2022 - Evaluation and Treatment of Noninfectious Cystitis Conditions

Question 1

Figure 1. Cystoscopic appearance of non-oncologic conditions that may mimic malignancy. A, Interstitial cystitis/bladder pain syndrome with telangiectasias.
B, Chronic urinary retention with papillary polypoid cystitis. C, Bladder pain syndrome with urothelial punctuate hemorrhage. D, Chronic
indwelling catheter cystitis showing granulation tissue and unremarkable urothelium. E, Female chronic urinary retention with debris and squamous
metaplasia of the bladder trigone. F, Hemorrhagic radiation cystitis showing partially denuded urothelium with acute and chronic inflammation.
G, Radiation cystitis with chronic catheter cystitis. H, Chronic fungal urinary tract infection with urothelial granulation tissue. Images courtesy
of Dr Amy Dobberfuhl.

Question 2

What is cystitis, and what are its key symptoms?

Answer 2

Cystitis is inflammation of the bladder, defined by dysuria, frequency, urgency, suprapubic pain, hematuria, and fever. It requires determining if the cause is infectious or noninfectious.

Question 3

What are the initial evaluation steps for noninfectious cystitis according to the AUA guidelines?

Answer 3

The initial evaluation includes a complete history, focused physical exam, review of prior urine cultures, and possibly obtaining a catheterized urine specimen.

Question 4

What should be assessed in patients with cystitis for complicated risk factors, and when might additional imaging be considered?

Answer 4

Assess for risk factors like failure to respond to therapy, fever, hematuria, diabetes, etc. Cystoscopy and upper tract imaging may be considered for complicated cases.

Question 5

What considerations should be made when routine urine cultures are negative for cystitis, and what procedure may be necessary?

Answer 5

Consider noninfectious causes if routine cultures are negative. If a bladder lesion is identified, a biopsy is typically necessary to exclude malignancy.

Question 6

What is the pathophysiology of IC/BPS, and what factors might contribute to its onset?

Answer 6

IC/BPS’s pathogenesis may include chronic inflammation, autoimmune dysregulation, bacterial cystitis, urothelial dysfunction, deficiency of glycosaminoglycan barrier, and urine cytotoxicity. It may start with a painful event and persist due to neural hyperexcitability or central nervous system dysregulation.

Question 7

What has animal research revealed about the neural components involved in IC/BPS?

Answer 7

Animal research found that the bladder is populated by afferent fibers, including C-fibers that transduce pain and urgency. A-delta fibers relay the sensation of bladder fullness, and cholinergic parasympathetic fibers are responsible for bladder emptying.

Question 8

What are the AUA guidelines for diagnosing IC/BPS?

Answer 8

AUA guidelines include a careful history, physical exam, laboratory examination, voiding symptoms, pain levels, and bladder diary. In complex cases, cystoscopy and urodynamics may be considered.

Question 9

What are the potential treatment options for IC/BPS, and what procedures might be considered?

Answer 9

Treatment may include behavioral treatments, medications, instillations, procedures, and surgery. Bladder biopsy for suspicious lesions, and ablative treatment for Hunner ulcers (with laser or electrocautery) should be considered.

Question 10

What are the characteristics and histological findings of the acute phase of radiation cystitis?

Answer 10

Includes urinary urgency, frequency, nocturia, dysuria, bladder spasm, reversible inflammation, loss of glycosaminoglycan layer, urothelial sloughing, edema, and epithelial hyperplasia.

Question 11

What are the characteristics and histological findings of the late/chronic phase of radiation cystitis?

Answer 11

Occurs years later, showing chronic inflammatory fibrosis, collagen deposition, smooth muscle atrophy, edema, endarteritis, hemorrhage, and may present years to decades after therapy.

Question 12

What are the steps in diagnosing radiation cystitis?

Answer 12

Includes history, physical exam, urinalysis, surgical history, radiotherapy details, cystoscopy, renal bladder ultrasound, post-void residual, bladder diary, and possibly urodynamics.

Question 13

What are the treatments for acute radiation cystitis?

Answer 13

Includes phenazopyridine, anticholinergics, beta-3 agonists, hydration, and possibly intradetrusor botulinumtoxin A for refractory cases.

Question 14

What are the treatments for hemorrhagic radiation cystitis?

Answer 14

Includes clot evacuation, continuous bladder irrigation, cystoscopic fulguration, intravesical instillation, arterial embolization, urinary diversion, cystectomy, and hyperbaric oxygen.

Question 15

What is the pathophysiology of chemotherapy-induced cystitis, and what compounds are involved?

Answer 15

Ifosfamide and cyclophosphamide generate acrolein, leading to cell death through reactive oxygen species and nitric oxide. Hemorrhagic cystitis occurs 24 to 48 hours after a dose.

Question 16

How is chemotherapy-induced hemorrhagic cystitis diagnosed?

Answer 16

Diagnosis includes gross hematuria, chemotherapy history, cystoscopy showing urothelial bleeding, neovascularization, telangiectasias, and laboratory workup (blood count, serum creatinine, coagulation parameters).

Question 17

What are the preventive and treatment measures for chemotherapy-induced hemorrhagic cystitis?

Answer 17

Prevention includes forced saline diuresis, mesna, drinking 2 liters of fluid per day, voiding at first sensation, and monitoring for hematuria and urine output. Mesna binds to acrolein to reduce toxicity. The algorithm for hemorrhagic radiation cystitis may be applied if hematuria develops.

