Lower Urinary Tract Flashcards
cystocele
bladder protrudes into the vagina and creates a pouch that fails to empty readily with micturition
ureteropelvic junction obstruction
): most common cause of hydronephrosis in infants and children,
o more common in women and is bilateral
diverticula
saccular outpouching of the ureteral wall
o leads to recurrent infections, due to sites of urinary stasis
o may predispose to VUR if it impinges ureter
o commonly due to persistent urethral obstruction
o Congenital form: due to focal failure of development of normal musculature during fetal development
o Acquired form: most often seen w/ prostatic enlargement producing obstruction to urine flow and thickening of bladder wall
o rarely carcinomas may arise
exstrophy of bladder
o a developmental failure in anterior wall of abdomen and bladder
o exposed mucosa may undergo metaplasia and is subject to infections that can spread to upper GU tract
o increased risk of adenocarcinoma arising from bladder remnant
o amenable to surgery w/ long-term survival rate
VUR
• Vesicouteral reflux:
o ureter enters bladder at unusual angle the valve does not work properly resulting in retrograde urine flow back into ureter and kidney
patent urachus/urachal cyst
• Patent Urachus/Urachal cyst:
o fistulus urinary tract connects the bladder w/ the umbilicus
o carcinomas or glandular tumors may arise from such cysts
ureteritis
inflammation, typically not assoc. w/ infection
pyelonephritis
kidney infection
hydronephrosis
water in kidney
hydroureter
ureteral dilation
fibroepithelial polyp
• fibroepithelial polyp: tumor-like lesion that presents as small mass projecting into the lumen, often in children
urothelial carcinoma
primary malignant tumors of ureter – resembles those in renal pelvis, calyces and bladder
sclerosing retroperitoneal fibrosis
o common cause of ureteral narrowing/obstruction
o fibrotic proliferative inflamm. process encasing retroperitoneal structures and causing hydronephrosis
cystitis
= bladder inflammation
Organisms causing cystitis:
• E. coli, Proteus, Klebsiella, Enterobacter (Staph and Saprophyticus are less likely)
• women more likely to develop
• Candida albicans seen in IC patients
• Schistomiasis – rare in US but seen in Egypt - assoc. w/ squamous cell carinoma of bladder
cystitis is often before pyelonephritis
Predisposing factors: • bladder calculi • urinary obstruction • DM • instrumentation • IC
Morphology:
• see hyperemia of mucosa, sometimes exudate present
clinical triad of cystitis
- frequency
- lower abdominal pain (over bladder, suprapubic region)
- dysuria (pain with urination)
- also see low-grade fever, turbid urine, occasional hematuria
hemorrhagic cystitis
- pt. receiving cytotoxic anti-tumor drugs such as cyclophosphamides often develop this
- adenovirus has been shown to cause it as well
interstitial cystitis
chronic pelvic pain syndrome
• occurs most freq. in women, ages 30-40 years
• intermittent severe suprapubic pain, urinary frequency, urgency, hematuria, dysuria
• often followed by late stage ulceration
• Mast cells characteristically seen, along w/ inflammation and fibrosis of bladder wall and fissures
malakoplakia
- chronic inflamm. rxn that appears to stem from acquired defects in phagocyte function
- E. coli or Proteus species
- more common in IC patients
- more common in females that are middle aged
- lesions are 3-4 cm soft, yellow, mucosal plaques made of foamy macrophages stuffed with bacterial debris
- foamy macrophages have Michaelis-Gutmann bodies – suggesting defective function
polyploid cystitis
- inflamm. condition resulting from irritation to bladder mucosa
- indwelling catheters most common cause
- has been misdiagnosed as papillary carcinoma
cystitis cystica and cystitis glandularis
- Cystitis Cystica (CC) and Cystitis Glandularis (CG) are common chronic reactive/inflammatory disorders which occur in the setting of chronic irritation
- Metaplasia of the urothelium is incited by irritants such as infection, calculi, outlet obstruction, or even tumor
- The urothelium proliferates into buds (nests of von Brunn) which grow down into the connective tissue beneath the epithelium into the lamina propria.
- The buds then differentiate into cystic deposits of CC or into intestinal columnar mucin-secreting glands (goblet cells) resulting in CG.
- The histologic features of both CC and CG are usually present, rather than either in its pure form
- CC and CG can occur at any age, and there is a reported prevalence of 2.4% of children associated with UTIs.
