitumor therapy?
Hemorrhagic cystitis
What drug can induce hemorrhagic cystitis?
Cyclophosphamide –> excretes Acrolein (urotoxic)
What are the 2 special types of cystitis?
Malakiplakia of the urinary bladder
Interstitial cystitis
What special type of cystitis where there is a defect in phagocytic & degradative function of macrophages?
Malakoplakia of the urinary bladder
What is the gross pathologic finding of Malakiplakia of the urinary bladder?
Yellow soft plaques on the surface of the urinary bladder
What is the histologic pathologic finding of Malakiplakia of the urinary bladder?
Abundant foamy histoicytes & Basophilic laminated targetoid sutrctures like Michaelis Gutmann bodies
What are Michaelis-Gutmann bodies?
Laminated targetoid structures formed by CaPO4 deposition on bacteria/their fragments
What special type of cystitis is aka chronic pelvic syndrome/Hunner’s cystitis due to an unknown cause?
Interstitial cystitis
What are the clinical symptoms of Interstitial Cystitis?
Urinary frequency INC
Dysuria
Hematuria
Suprapubic pain –> FIbrosis of the muscular bladder wall
What are Hunner’s ulcers/Hunner’s lesions/Hunner’s patches?
not ulcers in the usual sense but are distinctive areas of inflammation in the bladder wall that characterize the “classic” form of interstitial cystitis
What is the histology of Interstitial cystitis?
Non specific edema, congestion, and nonspecific inflammatory infiltrates
dx is only made after other causes have been rules out (repeat urine c/s are all neg for bacte, fungi and viruses)
What is a condition often accompanied by cystitis in women & prostitis in men?
Urethritis
What are the 2 LUT metaplastic lesions?
Cystitis Glandularis Et Cystica
Squamous cell metaplasia
What are Brunn nests in Cystitis Glandurlaris Et Cystica?
common lesions in the urinary bladder where clusters of urothelium lie under the surface mucosa
What lesion in Cystitis Glandularis Et Cystica has this transformation of the centrla epithelium into cuboidal/columnar lining?
Cystitis glandularis
What lesion in Cystitis Glandularis Et Cystica has cystic spaces filled with clear fluid lined by flattened urothelium?
Cystitis cystica
What metaplastic lesion has pure SCC associated with chronic irritation & infection?
Squamous cell metaplasia
What are the 2 types of ureteral obstructive lesions?
Extrinsic & Intrinsic lesions
What are the intrinsic lesions of ureteral obstructive lesions?
Calculi
Stricture
Tumors
Blood clots
Neurogenic interruption of the neural pathways to the bladder
What are the extrinsic lesions of ureteral obstructive lesions?
Pregnancy -> relaxation of SM
Periureteral fibrous scarring
Sclerosing Retroperitoneal fibrosis
Periureteral tumor extension
What are the 3 conditions that can arise from intrinsic and extrinsic lesions of the ureter?
Hydrourter
Hyronephrosis
Pyelonephrosis
What are other causes of ureter obstructive lesions?
Unilateral obstruction
Bilateral obstruction
What LUT disease has fleshy outgrowings in th edistal urethral mucosa that has inflamed granulation & tissue covered by friable mucosa?
Urethral caruncle
What are the causes of urethral caruncle?
Distal urethral prolapse
Estrogen withdrawal at menopause
Where does Urethral caruncle originate from?
Posterior lip of the urethra
What tumor-like lesion in the LUT occurs in children and is composed of loose vascularized CT overlaid by urothelium?
Fibroepithelial polyp
Where can urothelial tumors arise?
Pelvis, ureter, bladder, and distal urethra (anywhere w/ ureothelium)
What are the risk factors of urothelial cancer?
Cigarette smoking
Occupational exposure
Irradiation
Chronic abuse of peracetic containing analgesics
Chronic cystitis caused by S. haematobium
What occupation hazard is found to be a bladder carcinogen?
Aromatic amines
What genes play a part in the formation of urothelial tumors?
Inactivation of TP53 & RB tumor suppressor genes
What are the urothelial tumor preursor lesions?
Non-invasive papillary tumor -> most common
Flat non-invasive carcinoma - aka Carcinoma in situ
What is the diff betw benign urothelium & carcinoma in situ?
CISU = UMBRELLA CELL LAYER is generally lost
BU = lack of marked atypia of basal & intermediate cells
What are the 4 morphologic patterns of Urothelial lesions?
papillary urothelial neoplasm, non-invasive
Invasive papillary carcinoma
Flat non-invasive carcinoma
Flat invasive carcinoma
Are px whi have had papillary tumors of the urinary bladder at risk of developing invasive carcinoma?
yes, these morphological patterns depend on how it grows
What is the morphological pattern of urothelial lesion that grows SLENDER, FINGER-LIKE projections towards the centers of the bladdeR?
Papillary urothelial neoplasm, non-invasive
What is the morphological pattern of urothelial lesion that frequently multiplies & the most common form of urothelial lesion?
Invasive papillary carcinoma
What is the morphological pattern of urothelial lesion that grows flat and there’s a precursor lesion & invasion in the lamina propria and muscularis (THICK)?
flat invasive carcinoma
non-invasive if di aabot ng lamina propria & muscularis
What are the 3 important gross features of urothelial lesions?
Flat lesions
Papillary tumors
Papillary Exophytic cauliflower-like large tumors
What urothelial lesion is classified as carcinoma in situ?
flat lesions
What urothelial lesion is seen as a small exophytic tumor that project into the lumen as wart-like papillary outgrowths?
Papillary tumors
What urothelial lesion is seen as an exophytic cauliflower-like large tumors?
Papillary exophytic cauliflower-like large tumors
What is the classification of non-invasive papillary urothelial tumors?
- Papilloma
- Papillary Urothelial Neoplasm of Low Malignant Potential
- Non-invasive low grade papillary
- Non-invasive high grade papillary
What is a type of Urothelial neoplasm that has a thicker urothelium w/ INC density of cells?
Punlump
What is the diff betw non-invasive LOW & HIGH grade papillary urothelial carcinoma?
LOW - urothelial lining displays MINIMAL cytologic atypia, irrespective of thickness
HIGH = marked cytologic and architectural atypia
-> highest risk of muscle invasion
What are the 4 non-invasive papillary urothelial tumors? From these 4, what are those at risk of muscl e invasion?
Urothelial Papilloma
Punlump
Non-invasive LOW grade papillary urothelial carcinoma = MODERATE risk of muscle invasion
Non-invasive HIGH grade papillary urothelial carcinoma = HIGHEST GRADE of muscle invasion
What is an invasive urothelial carcinoma?
it has penetrated the basement mebrane, invaded lamina propria/deeper into the muscularis propria
Grade & Depth of invasion = best determinants of prognosis
What is the gross feature of Invasive urothelial carcinoma?
Subtle bladder wall thickening to obvious exophytic mass
What is the histologic feature of invasive urothelial carcinoma?
high grade nuclear and architectural atypia
invasion of the lamina propria and muscularis propria
frequent mitosis
What are the clinical features of urothelial tumors?
Painless gross hematuria
How do we stage bladder cancer using TNM?
Ta = non-invasive papillary
Tis = carcinoma in-situ, flat
T1 = lamina propria
T2 = Muscularis propria
T3a = microscopic extension beyond the UB wall
T3b = gross extension beyond the UB wall
T4 = invades adjacent structures