Question 18

What is the pathophysiology of chemical cystitis, and what agents or substances can cause it?

Answer 18

Chemical cystitis is inflammation caused by agents like cyclophosphamide, ketamine, soaps, gels, spermicides, dyes, or mitomycin. Direct contact with the female urethra can create an allergic-chemical reaction, leading to inflammation.

Question 19

How is chemical cystitis diagnosed?

Answer 19

Diagnosis includes obtaining a history of exposure to chemical agents, understanding timing and onset of symptoms, and possibly using a bladder and environmental exposure diary to identify associated exposures.

Question 20

What are the treatment options for chemical cystitis?

Answer 20

Treatment includes removal and avoidance of the offending agent. Specific recommendations for chemotherapy-induced and ketamine cystitis are also considered.

Question 21

What is the pathophysiology of ketamine-induced uropathy, and what are the changes observed in the bladder biopsy?

Answer 21

Ketamine undergoes oxidative metabolism, with its major metabolite excreted in urine. Bladder biopsy shows ulcerated mucosa, denuded urothelium, granulation tissue, and other changes. Symptoms may persist or progress despite cessation of ketamine.

Question 22

How is ketamine cystitis diagnosed?

Answer 22

Diagnosis includes recognizing symptoms in young adults with illicit drug abuse, cystoscopy showing ulcerative cystitis, upper tract imaging, urodynamics showing low compliance, decreased bladder capacity, and possibly ureteral involvement.

Question 23

What are the treatment options for ketamine cystitis?

Answer 23

Treatment includes ketamine abstinence and counseling, with severity-based management. Stages I and II use conservative treatments like anti-inflammatory agents, while stage III may need reconstructive surgery. Ongoing abstinence is essential.

Question 24

What characterizes eosinophilic cystitis, and what factors are associated with it?

Answer 24

Eosinophilic cystitis is characterized by transmural inflammation with eosinophils, possibly from IgE-mediated activation. Associated factors include allergies, bladder trauma, parasitic infections, and certain chemotherapeutic agents.

Question 25

How is eosinophilic cystitis diagnosed?

Answer 25

Diagnosis involves recognizing common symptoms, urinalysis showing proteinuria and microscopic hematuria, urine cultures, Giemsa and Wright stain for eosinophils, imaging for bladder wall changes, cystoscopy, and deep bladder biopsy showing eosinophilic infiltration.

Question 26

What are the treatment options for eosinophilic cystitis?

Answer 26

Treatment includes removal of causative factors, nonsteroidal anti-inflammatory drugs, antihistamines, corticosteroids, intravesical treatments, and surgical interventions like transurethral resection or cystectomy. Long-term follow-up is required.

Question 27

What is follicular cystitis, and what are its characteristics and potential associated factors?

Answer 27

Follicular cystitis is a nonspecific inflammatory disease characterized by lymphoid follicles in the bladder wall. Symptoms include inguinal pain, hematuria, and urinary urgency. It may be associated with bladder cancer, UTIs, bladder outlet obstruction, and certain treatments.

Question 28

How is follicular cystitis diagnosed?

Answer 28

Diagnosis of follicular cystitis involves cystoscopy showing discrete nodules in the urothelium and histopathological examination revealing lymphoid follicles with germinal center formation. Bladder biopsy may be needed, and immunohistochemistry helps exclude other conditions.

Question 29

What are the treatment options for follicular cystitis?

Answer 29

Treatment for follicular cystitis may include antibiotics, prednisone, oral vitamin A, pentosan polysulfate sodium, and intravesical dimethyl sulfoxide. In some cases, transurethral resection, palliative cystectomy, and radiotherapy may be used.

Question 30

What causes foreign body cystitis, and what are common examples of foreign bodies?

Answer 30

Foreign body cystitis is caused by intravesical foreign bodies, often resulting from medical procedures, self-insertion, or migration from neighboring organs. Common objects include catheters, stents, intrauterine devices, surgical staples, synthetic mesh, and parts of endoscopic instruments.

Question 31

How is foreign body cystitis diagnosed?

Answer 31

Diagnosis of foreign body cystitis may include symptoms like dysuria and urinary frequency, urinalysis showing hematuria, imaging to identify radiographic foreign bodies, and cystoscopy to confirm presence and assist in removal planning. Evaluation for fistula may be needed in case of incontinence.

Question 32

What are the treatment options for foreign body cystitis?

Answer 32

Treatment for foreign body cystitis aims at removing the object, using endoscopic methods if possible. If not, open surgery like urethrotomy or suprapubic cystotomy may be required. Follow-up is essential to monitor for potential urethral stricture.

Question 33

What are the key factors to consider in the management of BPH in men aged 80 and over?

Answer 33

Comorbidities, operative risk, polypharmacy, living environment, resources, mental acuity, ability to toilet, fall risk, and individualized treatment options.

Question 34

What are the recommended diagnostic tests to understand the true etiology of perceived BPH issues in elderly men?

Answer 34

Voiding diary, urodynamics, and cystoscopy.

Question 35

Why is an individualized approach essential in managing BPH in elderly men?

Answer 35

Due to variations in health, living environment, tolerance to treatments, and the complexity of management choices, an individualized approach is essential to ensure proper diagnosis and treatment.