- A slight male predominance is reported
- Symptoms include those of chronic irritation, such as frequency, dysuria, urgency, and hematuria.
squamous metaplasia
- occurs in response to injury
* urothelium replaced by nonkeratinizing squamous epithelium, which is more durable
Nephrogenic Adenoma:
• results from implantation of shed renal tubular cells at sites of injured urotehlium
urothelial tumors
“Transitional Cell Carcinoma”
• 90% of bladder cancers
• two distinct precursor lesions to invasive urothelial carcinoma: noninvasive papillary tumors and flat noninvasive urothelial carcinoma (CIS)
• CIS = Carcinoma in Situ – describes lesions w/ features of malignancy but are confined to the epithelium, showing no evidence of BM invasion
• ½ of individuals w/ bladder cancer, have tumor invasion of bladder wall at time of presentation
• invasion of detrusor muscle (muscularis propria) = decreased survival rate
pathogenesis of urothelial tumors
- more common in men, developed nations, urban areas
- patients b/w 50-80 years
- cigarette smoking is most important influence
- industrial exposure to aryl amines, Schisosoma haematobium, long-term use of analgesics, cyclophosphamide (IM suppressive agent), irradiation
- p53 mutation = bad sign
- high grade invasive tumors: see loss-of-fn. mutation of TP53 and Rb tumor suppressor genes
- low-grade noninvasive tumors: see HRAS oncogene mutation
- low-grade papillary tumors: FGFR3 and RAS mutations
clinical features of transitional cell carcinoma?
- painless hematuria: most common manifestation
- frequency, urgency, dysuria, pyelonephritis, hydronephrosis may all occur as well
- high rate of recurrence after tumor excision
- Papillomas, papillary urothelial neoplasms of low malignant potential and low-grade papillary urothelial cancer yield 98% survival rate
- high grade leads to death in 25% of cases
- primary CIS is less likely to invade than when it is assoc. w/ infiltrating urothelial cancer
- squamous cell and adenocarcinoma are assoc. w/ worse prognosis than urothelial carcinoma, yet stage for stage they are the same
tx of transitional cell carcinoma?
• clinical investigation via cystoscopy and urine cytology
• Majority: have transurethral resection and surveillance, followed by chemo
• Miniroty: have segmental cystectomy (invasive) and immunotherapy
o radical cystectomy reserved for tumor invading muscularis propria, CIS or high grade cancer, VIS extending into prostatic urethra and ducts
papillomas
Papillomas: better • 1% of bladder tumors • seen in younger patients • small, delicate structures attached via a stalk = “exophytic papillomas” • no atypia/dysplasia • small and extends from surface • low/moderate recurrence rate • “inverted papilloma” o occurs in younger males o typically a raised “bump” in the trigone covered by grossly normal mucosa
papillary urothelial neoplasms of low malignant potential
(PUNLMP) better • similar to papillomas but have thicker urothelium • larger than papillomas • moderate recurrence rate • minimal cellular atypia
low-grade papillary urothelial carcinoma
less than 10% invade – ok
• 45% of papillary tumors
• cells are evenly spaced (maintain polarity and cohesive)
• mild degree of nuclear atypia, infrequent mitotic figures seen
high-grade papillary urothelial carcinoma
over 80% are invasive - BAD
• 30% of papillary tumors
• non-cohesive cells with large hyperchromatic nuclei
• highly anaplastic, atypical mitotic figures, loss of polarity
• high recurrence rate
carcinoma in situ (CIS)
INVASIVE
• flat urothelial carcinoma
• cytologically malignant cells w/ flat urothelium
• lack cohesiveness, resulting in shedding of malignant cells into urine
• CIs usually appears as area of mucosal reddening, granularity, or thickening w/out evident intraluminal mass
• if untreated 50-70% of CIS progress to invasive cancer
invasive urothelial cancer
INVASIVE
- may be assoc. w/ papillary urothelial carcinoma (usually high grade), or with flat urothelial carcinoma (CIS)
staging in bladder cancer
- high recurrence following treatment
** muscle invasion invasion i.e., depth of muscle invasion is the major prognostic issue to be established
T2-T4 50% 5-Year disease-specific survival
squamous cell carcinoma
- more freq. in countries where urinary schistosomiasis is endemic
- assoc. w/ chronic bladder irritation and infection
Mixed urothelial carcinomas w/ areas of squamous carcinoma:
- more frequent than pure squamous cell
* invasive, fungating tumors that are infiltrative an ulcerative
primary malignant lymphoma
- adults, age 65 y/o, very rare, more common in females
- usually non-hodgkin lymphoma
- radiosensitve, thus good prognosis
leiomyoma
benign smooth mm. mesenchymal tumor
sarcomas in bladder
uncommon in bladder
most common in infancy/childhood is rhabdomyosarcoma
o malignant mesenchymal tumor typically in children,
o rare, average age is 4 y/o
leiomyosarcoma:
o malignant mesenchymal tumor
o adults, 60 y/o, rare, more common in males
o seen in post chemo/radiation
